Hostels Nauseated London

Retrenchment and thirst for novelty: the model for Proust Cyclothymic









I asked before yesterday to Charles Barber to translate his interview is on its portal on its website:

http://www.charlesbarberwriting.com/ Charles Barber was educated at Harvard and Columbia and worked for 10 years in New York with people with mental illness and homelessness. The book "Comfortably Numb: How Psychiatry is Medicating IS Nation" was published in 2008 and the work of Barber has been the subject of articles in The Washington Post, The New York Times, The Nation, and Scientific American Mind. He taught at Wesleyan University and is a leader of "The Connection", an innovative social services agency and teaches psychiatry at the Yale University School of Medicine.
I've already mentioned his remarkable book that I bought from the bookstore at Harvard last September. Its independence, professionalism linked to his experience in the field and especially its social perspective makes him a trusted voice and original. It is part of Anglo-Saxon favorites like Kay Jamison, Peter Kramer and David Healy. point of view with regard to diagnoses, treatments and drugs is quite different even if all adopt a very humanist (not always the case in France!): Jamison, as BP I, adopts a perspective traditional and goes a long way in accepting the disease. Kramer is a philosopher and knew the right questions, Barber and Healy (psychiatrist who is not) represent a minority view in the U.S. and critics but pose troubling questions about both the diagnosis and treatment information. They can not be suspected of being under the influence and they have the merit of open debate.

I give you the link to see a review of his book by Dr. Peter Kramer ("Listening to Prozac") in "Slate". The latter shares some views with Barber, especially on the role of the pharmaceutical industry but disagreed on the increase in diagnoses and the fact that Americans are the biggest consumers of drugs used in global psychiatry.
"> http://www.slate.com/id/2184073/


Similarly, Judith Barber joined Kramer and Kramer criticizes harshly enough on the U.S. as" Prozac Nation ", she thinks Like Kramer that people who take drugs have good reason to do so.


http://warner.blogs.nytimes.com/2008/02/14/overselling-overmedication/


I also offers another item Kramer in "Slate" on a lawsuit from the Attorney General (Attorney) Eliot Spitzer against the GlaxoSmithKline for allegedly manipulated or suppressed research data for its drug Paxil appears as safe and effective for depression in children and adolescents, whereas this was not the case. He criticizes the conclusion of his article that the research laboratories control and manipulate the information so often venal. "For their sake" and according to Kramer, "this may be madness"
Psychiatrists, Children and Drug Industry's Role By GARDINER HARRIS , BENEDICT CAREY and JANET ROBERTS
Published: May 10, 2007
The intersection of money and medicine has Become One of The Most contentious issues in psychiatry ..

http://www.nytimes.com/2007/05/10/health/10psyche.html?partner=permalink&exprod=permalink


My free translation of the interview presentation of the book you Barber can read in English on its web page:



Question: Americans account for two-thirds of the market for anti-depressants and other psychiatric drugs. What drives Americans to be "comfortably numb"?

Response Charles Barber: Americans have always loved the quick repairs, and crush the enemy with technology-it is a foreign country or a medical problem. And we love it more than ever, probably nurtured by our attention to smaller and smaller, and our desire that everything should happen at the speed of a click of a mouse. Another factor that led the Americans to take drugs is the increasing isolation of people, simultaneously accompanied by an obligation of success and accomplishment, to find happiness. The upshot is that Americans rush to consultation, in particular for antidepressants, the most prescribed drug in number. We believe that we will find we will remove our distress.

Question; During the last decade, the public began to see mental illness as something common and easily treatable with drugs: celebrities declaring their problems, ordinary people talking about their pills. You think that attitudes towards people really affected by mental illness have changed?
Answer: No. Real sick-schizophrenics and bipolar patients, for example-are also stigmatized as before. It may now be acceptable and even cool to talk about antidepressants at a party, and it certainly cool for an actress to talk about her depression on the Oprah Show (as it is controlled and has a new movie in sight) but let's see what would happen if you were talking about the voices you hear or visions? People will flee as quickly as they can. And with rates Psychatrie drugs consumed by the masses, the number of people with severe mental disorders are adequately treated remains very low.
Question: Recently, there has been a considerable increase cases of depression, bipolar disorder and other psychiatric cases. Do you think these diseases are best diagnosed or over-diagnosed?


