Mood Swings

The psychiatric wisdom of John Kenneth Galbraith

Dr. Nassir Ghaemi — Sun, 07 Feb 2010 20:46:15 +0000

I've been reading a lot of John Kenneth Galbraith recently. Galbraith, the economist and Kennedy confidante, died a few years ago at a ripe age, soon thereafter followed by his right-wing opponent and friend William Buckley. It seems to me that in the age of the talking heads, we have no one even approaching the stature of Galbraith or Buckley, on either left or right. So I went back to Galbraith's memoirs and essays and found myself wishing to turn the clock back 40 years to enjoy his company in person. Here we had an economist who was also an expert observer of human psychology, perhaps because, if one reads his memoirs carefully, he was treated psychiatrically himself for manic-depressive illness.

Here are some Galbraithian insights, some of which are paraphrased, mostly from his memoirs:

On the no business meeting: "Meetings are held because men seek companionship, or, at a minimum, wish to escape the tedium of solitary duties. They yearn for the prestige which accrues to the man who presides over meetings, and this leads them to convoke assemblages over which they can preside. Finally, there is the meeting which is called not because there is business to be done, but because it is necessary to create the impression that business is being done. Such meetings are more than a substitute for action. They are widely regarded as action...."

On self-pride:

"Nearly all of my colleagues and professional acquaintances, after conceding my affirmative qualifications, said that I had an unduly well-developed view of my own intellectual excellence....Years later when Newsweek wrote about me, JFK asked what I thought of it; I said I thought it was fine but I didn't see why they had to call me arrogant. I don't see why not, said the President, everybody else does."

"People in the world can be classified by the maximum length of time their thoughts are diverted from themselves."

On academics, politics, and truth:

"All academic disciplines have their feuds - intense conflicts much cherished by their participants and regularly combining differences in scholarly method or conclusion with deep personal dislike."

"With their salaries slipping, economics professors often seek outside income, and one obvious place of resort is the big corporation....Most sell out for a shockingly low sum, not being aware that a reputation can be sold only once or twice."

"Both scholarly and political life require criticism of others and invite attack or reprisal. Anyone who is initiating combat should, as a matter of elementary caution, gauge the extent and severity of the probable reaction and consider his defense. If attacked, he should promptly and strongly respond. This is vital. In the past it has been possible to attack academic people with impunity, for they are thought unlikely to react in a dangerous way. Their rule is to remain silent, ‘not to stir up the animals.' This is most unwise; a demonstrated capacity for reprisal serves valuably as a deterrent."

"A professor is judged by his or her peers. These are omnipresent, always looking for scholarly competence and perception, or, more poignantly, their absence. So even a full professor...must always stand at attention....From this heightened sensitivity to scrutinizing peers comes a certain dulling of personality. No one can now afford to seem eccentric. Nor is the judgment above reproach. Professors considering and selecting others for promotion define excellence, perhaps inevitably, as that quality of mind and work that most resembles their own."

"The experience of being disastrously wrong is salutary; no economist should be denied it, and not many are. The best, most elegant and most applauded designs can fail, and greatly to your surprise if, in persuading others of their excellence, you have persuaded yourself."

"Scholarship in the social sciences is assessed by its depth and precision but also by the length of time it has required. A quickly completed job, regardless of quality, is bad. A five-year effort is good per se. A lifetime work, not quite finished at death, is superb."
'.

Iran: Psychiatric reflections

Dr. Nassir Ghaemi — Mon, 01 Feb 2010 03:06:37 +0000

And what of Iran? So I am asked not infrequently. I have not known what to say, because there is so much one could say. Almost anything one says would make someone angry. I've also noticed that, while psychiatry itself is a controversial topic, producing strong emotions, and sometimes harsh judgments, it pales in comparison to politics. To combine the two has been, I have found, a not always heartening experience. Nonetheless, my main criterion for writing a post for this blog is that I have something to say.

Many Iranians abroad, and some inside Iran, are extremely angry at the Iranian regime; many Americans also remain extremely rageful at Iran, holding grudges that date back to 53 hostages from 1979. All this acrimony, now mixed in the US with fear of terrorism and revenge feelings after 9/11, produces much confusion and little wisdom. So, if I may, as an Iranian and a psychiatrist, I will venture a few words.

There are those Iranians in America, and many Americans, who want to see events there as a matter of good versus bad; the US should support democracy, they say, and oppose the Iranian regime, loudly. Another Iranian revolution is their wish. There are others, more Americans perhaps than US-based Iranians, who are tired of more and more conflict: Hands off Iran, they say; let's not start another drumbeat that leads to a third American invasion of the Middle East. The Iranian regime should be reformed, they believe, but less conflict, not more, is the preferable path to such change.

