Sunday, 9 March 2014

New Consensus on Antidepressants in Bipolar

The International Society for Bipolar Disorders recently released the findings of a task force on the use of antidepressants in Bipolar Disorder. The evidence continues to accumulate that antidepressants alone and in combination with mood stabilizers have a very small role if any, in the pharmacological management of bipolar depression. There is increasing acknowledgement that antidepressants can be harmful. Antidepressants can lead to longterm mood instability, cycle acceleration, mood switching, mixed states and increased risk of suicide.

The results summary of the task force appears quite clear:

"There is striking incongruity between the wide use of and the weak evidence base for the  
efficacy and  safety of antidepressant drugs in bipolar disorder. 
Few well-designed, long-term trials of prophylactic benefits have been 
conducted, and there is insufficient evidence for treatment benefits with  
antidepressants combined with mood stabilizers. A major concern is 
the risk for mood switch to hypomania, mania, and mixed states..."

However the conclusion summary is a little more ambiguous:

"Because of limited data, the task force could not
make broad statements endorsing antidepressant use but acknowledged 
that individual bipolar patients may benefit from antidepressants...."
Undoubtedly this was the result of the need to reach 
consensus among several dozen international experts.It remains very difficult for some psychiatrists to 
concede that antidepressants do more harm than 
good because this is superficially counterintuitive. It is also hard to admit that one's longstanding clinical 
practice may have been erroneous.


The International Society for Bipolar Disorders (ISBD) task force report on
antidepressant use in bipolar disorders.

Am J Psychiatry. 2013 Nov 1;170(11):1249-62

Monday, 27 January 2014


1. Reduce the fear of difference

2. Provide education about mental health and mental illness in the schools.

3. Encourage those affected by mental illness to go public, especially celebrities and high profile individuals who can make an impact on public opinion.

4. Appoint individuals who have experienced mental illness to boards of hospitals, community agencies and mental health programs.

5. Challenge the media. Write to editor's, call television stations and comment on social media when there are inappropriate references or stigmatizing portrayals of people with mental illness.

6. Promote the restoration of the person's wholeness, subjectively and objectively, by facilitating their multiple roles, emphasizing that the person is not an illness but has an illness.

Sunday, 19 January 2014


One of the most damaging effects of psychiatric illness is the experience of stigma. Stigmatization is the social rejection of those with mental illness. This may be seen in the tendency to ridicule or shun those with mental illness. It is seen in employment discrimination and in the derogatory language that is pervasive among many in society.
"Stigma" is a Greek word that once referred to the bodily signs that were used to show that there was something morally wrong with the person so marked. These signs were made by cuts or burns and indicated that the person was a slave, a criminal or a traitor.....a blemished person to be avoided. The numbers tattooed on the arms of concentration camp inmates by the Nazis and the yellow stars Jews were forced to wear are examples from more recent history.
Stigmatization induces feelings of anxiety, insecurity, shame and even self-hatred. Self-hatred is the result of internalizing the attitudes of others. Every new situation every new encounter brings with it the anxiety of not knowing whether one will be accepted, rejected or shamed.
Stigmatization is reinforced by distorted representations of individuals with mental illness in the media. Newspaper accounts are often sensationalist. Many false stereotypes appear in movies and television shows which often demean or mock those with mental illness.
This stigmatization is often extended to families, counselors and psychiatrists. The stigma associated with mental illness is so widespread that we have trouble agreeing on terminology to describe it. We use multiple euphemisms. What is the most reliable term to describe the distress and impact experienced by individuals with mental illness? Mental health issues, mental illness, psychiatric disorder, psychiatric illness?
In an attempt to reduce stigma many prefer the vaguer and more dilute term "mental health issues". The problem with this term is that it trivializes the problem and does not convey the seriousness and enormity of some of these conditions.  Could you imagine a surgeon telling a patient with a fractured spine that he has "back issues".

The basis for stigma is fear.

