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Dr. Bob is Robert Hsiung, MD,
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Posted by Simon Sobo, M.D. on September 15, 2010, at 14:51:22
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by SLS on September 15, 2010, at 12:42:06
> Thanks for attending to my comments and providing information.
>
> > Don't know if you read my article. I would appreciate your telling me whether you have.
>
> I did the best I could.
>
> > I did not do a scientific study
>
> That's all I'm saying.
>
> > but rather wrote it when all of a sudden half the patients being discharged from inpatient units were suddenly being discharged with a bipolar diagnosis.
>
> Perhaps a change in the rate of diagnosis of BP reflects greater accuracy in diagnostics. How would we go about testing this hypothesis?
>
> > When I called the doctors about their diagnosis they cited "mood swings" as the reason.
>
> All of them? I find the use of the term "mood swings" as a diagnostic descriptor offered by professionals in the mental health field to be quite disappointing. The only time I heard one of my doctors use the term "mood swing" was in describing the title of Ronald R. Fieve's book "Mood Swing - Fieve". Otherwise, I have never heard any professional use the term in front of me. I guess I have been lucky in this regard.
>
> > I don't get your reasoning regarding Dr. Frances' opinion that there is a pseudoepidemic
>
> Again, you are offering only the opinions of others. Where is the evidence you would present to validate these opinions? What evidence do these people use to substantiate their opinions? To me, it looks like Zimmerman's work offers the kind of methodology that would help resolve these questions. Perhaps you can comment on this.
>
> In my opinion, the fad of overdiagnosing bipolar disorder has been in decline over the last 10 years. I can't prove this, though. My opinion is the result of observing the prescribing habits of doctors in a partial hospitalization program. Of course, this is far from being scientific evidence.
>
>
>
> - Scott
>
I see we are coming from very different places but I will try to throw my views across the the bridge and enter your paradigm.I love science when it delivers the goods. I love it as a method of trying to find solid answers to questions through well thought out experiments. We must never abandon this ideal for the generation of possible hypotheses and data that will "prove" or "disprove" a bit of knowledge,
However, unfortunately, we may be asked questions that we need answers to now and simply don't have the scientific information to answer the questions. It may be decades away.
You seem to be saying, the only thing worthy of discussion in that case is that which has been shown to be statistically valid. Everything else is wild speculation by do-dos who would rather speculate than cite evidence. If we turn to that kind of discussion we have the chaos of opinionated people and anyone can be right or wrong.
I say we have to do the best we can when science can't help us. There are better reasoned and worse reasoned, better observed and worse observed phenomena. Not being open to discussion that isn't based on solid science is a perversion of science's purpose, a one dimensional restraint on formulating the best answers you can come up with. As an example of this I don't understand what you don't understand when you say Dr. Frances is not citing evidence, is merely expressing an opinion.
>Perhaps a change in the rate of diagnosis of BP reflects greater accuracy in diagnostics. How would we go about testing this hypothesis?The "greater accuracy in diagnosis" is based on criteria his committee proposed! He's saying those criteria were mistaken and warning the creators of DSM V to not make the same mistake. Sure his DSM IV committees could have blundered into better criteria so that now we are discovering new and very real bipolar patients, but the burden of proof is on those refuting him. And it ain't gonna be answered by statistics..
Any way, the main point is you are depriving yourself of a rich source of important information and perspectives if you only considered statistically valid information. If we are talking about scientifically known information (e.g. penicillin treats a strept throat because it kills stretococcus) some one else' theory about Karma can be ignored. But if we are talking about the vast array of unanswered questions in psychiatry, the criteria is sensible or not sensible. Claiming the prestige of science is a false statement of validity and value when very little is scientifically known,
Put another way (quoting one of my articles) "Equally questionable is the use of DSM IV to dictate evidence based treatment, which implies unwarranted scientific validity. Given the choice between what is understood and proven through scientific method and what is, in essence , opinion or formulation, science should command absolute loyalty. But that doesnt mean that using a scientific format, or waving its banner, adds validity to those who speak as scientists. Its virtues can act as a smokescreen. The language, the prestige, the trappings of science can be so distracting that sciences core value is overshadowed, absolute clarity about what is known and not known."Those using the science paradigm to exclude interesting, (or possibly the best formulation for now) because it is unproven by strict statistical criteria are not speaking in the modesty of our shared ignorance. They are shouting down reasonable alternatives and claiming to be"experts" (a favorite self description and a term I find ludicrous given our state of knowledge)
Scientific curiosity and its method of validating ideas is a wonderful tool that has served us well. It is silly when used to stifle discussion and formulations
Posted by Lou Pilder on September 15, 2010, at 16:47:14
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 15, 2010, at 11:23:15
Friends,
If you are considering posting in this thread or parallel threads, I am requesting that you view the following video. If you could, I think that there couldbe more infomation in this thread that could be important in any future posts here.