It is hard for many Iranians, in Iran or the US, to be sober-minded. Every Iranian family, mine included, has suffered from politics in Iran - through the deaths of relatives, exile, loss of home, careers, livelihoods. Politics for Iranians is not a theoretical exercise; perhaps only families of US soldiers in today's wars can appreciate the reality: it is a painful experience. And pain produces the two equally sterile extremes of rage and indifference.

I have seen and felt enough of this pain to be cautious about asking for more. Iran has had three revolutions in the last century, about one every two generations (the Constitutional Revolution of 1905-1911, the Mossadegh oil nationalization movement of 1951-53, and the Islamic revolution of 1979). The current unrest comes right on schedule. But what has all this conflict produced? The first Constitutional revolution ended in a new autocratic monarchy; the Mossadegh movement, crushed by the CIA, led to a second autocracy; the Islamic revolution became radicalized after the US supported Saddam Hussein (we will ignore here the obvious irony) in the 1980s war with Iraq.

All this action and reaction makes me think of the wisdom of Lord Acton: the purpose of revolution, he said, is prevention of revolution. If revolutions fail to produce a society which can manage its needs without more revolution, something is wrong.

This is why I sympathize with those who think the US should either just keep out of Iran's affairs, or, preferably, should fully engage in a constructive way with Iran's government and people. Rhetoric and threat is useless at best and harmful at worst. Preaching about democracy will not help; after the CIA coup of the 1950s and the Iraq war of the 1980s, most Iranians don't trust American preaching. If we can engage in multibillion dollar commerce with communist China, we ought to be able to at least handle tourist visas with Iran. The case for engagement has been well made recently by Stephen Kinzer, the author of a best-selling history of the US coup d'etat against Iran's last democracy.

On a recent trip to the Persian Gulf, I came across an article about a conference in which a Pakistani engineer, reflecting on Pakistan's chronic instability, argued that the problem in the Middle East was that politics receives too much attention. There is not enough focus on creating jobs, running businesses, doing scientific research. If every Pakistani put all his or her effort into creating five jobs, instead of debating about politics, the country would be better off, he said. I would add: The point of politics is nothing messianic; it is to let people lead normal lives, to raise their children, live comfortably, have leisure time, attend sporting events, visit neighbors and friends. If all this is sacrificed in the name of some idea - whether it be called democracy or monarchy or revolution - one wonders whether it is worth it.

There are solutions. There was once a country ruled for centuries by autocratic kings and religious extremists, one controlled despotically as recently as the 1970s, and now a stable democracy (albeit with a constitutional monarchy): Spain. The history of Spain in the 19th and early to mid 20th centuries is like the current history of Iran and Pakistan and much of the Middle East. After much pain, Spain evolved, or was allowed to evolve, to where it is. Of course it helps if one's neighbors are France and England rather than Russia, Iraq, and Afghanistan. But the principle is there: A nation with much religious and civil discord - if, in part, left alone, and, in part, economically and politically helped by its neighbors- was able to gradually progress to a society where life can be about living, not surviving.

It is easy to speak in abstractions: democracy, revolution, imperialism. But these ideas do not do justice to the complexity of what is real; they do not meet the simple needs of simple lives. We contemplate our ideas in the sunlight of heaven, said Acton, and apply them in the darkness of earth.

What's the matter with Massachusetts?

Dr. Nassir Ghaemi — Sat, 23 Jan 2010 17:33:31 +0000

I'm sitting in the John F. Kennedy Library and Museum, looking out at the deep blue waters of Boston Harbor - an ironic place to muse on why this state voted for a Republican to replace the late Senator Ted Kennedy, and thereby practically ruin his beloved health care reform.

I hear all the Democratic leaders refusing to point fingers or lay blame. Civility, while praiseworthy, should not justify denial. We need to tell the truth. The whole country is affected by what happened, and they deserve an explanation.

A few elections ago, when the American people - actually mainly those who lived in the Midwest heartland and the South - inexplicably re-elected George W. Bush, some asked What's the matter with Kansas? Many concluded that Democrats needed to appeal to the electorate on cultural values, or, as psychologist Drew Westen put it in his smart book, emphasize that voters behave based on emotion primarily, not reason; they ask: would I have a beer with him? Not: Do I agree with him on the issues?

In 2008, Democrats in general, and Obama in particular, seemed to have learned these lessons. How soon we forget.

Scott Brown and the Republicans did not win the Massachusetts race; Martha Coakley and the Democrats lost it. When the special election was called in September, Democrats initially waited to see if Joe Kennedy would take his uncle's mantle. (In retrospect he should have; but apparently he got scared away by some Boston Globe articles tying his non profit heating oil company to Hugo Chavez). Then Democrats waited to see if senior politicians would come forward; none did. (The dean of the Congressional delegation, the highly respected and charismatic Edward Markey, said he could do more for the state and the country as a senior congressman than as the most junior member of the senate. And that reasoning made sense at the time!) Only Attorney General Coakley came forward, a mid-level state bureaucrat with the charisma of a door-pin. Lunchbucket Democrat congressman Stephen Lynch thought about it but begged off when he could not secure full union endorsements, already locked up by Coakley and another working class liberal democrat, Mike Capuano (holder of the Cambridge-based House seat of Joe Kennedy and Tip O'Neill and John Kennedy). Two other political unknowns joined the race (a founder of the City Year volunteer corps; and a co-owner of the Boston Celtics). In repeated debates, Coakley avoided answers and remained as boring as possible, while the other three men avoided any appearance of being sexist by hardly criticizing her. "I'm glad I'm a girl," Coakley and her followers sang at one event. Political correctness won out, and the few voters who went to the primary either voted for a name they recognized (either Coakley or Capuano), or they voted for the frontrunner (Coakley), or they voted for a chance for a female Senator.