Answer: As always with this kind of thing is a bit of both. Certainly in the past, the great-uncle who was just considered strange or isolated really suffered from schizophrenia and no one knew or wanted to know. But things have gone very far in the opposite direction. Now problems of everyday healthcare and are treated with medication. Psychiatry has increased the number of diagnoses so significantly over the past 30 years can be diagnosed as "disorder acclimation or the brother and sister" or "phase problem of life." Have difficulty getting used to a new situation or have family problems may be painful or disturbing, but they are definitely not medical problems. Major studies estimate that a quarter of Americans suffer from a psychiatric problem each year, and most will be mentally ill at some point. I reject this approach. Serious mental disorders are a serious condition that affects a rather small proportion of the population.
Question: You describe the difference between depression and depression, the last part of human life and the first major illness with specific symptoms. Why do you think these are bad people who take drugs?


Answer: It is common for less severe cases are treated and on medication. Major depression is a disorder that is life threatening and has nothing to do with "feel the spleen" or having "difficulties with the winter." Confusing the two-serious mental disorder versus everyday problems-has prompted more than any one-on medical treatment for people who failed to meet not really the criteria for psychiatric illness. Moreover, even for serious cases, drugs are not the only approach. The cognitive-behavioral therapy has also shown itself even more effective than drugs for mild and moderate depression, without side effects and with lower relapse rates. Diet and exercise can also make a big difference, even for major depression. With our zeal for drugs, we neglect these approaches are very effective but not as simple as taking a pill.

Question: You note that "each generation of American chooses either a new drug, or it creates one ... The drug war will never win because Americans do not want to win. "How the war against drugs is Different or similar to the dependence of Americans on the respect of anti-depressants?

Answer: The difference between drugs and medicines (same word in English: drug) may be much smaller than what one might imagine. pharmacological profile of the Ritalin for example is very similar to that of cocaine. We also tend to blame others for our drug problems - the Colombians for cocaine, for example-rather than us trying to look inside to know why we are depressed and anxious and so attracted to drugs.

Question: You note that the profits of the 10 largest pharmaceutical companies in 2002 being more important than all the profit gains of 490 500 companies. What is the role of trade in the area of mental health-for example, doctors paid by the laboratories for writing articles in medical journals?

Answer: The mental health industry involves a lot of money. Many psychiatric drugs are the winners of the best sales the world. Antidepressants were the most profitable products in the world in the 90s. Of course the mix of all that money with the medicine can have disastrous results. Studies show that drug trials, carried out by people who have a conflict of interest in the drug evaluated were 5 times more likely to have positive results.

Question: The role of drugs and children is a sensitive issue. What are the risks to children and families who see only the positive effects of the pills?

Answer: Drug Treatments for Children are of particular concern. Giving medications to children involves changing their minds as they grow in directions that nobody understands. The rates of these treatments for children have skyrocketed in recent years, along with the controversial use of psychiatric diagnoses for children. As with adults, I think there is a small percentage of children who are really sick right diagnosis and need medication. Medication for ADHD may be broadly effective, but the increased use of psychotropic powerful and mood stabilizers, and the fact of combining them, is disturbing and largely inappropriate.
Question: Psychiatry in the United States has evolved into a phase that you call the "Corporate Psychiatry", where the emphasis is on profits and salaries paid only for medicines. Who should be blamed for this focus on drugs as an end in itself, the only solution? Mutuals, laboratory or physicians themselves?


Answer: While the labs were very manipulative in their practice of marketing, finally I blame the doctors. Insurance and laboratories are what the industry is supposed to do in the U.S.: profit. Attacking these industries for that is like criticizing a leopard attacks a deer. Unlike doctors, "Big Pharma" and mutuals have not taken the oath of Hippocrates.
Question: Are you suggesting alternative approaches, stage of change, motivational interviewing, commitments with peer requires a paradigm shift: "the cure may exist in the context of the disease." You also say that we must listen carefully to those who are sick about what works for them. Can you make a synthesis of these approaches and the need to change our way of seeing the disease and treatment?


