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December 21, 2005
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A Sudden Shift in Moods; With Cyclothymia, a Milder Form Of Bipolar Disorder, Life's Little Ups and Downs Can Loom Large
The Washington Post; 12/20/2005; Stacey Colino Special to The Washington Post
A Sudden Shift in Moods; With Cyclothymia, a Milder Form Of Bipolar Disorder, Life's Little Ups and Downs Can Loom Large Byline: Stacey Colino Special to The Washington Post Edition: FINAL Section: Health
Like most teenagers, Andrew Solomon was often at the mercy of his moods -- but in his case this situation persisted into his thirties.
"During my up periods, I'm lucid and articulate," said Solomon, author of the partly autobiographical "The Noonday Demon: An Atlas of Depression," which won the National Book Award for nonfiction in 2001. "I have clarity and can see patterns in my work, and I can write loads of publishable material in one night. I'm also very affectionate with people I care about."
But when his moods would turn, as they invariably did, he could withdraw or have angry outbursts.
Once, after an annoying phone call, he slammed down the phone so hard it broke. Another time, when an acquaintance who frequently drank too much showed up at his home tipsy and immediately poured herself a cocktail, Solomon "smashed the glass and yelled at her that she had to leave immediately," he recalls. After such explosions, he would "spend the next week apologizing."
Yet it wasn't until three years ago that Solomon, now 42, learned there is a word for the mood swings that have affected him since his youth: cyclothymia.
Cyclothymic disorder, as it is sometimes known, is a milder cousin of bipolar disorder. Like bipolar disorder, cyclothymia has high and low phases, though the highs are not as high and the lows not as low. It can be crippling nonetheless. And it is a risk factor for bipolar disease itself, with up to 50 percent of those with cyclothymia eventually developing bipolar disorder. Major depression is also a higher risk.
The hypomanic, or upbeat, phase features symptoms such as elevated mood, increased self-esteem, decreased need for sleep, racing thoughts, an increase in goal-directed activity and excessive involvement in pleasurable activities.
These symptoms might last for four or more days, then alternate with periods of mildly depressive symptoms such as sadness, pessimism, fatigue, feeling guilty, trouble concentrating and changes in sleep or appetite. For a person to be diagnosed with the disorder, this alternation persists for at least two years.
The American Psychiatric Association estimates that 2.2 million U.S. adults have cyclothymia, about half as many as those with bipolar disorder. But as bipolar disorders have gained visibility in the clinical community and popular culture, cyclothymia is being identified and treated more often.
"There's been a general increase in awareness of bipolarity as prominent people have come out with books about it," said Fred Goodwin, professor of psychiatry at the George Washington University Medical Center and the author of "Manic-Depressive Illness." Bipolar conditions have also gained clinical prominence thanks to the introduction two years ago of Lamictal (lamotrigine), an anticonvulsant drug that has been proven to delay the mood swings, especially the depressive ones, associated with bipolar disorder.
"It's called 'therapeutic optimism,' " Goodwin explains. Once a treatment is proven effective for an illness, there is "high motivation to look for people who have it. With a drug like Lamictal . . . there's further motivation to evaluate whether someone is just moody or whether this is something that could be helped with pharmacology." Carol C. Kleinman, an assistant clinical professor of psychiatry at the George Washington and a psychiatrist in private practice in Chevy Chase, estimates that 60 percent of people with cyclothymia respond to an anticonvulsant agent.
While cyclothymia's mood changes can be abrupt and unpredictable, they are not as severe as in the more serious forms of the disease, which are known as Bipolar I and Bipolar II. The main difference between cyclothymia and Bipolar I is in the severity of mania, and the difference between cyclothymia and bipolar II in the severity of depressive symptoms.
But the milder condition can still be disabling and disorienting. "People who have more or less continuous mood fluctuations, as people with cyclothymia do, can end up with more limitations in life than people with major disorders," Goodwin said. "Because they don't know how they're going to feel from day to day, they don't have a firm footing in relationships or in their work. And they lack the ability to have confidence in what a mood means, whether it's a signal about a relationship or a work situation or a spontaneous change."