We were all to blame. The Massachusetts Democratic Party, and democrats like me, all assumed that Coakley would now win. We forgot that this "safe" Kennedy seat had been Republican for a century until JFK won it, barely, in 1952. In fact, this seat has been democratic only when held by a Kennedy, dating from now back to the Civil War. When JFK ran for president, he barely won Massachusetts, and he lost his native Cape Cod to Nixon. Massachusetts has had mostly Republican governors for the past 20 years. Massachusetts is not a purely Democratic state.

But perhaps the emotion surrounding the death of Ted Kennedy swayed us too much. We forgot that there were plenty of people in Massachusetts who would vote Republican in the right circumstances.

Time was short. In only three months, a campaign for the nomination had begun and ended. About two months were left before the general election; it was early December. Scott Brown had been basically unopposed, campaigning hard for months, and now he turned it up; advertisements went on the air, comparing his tax cut policy to JFK (as well as his visual photogenicity); he went on every radio news and sports talk show (most of which are conservative, even in Massachusetts), showed up and shook hands at the Fenway Park Winter Classic Boston Bruins hockey game (a huge event), and was, in short, everywhere. In his TV ads, he was seen driving around the state in his pickup truck, logging 200,000 miles. Coakley had no ads. She took a two week vacation over Christmas and the New Year. By early January, when the polls began to show some strength for Brown, she only had 2 weeks left before the election.

She went to Washington DC and asked for money from the DNC.

She did not go to the Boston Common and ask for votes. She did not campaign.

In 1952, when JFK initially won this seat, he put up a map of the state, and put pins in each place he visited, and, over a number of years, made sure he visited every hamlet in Massachusetts at least twice, agreeing to go on any occasion, whether it be a Rotary club meeting or an elementary school event. (All this despite his father's money; he still barely won). In 1994, when Ted Kennedy faced his only serious race versus Mitt Romney, I was a door to door volunteer for Kennedy, and I saw him campaigning heavy and hard throughout the state for about a year.

John and Ted Kennedy worked hard to get and keep this Senate seat. Martha Coakley hardly worked.

There is an old story from Tip O'Neill. In his first Congressional election, he campaigned all over Cambridge and worked hard, but he found out that his next door neighbor, an elderly woman, had said she would not vote for him. He went to her house and said, to paraphrase, Mrs. Finley, you've known me all my life; I shoveled your driveway, mowed your lawn, delivered your paper, beginning when I was 10 years old. Why aren't you going to vote for me? Tommy, she answered; you never asked me.

Always ask someone for their vote, Tip O'Neill concluded. The voters want to be asked. We don't like to be taken for granted. We are, as the incomparable Boston Globe columnist Brian McGrory wrote in a post-election column, like a date at a dance; if you ignore us, we'll start dirty dancing with the handsome fellow winking from the bar.

Coakley did not ask anyone for their vote, until it was too late. She deserved to lose, according to Tip O'Neill's book of politics.

Some voted for Brown on the issues; but many voted because they wanted to have a beer with him, and they could not imagine Coakley in a bar. Many more did not vote for Coakley or Brown, and stayed home, because they disagreed with his policies and they were disaffected by her hauteur. I was almost one of them; the main reason I voted was to try to stop Brown at the last second. I knew the election was lost when, on election day, my barber told me that he and his wife - who had almost always voted democratic for 40 years, and who had voted for Obama in 2008 and for Capuano in the recent Democratic primary - had voted for Brown.

And being a woman was no longer a benefit for Coakley. Can you imagine that Coakley would have even been a candidate had she posed nude in the past? No one asked Brown that question.

You would think that these politicians would understand some of the basic rules of politics. I would be a horrendous doctor if I didn't know the basics of how to do a physical examination.

How can you run for office, and not know how to run for office?

Obama in Oslo: Between King and Machiavelli

Dr. Nassir Ghaemi — Mon, 21 Dec 2009 13:08:14 +0000

After the recent election, a popular t-shirt showed the faces of Obama and Martin Luther King, with the legend: The Dream Achieved. Recently, in the Nobel Peace Prize ceremony, Obama had to directly address how his politics relate to those of his cultural predecessor as an African-American leader. How could he justify his role as leader of wars with his prize, and his status as King's successor? It was not until I recently went to the Middle East for a psychiatric conference in Qatar that I began to understand the dilemma. Sometimes you have to leave America to understand it.

