An article in a recent issue of the New England Journal of Medicine finds that anti-depressants don’t contribute significantly to the recovery of bipolar patients. It is estimated that some 70% of bipolars are also being prescribed one or another anti-depressant. Since these are not fast-acting medications, it is often difficult to tell which of the medications being prescribed are actually doing the work.The surprise in the paper, however, was something else. It turns out that the placebo group did better than the medication group! Not only did the addition of anti-depressants fail to improve outcome, but the outcome was actually somewhat worse overall than among those who did not have anti-depressants added to their regimen. The difference was not statistically significant, according to the researchers. Some 23.5% of the treatment arm made “durable recoveries,” whereas some 27.3% of the placebo group did so.

Now the real surprise of the paper lies in the author’s definition of “durable recovery.” Any eight-week period over which the patient experienced no more than two symptoms of depression or two manic symptoms justified the assignment to the bin “durable recovery.” This would seem to be a rather low bar, and probably offers back-handed testimony to the poor state of medication management of Bipolar Disorder.

One of the challenges we face in getting neurofeedback accepted is that pharmacologists see their own work as setting the gold standard for remediation. Medication is real medicine, after all, and anything else probably falls somewhat short of what medication can accomplish. Given the difficulty of proving out medication efficacy in formal studies, anything else would surely stumble over that hurdle. Smugness ensues, particularly when those same folks hold the purse strings to the studies.

What cannot be processed in that worldview is the possibility that another remedy is actually considerably better than what can be routinely accomplished with medications. This is our clinical experience. Of course it is not ultimately an either/or issue. The clients we see are typically on medications when they arrive, and many remain on some level of medication when they depart. But the dosages are less in nearly every case, and the functionality and stability will have improved in essentially every case. (I am aware of only a single treatment failure over the years, not counting those who abandoned the training during the early phase. And this one was a special case of a vegetarian whose diet was not doing his brain any favors.)

There is yet another lesson to be drawn from the above study. The authors don’t anticipate that prescribing physicians will necessarily withdraw their bipolar patients from anti-depressants, although such prescribing may be done more conservatively in the future. This is not an unreasonable position to take. After all, there is considerable variety in clinical presentation, and many patients do benefit from anti-depressants, despite what the overall statistics may indicate.

This brings us back to the issue of formal diagnosis. Perhaps the greatest effect of elevating the issue of diagnosis is that it frames the entire discussion around that issue. It is implicit that there exists a singular, homogeneous entity that is being referred to. The application of statistical analysis assumes that the population is uniform with respect to the relevant parameter. The resulting statistical tyranny tends to get in the way of any more subtle evaluation that might see such behavior as multi-faceted, perhaps requiring a very different kind of understanding and possibly even a multiplicity of remedies.

In the application of neurofeedback, the whole issue of diagnosis fades into relative insignificance. There is no “threshold” that determines the appropriateness of neurofeedback, entirely irrespective of clinical presentation. And there are no discrete choices to be made with respect to one “procedure” or another. The brain is trained by one or more of our standard approaches, and the most effective ones will be emphasized and selected for going forward. This strategy is actually very similar to what is done with medications, but on a much more compressed timescale because we observe the effects of our intervention essentially immediately.

(Source: www.nejm.org March 28, 2007)

This entry was posted on Tuesday, May 1st, 2007 at 12:50 am and is filed under Diagnoses, Durable Recovery, Efficacy, Placebo. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.