The German psychiatrist Ewald Hecker introduced the concept of cyclothymia in 1877, but its definition has evolved from a mild problem with mood to its current status, in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), as a mood disorder alongside bipolar disorder and major depression. Cyclothymic disorder also appears in the International Classification of Diseases (ICD-10), published by the World Health Organization.
Yet the condition has traditionally been overlooked by those who have it and the doctors who've treated them. This may be because there's a fine line between pathological and normal mood fluctuations.
"The threshold is when a person is really having trouble in their relationships or at work or in school," said Kleinman. "Often, he added, "it's a friend or family member who says, 'I think there's a problem here.' "
Complicating matters, people usually seek professional help when they're feeling down, not up. " . . . They come in because they're depressed or hurting," Goodwin said. "They don't come in saying, 'Doctor, I'm hypersexual or too creative.' We'd all love to have that." People who come in during a down period of cyclothymia may be misdiagnosed with -- and mistreated for -- unipolar depression.
In therapy, there's also a mood-driven memory bias: When people are depressed, they tend to remember their past depressions, not their periods of euphoria or super-productivity, according to Goodwin. So what they report can give a mental health professional a skewed picture of what's really been going on with them.
Cycles of Vulnerability
The cause of cyclothymic disorder, which usually begins in the teens or twenties, is unknown, but there appears to be a genetic component. People who have a family history of bipolar disorder are particularly susceptible. In a recent study involving healthy, symptom-free volunteers, researchers in France found that a cyclothymic temperament clusters in families with affective disorders, particularly in those with a legacy of bipolar disorders or depressive disorders.
There's also likely an environmental influence, since stress, personal loss, drug or alcohol use, or even insufficient sleep can trigger episodes or mood fluctuations. In people with cyclothymia, "the brain has less capacity to buffer itself against what's happening in the environment," Goodwin explains.
Linda Sexton was diagnosed with cyclothymia in 1983, when her children were toddlers. A daughter of the poet Anne Sexton, who suffered from severe depression and committed suicide when Linda was 21, Linda began to have mood swings when she struggled with disciplining her children.
"When I found myself replicating the spanking I had experienced as a child and promised I wouldn't do, I went into therapy," said Sexton, who lives in the San Francisco Bay area. "I was having periods of depression during which I was unable to complete tasks and didn't feel like I had anything to offer my children, which was killing me because I considered them the most precious thing in my life." Then she'd have surges of hypomanic behavior -- for instance, going out and buying 10 pairs of shoes at a time.
Gradually, her cyclothymia got worse, especially when she was treated with antidepressants. She had free-floating anxiety and surges of self-hatred. Her marriage fell apart. In 1996, Sexton was diagnosed with a full-blown bipolar disorder.
At this point, diagnosing cyclothymia isn't an exact science.
"It's kind of a cookbook diagnosis that's based on a standard number of criteria the patient meets," explains Dave M. Davis, a clinical psychiatrist and medical director of the Piedmont Psychiatric Clinic in Atlanta.
Currently, mental health professionals rely on a clinical evaluation, DSM-IV checklists and an accurate history of the person's moods and behavior. A relative of the patient can often help with compiling such a history, Goodwin said, because he can make connections between a person's behavior and negative consequences or recall a pattern of behavior.
"I had a lawyer once who had come in because he was feeling depressed," Goodwin recalls. "He didn't see himself as hypomanic, but he was so irritable that his kids didn't want to come home and eat with him. His wife reminded him it was the same summer that he bought three cars and called all of his bosses [expletive]s and got fired. Then he turned to his wife and said, 'Is this what the doctor meant by hypomania?' He just hadn't put two and two together."