I came across an editorial in the English language Arab News daily, written by Uri Avnery, an Israeli intellectual who has been a long-time advocate for peaceful compromise with the Palestinians. He wrote about Obama's recent Nobel address. In the US, it received scant news attention, just brief clips about how he defended the need, as head of state, for continued military activity in places like Afghanistan. Here is Avnery's take:"My first impression was that it was almost impertinent: To come to a peace ceremony and there to justify war. But when I read it for the second and then a third time, I found some undeniable truths. I, too, believe that there are limits to nonviolence. No nonviolence would have stopped Hitler. The trouble is that this insight serves often as a pretext for aggression. Everyone who starts a stupid war pretends that there is no alternative." Avnery has this view of Iraq and Afghanistan, and faults Obama for pretending there is no alternative in those places.

He especially worries how this attitude will play out in Israel:"In all the long Oslo speech, Obama devoted 16 whole words to us: ‘We see it in the Middle East, as the conflict between Arabs and Jews seems to harden.' Well, first of all, it is not a conflict between Arabs and Jews. It is between Palestinians and Israelis. That is an important difference....If the conflict is indeed hardening, the US, and Obama personally must carry much of the blame." He notes how Obama has backed off any pressure on Israel, such as in its settlements policies, whereas even George Bush asked for more restrictions, which the Israelis now ignore without any reaction from Obama: "In Jerusalem the settlement activity is in full swing. Palestinian families thrown out of their homes to the jubilant cries of the settlers, and the few Israeli protesters against the injustice are sent to hospitals and prisons. The settler groups engaged in these activities receive donations from the US that are tax-deductible - thus Obama is indirectly paying for the very acts he condemns. And Obama? Oybama."

Reading Avnery crystallized my own discomfort with Obama's Nobel speech. The president referred to Gandhi and Martin Luther King, and commented that he was aware that they were totally committed to nonviolence, but that he, Obama, as head of state, had to accept the limits of nonviolence and the need for military action at times. Machiavelli could not have said it better, and I don't mean this as a criticism: Machiavelli was a genius and simply correct in his view that in politics one has to engage in harshness, even violence, at times, as long as it is for the benefit of the state, i.e., in our times, the people. Thus could Obama justify his role as leader of wars while accepting a peace prize; thus he did.

But Machiavelli does not exactly conflict with Gandhi and King, and his ideas do not necessarily negate Gandhian/Kingian nonviolence. Let me explain: Machiavelli said that human beings are inherently aggressive, violent, and deceitful; hence the need, at times and judiciously, to deceive, threaten, and even harm them in the interests of the state. King in particular, and to some extent Gandhi, agreed with Machiavelli: human beings are inherently aggressive, violent, and duplicitious; but the response of being aggressive, violent, and duplicitious is a bad solution, not just because it is morally wrong - which it is - but because it is pragmatically harmful: it produces more violence and aggression, and history becomes what Gibbon once famously described, the register of the crimes, follies, and misfortunes of mankind. We engage in nonviolence, King explained, not despite the fact that humans are violent, but because they are so.

Machiavelli might have responded that this was fine for personal human relations but not for politics, as Jesus Christ taught when he said that to Caesar belonged what was Caesar's. King and Gandhi applied Christ's theory to political life, though, and showed that it worked. And King applied it not only to domestic injustice but also to foreign policy, as his adamant opposition to the Viet Nam war demonstrated.

Nonviolence does not mean pacifism, as both Gandhi and King repeatedly asserted. It is not passive acquiescence with injustice, to use King's words; it is nonviolent, rather than violent, resistance to injustice. It requires more courage and creativity than violence, but it is no less resistant. Economic sanctions, for instance, are as much a form of nonviolent resistance as marching from Selma to Montgomery.

Now there are limits, it is true. Gandhi tried to teach a nonviolent response to Hitler, for instance, writing letters to him and advising the British and Poles to resist peacefully, and he has been pilloried for years for his apparent naivete. But if we read the first lines of the history of the Second World War written by his enemy, Winston Churchill describes in exasperation how that war was an unnecessary war, one which could have been well avoided with a more realistic British foreign policy towards Hitler in the 1930s. Thus even Hitler is not a counterexample: if we engage in consistent and persistent nonviolent politics, we will never reach those extreme limit situations where wars will be necessary.

One might say that Obama is cleaning up the mess of others in Iraq and Afghanistan; that may be, but Avnery's point is right: What about Israel? Obama is not engaging an active policy of nonviolent resistance to those activities that are creating more and more conflict, and eventually may lead to violent outcomes. If he does not act nonviolently now, he will have to act violently in the future. And then, at that point, one expects that we will say that there is no alternative.