Lou
To see thisd video:
A. pull up google
B. Typs in:
[Part 2 of 10 Psychiatry]
you will see a picture of a man and the time is 10 min posted on Jan 15, 2009
Posted by SLS on September 15, 2010, at 16:53:57
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 15, 2010, at 14:51:22
I'm not sure that either one of us knows where the other is coming from.
In any event, I would be curious to know what you think are the true rates of bipolar disorder for adults and pediatric, and how these compare to the current "overdiagnosis" rates you allude to.
- Scott
Posted by Simon Sobo, M.D. on September 15, 2010, at 17:09:09
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by SLS on September 15, 2010, at 16:53:57
I don't have the slightest idea what the true rate is. I base my opinion on a phenomenon that became obvious to me in my practice in New Milford CT. I was absolutely astonished by the number or people coming to me with a bipolar diagnosis from the hospital and other clinicians who were clearly not bipolar. I then started to write to other colleagues about their experience and they were seeing the same thing. I still think you should read some of my clinical material describing what was (and is) being called bipolar disorder. The writer from New York magazine that called me after reading my article and published her cover story "Are You Bipolar?" based on her experience and her friends' experience of being labelled bipolar is a further example. Many others called me including a noveliest who teaches writing at a good university whose son was labelled bipolar etc, etc etc.
As for the childhood diagnosis of bipolar I suggest you read some of the stories done by Benedict Carey in the New York Times or especially watch this story on Frontline on this subject http://www.pbs.org/wgbh/pages/frontline/medicatedchild/view/
If you are truly interested in this subject those are good place to begin. You will shocked by what is going on in my esteemed profession
> I'm not sure that either one of us knows where the other is coming from.
>
> In any event, I would be curious to know what you think are the true rates of bipolar disorder for adults and pediatric, and how these compare to the current "overdiagnosis" rates you allude to.
>
>
> - Scott
Posted by violette on September 15, 2010, at 18:42:44
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » violette, posted by SLS on September 15, 2010, at 10:15:52
Thanks for the info Scott..though I'm personally happy taking my doctor's word for it....
And to be frank, I'd rather see overdiagnosis of bipolar than people dx'd with personality disorders--dx that may not be covered by insurance or which can affect them for the rest of their life, ie employment, stigma..as long as they get the appropriate treatment.
If the overdiagnosis of bipolar is such a problem, doctors who revise the DSM could combine the axis i and ii if they wanted to. Any mental illness should be reimbursed-whether it's temporary traits or more permenant traits. I don't blame the doctors in the hospital for sometimes giving borderlines a bipolar dx and hope they continue to do so...to enable those who need intensive help to have access to treatments they may otherwise not have.
Posted by Phillipa on September 15, 2010, at 19:58:47
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 15, 2010, at 17:09:09
Very familiar with New Milford Ct being originally from CT any chance you know a pdoc from Wilton Dr Richard Hamilton as he was mine and wonderful. When I move to VA Beach area a psychiatrist I worked with labeled all his patients bipolar said they had been misdiagnosed if had another diagnosis. They were given lithium. He didn't go by lithium levels if they were low the patients response to them. Also quite a few Alchohoics received lithium and they looked relaxed in about two days. Now when I had pms and this was a very friendly and respected RN's greatly he would say dissolve small amount of lithium in a solution and drink and it would eliminate it. I'm really learning a lot from your posts and hope you stay awhile. Would love to here of Dr. Hamilton practiced in Norwalk Hospital. Phillipa a great doc in my opinion of course
Posted by emmanuel98 on September 15, 2010, at 20:10:25
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by violette on September 15, 2010, at 18:42:44
I have had very unstable moods. I get severely depressed, then snap out of it when I get busy. One psychiatrist I saw in a hospital suggested this was "hypomania" and I was bipolar 2. But there's a difference between hypomania (whatever the heck that is) and just feeling normal when busy. I think it's more likely that I have occasional bouts of atypical depression with mood reactivity and that I'm just moody. I don't get into hyper states, I just feel better sometimes.
