myths and realities - mh podcasts

[MitchyInge]

slightly controversial but hopefully of interest

am just c&p ing transcript as audio thing not working too well just yet

Subsequent podcasts in the myths and realities series will be on:

• Genetics and Mental Illness
• Child Abuse and Mental Illness
• The Family and Mental Illness
• Trauma and Posttraumatic Stress Disorder
• Psychotherapy
• Borderline Personality Disorder

My Name is Dr Vivek Datta: I am a Visiting Research Fellow in Psychological Medicine at the Institute of Psychiatry in London. In this Podcast I will be talking about the myths and realities of medication for bipolar disorder.

Bipolar Disorder is a serious mental illness characterised by mood swings from elation to depression. It affects 3% of the population, although only about 1 in 200 people experience the most severe form of the illness. Over the past 4 years there has been raised awareness of the condition due to efforts in the media. This has lead to unprecedented numbers of individuals presenting to their doctors believing they have bipolar disorder. Whilst more people being diagnosed and treated for this potentially devastating condition may seem like an entirely positive outcome, it is not. Most of these individuals will have been told they will need to take some sort of medication, possibly for life. Whilst there is little doubt of benefit of medication for the more severe episodes, the evidence is less clear cut for milder forms of the illness. Furthermore, the evidence of benefit or long term treatment with these medications is questionable, and in the case of antidepressants, treatment may be potentially lethal. There are 6 myths surrounding the medical treatment for bipolar disorder which I am going to explode in this podcast.

Myth 1: Medication for bipolar disorder corrects a chemical imbalance in the brain

Psychiatrists often explain the effects of medications to their patients by saying the drugs correct a chemical imbalance in the brain that is supposedly responsible for the lived experience that is collectively diagnosed as mental illness. But it is simply not true. It is easy to understand the allure of such a simple explanation: illness caused by chemical imbalance, medicine corrects chemical imbalance, and balance and harmony will preside in the brain once more. The reality is that this was a marketing ploy developed by PR companies commissioned by the Pharmaceutical Giants in order to sell more drugs. It worked.

That is not to say there is not something going on the brain during a manic episode, or during a period of depressive despair. Of course there is, in the same way that normal joy, sadness, anger, and so on share neural correlates: functional imaging of the brain will show the emotional circuits active during periods of intense feeling. But that is not the same as a chemical imbalance.
I should also point out that I am not saying there isn?t a biological basis to mental illnesses like bipolar disorder. Of course there is. A number of genes have been identified that are found in at least some individuals with the illness, occurring significantly more commonly in manic depressives than could be expected by chance alone. However, the exact mechanisms are nowhere near fully understood, and we do not really understand how the medications exert their effect.

There is no doubt medications play a key part, particularly at curtailing the excesses of mania, and containing psychotic symptoms. But the notion of a chemical imbalance is a marketing ploy at best, and a fraud at worst.

Myth 2: Bipolar Illness always requires long term treatment with medication

Newly diagnosed patients confronted with their doctor are frequently told they will need long term treatment with medication, and the most vociferous psychiatrist may intrepidly suggest indefinite treatment. I am sure that a minority of patients really do require indefinite treatment. However, it is not currently possible to predict who these individuals will be early on in the course of treatment. Long term treatment with medication is the gold standard for bipolar disorder. It was conventional wisdom holds. But is it what the scientific evidence tells us?

Shockingly, for an illness is that is relatively common, and considering the potent nature of these medications, there is very little research that answers this question. That is to say, large scale clinical trials conducted over a number of years showing that treatment with medication is better than no medication, and whether different treatments are superlative or comparable to each other. Many of the longest studies last 12 months, 20 months at most. With the possible exception of lithium, there is little evidence to suggest that taking any of these medications for more than 18 months significantly improves outcomes on any
measure, be it symptoms, number of episodes, hospitalisation, self harm, suicide, social functioning, or occupational functioning. Worse still, despite combination treatments being commonly used in clinical practice, the scientific evidence is left wanting. Not only do we not know whether one combination is better than another and for whom, we don?t really know whether combination therapy is better than taking brown and orange smarties for people with bipolar disorder.