I don't suppose that receiving the Nobel Peace Prize should entail a need to abjure war forever; but perhaps if our leaders would more consciously follow the principles of Gandhi and King, we might one day create a world where we can avoid such no-alternative-to-war dead ends. Then I'll put my t-shirt on.

Death by DSM

Dr. Nassir Ghaemi — Mon, 14 Dec 2009 15:06:48 +0000

A few years ago, a middle-aged man had been newly diagnosed with depression (major depressive disorder, MDD; in contrast to bipolar disorder). His doctor treated him for a few years with different antidepressants, mostly without success. Finally, the man wrote his wife a note; they had no children. It's not your fault, he wrote; the pain is just too much. He killed himself.

The husband consulted a lawyer who called me. There is a strange fact in the history, the lawyer noted, after sending me some records. I looked at the chart. There, about a year previously, after starting an antidepressant, the patient had become hyperactive, overtalkative, spent a lot of money, did not sleep and was not tired, and was giddy - all this lasted for 2 weeks. It had never happened before; it never happened again, at least not that way.

The doctor diagnosed a manic episode, and added a neuroleptic to the antidepressant. The patient calmed down, and felt better for a while. Then the patient wanted to come off all medications for a while to see how he was; the doctor concurred. A few months later, on nothing, the doctor's noted documented racing thoughts and poor concentration. Another antidepressant, a few months of increasing depression, and then the end.

The doctor's expert witnesses, senior psychiatrists at prominent universities, argued that there was no legal malpractice. The doctor had followed the text of DSM-IV: mania, if induced by an antidepressant, does not count as bipolar disorder. Besides, they argued, the patient was 40 years old, and had no prior documented depression or mania, and bipolar disorder usually begins around age 20. The doctor's record had noted a period of sad mood and trouble sleeping at age 25, for which the patient received antidepressant treatment. Was that a first major depressive episode? No, said the doctor's experts: just understandable "demoralization" related to work stress.

The legal standards are high for malpractice, which is understandable. Negligence means not doing what is the competent standard of care in one's community. DSM-IV represents the standard of care, and the doctor followed it. There was no legal case.

But the patient still died. The doctor's defense was that DSM-IV was followed. Perhaps then DSM-IV was at fault.

Some researchers are skeptical about the reality of antidepressant-induced mania because some small studies do not find a difference between antidepressant and placebo (but a statistical law is that failure to find a difference is not the same as no difference), and because other studies find low rates (about 10% in one recent large study, equivalent to placebo, but that study used mood stabilizers, which are known to decrease risk of antidepressant induced mania; thus, one cannot conclude that antidepressants alone do not cause mania). Here is the stronger research evidence, I believe, that antidepressant-induced mania occurs, and that it almost always means the patient has bipolar disorder. Depending on the study population (e.g., type I vs type II) antidepressant-induced mania happens in about 5-50% of patients with bipolar disorder. According to almost all studies of carefully diagnosed MDD (i.e., with standardized interviews to rule out type I and type II bipolar disorder), the rate is much less than 1%. For instance, in a standard large recent study of MDD (STARD,with about 3000 patients), which used 4 different cycles of antidepressants one after another, mania cases only happened in less than ten persons, or about 0.3%. The relative difference is huge: 5-50% divided by 0.3% means that if antidepressant induced mania occurs, the patient is at least 166 times more likely to have bipolar disorder than MDD. (That is about 10 times the likelihood of getting lung cancer if one smokes cigarettes).

In 1994, when DSM-IV was written, the judgment was made to exclude antidepressant-induced mania from the definition of bipolar disorder, mainly to avoid the horrible bogeyman of overdiagnosing bipolar disorder.

When the current psychiatric system of diagnosis was set up with DSM-III in 1980, the authors clearly stated that they hoped that future revisions would change the system for the better, that research would guide judgments, and that new ideas would not be avoided simply because they were new. Instead, what has happened is that the DSM system has become a Bible, and some psychiatric leaders, like Allen Frances who headed DSM-IV, are explicit in their opposition to any changes unless overwhelming reasons exist to make those changes. This is nothing by a mental law of inertia, an opposition to change for the sake of opposing change.

I do not agree with those who bash DSM, partly as a means of bashing the profession of psychiatry. DSM itself is not the problem; all medical professions have diagnostic criteria (DSM like criteria exist for migraine and epilepsy and rheumatoid arthritis). The problem is not the method of diagnostic criteria; the problem is not paying attention to science.

Unfortunately, this kind of ideological conservatism led to a loophole in DSM-IV which appears to have led to the demise of this person. The doctor was not to blame, to the extent that he followed the rules. Perhaps, then, those rules need to be called into question.

The pseudoscience of bipolar overdiagnosis: Relax, you're really not bipolar

Dr. Nassir Ghaemi — Tue, 13 Oct 2009 20:24:19 +0000

The famed physicist Richard Feynman once emphasized an underappreciated hallmark of science. He based it on an observation from the Second World War, when cargo airplanes dropped supplies on military bases in the South Seas islands. After the war, when the cargo planes stopped, the islanders invented a cargo cult, mimicking what they had observed, in the hopes of coaxing the planes to return. They created replicas of airplane landing strips; they put up lights; they signaled to the skies.

