(If you haven’t read yesterday’s blog, A Million Little Lies, start here.)

A Million Little Pieces author James Frey appeared on Larry King Live Wednesday evening, 1-11-06, to answer questions raised about the authenticity of his memoir. Most strikingly, he was not at all like Trudeau, who in defense of challenges against his book, ‘Natural Cures,’ came across to me like a used car salesman. Frey was subdued and somewhat anxious appearing. He spent most of the interview looking down at the table.

He readily admitted to changing some of the "facts" in his life story but defended it saying only 18 of 432 pages have information being disputed and that a memoir is supposed to be a "subjective" recollection of one’s life.

He said several times that the book reflects the essential truth of his life and that it’s supposed to be the story of his intensive rehab treatment of alcohol and drug addiction, which he says no one disputes.

The most enlightening information that came out of the interview is that he had originally sent his book to several publishing companies as fiction, and it was rejected. It was the eventual publisher (Random House) that made the decision to publish it as a memoir. In the interview, he came across as a person who got in over his head - especially after he received a call from Oprah that forever changed his life and propelled him into the limelight.

In a dramatic finale, just as the program was ending, Larry King announced that they were going past their time limit because Oprah was on the phone. She had not yet made any public comments about all the controversy. She was supportive of the author and his story. She described the controversy as "much ado about nothing." She only took issue with the publisher who she relies on to "define the category the book falls into and the authenticity."

Would the book have been No. 1 if it had been published as fiction? My guess is no. ‘Pieces’ has sold over 3.5 million copies and the sequel, My Life as Leonard, is already up to No. 6. Ironically, Memoirs of a Geisha, currently No. 2, is fiction.

You do the math - millions of books at $20 each, a movie produced by Brad Pitt - we’re talking big bucks.

Frey seemed shaken by all the controversy. He said that they added a disclaimer to his second book - mainly about his supposed time in prison. He seemed sincere when he said he would never again write about himself, less convincing that he had no negative feelings or ill will toward TheSmokingGun.com.

I ended up not feeling negatively toward him but again at the mercy of big business - the publishing house. I believe Oprah is sincere in her support of the author, and the book offers hope. But I wonder about her closing description of a 10-year-old boy already tormented by drugs, alcohol and alienation. According to numerous reports on TheSmokingGun.com, he seemed like a normal teenager. Was his addictive illness really so severe that his recovery was heroic? To patients with severe addiction, 6 weeks in rehab rarely leads to a normal life. Relapses are the rule. (more on addictions)

Addiction is about denial and lack of control. A Million Little Pieces seems to be about, "where’s the money?".

Question: I take Zyprexa and Cymbalta for depression. I would like to get off the Zyprexa*. Is there another combo that will work just as well, such as Cymbalta-Effexor, or Cymbalta-Wellbutrin? Thanks for the help - I enjoy your website.

– Max
*Max clarified this was due to “side-effects mostly. I have to have blood test to make sure it’s not affecting my liver and sugar. Cost is a consideration.”
Answer: Current clinical research evidence for effective treatment of depression not responding to antidepressant alone (*see note) is strongest for the “atypicals,” including Zyprexa. There are secondary differences with each of the others. Risk of metabolic side effects and weight gain vary within the group. (Note: Assuming adequate dose and duration and preferably including a broad-spectrum antidepressant like Cymbalta or Effexor, which modulate both serotonin and norepinephrine.)
My 1st choice in this group, considering side effects and efficacy, is Abilify. (more on Abilify) Changing to Cymbalta and Abilify would be the simplest alternative. However, due to genetics and other complexities, sometimes one specific combination works better than anything else.
There’s no current solution to cost concerns (unless limited income, then see www.needydrugs.com) because no generic substitution exists for your 2 meds (2 generic drugs could be combined to somewhat duplicate the main effects of Cymbalta and another 2 for Zyprexa - but this gets tricky.).
This doesn’t mean you wouldn’t do well on Wellbutrin (available in generic), but Wellbutrin’s effects are totally different and changing would be a gamble.
Good luck!
Dr. Jones

FAQs: Comparing Meds

Or a thousand little lies, or a hundred, or …

When do you stop counting and begin to doubt the truthfulness of what a person says? I have seen patients over the years who fabricate so much they don’t know what the truth is.

On 1-10-06 the major news services reported a story questioning the authenticity of James Frey’s bestseller, A Million Little Pieces, currently No. 1 on USA TODAY’s Best-Selling Books list.

The front page headline on the Life section in USA Today reads "Smoking Gun casts doubt on Frey’s ‘Pieces.’" TheSmokingGun.com’s article is entitled "The man who conned Oprah."

A Million Little Pieces (2003) is James Frey’s account of his six weeks of intensive rehab treatment for drug and alcohol abuse. Sales have soared to over 3.5 million copies after Oprah selected it one of her book club recommendations.

In his book Frey, 36, describes his criminal past that was associated with his alcohol and drug abuse. One example of distorting the facts, verified by both USA TODAY and TheSmokingGun.com, is that he described striking a cop with his car while drunk in 1992. He said his actions resulted in a melee. Interviews with the arresting officer, review of the legal documents, and verification by the local Ohio prosecutor all reveal that he was "polite, cooperative and quickly posted bond." Not quite a "mesmerizing story" as described on Oprah.com.

