In my last blog, I related how it helps to be a bit crazy to come up with a visionary idea. We bipolars tend to be blessed with craziness in abundance.
My visionary idea is a series of recovery guidelines for patients. These will involve interrelated stepped blueprints involving diagnosis, meds treatment, non-meds treatment, lifestyle choices, and other topics. The idea is to help patients form their own recovery plans that they can use in partnership with their clinicians, loved ones and others.
But vision requires a strong logical underpinning. So here is the method to my madness:
The Smoke-Filled Room
The dinner dishes are soaking in the sink, a toasty fire is roaring in the fireplace. Paul, my house mate, is seated in his favorite spot, feet propped on the low table, laptop open, reading his email. The topic is algorithms. Paul is a mental health advocate, who happens to be on a committee looking into their implementation here in California.
Algorithms are basically sequenced flow charts that guide clinicians in treating patients. In a more narrative form they tend to be called treatment guidelines. Basically, guidelines and algorithms recommend certain first options for a particular condition, and, depending how the patient responds, move on to second and third options. The idea is that evidence-based science should take the guesswork out of treatment.
I put another log in the fire. Paul is about to say something. I can feel a conversation coming on. It’s a conversation we’ve had numerous times before.
Background
I first became familiar with algorithms and treatment guidelines about six years ago, and quickly learned to mine them for clinical information. But my initial enthusiasm quickly started to diminish once I figured out that when it came to specifics, they are only good at recommending the obvious.
For instance, mania is fairly straightforward to treat. Just hand me a sledge hammer and I can probably set up my own unauthorized mania clinic with fewer side effects than meds, at least for the short term.
But what about long-term mania treatment? Uh, turns out the guidelines have little to say. Long-term treatment, you see, is far more problematic, and there is little in the way of scientific evidence to guide us.
So what good are treatment guidelines, then? Precisely my point. If you’re looking for definitive answers in these guidelines on treating bipolar depression, mixed depressive states, hypomania, rapid-cycling, and other permutations to our illness, you’re not going to find much. The silent treatment, mostly. A few tentative stabs in the dark, and also some wrong answers, inexcusably wrong ones.
Wrong answers? From various panels of top experts? How can this be?
I’m back in my seat now. The conversation is about to begin.
The Challenge
Paul and I have been brainstorming the topic over the course of several weeks. I have pointed out to him numerous instances of suspect treatment guideline recommendations. The most obvious one is that four North American guidelines recommend Lamictal as a first choice (in one case the only first choice) for acute (initial phase) bipolar depression. All four guidelines cite a single published study as their rationale for the recommendation. What these guidelines neglect to mention is the four unpublished studies (plus three more for unipolar depression) in which Lamictal fared no better than the placebo.