They did everything that normally preceded the landing of cargo airplanes. But the planes never landed.

Many pretend to practice science, Feynman argued, like the South Seas Islanders practiced air supply. They have all the bells and whistles; all the methods approximate standard science; but they lack something essential, something without which cargo cult science is merely a pseudoscience.
That missing piece is an attitude: Feynman called it a bending over backwards to see more than just one interpretation; an interest in refuting, and not just confirming, one's hypotheses; a wish not to fool oneself, first and foremost; a willingness to put one's own beliefs on the line - in short, "utter honesty" that goes far beyond everyday truthfulness. Feynman contrasted it with advertising: I might try to sell you my brand of soap, by talking up its strengths, minimizing its weaknesses, and ignoring its competitors. One need not lie to advertise in that manner; but neither is one being utterly honest.

Science as advertising is pseudoscience.

(Here is Feynman in his own words: "Details that could throw doubt on your interpretation must be given, if you know them. You must do the best you can--if you know anything at all wrong, or possibly wrong--to explain it. If you a theory, for example, and advertise it, or put it out, then
you must also put down all the facts that disagree with it, as well as those that agree with it...In summary, the idea is to try to give all of the information to help others to judge the value of your contribution; not just the information that leads to judgment in one particular direction or
another.")

We see this among those academics currently engaged in an anti-bipolar crusade. One blog post to which I responded consisted of an approach (ironic for critics of "corporate psychiatry") similar to advertising - providing one-sided data, ignoring contrary evidence, and silent on much that matters. Another knights templar group, about which I wrote my second blog posting ("Relax, you're not bipolar") about their initial article a year ago, is obsessed with the idea of bipolar overdiagnosis. Confirmed by CNN and Public Radio, this research group continues to publish in psychiatric journals with evidence that is non-evidence. Recently, another paper from the same study seeks to show that bipolar disorder is overdiagnosed when patients frequently have other conditions like borderline personality disorder or plain old vanilla depression (major depressive disorder, MDD). Yet the original paper on which that claim is based shows exactly the reverse: it proves that bipolar disorder is underdiagnosed, not overdiagnosed. How?

In the original study, about 30% of persons with bipolar disorder (based on the researchers' gold standard interview) had never been previously diagnosed with it (underdiagnosis); yet only 13% of persons had been diagnosed with bipolar disorder who did not really have it (overdiagnosis; again based on the researchers gold standard). Now, first grade mathematics teaches that 30 is greater than 13, and third grade teaches that it is over twice as great: thus bipolar disorder is over two times more underdiagnosed than overdiagnosed; thus it is predominantly underdiagnosed, not overdiagnosed.

There is another way of looking at the material, which makes the same point. Instead of the relative risk, this approach brings in the absolute difference. One effect could be 2% vs 1%; another could be 80% vs 40%; both are two fold relative risks, but the absolute effect of one is much larger than the other (80% is much larger than 2%). This measure of absolute difference - called the "Number needed to harm" (NNH) for bad outcomes - involves the reciprocal of the actual percentage difference. In this study the NNH for overdiagnosis would be the reciprocal of 13% = 7.7. The NNH for underdiagnosis would be the reciprocal of 30% or 1/0.3 = 3.3. (A NNT of less than 5 is considered huge, 5-10 moderate, 10-20 small. Usually this approach applies to drugs, so that one can say a drug with a NNT of 5 has major benefit. Here we are applying it to the likelihood of being underdiagnosed versus overdiagnosed). Using the data from this study, we can see that the chance of harm by underdiagnosis is huge, and by overdiagnosis, though not absent, is only moderate. Again, the data themselves show predominant underdiagnosis, not overdiagnosis.

How did the researchers ignore their own data? How could they come up with the opposite conclusion?

Let me bend over backwards.

Their conclusions follow, though still falsely, based on another way of looking at those data. I started by asking the question: What diagnosis did the patients have (confirmed by the researchers as bipolar, or confirmed not bipolar), and then what diagnoses had they previously received mistakenly? This is the way to show that someone was misdiagnosed, and how frequently (predominantly over or underdiagnosed).

The researchers' published paper does not report the above analyses. Instead they ask the question: Which patients were diagnosed as having bipolar disorder in the community? Then, how many of them were confirmed by the researchers to have bipolar disorder? The answer to that question was 42%; thus 58% were claimed to be overdiagnosed.

So, interpreted one way, the evidence shows that bipolar disorder is underdiagnosed; the other way, it seems overdiagnosed. How come the researchers only reported one interpretation?