To tell the truth, I don't even know what bipolar 2 is or how you would diagnose it. Hypomania is such a vague concept. Yet clinicians use it to justify mood stabilizers. My p-doc, who I also see for therapy refuses to diagnose me as having anything but recurrent depression.
Posted by Simon Sobo, M.D. on September 15, 2010, at 20:39:57
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by Phillipa on September 15, 2010, at 19:58:47
> Very familiar with New Milford Ct being originally from CT any chance you know a pdoc from Wilton Dr Richard Hamilton as he was mine and wonderful. When I move to VA Beach area a psychiatrist I worked with labeled all his patients bipolar said they had been misdiagnosed if had another diagnosis. They were given lithium. He didn't go by lithium levels if they were low the patients response to them. Also quite a few Alchohoics received lithium and they looked relaxed in about two days. Now when I had pms and this was a very friendly and respected RN's greatly he would say dissolve small amount of lithium in a solution and drink and it would eliminate it. I'm really learning a lot from your posts and hope you stay awhile. Would love to here of Dr. Hamilton practiced in Norwalk Hospital. Phillipa a great doc in my opinion of course>
Don't know the doctors you mentioned. I find the story about adding lithium for PMS fascinating. I don't have the balls to do something like that and I just can't bring myself to call it BP so it is "legitimate" to do it. I'm a real chicken. I criticize the mainstream for their obsession with diagnoses, and while I make a case for using meds for the particular psychological effect I think they have. and try to integrate that with what the patient seems to need regardless of diagnosi., It never occurred to me to use lithium that way. Perhaps that is because I don't really have a feel for what it does psychologically. I know it helps bipolar and sometimes unresponsive depressions but I just don't understand the psychological effects like I do SSRI and dopamine agonists
the real killer is that there is no journal where me and other clinicians of like mind could communicate their opinions and observations so that we might educate each other ( thereby helping patients with oriIginal sensible treatments.) The journals are all of the variety manifested by the other poster's point of view. It rules all of the journals. Like what numbers can you cite as "evidence." Otherwise there is nothing to talk about.
Frankly, I've given up. I tried to sell this point of view to the main journals, but they are locked tight in their paradigm. This is the first writing I've done in psychiatry in quite some time. I've turned to screenwriting. Now that is a very hard business to get a foot through the door. Anyone know someone?
As for posting here. It probably won't be long. My bluntness usually sets people off and pretty soon the squabbling begins. It's my fault as much as my critics. I could be nicer, but I am at an age where you start to get grumpy, or you don't have to make believe you are a goody goody person. I value frank talk more than nice nice talk. Like everyone else, however, I don't like where the frankness too easily leads. Useless "I am smarter than you" competitions. Later that night I can awake from a nightmare where I am a dummy. It really sucks
But thank you for appreciating my company. Believe it or not I like that as much as anyone else.
Posted by Simon Sobo, M.D. on September 15, 2010, at 20:49:36
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by emmanuel98 on September 15, 2010, at 20:10:25
Sounds right to me. The kind of quick change in mood you are talking about is exactly the nonsense an unpsychological psychiatrist would describe as a "mood swing" and be dead wrong. There are more and more psychiatrist thinking this way. It's pretty amazing watching my field be taken over by people with zero capacity for understanding human motivation.
If you are interested in what Bipolar 2 is and more relevantly, what it has mistakenly become, you might try some of my articles
Posted by Simon Sobo, M.D. on September 15, 2010, at 20:59:32
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by violette on September 15, 2010, at 18:42:44
Agree that making a diagnosis so insurance companies will reimburse is a legitimate strategy, but if so the patient should be told that is what is happening, so he doesn't believe he must take medication for his "chemical imbalance" that will be with him for life.