Response: Lessons from the "movement cure"-made by those who have suffered from severe mental illness and felt better-are very different messages and marketing from laboratories that say how to treat diseases.
Former patients say only get better not to remove all the symptoms but to learn how to have a rich life, even with the presence of symptoms fortunately reduced returns. The former patients also say that the social context is crucial to get better: the strength of their relations and supporters make a big difference, as if to find something or someone, give a reason for wanting to go better. They also say they improve when they take charge of their healing rather than being passive in taking a pill or by simply following what the doctor said.
Motivational interviewing (MI) and the Stages of Change are procedures and ways of seeing the disease who have two decades since Prozac was introduced, but nobody knows this because there is no money or marketing associated with these methods. They involve, in one sentence, listening to patients instead of listening to Prozac. The Stages of Change model of change that are cyclical rather than linear (We must go through several cycles to obtain a different behavior). and MI, first developed for people who are experiencing substance abuse, is a way to meet clients "where they are" and then help them find their domestic reasons to get better. The MI approach is exactly opposite the old way of involving the confrontation of patients, but it is highly strategic and specific techniques are used to find items that the person can use for its own change. Research shows that the MI is effective in changing patient behaviors on many unhealthy behaviors in including depression and anxiety. /. END


Also I invite you to these very interesting articles in The New York Times on conflicts of interest evoked by Barber (including two great professors of medicine who have lied about their fees from pharmaceutical laboratories agreed by Sen. U.S. Congress, Charles Grassley during an investigation): Researchers Fail to Reveal Full Drug Pay and Top Psychiatrist Did not Report Drug Makers' Pay.
Another very informative article on children in psychiatric treatment (Tough Choices for Tough Children's author Judith Warner).
http://www.nytimes.com/2008/10/04/health/policy/04drug.html?partner=permalink&exprod=permalink



http://www.nytimes.com/2008/06/08/us / 08conflict.html? partner = permalink & exprod = permalink



http://warner.blogs.nytimes.com/2008/11/20/tough-choices-for-tough-children/

And here: a Socialist MEP Catherine Lemorton, rapporteur of the parliamentary commission on the drug told the lobbying of some laboratories with members of the National Assembly: back the words "member of Lobbying face" on the search engine Dailymotion.com.
To conclude, the real ethical issues facing medicine today, especially on clear scientific information and iatrogenic effects of certain drugs based on dose and duration of treatment.
It is clear that in general we can not do without drugs, but since France is one of the largest consumer in the world, we can just ask the question whether it is unnecessary to abuse by some physicians but also patients who want a "quick-fix" when they are not really in a hurry.
all about final diagnosis, especially in the field depression and bipolar disorder, where those who should care does not always do so and those who could use methods of cognitive therapies abstaining.
As always, the truth lies between these two fronts, "any drug" or "everything except drugs." What will I win or lose with one or the other and above all that tells me my reason and my conscience.
Personally, I think drugs are useful and necessary when the patient is in real psychological and social distress, depression (not depression), depression stirred (not angry) or hypomanic or manic phase (not hyperthymic). As we say in our book ("Cyclothymia, For worse and for better"): "As long as there is no break no need to repair" (p.191). The question then remains: what to do after the storm, when we continue the voyage in calm weather? Keep the life jacket on him or at hand. Here is the whole issue. But this is only my opinion. It is true that 400 mg of lithium per day is worth two bottles of wine and that drug use and health of body and mind of the patient should be the priority. Then

and complex .... Is that to feel depressed or "sick" means that the east really? The subjectivity of the patient is sufficient. I think not, because as David Healy, requires objective criteria such as hospitalization or be absent from work for more than a month. And yet, there would be objections to make.

We must return to the quantification of cyclothymia as proposed by Peter Kahn in 1909.

Nothing is simple with cyclothymia and psychiatry today.

Buddy The Cake Boss Fondant

Interview with Charles Barber about his book, "Comfortably Numb: How Psychiatry Medicating IS a Nation "






After "Two Lovers", here is an excellent film that describes a couple original and beautifully Cyclothymic: Revolutionary Road. I think this is one of the best role of Di Caprio and Kate Winslet especially (With the dangerous side of hypomania), larger than life. We see the female character's mental deterioration following a failed vocation as an actress and a theater project. The male character is very stable and cyclothymic made a choice "reasonable" will result in the progressive destruction of the couple. At the end of the film, the neighbor described them as "whimsical "...( capricious, unstable, unrealistic and tempting). Very beautiful word in English, perfectly fair to describe the Cyclothymia: the whimsical disorder

If I were a psychologist or psychiatrist, I show it to my patients or my students as beautiful illustration of cyclothymia.

