You find yourself in the emergency room in an acute manic episode. The treating physician writes out a prescription for lithium, and this being the era of the HMO, he or she releases you the next morning. The lithium doesn't work. Now what?

Or you may find yourself in the same place as a result of a deep dark depression, and once again you are subjected to what amounts to drive-by psychiatry, this time an SSRI and out the door. The SSRI's side effects turn out to be as bad as the depression, which still persists. Again, now what?

All too often, we are subjected to shoot-from-the-hip treatment, where the doctor or psychiatrist takes his or her own individualistic approach using you as the guinea pig. But things are changing. A little noticed but highly significant trend in pharmacological treatment has been the development of algorithms and guidelines. Essentially, algorithms and guidelines recommend initial treatment for anticipated clinical situations, such as mania with psychosis, then attempt to answer the question "what next?" if the patient doesn't adequately respond. Algorithms and guidelines are not meant to replace a clinician's judgment, but can hopefully provide a ready reference.

In 1996, the Texas Medication Algorithm Project (TMAP) was started to explore ways to develop cost effective mental health care in the public sector, including bipolar disorder, depression, and schizophrenia. Phase I involved developing guidelines based on expert consensus, with publication following in 1999.

The TMAP algorithm for mania/hypomania resembles a flow chart of seven-tiered boxes and connecting lines. The first tier, stage one, lists two types of mania/hypomania (mixed/cycling or euphoric), with corresponding recommended first treatments, all involving one drug (Lithium or Depakote for euphoric mania; Depakote or Tegretol for mixed mania).

If there is no response or a partial response after exhausting the options in stage one, TMAP suggests combining the drugs. At stage five, TMAP recommends adding an atypical antipsychotic to a mood stabilizer and at stage six ECT is an option.

The TMAP algorithm was superceded by the 238-page Texas Implementation of Medical Algorithms (TIMA - see article), published in 2001. Atypical antipsychotics, a next-to-last choice for mania but two years before, jumped to a number one option.

In 2000 came the publication of 104-page Expert Consensus Guidelines for the Treatment of Bipolar Disorder, drawing from 58 experts, covering 48 clinical situations with 1,276 options for intervention. Its two algorithms for mania and depression treatment provide the same kind of handy step-by-step visual blueprint pioneered by TMAP-TIMA. At four years old, the Expert Consensus Guidelines are already dated, an acknowledgment that our learning is hardly standing still, which should be regarded as highly encouraging.

As well as short shelf lives, the other weakness of algorithms and guidelines that are based on consensus, even expert consensus, is that they drown out innovative minorities, say practitioners who are getting good results with omega-3 as add-ons to conventional meds. The other weakness is they are based on opinion rather than hard data. For example, it is taken for granted that brand name drugs work better than generics and that atypical antipsychotics work better than older generation antipsychotics despite little published evidence to support this.

The TMAP process was and continues to be highly political. According to whistle blower Allen Jones, an investigator with the state of Pennsylvania until he was fired, the drug industry contributed $152,000 to Texas candidates for public office in 1998 when TMAP was getting going, up from zero in 1994. The project was also heavily underwritten by the drug companies. TMAP has been adopted in Pennsylvania and several other states, where doctors working with public sector patients must prescribe brand name drugs and only use generics after the brand names have failed.

Ironically, what began as a way of saving money is now bankrupting Texan health and mental health programs. According to an article in the Dallas Morning News: "While the growing and aging population is a contributing factor to the rise in cost in Texas, there also has been a dramatic increase in the use of 'new generation' drugs such as Zyprexa, an anti-psychotic, and Prozac, an antidepressant.”

A slightly different approach are the 50-page Practice Guideline for the Treatment of Patients with Bipolar Disorder (see article) issued by the American Psychiatric Association in 2002, and the 25-page Evidence-based Guidelines for Treating Bipolar Disorder (see article), published in 2003 by the British Association for Psychopharmacology, both drawing from a panel of experts, but with more emphasis on data from available drug trials. This time, you have to visually imagine the step-by-step series of treatment options without the aid of algorithms.

An obvious weakness is that with very little hard data on the treatment of bipolar depression and long-term treatment of bipolar in general, not to mention other areas of the illness, the authority of these guidelines is sharply limited.

Despite their considerable shortcomings, treatment algorithms and guidelines represent a welcome new era of rationality to traditionally the least scientific of the medical disciplines, and may compensate somewhat for the HMO-imposed 15-minute meds checks that now pass as consultations. Additionally, the patient benefits from knowing where he or she stands in the treatment picture and why.

Significantly, two of the principal authors of two algorithms are now heading up the largest clinical trials ever for the treatment of depression and bipolar disorder. A John Rush MD of the University of Texas and the TMAP Depression Algorithm is leading STAR*D for depression, and Gary Sachs MD of Harvard and the Bipolar Expert Consensus Guidelines is in charge of STEP-BD for bipolar, both funded by the NIMH and involving thousands of patients in centers throughout the US, appropriately enough tested in phased algorithm fashion. We are getting smarter all the time.

For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.

Updated June 24, 2004

Treatment articles All articles

Discussions

Lynda (June 10, 2004): Well, I find myself thinking like a lawyer, with a fool for a client. Since I have only "suffered" from one episode of hypomaniac, and have just started tinkering with Paxil/Lexapro, these fundamental questions keep nagging at me.

Is someone called "ill" only if their symptoms bruise or break the social contract? If I can live with mild mania and a certain cantankerousness as the "poles" of my personality, who's to say these should be administered to? (as in meds).

Suddenly what I thought of in loose Jungian terms as my self, has become a compendium of tweakable impulses, drives etc. Is it my morals, or Paxil makin' me randy at 48. Or peri-menopause. Persephone herself couldn't sort all this out. If nobody knows what the personality is, how can they help me steer it?

Meant light-heartedly, yet seriously.

McMan (June 10): Hi, Lynda. Two things - 1) I would maintain that mild hypomania shouldn't be treated, depending on individual circumstances, but this is probably against mainstream psychiatric opinion. If it isn't interfering with function and not causing a problem and not the beginning of a cycle into mania, I see no reason to mess with feeling good, particularly with regard to the side effects BP meds cause (see my article, Oh To Be Hypo). 2) You do have a fool for a client. Antidepressants can cause switches into mania, hypomania, and rapid cycling. The antidepressants could be making you feel too good for your own good. Please talk to your real doctor and find out what's going on.

Post your opinion here.

John McManamy

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John Rush (top) and Gary Sachs (below): Getting smarter all the time.