However you are wrong that bipolar is a good diagnosis from the point of view of getting insurance or employment opportunities
Posted by Phillipa on September 15, 2010, at 21:56:14
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 15, 2010, at 20:39:57
Oh I feel that there are quite a few people here that are interesting in your views. One thing I noticed and it stood out is when I reviewed all my floors patients labs for the day that a good majority had thyroid disorder. In what way do you see this or what do you feel it indicates. And if you like you can babblemail me . Which is private message. Simply click my posting name in blue and a screen for typing private mail appears. Your name is in black so yours is off. And when you get to the end of the message make sure you click at the bottom to send. I find your views fascinating. Thanks Phillipa
Posted by Simon Sobo, M.D. on September 16, 2010, at 5:34:09
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by Phillipa on September 15, 2010, at 21:56:14
If those lab results were from patients taking lithium it is not surprising at all. Hypothyroidism is a very common side effect of chronic lithium treatment. I check for it once a year. Thyroid abnormalities usually have major effects psychologically
> Oh I feel that there are quite a few people here that are interesting in your views. One thing I noticed and it stood out is when I reviewed all my floors patients labs for the day that a good majority had thyroid disorder. In what way do you see this or what do you feel it indicates. And if you like you can babblemail me . Which is private message. Simply click my posting name in blue and a screen for typing private mail appears. Your name is in black so yours is off. And when you get to the end of the message make sure you click at the bottom to send. I find your views fascinating. Thanks Phillipa
Posted by Simon Sobo, M.D. on September 16, 2010, at 5:58:44
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Conundrum, posted by SLS on September 14, 2010, at 8:15:16
Response to a medication is not, repeat is not, diagnostic, of anything. Much of the discussion here is based on that mistaken assumption. When I was beginning practice it was not unusual to treat panic and high anxiety patients with "major tranquilizers" The "minor tranquilizers" were the benzodiazipines. This stopped when it became clear that tardive dyskinesia was a real problem. Then suddenly drugs like Thorazine and Haldol were being called "anti-psychotics" as if that is all they did. Thorazine was originally a preanesthetic calming agent until some one thought of using it in psychiatry, The newer atypical neuroleptics didn't cause anywhere near as much tardive dyskinesia so they began to be used more and more in non psychotic conditions.
I disagree with your doc's assessment that if you use a "mood stabilizer" it will help with mood instability. I suggest you take a look at my discussion of this very point in my article "Mood Stabilizers and Mood Swings: In Search of a Definition" http://www.psychiatrictimes.com/mood-disorders/content/article/10168/54226
Mood stabilizer is a real sloppy term that seems to be applied whenever an anti manic drug is found. In my opinion SSRIs, when they work, are damn good mood stabilizers, in the sense that term has been commonly applied, when given to a non manic patient
> > My pdoc has recently suspected I have issues with mood stability. I'm not sure it fits. I haven't responded well to lamictal or abilify, except that abilify seems to work like a cup of coffee for a few days and then stops. I'm not sure the lamictal has done anything at all and I am on 400mgs now.
>
> I was on Lamictal 300mg for quite awhile. It produced unacceptable cognitive impairments. When I first reduced the dosage to 200mg, I experienced an increase in the severity of depression for two days, and then stabilized. Similarly, I have recently reduced to 100mg with the same outcome. I feel no better at 100mg than I did at 300mg. I think people are fooled into raising the dosage when they experience transient improvements upon each dosage increase.
>
> > I'm guessing my suspected diagnosis will change since those meds didn't work and higher doses of abilify made me feel worse.
>
> That's disheartening. In what ways did Abilify make you feel worse?
>
>
> - Scott
Posted by SLS on September 16, 2010, at 6:11:01
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by violette on September 15, 2010, at 18:42:44
> Thanks for the info Scott..though I'm personally happy taking my doctor's word for it....
I think the DSM is woefully inadequate and just short of comical when it comes to describing Axis I disorders. I am not very knowledgable about Axis II disorders.
- Scott
Posted by ed_uk2010 on September 16, 2010, at 13:40:54
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 15, 2010, at 17:09:09
>I don't have the slightest idea what the true rate is.
Neither do I. Although I don't have any evidence, I get the distinct impression from this website that Bipolar II has become a catch all diagnosis for a wide variety of mood disorders. It seems to include a lot of patients who would have (in years gone by) received diagnoses such as agitated depression, treatment-resistant depression, recurrent depression etc.
I've also noticed that there seems to be a tendency to diagnose antidepressant adverse reactions (or lack of response) as being due to bipolar disorder eg. if an SSRI causes agitation/anxiety, it must be bipolar.
Posted by Simon Sobo, M.D. on September 16, 2010, at 13:59:26
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by ed_uk2010 on September 16, 2010, at 13:40:54
At least in children DSM V is specifically designating an entity for grouchy, agitated kids, so they can no longer be thrown into the bipolar waste basket and given antipsychotics.
As for agitated depression, treatment-resistant depression and the like some of them may indeed become manic depression, but it is far too glib to automatically diagnose them bipolar rather than be alert to the possibility.