This film by Sam Mendes is also and above all a great satire of conformity and a tribute to the lucidity of the insane (beautiful character of the insane mathematician) that Foucault would have appreciated.

Jackie Pigeaud in his presentation (Shores Paperbacks) Problem XXX wrote that the melancholic unstable may be all the others. That is what is expected of an exceptional actor, melancholy and manic and "it not by disease but by nature" (conclusion of Aristotle). As noted by Professor Colin Martindale's creative (and I add the cyclothymic) need stimulation but not necessarily an "adventure in the world", especially as their anxiety and depressive traits often condemn them to an avoidance of danger (if the character played by DiCaprio), but if hyperthymic predominates, the novelty seeking assumes risk-taking may be too large (Kate Wislet).
Unmissable.

http://www.revolutionaryroadmovie.com/

Victorious Tighty Whities

Cyclothymia in" Revolutionary Road ", a" whimsical disorder "





Although I am involved with my colleagues in the Philadelphia Project, it seemed important to do a little break and make you part of my past reflections. As you know, my last readings and meetings have led me to be more cautious on the issue of treatment of cyclothymia and bipolar attenuated. It is obvious that there is a risk of skidding on drug prescriptions. Some independent psychiatrists, in the U.S. but also in France, remain skeptical about the merits and effects of treatment on long-term ("prophylaxis") as it does there would be no conclusive scientific studies.
I suggest you carefully read the article by David Healy that I propose below
. It is quite instructive and even disturbing. Other scholars such as Charles Barber, Peter Breggin (See her extensive website and plug in Wikipedia U.S.) or Monique Debauche share the analysis of Professor Healy.

As Healy points out, was given before lithium and Depakote during manic episodes and the term "thymus regulator" was invented by a laboratory to accept the molecule in the long term: "From the 1950s on, The Depression of manic-depressive Illness Have Been Treated With Antidepressants And The Gold manias With lithium antipsychotics. Lithium Was The only officer Thought To Be Prophylactic Against Further episodes of manic-depressive-illness [3]. lithium Goal Was Not Originally Referred to as a mood stabilizer. The term "mood stabilizer" had barely Been Heard Before of 1995 When Abbott Laboratories got a license for anticonvulsant sodium valproate physician before (Depakote) for Treating acute mania [4].

must also not forget that only lithium and Depakote have Authorisation Placing on the Market (AMM) in France (Ll'AFSSAPS) for bipolarity.

Similarly the issue of clinical studies, their implementation and especially the interpretation of results is debatable and requires real additions information (cf. the article by Dr. Debauchery I quote below).

This issue of drug effects on health but also on "well be cognitive" must be urgently addressed by the "patient-patrons.
I agree with the term cyclothymia and bipolar offset because the bipolar spectrum is obvious, what worries me most is the tendency to automatically prescribe medications during a first visit (CF number Psychologies of September and what Breggin said in the Oprah Winfrey Show 2 avril1987 "
Mental health clinicians Their customers should" judge in terms of Their empathy and support; If They failed to show interest in 'em and Tried to PRESCRIBE drugs "during the first session, he Advised to seek assistance Such customers elsewhere ".
Dr. Serge Hefez (read his excellent paper in Psychology of September "the use of drug suits everybody") and Charles Barber (author of essential book "Comfortably Numb") believe that taking a pill is less effort than make a cognitive therapy: It seems obvious. It is true that the doses prescribed for bipolar offset are generally less strong than for BP I, but should they take his life? Difficult question. I'll let you ask questions to your therapist but always several opinions. Testis unus, testis nullus, a principle of law.
Fortunately many psychiatrists offer CBT directly within their firm or refers patients to psychologists. Dr. Gay in a forum on Psychologies Magazine said this:
"Our mood changes in response to situations, events that confront us, as far as our personality. If these fluctuations are of a lesser degree, may correspond to what is meant by the term "cyclothymia" the mood swings are less durable and less intense, but still debilitating. stabilizers treatments may be prescribed, but
these disorders is based primarily on psychological measures and better management of daily life.
.
He is right but I found that Dr. Gay had a tendency to minimize the impact of cyclothymia quality of life whereas only BP I were "true bipolar" (See his book: Living with manic -depression). It is clear that BP down may be a real disorder. The issue of diagnosis does not arise but that the proper treatment without risk to the well being of the person. It is interesting to note the controversy among experts, but patients are also entitled to have several opinions and learn to form their own opinion. The truth will be difficult to know therefore act according to our conscience and intuition.