Back on an Even Keel
"There isn't much point in treating cyclothymia without mood stabilizers," Goodwin said. "This is not something over which [people] can exert total voluntary control."
While drugs like lithium and depakote have been the treatment of choice for both bipolar and cyclothymic disorders in the past, they often carry unpleasant side effects such as weight gain and sluggishness.
In 2003, a breakthrough came with the FDA's approval of Lamictal for the long-term treatment of bipolar disorders. "It's very effective on the depressive side and mildly effective on the high side," Goodwin said. "With it, these people can begin to trust their emotions again."
What doesn't help are antidepressants taken by themselves, as Jennifer Richards discovered after being misdiagnosed with depression more than 10 years ago.
"The antidepressants I was given made my moods worse," recalled Richards, a receptionist in Boston. "I'd feel invincible and drive 100 miles an hour or max out my credit cards. Or I'd become very angry, loud and obnoxious; I hadn't experienced outbursts like that before. Friends stopped talking to me, and I was fired from two jobs."
It wasn't until she began treatment with a new psychotherapist that she was diagnosed with cyclothymia and put on a mood stabilizer. After that, she said, "I wasn't afraid of myself anymore."
Not only can antidepressants throw someone with cyclothymia into mania, they can boost the risk of having the disorder evolve into full-blown bipolar, Goodwin said. "It happens up to one-third of the time. Antidepressants should only be used with a mood stabilizer, and they should not be used indefinitely."
The trouble is, people are often reluctant to take a mood stabilizer when they're on a high swing.
"When you're hypomanic and you feel euphoric and on top of the world, who wants to take a medication that will take that away?" said Prentiss Price, a psychologist at the Counseling and Career Development Center of the Georgia Southern University in Statesboro and author of "The Cyclothymia Workbook." "But the higher the mood gets, the more at risk you are for problems with judgment or risky behavior."
Of course, therapy is also important. "They need to relearn who they are and get off their addiction to their highs," Goodwin said. "It's like cocaine addicts: They feel like they need that high to be interesting, appealing, sexually attractive or fun people."
Thanks to medication and psychotherapy, Andrew Solomon's moods are now under control: He still has up days and down days, but he spends more time on an even keel.
"Now I usually have reactive swings," he said. "When something happens, I might have an exaggerated response to it. But my moods have become more logical and rational and less extreme. They're easier for me and for other people to live with." *
For more information about mood disorders:
Families for Depression Awareness (www.familyaware.org), offers help in recognizing and dealing with depressive and mood disorders.
Depression and Bipolar Support Alliance (www.dbsalliance.org), offers confidential screening for bipolar disorder, depression and anxiety, plus information and referrals to support groups.
Stacey Colino is a Washington area freelance writer. Comments: firstname.lastname@example.org.
Copyright 2005, The Washington Post. All Rights Reserved.
For the Most Needy, A Tough Switch; The Frail and Mentally Ill May Get a Rude Jolt When Medicare Drug Program Goes Live Jan. 1
The Washington Post; 12/20/2005; Christopher J. Gearon Special to The Washington Post
For the Most Needy, A Tough Switch; The Frail and Mentally Ill May Get a Rude Jolt When Medicare Drug Program Goes Live Jan. 1 Byline: Christopher J. Gearon Special to The Washington Post Edition: FINAL Section: Health
Antionette Keys was relieved to discover that her new Medicare prescription drug plan covers the medications she takes for bipolar disorder. And when that plan takes effect on Jan. 1, she will be able to get her four medications at the same pharmacy she always uses. Keys, 40, will see her drug costs jump from $4 a month to $10, but she figures she can handle that.
To those administering Medicare's new Part D drug benefit, Keys is known as a "dual eligible." Her mental health condition is a substantial enough disability to make her eligible for Medicare. And because her income is too low to support herself and her teenage son, she qualifies for Medicaid, the program for the poor that now covers almost all of her drug expenses.
