Friday, Central Connecticut. I'm at my mom's place, not far from where I grew up. My brother and sister-in-law will be arriving shortly. There is no internet at my mom's, so I will get this off sometime tomorrow. To rewind:
Wednesday, Washington DC - I wake up refreshed from a sound sleep. I'm out of the danger zone. The night before I was only able to sleep for two hours. I turned up for my third full day at the American Psychiatric Association's annual meeting fully prepared to abort my mission. With this illness, being a hero is not an option.
Rewind a bit to Tuesday - Lack of sleep is the royal road to mania, but I am observing that my sleep-deprived state of exhaustion is slowing me down rather than speeding me up. So far, so good. My favorite brain scientist, Husseini Manji MD, head of the Mood and Anxiety Disorders unit at the NIMH, is speaking, and I can almost follow his presentation
A lecture on brain science to me is what a Rolling Stones concert is to most of the rest of you (can't get enough of them signal transduction pathways) and I find myself perking up.
The next talk - on PTSD - happens to be in the same room. I step out into the light, and I run through a systems check - fatigue level, mania risk, other stressors. I'm good to go. I grab a coffee and head back into the room.
The talk wraps up around 12:30. A very important session is taking place in an hour and a half. Soldier on or call it a day? More systems checks. I head off to the poster sessions and strike up some conversations with a few of the researchers present. Then I chill out in the media room.
The 2 PM session is a three-hour marathon on whether or not antidepressants should be used for treating bipolar disorder. Some important new findings have just been reported, and all the key players are there.
Gary Sachs MD of Harvard runs through a series of NIMH-underwritten STEP-BD findings published about two months ago. These real-world trials found that the addition of an antidepressant to a mood stabilizer conferred no clinical benefit. About 25 percent of patients got better on an antidepressant with a mood stabilizer, but those talking a placebo with their mood stabilizer did even better.
The surprise finding was that that the antidepressants did not flip patients into mania, but Frederick Goodwin MD, co-author of the definitive book on bipolar, had an answer for that. STEP and other studies, he said, did not check for switches into depression. In those with bipolar and recurrent depression, an antidepressant may speed up the cycle, paradoxically resulting in more frequent depression..
Thus, while a mood stabilizer may be effective in preventing a patient from cycling into mania, it may be useless in protecting patients from sliding down into depression.
Complicating matters are two studies by Lori Altschuler MD of UCLA. These found that 14 percent of patients did well staying on an antidepressant with a mood stabilizer. The catch is we don't know which 14 percent. STEP-BD tried to tease out this subpopulation, but to no avail.
I emerge from the session and run into an acquaintance from New Jersey. I unwind with him over a burger in a sports bar. I'm back at my hotel by seven. I force myself to stay awake till 8:30. I'm asleep before my head hits the pillow.
Wednesday (again) - I arrive for a morning session on PTSD only to realize there is a session on treatment guidelines going on at the same time.
The APA's Depression Treatment Guidelines dates from 1999 and the Bipolar Guidelines from 2002. Revised Guidelines for both are in their second draft. A third draft is in the works, and both final versions are expected to be published in Spring, next year.
Robert Hirschfeld MD of the University of Texas, Galveston chairs the Bipolar Guidelines expert panel. He reveals that the trial evidence does not justify recommending Lamictal as a first choice for treating acute (initial) phase bipolar depression. The med has failed four trials in this phase of treatment, with only one finding that can be interpreted as a success.
On the other hand, Lamictal faired well in at least one long-term study.
Seroquel, on the other hand, has come up trumps in a number of short-term trials, and is a no-brainer for initial treatment. But side effects may make the med problematic for the long term.
There is also strong evidence for cognitive behavioral therapy and other short-term talking therapies with meds.
At an afternoon session, a four-or-five person panel is discussing the pros and cons of the 10-minutes meds check. I catch the first speaker, Charles Nemeroff MD, PhD of Emory University, who is very much opposed to this aspect of mangled care.
Time to head out. A Washington DC friend, Karen, picks me up at my hotel at four, and we visit the FDR Memorial. Karen senses that I have been indoors in dark rooms for way longer than is good for me. The fresh air and outdoor light come as a welcome tonic, not to mention the inspiration from being in the presence of a giant among me.
Karen's husband Alan joins us in a downtown pub, and later we check out the memorial of my other favorite President, Lincoln.
Then it's AMTRAK to Connecticut first thing in the morning.
More later ...
Published On: May 12, 2008
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