An Epidemiology 101 course (which most psychiatrists never receive) would suffice to learn the difference between reliability and validity. Reliability means whether two clinicians, using whatever methods they choose, diagnose the same thing. If we agree to call X with the label "Y", then we are reliable. If the reality is that X is X, not Y, then our claim that X is Y, though reliable, is not valid.

In this kind of research, the question is whether clinicians are correctly diagnosing their patients. Their diagnoses are in question; they are not proven; they are being studied. Thus, to begin with clinicians' diagnoses is to ask the question of validity, not to answer it. We answer with the researchers' diagnoses in psychiatry, based on the standard research diagnostic interview that systematically assesses DSM-IV criteria. The analysis of clinicians' diagnoses is about reliability; it shows that we disagree on what we call bipolar disorder. It indicates that the bipolar diagnosis, in the community, is unreliably made.

It does not demonstrate overdiagnosis. Overdiagnosis reflects something different: it means that many people who do not have disease X are diagnosed with it, and predominantly so, meaning that not many have disease X and yet are not diagnosed with it. To answer that question, we really need to know who has the disease and who does not. We need to start with the proven diagnoses, the researchers' systematic interviews. That is the analysis I did; and it demonstrated predominant underdiagnosis.

Indeed, there are numerous illnesses that are unreliable and yet underdiagnosed. Asthma is considered still underdiagnosed; many who have it are not diagnosed with it and are mistaken as having other conditions; yet it is also unreliable: clinicians frequently disagree on when it is present, and mistake it with bronchitis or other lung conditions. The same holds for celiac disease, and chronic cholecsystitis, and dementia. Unreliability is not the same thing as underdiagnosis.

People disagree on what they call bipolar disorder, but predominantly - and this is my Feynmanesque critique because these critics' own data show it - bipolar disorder is much more likely to be missed when it is present than to be diagnosed when it is absent.

The ghost of Richard Feynman haunts this unseemly debate. I ask again: How did the researchers ignore their own data? How could they come up with the opposite conclusion?

One cannot say they were ignorant of the evidence. They published the data in their paper, in a table. They just did not make the calculations that I made above; they did not analyze it in a way that could refute their views; they did not put their own beliefs to the test of utter honesty. Their paper has all the bells and whistles of science, but it is not science; it only looks at one way of analyzing the data that appears to support the interpretation that the authors wish to show, while ignoring other (more valid) ways that refute the authors' hypotheses. Their analyses are not false, just incomplete. They produced honest advertising; not utterly honest science. They are not dishonest; as Feynman argued, they are just unscientific: they fooled themselves so fully that they can now proceed to honestly fool others.

So scientific journals publish the papers, the general media repeat the conclusions, and word spreads that bipolar disorder is overdiagnosed....especially, I am sure, in the South Seas.

For Ted Kennedy and a Friend: An Appreciation

Dr. Nassir Ghaemi — Thu, 27 Aug 2009 03:32:13 +0000

Over a year ago, my first posting in this blog was about Senator Edward Kennedy's illness. Now he has died, and many of us feel impoverished. Having lived in Massachusetts for most of the last 20 years, I had the privilege of seeing Senator Kennedy a few times, at political rallies, at events at the JFK School of Politics at Harvard. I have always thought that it was a major privilege of being in Massachusetts that we have such honorable political leadership at the national level.

A week ago, a friend of mine, Franco Benazzi also died - tragically young and rapidly - of a brain tumor. Franco was a psychiatrist in Italy, a researcher about bipolar disorder, whose work focused on discovering that most mood episodes are neither depressed, nor manic, but mixed, a viewpoint that goes against many current assumptions about how to diagnose and treat mood disorders. If correct, as I believe he was, we need to change our understanding of "depression" radically.

Kennedy was a politician; Benazzi a doctor. Both lived for others. Kennedy's struggles personally and his accomplishments politically are at a different level. But the differences in quantity do not change the same basic quality: they both tried to help humanity.

Skeptics abound in our world: those who say that politics is useless, that psychiatry is corrupt. All their complaints, though loud and tiresome, are written in sand. What endures in the future is the truth that lies underneath the hard and silent work of the Kennedys of the world - and, I would like to think, also of the unheralded Benazzis.

In one of his last speeches, Senator Kennedy commented that the future will outlast us all, but that we will live on in the future that we make. I firmly believe this about him and Franco and those who try to constructively contribute to understanding and making gentle the life of this world.

As I bid goodbye to this honored leader and this esteemed friend, hoping to live up to their examples, I find that this poem (written by Mary Frye and also attributed by some as an Indian ballad for the dead) is a helpful reminder that these worthy dead are still alive in our lives and in our world:

Do not stand at my grave and weep.
I am not there. I do not sleep.
I am a thousand winds that blow.
I am the diamond glint on snow.
I am the sunlight on ripened grain.
I am the gentle autumn rain.
When you awake in the morning hush
I am the swift uplifting rush
Of quiet birds in circling flight
I am the soft starshine at night.
Do not stand at my grave and cry.
I am not there. I did not die.