The nation's 6.4 million dual eligibles -- more than 200,000 of them live in the District, Maryland and Virginia -- present a big test for Part D, which goes live on Jan. 1. They are among Medicare's most vulnerable beneficiaries, and when the clock strikes midnight on New Year's Eve, the dependable and robust drug coverage they receive through Medicaid will disappear, replaced by more restrictive and complicated plans.
Dual eligibles include many frail elders, developmentally disabled individuals and nursing home residents. Most live in or near poverty, and they tend to be less educated than other Medicare beneficiaries. They also are more likely to suffer diabetes, Alzheimer's and stroke, and they take more prescription drugs than the typical retiree.
"They don't know what's going to hit them," said Jeanne Finberg, an attorney with the National Senior Citizens Law Center.
Under Part D, patient advocates say, dual eligibles will have fewer legal protections and could pay more for their drugs than before. Many may need quick help from their doctors to continue medications they have long taken, while others will be switched to different drugs.
"In most cases, this will not be a change for the better," said Thomas Clark, the director of policy and advocacy for the American Society of Consultant Pharmacists. "For some, this delay could be catastrophic," he said.
Asked what it is like when she misses her medications, Antionette Keys says, "Think of the most scary thing that has happened in your life. You don't want it to happen again."
Like most dual eligibles, Keys was assigned at random to one of the private insurance plans approved by Medicare. Her plan, SilverScript, is a subsidiary of Nashville-based Caremark Rx; its national network of pharmacies includes 107 in the District.
Clark's group is one of several plaintiffs in a lawsuit claiming that the federal government has done inadequate planning to protect dual eligibles. Bush administration officials, however, sound confident that beneficiaries will get assigned to a drug plan that meets their needs.
"There still may be a few people who fall through the cracks" and aren't enrolled in a plan on Jan. 1, said Mark McClellan, administrator of the Centers for Medicare and Medicaid Services (CMS), but there will be a process in place to ensure that all dual eligibles can get their drugs.
Still, many patient advocates, providers and Medicaid officials fear that frail seniors, the mentally ill and other seriously ill patients -- or their caregivers -- will show up at pharmacies early next month and be told that their Medicaid drug coverage has ended and the new drug plan that has been randomly assigned to them doesn't cover some of their medications or does not use their pharmacy.
"Many of these patients are unaware that they've been auto-assigned" into a Part D drug plan, said Wallene Bullard, a pharmacotherapy specialist at Howard University School of Pharmacy. As a result, she predicted, "pharmacies will face a chaotic time in the first two weeks of January."
"We are concerned," said Jeff Gruel, director of the Medicaid pharmacy program in Maryland. "I don't know the extent [to which] these plans have dealt with this population. It's a unique population."
Rob Maruca, director of the District's Medicaid program, said its dual-eligible clients concerned about confusion in the early days of Part D can double up on their medications this month to get them through January.
Dual eligibles are likely to go without their medications if they encounter sudden problems in obtaining their medications, said Patricia Nemore, an attorney at the Center for Medicare Advocacy. Doing so, even for a short time, can be dangerous, Clark said. People taking anti-seizure medications, for example, could collapse into life-threatening seizures, while people with diabetes could wind up in a coma if they stop taking insulin or other drugs for short periods.
If she misses her medication, Keys said, "I don't function at all." She gets paranoid, weepy and puts herself into dangerous situations. "My family members can't deal with me, so it's better to stay in the street. I sometimes even get in trouble with the law."
An Inferior Benefit?
"My biggest concern with the duals is we aren't hearing about this from our clients," said Sarah Lichtman Spector, an attorney with Legal Aid Society of D.C. "These are the poorest and most disabled" citizens, with many facing literacy and language barriers. "I'm terrified [these] people aren't walking through my door every day. Come January 1, I think we'll be in crisis."
For those who have sought help, one complication is a lawsuit that has blocked use of a computer tool for matching a person's drug needs with the available Part D plans.