A person may be regarded as "manic" or "bipolar" but it will explain what is meant by this label and especially what therapies or steps to take to get better. That's what we intend to do in the Philadelphia Project.


After reading the fascinating article by David Healy, read the French of Mr. Debauche: http://pharmacritique.20minutes-blogs.fr/archive/2008/05/17/marche-des-psychotropes -Build-historical-of-a-deriv.html

And one titled: Cognitive Side Effects of Antiepileptic Drugs in Children by David W. Loring, Ph.D. (Psychiatric Times September 2005): http://www.psychiatrictimes.com/display/article/10168/52286.


The flap about child care is also to explore when we know the problems of over-diagnosis of ADHD in the U.S. but the question of "all pole" may also arise. What is true for adults-for caution against drug-, is even more for children and adolescents.




The Latest Mania: Selling Bipolar Disorder David Healy

Funding: The author No Specific Funding Received to write this article.

Citation: Healy D (2006) The Latest Mania: Selling Bipolar Disorder. PLoS Med 3(4): e185 doi:10.1371/journal.pmed.0030185

Copyright: © 2006 David Healy. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

David Healy is at the North Wales Department of Psychological Medicine, Cardiff University, Cardiff, Wales, United Kingdom. E-mail: healy_hergest@compuserve.com
One of the most famous direct-to-consumer television adverts for a drug begins with a vibrant woman dancing late into the night. A background voice says, “Your doctor probably never sees you when you feel like this.” The advert cuts to a shrunken and glum figure, and the voiceover now says, “This is who your doctor usually sees.” Cutting again to the woman, in active shopping mode, clutching bags with the latest brand names, we hear: “That's why so many people with bipolar disorder are being treated for depression and not getting any better—because depression is only half the story.” We see the woman again depressed, looking at bills that have arrived in the post before switching to seeing her again energetically painting her apartment. “That fast- talking, energetic, quick tempered, overdoing it, up-all-night you,” says the voiceover, “probably never shows up at the doctor's office, right?”

No drugs are mentioned. But viewers are encouraged to log onto www.bipolarawareness.com, which takes them to a Web site called “Bipolar Help Center,” sponsored by Lilly Pharmaceuticals, the makers of olanzapine (Zyprexa). The Web site contains a “mood disorder questionnaire” (http://www.bipolarhelpcenter.com/resources/mdq.jsp). In the television advert, we see our heroine logging onto www.bipolarawareness.com and finding this questionnaire. The voice encourages the viewer to follow her example: “Take the test you can take to your doctor, it can change your life….getting a correct diagnosis is the first step in treating bipolar disorder. Help your doctor to help you.”

This advert markets bipolar disorder. The advert can be read as a genuine attempt to alert people who may be suffering from one of the most debilitating and serious psychiatric diseases—manic-depressive illness. Alternatively, the advert can be read as an example of what has been termed disease mongering [1]. Whichever it is, it will reach beyond those suffering from a mood disorder to others who will as a consequence be more likely to see aspects of their personal experiences in a new way that will lead to medical consultations and in a way that will shape the outcome of those consultations. Adverts that encourage “mood watching” risk transforming variations from an emotional even keel into potential indicators of latent or actual bipolar disorder. This advert appeared in 2002 shortly after Lilly's antipsychotic olanzapine had received a license for treating mania. The company was also running trials aimed at establishing olanzapine as a “mood stabilizer,” one of which was recently published [2].


Mood Stabilization
From the 1950s on, the depressions of manic-depressive illness have been treated with antidepressants and the manias with antipsychotics or lithium. Lithium was the only agent thought to be prophylactic against further episodes of manic-depressive illness [3]. But lithium was not originally referred to as a mood stabilizer. The term “mood stabilizer” had barely been heard of before 1995 when Abbott Laboratories got a license for using the anticonvulsant sodium valproate (Depakote) for treating acute mania [4].

