NEJM -- Treatment of Bipolar Depression
This editorial from the New England Journal of Medicine talks about recent studies on the use of antidepressants for bipolar disorder (the manic/depressive illness). This is of some interest to me because I have recently been reading at work psychiatric reports on someone who was initially diagnosed with this.
It would appear that American psychiatrists don't like to give anti-depressants for it because they believe it increases the risk of manic episodes. Apparently, European psychs don't worry about this much, and a recent study seemingly backing them up. However, the editorial questions whether this is a valid conclusion from the study.
This strikes me as odd: that there are different schools of thought depending on which continent your psychiatrist works.
Given that bipolar and anti-depressants have both been around for a long time, I would have thought that such an issue would have been sorted out long ago.
Instead, you get the feeling that, to a large extent, psychiatric patients are treated by trial and error, with individual biases not necessarily supported by studies playing a significant role.
Everyone should keep their fingers crossed for their continuing mental health.
3 comments:
Steve - I'm surprised that you seem surprised that people with mental illnesses are treated by trial and error, as you put it.
With bi-polar, it's even worse than that. The average person with the illness can spend a couple of decades going to doctors before being correctly diagnosed.
Think about that!!
Unless someone with bi-polar is clinically depressed, at a point in time, anti-depressants are NO USE AT ALL.
Lithium is the only treatment for bi-polar, and even then, only people with the condition at the extreme end of the spectrum would want to be taking lithium for the rest of their lives.
The modern serotonin uptake, or inhibitor, antidepressants have nothing at all to do with the brain chemical imbalance in people with bipolar.
Mind you, where the serotonin drug push is concerned, no one actually knows if any of the medications work, that is, they literally don’t know whether they act on the brains serotonin or not, and if they do, in what manner.
Anti-depressants are not, and have never been, a treatment for bi-polar. Which won’t ever stop most GPs from prescribing anti-depressants to their bi-polar patients, of course, and that is the extreme misfortune of people with this illness – badly, wrongly, poorly treated, and it never seems to end. Getting a correct diagnoses is merely the beginning of getting wrong treatments.
Caz, you sound very knowledgeable about this. Do you have a professional, or personal, interest in this? Working out what background you come from is very difficult for me.
I guess the "trial and error" side of it was not really the surprise for me; it was more that it was done in such an non evidence based way. (I think this is generally true with modern medicine, though.)
As I said, the idea that European and American psychiatrists whould broadly have different schools of thought on the anti-depressant use issue also surprised me.
I wonder whether the advances in brain scanning will ever turn out to be useful in terms of diagnosis of individual psychiatric patients. I would think this is a better line of research with the technology than the stuff such as trying to find a "god spot" in the brain or such guff.
Only a personal interest Steve.
Not sure why US and European doctors would have such different approaches to this, although it's worth bearing in mind that many with bi-polar are often poly-medicated (rightly or wrongly), as noted in the article, and that treatments need to be individualised.
I guess what they're really saying is that it is a difficult thing to treat and they still don't have answers for what is best. Finding a one-size-fits-all is never going to happen, given the nature of the illness.
Brain scanning has shown dramatic differences in brain activity for people with bi-polar and for people with high anxiety or obsessive compulsive disorder, for example. The differences are stark, compared to normal baseline. If nothing else, it establishes that the problem is within the wiring of the brain, not mere neurotic behaviours (as some doctors are wont to believe). Wildly differnt areas of the brain light up in unexpected ways - and places - for people with bipolar and other conditions. Obviously the scans can also show if a person seems to have more than one condition that might need to be addressed.
The problem with scanning is that it's expensive, so it's difficult to imagine a time when it will be a routine diagnostic tool, to help guide what types of medications might be most helpful for each individual. But I agree with your thought that this would be a really constructive way ahead.
There is definitely no "god spot"! Lots of interesting stuff going on in people's brains, but it's the normal brain that is more confined, that is, if you like, will show a single spot, or two spots of activity in response to something. On the other hand, the brains of people with mental illnesses light up all over the damned place like a xmas tree. That's what I gather from the examples I have seen. It might not hold true for all illnesses, of course.
Early days yet as to how this can be most fruitfully used. At the moment it seems to be at the fun "gosh look at that" stage - the fun of finding that there really is brain wiring basis for many human differences. It's a good start though! Perhaps in years to come we will finally see greater community understanding and improved medical treatments.
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