When it comes to bipolar II disorder, the more common form of the illness, the scientific evidence is even more lacklustre. It is only in the past 10 years anyone has really started looking at this group and even then only in rather paltry numbers. It is possible that some of these individuals would do fine on antidepressants alone with moodstabilisers, and others still may never require medication at all and may benefit from psychological treatments. Preliminary work is underway here, but it is still early days.

Myth 3: Antidepressants are helpful for treating and preventing bipolar depression

There is some evidence supporting the use of antidepressants, particularly the serotonin reuptake inhibitors for the depressive phase of bipolar disorder. However, despite guideline upon guideline, and study after study showing no benefit whatsoever for long term antidepressant therapy for bipolar disorder, I still see patients on this combination, usually as a result of their own reluctance to stop. It seems there is something powerful in the name ?antidepressant?, and patients seem genuinely concerned that the rest of their medication may be dulling their capacity for joy.

It is not just that long term treatment with antidepressants are largely ineffective in bipolar disorder (here I am mainly talking about bipolar I disorder- where periods of mania occur), it is that they can be dangerous, and possibly even lethal. Antidepressants can cause a person to ?switch? from depression into mania with all those ramifications. They may make the illness more hard to treat in the long run. Antidepressants are also believed to be the number one cause of rapid-cycling, which is where 4 or more episodes occur in a year. Furthermore, antidepressants are associated with mixed affective states, where individuals experience the hell of the combined fury of manic and depressive symptoms simultaneously. It is unclear whether they increase risk of depression ? the evidence is unclear either way but it is a theoretical risk, perhaps by causing mixed states which are known to carry a high suicide risk. Certainly they may be beneficial for short term acute depression in combination with an antimanic drug, but long term their effects range from the useful to the lethal.

Myth 4: The new antipsychotics are better and have fewer side-effects than the older antipsychotics

Amid much lobbying and marketing hype from the pharmaceutical companies, the newer so-called atypical antipsychotics are now commonly prescribed first line in both schizophrenia and bipolar disorder. We were told they were better. We were told they have fewer side effects. We were lied to.

Although there are some differences between the drugs, all antipsychotics pretty much work in the same way, which is they block D2 dopamine receptors in the brain. Dopamine, amongst other functions, is associated with attentional processing, and by dampening this down, the drugs seem to suppress manic excitement as well as delusions and hallucinations. They usually leave the user not really caring about anything much either. And old or new there isn?t much difference between them. Except the price tag. The newer drugs seem to have different side-effects too. Less likely are horrible movement disorder type side-effects (though they can still occur) and more common are metabolic effects such as diabetes, high blood pressure, obesity and high cholesterol. Which all require treatment with more medication!
Actually, the newer drugs are better in one respect. The newbies like olanzapine and quetiapine don?t seem to cause depression unlike the old drugs such as haloperidol and perphenazine. Somehow these atypical antipsychotics have found a new market as treatments for bipolar depression. Whilst they certainly don?t seem to cause depression like their older counterparts, I have not been able to convince myself of whether they are really useful treatments for depression, or simply improve sleep and appetite.

Myth 5: Mood stabilisers like valproate and lamotrigine are better than old-fashioned lithium

The term mood stabiliser was first used to describe lithium, when it was found to restrict the boundaries of normal human experience. However, it wasn?t until Depakote or sodium valproate came along as a treatment for mania in 1994 that the term became common currency. But like the terms ?antidepressant?, and ?chemical imbalance?, it is a marketing not a medical term. At that time valproate was touted as a better alternative to lithium. It is more tolerable, it works more quickly, it does not affect the kidneys, it seems to work for mixed episodes and in patients with acute mania in the context of rapid cycling.... And yet still I denounce it as inferior to lithium. Lithium may be old but it is tried and tested. It is useful for acute mania and acute bipolar depression, reduces the suicide rate and rates of suicidality in this population, and seems to reduce frequency of recurrence. Valproate does not have any convincing evidence for an effect in bipolar depression, it does not as once thought fare any better than lithium in rapid-cycling patients, it does not have the same dramatic effects on reducing suicidality, and it does not seem to reduce frequency of episodes ? not on its own anyway. But combined with lithium, it seems to be better than lithium alone.