After 1995, there was a dramatic growth in the frequency with which the term “mood stabilizer” appeared in the title of scientific articles (see Figure 1). By 2001, more than a hundred article titles a year featured this term. Repeated reviews make it clear that the academic psychiatric community still has not come to a consensus on what the term “mood stabilizer” means [5–7]. But this lack of consensus did not get in the way of the message that patients with bipolar disorders needed to be detected and once detected needed mood stabilizers, and perhaps should only be given these drugs and not any other psychotropic drugs [8,9].

The growth of awareness of mood stabilization was sensational.
The first group of drugs to colonize this new mood stabilizer niche was anticonvulsants. Anticonvulsants are beneficial in epilepsy and were until recently widely thought to be beneficial by quenching the increased risk of succeeding epileptic fits brought about by fits that have gone before. Robert Post in the 1980s suggested that anticonvulsants might stabilize moods by a comparable quenching of the kindling effect of an episode of mood disorders on the risk of further episodes [10]. It was this idea that provided a pharmacological rationale for treatment of bipolar disorders that was so attractive to pharmaceutical companies, and, in their hands, the growth of awareness of mood stabilization and of bipolar disorders was sensational.

Bipolar disorders entered the DSM (Diagnostic and Statistical Manual of Mental Disorders) in 1980. At the time, the criteria for bipolar I disorder (classic manic-depressive illness) involved an episode of hospitalization for mania. Since then, the community-based disorders bipolar II disorder, bipolar disorders NOS (not otherwise specified), and cyclothymia have emerged. With their emergence, estimates for the prevalence of bipolar disorders have risen from 0.1% of the population having bipolar I disorder (involving an episode of hospitalization for mania) [11] to 5% or more when the definition of bipolar disorders includes the aforementioned community disorders [12]. A range of academic institutions has also grown more interested in the condition.

There has always been a rationale to using antipsychotics in bipolar disorders, as they are effective in acute manic states [13,14]. However, no companies making antipsychotics had previously sought a license for prophylaxis against bipolar disorders. Against a background of epidemiological studies indicating that the prevalence of bipolar disorders might be greater than previously thought [15,16], and growing academic interest in the condition, Lilly, Janssen, and Astra-Zeneca, the makers of the antipsychotics olanzapine, risperidone, and quetiapine (Seroquel), respectively, marched in on the new territory to market these drugs for prophylaxis of bipolar disorder. This, in turn, greatly expanded the number of companies with an interest in making the “bipolar market.” There was, however, no consensus on a theoretical rationale that would lead the average clinician to think these three drugs might “quench” the propensity to further affective episodes, as opposed to simply assist in the management of acute manic states.
But the increased prevalence estimates were based on community surveys that had no clear disability criterion, while acute treatment trials of antipsychotics for mania, and prophylactic trials of lithium for manic-depressive illness, have for the most part been conducted on bipolar I disorder. This necessarily raises the prospect that increased efforts to detect and to treat people risks crossing the line where the benefits of treatment outweigh its risks.


Along with this expansion in prevalence estimates came new journals, Bipolar Disorders (http://www.blackwellpublishing.com/journal.asp?ref=1398-5647) and the Journal of Bipolar Disorders (published by Lippincott, Williams, and Wilkins), a slew of bipolar societies, and annual conferences, many heavily funded by pharmaceutical companies. There is a growing amount of patient Web site and patient support materials that in the case of Zyprexa state that “bipolar disorder is often a lifelong illness needing lifelong treatment; symptoms come and go, but the illness stays; people feel better because the medication is working; almost everyone who stops taking the medication will get ill again and the more episodes you have, the more difficult they are to treat” [17]. Information available from Janssen (the makers of Risperdal) states “medicines are crucially important in the treatment of bipolar disorders. Studies over the past twenty years have shown beyond the shadow of doubt that people who receive the appropriate drugs are better off in the long term than those who receive no medicine” [18].

What Lies Beneath
There is, however, much less evidence than many might think to support these claims for the prophylactic drug treatment of manic-depressive illness (bipolar I). And there is almost no evidence to support such claims in the case of whatever community disorders (bipolar II, bipolar NOS, cyclothymia) are now being pulled into the manic-depressive net by the lure of bipolar disorder.