Suddenly I was just watching a movie

Dr. Nassir Ghaemi — Mon, 10 Aug 2009 16:26:58 +0000

Recently, one of my patients commented, a few weeks after starting lithium: "One day I was watching a movie, and suddenly I was just watching a movie."

This is a good description of how to judge when our medications work for psychiatric conditions: there is a recovery of the ordinary. One is able to feel things normally, not too strongly, and not too weakly.

In the face of the many critics of psychiatric drugs, and the claim that they alter brain states in an abnormal way, this experience reminded me that when they are used correctly, for the right conditions, they take an abnormal brain state and make it normal. The end result of being on lithium, if one has bipolar disorder and if the drug works for that person, is ending the natural abnormal states of one's mind and brain, and making them normal again.

My patient could not sit and watch a movie. She thought too much of her life's troubles, her problems, her weaknesses. Her depression ran her mind, and it was like a train conductor who never stopped at any station. It kept going and going and going, all day and all night, reminding her of all her worries, blanketing all her life experiences with the dull grayness of her sad interior.

When the depression had gone, after using lithium, she could sit and watch a movie, losing herself in it, and enjoying it, as a good movie or a good book should allow us to do.

Getting better is about being able to lead an ordinary life, with the many little joys of quotidian living, the petits bonheurs of domesticity, noticing good weather and appreciating it, seeing little children and enjoying them, hearing laughter and sharing it, observing sadness and comforting it.

The recovery of the ordinary is not much to ask, and yet what a great achievement when one sees it.

Professor Anti-Stigma

Dr. Nassir Ghaemi — Tue, 23 Jun 2009 04:30:03 +0000

When I interviewed for psychiatry residency, I met a well known expert in the problem of stigma with mental illnesses. She described her work, related to psychiatry and the humanities, and, in expressing interest, I made the mistake of mentioning the Black psychiatrist/revolutionary Frantz Fanon; I saw her frown and I knew the interview had ended dismally. Fanon, she said, was no scientist.

Years later, I treated a patient, who, fortuitously, began to work as an assistant to the aforementioned academic expert in stigma. My patient, a man who had bipolar disorder, had benefited from having worked for a man who sounded like a truly wonderful human being; my patient's previous boss had been very supportive whenever my patient had to miss work due to depression, as was frequent, or mania, as not infrequent. My patient's ex-boss unfortunately moved away, and, when my patient obtained new employ, he found himself working for Professor Anti-Stigma. Suprisingly, working for this professor was not so easy; many demands were made, unexplained days off were questioned harshly, and poor performance was not well tolerated. My patient had felt quite able to let his old boss know everything about his mental illness. But with his new boss, the anti-stigma specialist, my patient experienced stigma, and remained silent.

This experience reminded me of a theory held by one of my old teachers at Harvard, Harrison Pope. He used to say that academics study what they have: most depression researchers seem a little down; most schizophrenia researchers a little odd; many bipolar researchers a little hyper. I had begun to study the problem of lack of insight; Pope asked me: "What's your problem? You don't have insight?" (If I answer yes, even if true, I would disprove the question).

One might call it Pope's rule: Your motives are revealed by your focus. An interesting hypothesis, especially as confirmed in cases like that of Professor Anti-Stigma. If true, it would suggest, for instance, that many of those obsessed with the pharmaceutical industry and the role of money in all aspects of medical work might be themselves a bit overly fond of funds.

Perhaps; perhaps not: Pope's rule is hardly infallible; and yet the case of Professor Anti-Stigma stands as a warning.

The politics of radical empathy

Dr. Nassir Ghaemi — Mon, 22 Jun 2009 15:34:53 +0000

Poor Mexico, the saying goes: So far from God, and so close to the United States. Iran, one is tempted to say, suffers from the opposite problem, producing the same result: Perhaps it is too close to God (some would say too religious) and too far from the United States (some would say too ignored by the US now where it had been too controlled by it before). But even that is not exactly right: Obama is correct in keeping his distance now; the US would only complicate matters. And perhaps more distance from religion is not the solution either; as Gandhi once said, those who say religion and the state should be separate do not understand the nature of religion.

Political conflict is rarely simple. If any one party wins completely, all lose. If all parties are to win, none can win completely. Gandhi and King struggled with this quandary. Today nonviolence is too often seen as a tactic to avoid harm by a stronger enemy; Gandhi and King saw it as a moral principle - the willingness to suffer even more by resisting without fighting than by fighting back, so as to convince, rather than defeat, one's enemy.

The psychological concept that became the core of the politics of Gandhi and King was empathy, love in simpler language. A simple idea, endorsed by all, engaged by few.

Truth-force, Gandhi called it; a better word than nonviolence, since there is force indeed, but not physical force, nor even spiritual force, but rather the force of what is true, beginning with the most basic truth of all - so well stated by that Persian poet Saadi - that the sons of Adam are members of one body; where any part hurts, it all hurts.