This fear is the fear of difference, the fear of contagion, the fear of vulnerability.
Fear of differences exists in all societies and shows itself in many forms such as racism, anti-Semitism, homophobia etc. Fear of strangers is an evolutionary survival mechanism. It is the fundamental component of attachment behavior where the newborn infant instinctively attaches to its mother. This is to protect the infant from hostile predators and strangers. For many people this basic process may go wrong and they grow up lacking a sense of secure attachment. They experience heightened levels of anxiety and fear when they encounter something that is strange or different. This makes them prone to display prejudice and discrimination. They are  threatened by people who are in some way different from themselves. People who are more securely attached are much more receptive and open to others and able to establish more varied relationships.
 Stigma also derives from the fear of "contagion". The fear of contagion is the fear of catching a disease, particularly if the disease is incurable. One of the greatest historical examples of this was leprosy. Those with leprosy were cast out and isolated from society. There were similar attitudes towards those with AIDS. This has lessened as the treatment for AIDS has become so successful.
The fear of contagion is unconsciously and irrationally extended to psychiatric illness and leads to ostracization and isolation of those with the illness. This is based on the defensive reasoning of "out of sight, out of mind". What this attitude amounts to is really a denial that we are all vulnerable to illness of one kind or another and that this is part of the human condition that unites us rather than separates us.
The act of stigmatizing gives the individual a false sense of superiority or immunity. It is seen in openly hostile attitudes, derogatory humor, avoidance and ridicule.
Stigma involves regarding the person as an illness rather than as a human being with multiple roles and characteristics.
Blaming the individual with the illness for having the illness is the way that people attempt to delude themselves that they are immune.
The truth is that mental illness is no different in any way from physical illness. Mental illness has nothing to do with intelligence, character or moral integrity. It does not result because of our failings of deficiencies; it is not a punishment for our sins. Anyone, repeat anyone can become mentally ill, including your mother or father, bather or sister, husband or wife, son or daughter, and yes, you and me.

Sunday, 5 January 2014


Regarded as one of the greatest novels of all time, James Joyce's Ulysses is a vastly complex, multi-layered and interwoven adventure.  Joyce adapted  the major events of Homer's Odyssey to provide the overall structure of the novel. Each chapter roughly corresponds to a chapter in the Homeric myth. However within each chapter there are multi-levels of symbolism, stylistic trickery, artistic allusions and references to contemporary and historic events.
The central plot in the novel is Leopold Bloom's journey through Dublin on June 16th 1904. Leaving home and then finally returning late at night after multiple rollicking and human encounters. This parallels the journey of Odysseus/Ulysses as he returns from Troy to his waiting wife Penelope.  Bloom is returning to his wife Molly.
Within this lofty environment is set the more mundane and poignant theme of Leopold's relationship with his wife Molly. Leopold is well aware that Molly is having an extramarital relationship and that on that very day an assignation has been arranged for 4 o'clock.  A potent historic reference is to Charles Stuart Parnell the great Irish Nationalist Politician brought down by his affair with a married woman.
Stripping away the multiple layers of symbolism and literally thousands of references the essence of the story of Joyce's Ulysses is the relationship between Leopold and Molly Bloom. If we take a brief clinical history we have the narrative of a not so successful middle-aged man. He pursues a pedestrian low status occupation as an advertising salesman for a newspaper. He is a man with curiosity and interest in science and the arts but with limited grasp and intellectual depth. A man who nevertheless appears generous and kind in his dealings with others, who attempts to maintain a reasonable level of civility and politeness. A man with a lively sexual imagination but of questionable potency.
Bloom is very conscious of being a Jew by inheritance although fully aware of his father's conversion to Protestantism. He is always regarded as a Jew by others and is perceived as an outsider who does not belong fully in Irish society. Bloom was disappointed in his own father and yet could never have a son of his own. He has never gotten over the death of his son Rudy 11 days following birth. In fact he and Molly had not had sexual intercourse since that time. Bloom is somewhat of a romantic and a  poet in temperament if not in level of artistry. His sexual desires are still in play and achieve some release in flirtatiousness, masturbation, and a visit to Dublin's Nighttown.
Molly on the other hand is a red-blooded, full figured woman of arresting good looks and multiple admirers. She has had many loves and losses and indeed Bloom may have been somewhat of a compromise husband in his benign non-threatening and warm-hearted sentimentalism.  From an attachment perspective we can say that Molly and Leopold had achieved a level of companionate love but their relationship is now fraught with sadness, loss and economic disappointment.
Molly is frustrated and perhaps quite resentful of the distance and lack of sexual relationship between her and Leopold in the years since Rudy's death. Consequently she has fallen into a liaison with the vigorously named, hot blooded and well endowed " Blazes Boylan". This relationship although sexually extremely fulfilling is marred by Boylan's crudity and vulgarity.
Molly and Leopold have a teenage daughter Millicent (Milly) who is beginning to emerge as a young woman and has struck up with a boyfriend. This provokes the normal fatherly apprehensions within Leopold but also stirs up some unconscious reverse Oedipal rivalries between Milly and her daughter.
Bloom looks to Stephen Daedalus as a surrogate son. Stephen is a very introspective, philosophical and artistic young man who also represents Joyce himself. Stephen like Joyce is highly conflicted and confused about his feelings towards the Catholic Church and theology in general. He is guilt ridden about the way he handled his own mother's death refusing to grant her dying wish to pray with her.
Stephen's inner turmoil  seems to be reflected in his dissolute ways his heavy drinking companions and his debauchery.
Molly also has fantasies about Stephen but these quickly deteriorate from maternal nurturance to sexual desire.
Joyce tried to manufacture in Bloom a universal figure who resonates with Ulysses, Christ, Shakespeare, Moses, Irish Nationalist politicians and heroes in terms of a universal journey of departure and return. Journeys of birth, death and resurrection. Journeys that reflect intrapsychic maturation and unconscious conflict.
A major theme revolves around the fact that Leopold Bloom is identified as a Jew and a father who has lost a son. There are multiple portrayals of Bloom as a Christ figure with reference to the Christian theology of the Trinity and in particular the co-identity of the father and the son. The character of Stephen Dedalus represents Joyce as a young man while Bloom corresponds to an older Joyce. At times the two characters become blurred and merged. Joyce makes an interesting correspondence with Joyce/Bloom/ Stephen and Hamlet, Hamlet's father the murdered King and the ultimate father who is Shakespeare himself.
In attachment terms Bloom departs from his secure home base on the morning of June 16th 1904  and sets off on an exploration of the riotous and chaotic Dublin environment encountering various temptations and dangers along the way. These dangers include sexual allurements as well as the real potential for physical assault. He eventually reaches home very late the next morning tired, weary and chastened, to return once again to the warmth of the matrimonial bed and the psychological embrace of the universal Earth mother Molly Marion Bloom.
The book ends with a great climactic declaration, the end of a long reverie by Molly. It appears that Molly and Leopold will stay together even though the inherent dissatisfactions, regrets and unfulfilled longings have not been resolved. The future is by no means certain or safe for James Joyce is no conventional novelist.