With the possible exception of lithium for bipolar I disorder, there are no randomized controlled trials to show that patients with bipolar disorders in general who receive psychotropic drugs are better in the long term than those who receive no medicine [19]. This may stem in part from difficulties in conducting trials on psychotropic drugs that last more than a few weeks in conditions as complex as manic-depressive illness. One short-term, randomized, placebo-controlled trial (in which patients were only followed for up to 48 weeks) that some see as a basis for claiming that olanzapine may be prophylactic in bipolar disorder [2] has been regarded by others as indicating that this drug produces a withdrawal-induced decompensation when stopped [20]. Even in the case of lithium, there is some dispute over what has been demonstrated [19], with the best evidence stemming from large open studies in dedicated lithium services rather than from randomized trials [21].

This evidence of benefit for one agent (lithium) and possible benefit for one more (olanzapine) must be weighed against two harms associated with use of antipsychotics: (1) a consistent body of evidence indicates that regular treatment with antipsychotics in the longer run increases mortality [22–26]; and (2) there is evidence that in placebo-controlled trials of antipsychotics submitted in application for schizophrenia licenses there is a statistically significant excess of completed suicides on active treatment [27]. A range of problems associated with antipsychotics, from increased mortality to tardive dyskinesia, never show up in the short-term trials aimed at demonstrating treatment effects in psychiatry.
But aside from these hazards, there are also grounds to question whether the treatment effects that some think have been demonstrated in bipolar disorder trials translate into therapeutic efficacy. If use of these agents based on demonstrated effects leads on to efficacy, admissions for bipolar disorder might be expected to fall, but the evidence for this is difficult to find. In North Wales before the advent of modern pharmacotherapy, patients with bipolar I disorder had on average four admissions every ten years. In contrast, against a background of a constant incidence of bipolar I disorder, and dramatic improvements in service provision, bipolar I patients show a 4-fold increase in the prevalence of admissions despite being treated with the very latest psychotropic medications [11]. This is not ordinarily what happens when treatments “work,” but quite often is what happens when treatments have effects.


The selling of bipolar disorder stresses that the disorder takes a fearsome toll of suicides. And indeed the controversy surrounding the provocation of suicide by antidepressants has been recast by some as a consequence of mistaken diagnosis. If the treating physician had only realized the patient was bipolar, they would not have mistakenly prescribed an antidepressant. Because of the suicide risk traditionally linked to patients with bipolar disorders who needed hospitalisation, most psychiatrists would find it difficult to leave any person with a case of bipolar disorder unmedicated. Yet, the best available evidence shows that unmedicated patients with bipolar disorder do not have a higher risk of suicide.

Storosum and colleagues analyzed all placebo-controlled, double-blind, randomized trials of mood stabilizers for the prevention of manic/depressive episode that were part of a registration dossier submitted to the regulatory authority of the Netherlands, the Medicines Evaluation Board, between 1997 and 2003 [28]. They found four such prophylaxis trials. They compared suicide risk in patients on placebo compared with patients on active medication. Two suicides (493/100,000 person- years of exposure) and eight suicide attempts (1,969/100,000 person-years of exposure) occurred in the group given an active drug (943 patients), but no suicides and two suicide attempts (1,467/100,000 person-years of exposure) occurred in the placebo group (418 patients). Based on these absolute numbers from these four trials, I have calculated (see Figure S1 showing calculation, and see Figure 2) that active agents are most likely to be associated with a 2.22 times greater risk of suicidal acts than placebo (95% CI 0.5, 10.00).

Figure 2. Author's Graph of p-Value Function Based on Data in [30]
(Illustration: Sapna Khandwala)