In the past 16 years there has been an expansion of treatment options for bipolar. This is to be welcomed. Everyone is different, and what works for one individual does not for another. But make no mistake. There is still no match for lithium, despite its unpleasant side-effects, and clumsy monitoring schedules.

Myth 6: Prescribed medication is good for bipolar disorder whereas alcohol and illicit drugs destabilise mood

This is my personal favourite myth. The difference between a psychiatrist and a drug dealer is a medical education. We may like to pretend that prescribed drugs are superlative to alcohol and illicit drugs, but they are used in much the same way ? to alleviate symptoms of mental distress. Yes, it is true illicit drugs may be impure, and unrefined, and you may not be sure what you are getting. I am certainly not advocating their use. And I am sure that for every 1 person with bipolar who benefits from alcohol or illicit drugs, there may be 10 who are worse off. But recognising that we are all different, we cannot discount the possibility that alcohol and illicit drugs may actually be beneficial for some people who are not helped by conventional medication. Indeed, there are cases of patients who have successfully medicated themselves with alcohol for years, only to become acutely manic when discontinuing, and patients who truly seem to benefit from cannabis, despite its general association with a worsening course of bipolar illness. Indeed, a pharmaceutical derivative of an active component of cannabis ? cannabidiol is being investigated as a potential treatment for bipolar disorder and schizophrenia.

I hope I have exploded some of the myths surrounding bipolar medication, and shown that life is rarely simple, and science not so clear cut when the waters have been muddied by the profiteers and other vested interests. Thank you for Listening.

just shamelessly bumping

really really interested in thoughts on this

(I am not dr v.d. but the all important driving force behind this, haha)

thanks for posting these mitchy - really interesting. Have just scanned through but will read more thoroughly...

I like the number 6, you could make a joke out of it:
"what's the difference between a psychiatrist and a drug dealer? A medical education"!!

HA ha

This sounds pretty dangerous to me. Not an MH professional, but have experience of bi-polar in others and the idea that it's as valid to treat with skunk as lithium.. eek!

yeah but what about illicit drug dealers who have a medical education?

riddled with flaws it is

but is embryonic first attempt so that's ok

thank you so much for looking! and commenting!

peradua - "I am sure that for every 1 person with bipolar who benefits from alcohol or illicit drugs, there may be 10 who are worse off."

is just poor logic to extrapolate - brain has frozen suddenly? you know what I mean, you can say x is more probable than y for most people without assuming it is Bad for Everyone

That sentence you quote doesn't have any evidence basis even assumed - just 'I am sure'. When you're making claims about stuff and using numbers, 'I am sure' isn't actually the same as 'studies have shown that for...'

But my brain's not working at all well today either (PMT)

I didn't actually write it - that will be based on (I guess?) treating of several actual patients, would be difficult to conduct a good sized trial though wouldn't it. people probably not admit to substance abuse, or if successful management for them maybe not ever come to attention of psychiatrist

will pass that on though, as is exactly the sort of thing need to pick up on

"people probably not admit to substance abuse" - get them in the manic phase you'll get more info than you can cope with

I know a good dr who will chuckle at that statement at my expense

while I'm moderately disinhibited might as well reveal that I once asked my psych about possibility of blisters on my clitoris from compulsive masturbation complete with way too much detail about that particular act and when and where I was indulging

and also sang praises of particular medication that was making me have multiple intense orgasms - to which he gravely responded 'it is not the reboxetine, it is your disorder'

and other worse stuff that is toe-curling for its bizarrely prosaic content such as - oh no, I can't

Well I guess that explains the mitch