But is it necessary that all the facts be true? Is it not still a powerful story of addiction and recovery? There is no doubt that his book has inspired many people, and many have probably used it to help in their own recovery. So what difference does it make? Isn’t it just another example of sour grapes by Smoking Gun and "Oh goody, another controversy!" by the media?

Certainly exaggerating or embellishing to gild the lily is not as significant as Trudeau making up all kinds of crap in his book, "Natural Cures ‘They’ Don’t Want You to Know About." My biggest problem is once it is shown there are clear distortions of the facts, I’m left asking myself, "What part is true?" and "Why did he lie?"

The most obvious reason a person lies is to avoid repercussions or to profit in some positive way. Was it his life story that moved Oprah to tears, or was it his creative story telling?

A person who habitually lies to deceive and profit has at least some sociopath tendencies. Another reason a person habitually lies or makes up stories (fabrications) relates more to ADHD or Bipolar disorder. The truth is often routine, even boring. Some kids, teens or even adults who need more excitement realize that embellishing the story stirs up more excitement and is a natural stimulant for them. Embellishment can become a habit and in extreme cases, becomes a way of life.

What motivated James Frey? We don’t know, but I tell my patients the best way to understand behavior is to look at its consequences. In USA TODAY, 1-11-06, A Million Little Pieces was not only the top selling current book but also more than double the 2nd ranked book. Virtue has its own reward, but you may not be able to put it in the bank.

Premenstrual Dysphoric Disorder responds to medications that enhance serotonin levels. It can be inferred that the cause relates to dropping serotonin levels as estrogen levels fall (since estrogen increases serotonin). Lowering serotonin levels only causes mood symptoms in women who have a genetic predisposition or previous history of depression.
Unlike depression, symptoms of PMDD respond fairly quickly to medication. Typical mood symptoms of PMDD are sad, tearful, feeling overwhelmed, irritability and being overly emotional.
Before deciding whether to use medication every day or just in the last 1-2 weeks of the cycle it is recommended that mood charts be kept for 2-3 cycles. This is primarily to evaluate mood in the first half of the cycle. It is believed that many women have mood symptoms all the time but they are worse during the premenstrual phase. It may be that the lesser degree of depression in the early cycle is normal (by comparison). PME or premenstrual exacerbation of mood symptoms is best treated with daily medication - though sometimes increasing the dose in the last 7-10 days is helpful.

For true PMDD there are several reasons that limiting medication to a few days is helpful. The biggest reason is avoidance of potential long term side effects, especially sexual side effects, possible weight gain and blunting of emotion and motivation. Other reasons include the cost, stigma, and the hassle.
When using medication just during the late luteal phase (last few days of cycle) my first choice is Effexor. Because Effexor is the quickest to cross the blood brain barrier (due to low protein binding) it can be taken for the shortest number of days. It frequently starts working the first day (usually 37.5mg is adequate but sometimes 75mg is needed). Once Effexor is discontinued - usually once menses starts - the Effexor is totally out of the system in 3 days. Most medications take one week to be out of the system. Prozac (fluoxetine) aka Sarafem takes six weeks to clear - i.e., it can’t be taken just during the PMS phase. My 2nd choice and the second fastest to work is Lexapro 5-10mg. Ironically it’s Prozac (Sarafem) and Zoloft (slowest to work) that pursued and received FDA indications.
Although Effexor and Lexapro may work the first day it’s usually better to start them 2-3 days before symptoms usually start - this of course requires using a calendar and keeping track of due dates. If you can tell when you ovulate it’s easy - 14 days later you will start your period.

A new treatment was recently approved by the FDA for insomnia. Rozerem (Ramelteon) has a different mechanism of action than other sleep medications. It works by stimulating two of the melatonin receptors in the brain. It does not stimulate the melatonin receptor that can constrict arteries and so therefore should not have the potential risks associated with high doses of melatonin.

Since melatonin is a natural hormone that induces sleep, Rozerem should produce normal sleep. It has been shown to induce the normal sleep stages of EEG. Rozerem is not structurally or chemically related to melatonin. Melatonin is a much simpler structure and is derived from serotonin.
Studies have shown Rozerem (on the market as 8mg tablets) to be better than placebo at helping people stay asleep. It has a fairly short duration (1/2 of it is gone within 1-2.5 hours). My guess is that it is especially helpful when the sleep problem is related to the circadian rhythm being off - i.e., the normal melatonin peak being either early or more likely late due to lack of adequate am bright outside light exposure. Shift work and other irregular sleep schedules can also interfere with normal physiology of sleep.
Rozerem may be particularly helpful in adolescents - who don’t usually do well on typical sleep medications. It may also be helpful for insomnia in the elderly who have reduced melatonin (that usually peaks in the late afternoon or evening).
Rozerem probably won’t be helpful for severe insomnia or insomnia associated with anxiety or mood disorders. Development of tolerance hasn’t been seen but we don’t have very long studies. It may be helpful added on to other sleeping pills when they are not fully effective.
One concern is that melatonin can increase prolactin and decrease testosterone/estrogen levels. This effect has been reported in an occasional patient on Rozerem. Complications of this hormone effect could be decrease in libido in the short term but long term cause other physical problems.