The Bipolar Future
Until recently the general clinical wisdom was that it was very rare for manic-depressive illness to have an onset in the preteen years. But there is now a surge of diagnoses of bipolar disorder in American children [29,30], even though these children do not meet the traditional criteria for bipolar I disorder (from the Diagnostic and Statistical Manual of Mental Disorders) [31]. The mania for pediatric bipolar disorder hit the front cover of the American edition of Time in August 2002, which featured nine-year-old Ian Palmer and a cover title Young and Bipolar, with a strapline, why are so many kids being diagnosed with the disorder, once known as manic-depression?
A recent book, The Bipolar Child [32], brings out the extent of the current mania. Published in 2000, this book sold 70,000 hardback copies in six months in the US. As the Star Telegram reported in July 2000 [33], The Bipolar Child made all the difference to Heather Norris, whose mother, after reading it, challenged her physician to correct Heather's diagnosis from ADHD, treatment of which had made her daughter worse, to the correct diagnosis of bipolar disorder. As a result, Heather, at the age of two, became the youngest child in Tarrant County, Texas, to have a diagnosis of bipolar disorder. The Star Telegram article noted that “along with the insurance woes, lack of treatment options and weak support systems that plague most families with mentally ill children, parents of the very young face additional challenges. Finding the proper diagnosis for treatment is a nightmare because of scant research into childhood mental illness and the drugs that combat them.”

If
we consider adults alone for a moment, there is already the potential for creating an “epidemic” of bipolar disorder, because people are being diagnosed with the condition based on operational criteria that depend upon subjective judgements (rather than an objective criterion of disability, such as hospitalization or being off work for a month)
. The potential is compounded in the pediatric domain by the fact that the diagnosis is based on caregiver reports with little scope in most clinical practice for critical scrutiny of the social forces that may lead to these reports. Experts that appear willing to go so far as to accept the possibility that the first signs of bipolar disorder may be patterns of overactivity in utero [32] can only further compound these problems. If the resulting diagnoses were provisional, aimed at researching the natural history of childhood irritability, rather than reaching diagnoses that lead on to pharmacotherapy, there might be little problem. However, drugs such as Zyprexa and Risperdal are now being used for preschoolers in America with little questioning of this development [31].

Far from research bringing a skeptical note to bear on clinical enthusiasm, it appears to be adding fuel to the fire. What might once have been thought of as sober institutions, such as Massachusetts General Hospital, have run trials of Risperdal and Zyprexa on children with a mean age of four years old [34,35]. Massachusetts General Hospital in fact recruited trial participants by running its own television adverts featuring clinicians and parents alerting parents to the fact that difficult and aggressive behavior in children aged four and up might stem from bipolar disorder. This does more than recruit patients with a clear disorder; it suggests that everyday behavioral difficulties may be better seen in terms of a disorder. Given that bipolar disorder in children is all but unrecognised outside the US, it seems likely that a significant proportion of these children will not meet conventional DSM criteria for bipolar I disorder. And given that it is all but impossible for a short-term trial of sedative agents in pediatric states characterized by overactivity not to show some rating scale changes that can be regarded as beneficial, the outcomes of this research are likely to appear to validate the diagnosis and increase the pressure for treatment.

Several years after Heather Norris was diagnosed with bipolar disorder, the rationale for mood stabilization was greatly weakened by the results of the largest-ever randomized trial of immediate versus deferred anticonvulsant therapy for people who had experienced a single seizure [36]. The trial found that although immediate antiepileptic drug treatment reduces the occurrence of seizures in the next 1–2 years, such treatment does not affect long-term remission in individuals with single or infrequent seizures. The use of psychotropic medication for bipolar disorders was based on an analogy with epilepsy, rather than on demonstrations of proven clinical benefits over the long term or on the basis of a correction of a known pathophysiology. The absence of a solid theoretical or empirical basis for using psychotropic medication as “mood stabilizers” raises questions as to what lies in store for the Heather Norris's and others of this world exposed to these complex psychotropic agents from such a young age.

Supporting Information
Figure S1. Episheet Showing Author's Relative Risk Calculation, Based on Data in [30]
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Pink And White Cubefield

drugs disputed bipolarity attenuated: The critical view of some psychiatrists









Cyclothymia is featured in Psychologies of December. I am very satisfied with this small contribution in this popular magazine. For several reasons: The first is that the subject of the fragility Benoit Helme (p.108) that makes me seem very good, deep and original. The second, is that I liked the position of Psychologies against abuse of psychotropic drugs last September and the third is that I can speak briefly of cyclothymia and its benefits to readers informed.

For the record, I met the photographer called Olivier Roller (www.olivierroller.com), which, coincidentally my father had Fotographie FNAC Strasbourg after the release of his latest film he is almost 10 years.

Link's website Psychologies:
"> http://www.psychologies.com/article.cfm/article/10067/Nos-fragilites-sont-une-force.htm?id=10067&page=3