"Without this Web tool we will be, as a practical matter, unable to provide meaningful assistance to the approximately 600 Medicaid dual-eligible people who have asked us for help to make sure their assigned drug plan covers their medicines," said Suzanne Jackson, director of the Health Insurance Counseling Project at George Washington University School of Law. It was unclear last week when this legal action would be resolved.
Dual-eligible beneficiaries get the most financial assistance under the Medicare's new drug benefit, having their monthly fees waived if they join a plan with below-average premiums and paying $1 to $3 per prescription. They can also switch drug plans monthly, while other beneficiaries can only switch at the end of each year.
Still, some experts believe Part D is an inferior benefit.
For example, Medicaid recipients can get their prescriptions for free if they can't afford the co-payment; under Part D, a pharmacist can refuse to dispense a drug for lack of a co-payment.
About 20 percent of dual eligibles live in nursing homes, where rules differ a bit. These people don't have co-payments and their non-formulary drugs may be covered temporarily. But these individuals have no guarantee that the plan to which they are auto-assigned will include the long-term care pharmacy used by their facility. Meanwhile, many of the protections extended to nursing home residents do not apply to those in assisted living or other settings.
McClellan said duals will not be left out in the cold. If a beneficiary shows up at a pharmacy in January, he will be given his drugs, most likely a 30- to 45-day supply. This, McClellan said, should happen even at a pharmacy outside the network of the drug plan to which the person has been assigned and even if the drugs are not covered by that plan.
In addition, any dual eligible who has not been auto-assigned to a plan can be enrolled on the spot into a plan that covers his drugs. "That will all happen right there at the pharmacy encounter," McClellan said.
(Another set of dual eligibles -- those who have partial Medicaid benefits and whose income is higher than the group being moved into Part D on Jan. 1 -- will be assigned to a drug plan by June 1. They will pay $2 to $5 per prescription.)
Relying on Goodwill
Patient advocates say federal authorities have not done enough to guarantee a smooth transition. "The cutoff is very dramatic," Nemore said. "Suddenly as of Jan. 1, there is no safety net to pick up all the mistakes that are bound to happen."
Clark said key.phpects of the computer system that will allow pharmacists to check the formularies and beneficiary eligibility and enrollment were not operational as of last week.
"Physicians will be inundated" with requests from patients to switch drugs and to explain the plans to which they have been assigned, Clark predicted.
"The contingency plan seems . . . dependent on the goodwill of pharmacists and physicians" to assist beneficiaries voluntarily, Nemore said, and on smooth operation of the computer systems linking the government, the private firms operating Part D plans and the nation's pharmacies, .
The medical establishment also has qualms about the transition -- which begins on the same day that Part D starts serving millions of other Medicare beneficiaries who have voluntarily enrolled in the drug plans.
"We have been especially concerned that pharmacists and physicians could be overwhelmed in January," the American Medical Association said in a statement posted on its Web site. "The potential exists for confusion because, even though the Centers for Medicare and Medicaid Services has provided assurances that plans' formularies will be adequate to meet patients' needs, plans will undoubtedly have policies in place that will differ from patients' current drug plans in some respects."*
Christopher J. Gearon has written several articles for the Health section on the Medicare drug program. Comments: email@example.com.
Copyright 2005, The Washington Post. All Rights Reserved.
Judge lets brain lawsuits go ahead ; They are found not to be medical malpractice cases, as those being sued over brain donations argued.
Portland Press Herald (Maine); 12/20/2005; KEVIN WACK Staff Writer
A dozen families have won a key ruling that lets them move ahead with lawsuits challenging the removal of brains from relatives whose bodies were processed at the state Medical Examiner's Office.
Superior Court Justice Nancy Mills ruled last week that the lawsuits
are not medical malpractice cases, rejecting arguments made by the
defendants, including a Maryland research lab.
Even if their lawsuits had been permitted under the malpractice law, the families would have faced longer odds because Maine makes it harder to win medical malpractice cases than other types of lawsuits.