Sunday, 24 November 2013



The release of the DSM 5 in May 2013 unleashed a storm of controversy. Initially there was a great deal of disappointment that DSM 5 was essentially the same as DSM-IV with only modest changes. The changes were largely of a housekeeping nature: reordering, repositioning and making  some adjustments to diagnostic criteria.

Criticisms have come from two directions: on the "left" groups that place more emphasis on psychosocial factors in understanding and treating psychiatric illness. These groups have decried the biological reductionism of DSM. On the "right" the reverse criticism has been made i.e.  that there is inadequate incorporation of new findings from neuroscience.

One of the principal critiques of the Diagnostic and Statistical Manual is that it is based purely on an objective descriptive approach. This approach has been referred as a neo-Kraepelinian system in recognition of the pioneering work of Emile Kraepelin whose painstaking observations led to the early delineation of psychiatric syndromes.

This approach began with DSM-III and did achieve one of its principal goals of improving the reliability of psychiatric diagnosis. However the validity of the DSM categories has remained problematic.

Interrater reliability among the DSM 5 categories is extremely variable. For example there is good reliability for the diagnoses of  PTSD, bipolar 1 and binge eating disorder. There is very poor interrater reliability for major depressive disorder, generalized anxiety disorder and antisocial personality disorder.

The DSM system has also led to major problems with so-called comorbidity. Because of overlapping diagnostic criteria many patients are diagnosed with multiple disorders. For example a patient who meets criteria for PTSD may quite readily also meet criteria for major depression/dysthymia/borderline personality disorder. In reality the patient may have only one underlying condition when identified at the neurobiological level. The existence of false comorbidity makes prediction of treatment effects erratic and undermines the validity of research studies.

Have we advanced sufficiently in our understanding of the neurobiology of psychiatric disorders and childhood development to construct a new paradigm?

I believe that we have and I have proposed that the new paradigm could be based on two foundational sciences: affective neuroscience and attachment theory.

Jaak Panksepp pioneered affective neuroscience and identified seven basic emotional systems within the mammalian brain. He has elucidated the key brain regions and neural circuits involved in the generation of emotional states. This system can form the basis for a new classification of psychiatric disorders. Attachment theory provides the social and interpersonal context for understanding human psychology and psychiatric disorder.

The combination of these two models could provide a comprehensive and heuristic paradigm for the future practice of psychiatry and psychology.


Eppel A: Paradigms Lost and the Structure of Psychiatric Revolutions in Australian & New Zealand Journal of Psychiatry Volume 47 Issue 11, November 2013 p.992-994