Posted by SLS on September 16, 2010, at 14:52:52
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by ed_uk2010 on September 16, 2010, at 13:40:54
> >I don't have the slightest idea what the true rate is.
>
> Neither do I.Not the slightest idea?
Most of the older literature suggests that the rate of incidence of bipolar disorder is between 1% and 1.5%. More recent quotes go as high as 3%.
- Scott
Posted by ed_uk2010 on September 16, 2010, at 15:20:20
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 15, 2010, at 20:39:57
>As for posting here. It probably won't be long.
That's a shame. It's always good to hear from new people who have something interesting to say.
Posted by Tomatheus on September 16, 2010, at 18:28:34
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 16, 2010, at 5:58:44
> In my opinion SSRIs, when they work, are damn good mood stabilizers, in the sense that term has been commonly applied, when given to a non manic patientMaybe for some patients. I actually experienced a destabilizing of mood on the SSRIs Paxil and Prozac even though I had never experienced any mania or hypomania up to that point. I've also never experienced any mania or hypomania on Wellbutrin or the MAOIs. So, for me, inhibiting the reuptake of serotonin seems to be the *only* thing that does bring on hypomania and rapid cycling, and I find it hard to believe that SSRIs could be considered to be effective "mood stabilizers" (since they do the opposite to me).
Tomatheus
Posted by Phillipa on September 16, 2010, at 20:16:43
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers?, posted by Simon Sobo, M.D. on September 16, 2010, at 5:34:09
No this was a different hospital and docs and we treated all diagnosis's from depression, schizophrenia, bipolar, even substance abuse. I also was in charge here. And from personal experience I know the thyroid effects mood as now mine is hasimotos not caused by a med autoimmune. Also we did not use TCA's nor MAOI's. Klonopin was the drug of choice at the time for anxiety. When I had my first panic attack and it was bad ended up on miltown 400mg and valium 5mg TID. Also three beers a night. Now this was before nursing and felt great after a while so just discontinued the miltown. Never had a withdrawal effect wonder why? Now I'm 64 still on low doses of benzos but don't take during day. And they really don't work anymore. Also lost sense of taste and smell 7 years ago MRI tomorrow got to find out one last ditch attempt if a physical reason. Thanks for answering. And don't leave. Phillipa
Posted by Lou Pilder on September 16, 2010, at 20:18:16
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by Tomatheus on September 16, 2010, at 18:28:34
Friends,
'' If anyone suggests to you to take Paxil, I am requesting that you view the folloing video.
Lou
To see this video,
A. pulll up google
B. Type in:
[youtube, Paxil deaths]
You wll see a frame with writing on it.It was posted by dixiefd64
Posted by Lou Pilder on September 16, 2010, at 20:51:44
In reply to Lou's request-psiehmhunpsez, posted by Lou Pilder on September 16, 2010, at 20:18:16
Friends,
If anyone suggests that you take an SSRI, I am requesting that you viewthe following video..
Lou
To view this video;
A. pull up google
B. Type in:
[youtube, Ex-Parmaceutical Rep]
you will see a picture of a lady and the time is 9 min and the date is April 25, 2007
Posted by Simon Sobo, M.D. on September 16, 2010, at 21:26:19
In reply to Re: hrguru - Re: Anti-psychotics not mood stabilizers? » Simon Sobo, M.D., posted by Tomatheus on September 16, 2010, at 18:28:34
Sorry, I guess my statement about SSRIs was confusing. I didn't mean it is a mood stabilizer for bipolar patients. I meant that for non-bipolar excitable patients they often calm down the intensity of emotions. I call them the well whatever drugs. Sorry for the confusion
Posted by Lou Pilder on September 16, 2010, at 21:27:10
In reply to Lou's request-psiehmhunpsezesesariez, posted by Lou Pilder on September 16, 2010, at 20:51:44
Friends,
If you have been told to taske an SSRI, I am requesting that you view the following video.
Lou
To see this video,
Pull up google
B: Type in;
[youtube, SSRIs-song from the "reason"
you will see a red picture and was posted on Jan 15, 2009 and is 4 min
Posted by Phillipa on September 16, 2010, at 21:44:04
In reply to Lou's request-psiehmhunpsezmewdpstahybulizr, posted by Lou Pilder on September 16, 2010, at 21:27:10
Lou have taken SSRI's for years and paxil at l0mg worked well. So I didn't die it worked quite well for me. Did you have a bad experience with SSRI's . If so sorry. Phillipa
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