The ruling affects 13 cases, including two filed by members of the same family. In the lawsuits, plaintiffs from around the state allege that their loved ones' brains were taken from the Medical Examiner's Office in Augusta without proper permission.
The defendants, who have denied wrongdoing, include the Stanley Medical Research Institute of Bethesda, Md., its founder, Dr. E. Fuller Torrey, and Matthew Cyr, a Bucksport man who was paid $1,000 to $2,000 for each brain he sent to the research lab. The brains were used for research on the causes of severe mental illnesses, including bipolar disorder.
Defendants argued to Mills that Torrey is a medical doctor who qualifies under the malpractice law, known as the Maine Health Security Act, and that Cyr was acting on his behalf. But lawyers for the suing families wrote that it defies common sense to characterize a dispute involving a corpse as a health-care matter.
The judge, who is assigned to all of the brain harvesting lawsuits, sided with the plaintiffs in a nine-page ruling.
"The court concludes that the cases involving Dr. Torrey, SMRI, and Mr. Cyr do not fall within the requirements of the (Maine Health Security Act) because no health care practitioner or health care provider was involved," Mills wrote.
The ruling means the lawsuits will continue to move forward toward trials, with lawyers exchanging documents and interviewing potential witnesses.
Steven Silin, a Lewiston lawyer who represents seven of the suing families, said he is gratified by the judge's decision. He said the defendants were trying to use the Maine Health Security Act as a shield.
"And I think what this ruling does is take that shield away from them," Silin said.
Thomas Laprade, the lawyer who represents Torrey and the institute, acknowledged that the ruling is unfavorable and said it can't be appealed until after the cases are concluded. But he also said the decision doesn't affect his confidence that his clients will prevail.
"The more we learn about these cases, the more confident we get," Laprade said.
The defendants have scored some victories in recent months. Some counts of wrongdoing, including claims that the defendants violated a federal racketeering statute, have been dismissed or dropped by plaintiffs.
But the lawsuits pending in Maine are not the only problems facing Cyr and his co-defendants.
The U.S. Attorney's Office in Portland and a special prosecutor appointed by Maine Attorney General Steven Rowe have been investigating whether any laws were broken during the nearly four years when brains were collected.
Staff Writer Kevin Wack can be contacted at 282-8226 or at:
Copyright 2005 Blethen Maine Newspapers Inc.
Author of Fire Stories Sentenced for Arson
AP Online; 12/20/2005
David Cowan, whose books include "Great Chicago Fires: Historic Blazes That Shaped a City," pleaded guilty Monday to one count of arson Monday, prosecutors said.
Cowan, 42, of Chicago, apologized to the judge before the sentencing, defense attorney Thomas Durkin said.
Cowan was charged with setting a fire June 9 at a storage building near the historic St. Benedict Church, where he had worked before being fired earlier this year, Durkin said.
The blaze caused minimal damage and no one was hurt.
Durkin said Cowan had been drinking when he set the fire and has since been diagnosed with bipolar disorder and is undergoing treatment. He said the crime was related to Cowan's domestic problems, but would not elaborate.
Cowan worked for a fire department in a western suburb of Chicago for about seven years until 2003.
Copyright 2005, AP News All Rights Reserved
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The Warning Signs Of An Impending Bipolar Disorder Manic Episode
Bipolar disorder - as the name implies - involves two distinct set of symptoms. One set throws the individual down into the depths of a massive depression. The other places the individual who suffers with bipolar disorder at the top of a peak manic episode.
Most everyone can eventually recognize the warning signs of an impending depressive episode related to bipolar disorder. More likely than not, individuals with bipolar disorder try very hard to avoid it.
However, for many individuals with bipolar disorder, it's more difficult to recognize the signs of an impending manic episode. After all, a manic episode of bipolar disorder can be mistaken in some cases - especially in the very early formation -- for the lifting of the corresponding mood swing of the depression.
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