1 Boring Old Man

One key to their strategy was to reduce mental illness to a simple set of symptoms and behaviors to get primary care physicians comfortable treating major mental illnesses:

“Cindy is a 23 year old law student who presents with “chronic depression” and anxiety.  Believing her problems began in her late teens, she says she can’t remember the last time she felt good.  Medical history negative, but has been prescribed several antidepressants in the past without benefit. She reports that most of the medications did nothing at all, but 2 of them made her feel “jumpy, panicky and sleepless” Psychiatric family history:  Maternal grandfather was an alcoholic; her mother has been diagnosed as dysthymic and is in long-term psychotherapy with a social worker.”

“At PCP visit, she complains of sadness, lack of sustained interest in anything, insomnia and several vague physical complaints.  She also reports being easily distracted at school, irritable, unable to sit still and has racing thoughts.  She says she has been unable to complete class assignments and her grades are slipping.  What is your diagnosis?”

“Diagnosis of dysthymic disorder is made, and she is started on an antidepressant.  Within 4 days she becomes very anxious, agitated and hyperactive, with pressured speech and racing thoughts.  Now diagnosis of antidepressant exacerbation of mixed-symptom state to full blown mania is made.  Patient begins taking ZYPREXA (olanzapine) 10 mg qhs and within one week she reports significant improvement.”

Sound familiar? Even in this made up case, this would be a reaction to the SSRI until proved otherwise. Notice that this is mania without mania [euphoria, grandiosity], and ask a manic patient about anxiety and you get "No, I feel great! Are you anxious?" This line is pursued in case after case. They’re encouraging doctors to treat reactions to SSRIs as if they are manic attacks – blatantly. I’ve seen some of these reactions to SSRIs and heard about a lot more from patients. They usually come on quickly and clear when the medicine is stopped. I don’t know if true mania can be precipitated by SSRIs. I’ve never seen that happen, but it’s certainly reported and spoken about. A key point to me is that the SSRI reactions are ego-dystonic [unwanted, frightening] while mania is ego-syntonic [fine, from the patient’s perspective].[UPDATE: Manic patients are brought. I’ve never personally seen a manic patient who came in complaining of anything, except about being brought].

So back to the case I was asked about [ask them about their lives…]. That young man got Depakote + Abilify for his "Bipolar" – definitely diagnosed by the anti-depressant  reaction. The psychiatrist was on the Eli Lilly speaker’s bureau program and may or may not have been schooled in the use of those fictitious cases. But he used Abilify, another Atypical Antipsychotic rather than Zyprexa. I’d surmise that this is an example of the generalization of some drug company hype into the general psychiatric schema. And on another note, I wondered about the Pristiq the patient was on. In a later conversation with his mother, I asked about it and found that the dose of Pristiq had recently been lowered abruptly after they questioned the number of drugs he was on. Withdrawal now becomes another suspect in his recent escalation of symptoms [Yes, the later phone call was referring them elsewhere].

^{[to silent santa]}