For more about the autism-metallothionein link and Dr. Walsh's work, see my book The Natural Medicine Guide to Autism.
Biochemical researcher William J. Walsh, PhD, chief scientist at the Health Research Institute and Pfeiffer Treatment Center (HRI-PTC), is the heir-apparent of the late Carl Pfeiffer, MD, PhD, a pioneer in the biochemical treatment of illness and of mental illnesses in particular. Before he died, Dr. Pfeiffer asked Dr. Walsh to establish the center to carry on the important work in which they had both been engaged for decades.
HRI-PTC is a not-for-profit research and outpatient facility near Chicago, in Warrenville, Illinois. HRI is the research wing and PTC the treatment wing. Designed as a collaboration between biochemists and medical doctors, the organization specializes in biochemical treatment of mental, emotional, and behavioral disorders. Since its founding in 1989, it has treated more than 15,000 people with bipolar disorder, depression and anxiety disorders, schizophrenia, autism, attention deficit disorder, hyperactivity, and other behavioral, emotional, and learning problems.
“What I've been doing for the last 30 years,” explains Dr. Walsh, “is trying to develop chemical classifications for conditions such as bipolar disorder, depression, schizophrenia, behavior disorders, and autism because every one of these terms is an umbrella term or a garbage term that encompasses different categories.” The chemistry underlying the diagnosis is not only the key to individual treatment, but if biochemical commonalities could be found among individuals in each category, this could also potentially point the way to the cause of the disorder, with attendant prevention and even cure.
Although bipolar disorder clearly has a genetic component, that doesn't mean that the condition is “hopeless or incurable,” says Dr. Walsh. “What genetics means, to me, is chemistry. Chemistry can be adjusted and corrected.” He gives the example of someone with depression, in which a genetic component is involved (science acknowledges the role of genetics in depression). “Some people, whether with medication or with some other therapy, become free of depression. So does that mean it wasn't genetic? And they weren't really depressed?”
About two-thirds of the bipolar patients who come to PTC have “classical” bipolar disorder, while one-third are bipolar with psychotic features, Dr. Walsh reports. “Bipolar with psychotic features may just be a more severe version of bipolar,” he says, noting that all illness occurs as mild, moderate, or severe. “If you have a mild version, you'll be hypomanic. If it's moderate, you might be a classic manic-depressive. If it's severe, then you might have bipolar with psychotic features.”
Some patients with hypomania rather than full-blown manic episodes “still feel that it's out of control, that it's wrecking their life. They can't trust themselves,” notes Dr. Walsh. Others, experiencing their hypomanic periods as their most creative time, “want to get rid of the depression and keep the mania. But the severe manic-depressives, they want to get rid of both.”
Symptomatically and biochemically, bipolar with psychotic features is close to schizophrenia, states Dr. Walsh. “I've seen almost identical patients with identical symptoms and one is called schizophrenic and the other is called bipolar with psychotic features. I think it's just a matter of semantics.” In addition, the blood and urine tests of people with the two conditions show the same results. “We can't tell the difference between the biochemistry of the schizophrenic and the bipolar with psychotic features.” Dr. Walsh notes that the biochemistry of classical bipolar, however, is different from that of schizophrenia.
In biochemical treatment, it is the details of the biochemistry, rather than the diagnostic labels, that provide the direction for therapy. This approach has the advantage of addressing each person's unique biochemical condition. In contrast to prescription drugs designed to elevate serotonin or lower dopamine, biochemical therapy gives the body only what it needs, and it does so safely. The problem with the pharmaceuticals is that they're “affecting probably five to 15 other neurotransmitters, altering these people's brains and causing these things called side effects,” says Dr. Walsh.
Providing the body with missing nutrients restores its innate ability to correct and regulate its neurotransmitter levels and function. “It seems likely that the next century's treatments will implement natural body chemicals that restore the patient to a normal condition, rather than drugs that result in an abnormal condition,” Dr. Walsh states. “The world may eventually learn the wisdom of Pfeiffer's Law: For every drug that benefits a patient, there is a natural substance that can achieve the same effect.”174
While every individual is different, the top four biochemical trends in frequency of occurrence in the people with bipolar disorder who come to PTC are a methylation disorder that results in too high or too low levels of neurotransmitters, essential fatty acid imbalance, metal-metabolism problems, and pyroluria, a disorder that leads to extreme deficiencies in zinc, vitamin B6, and arachidonic acid, an omega-6 essential fatty acid.
These imbalances may be mild, moderate, or severe, which has a bearing on whether a person develops bipolar disorder or not. On the mild end of the spectrum, “if a person is in a great environment and life is pretty copacetic and calm, they may go through life without a breakdown,” states Dr. Walsh. However, if a person on the mild end “has a nasty environment or some troubling traumatic events in their life, they might break down because of that. But at the other end of the spectrum, with severe versions of these imbalances, I think it's inevitable. It doesn't matter what their life circumstances are, it's going to happen.”
In the 1970s, Dr. Pfeiffer developed a biochemical treatment model for schizophrenia that forms the foundation for the approach PTC uses today with both schizophrenia and bipolar disorder. Dr. Pfeiffer's model was based on his discovery of high histamine levels in some schizophrenics. Others had low histamine levels. Histamine is an essential protein metabolite (a product of metabolism) found in all body tissues, and although most people associate it with allergies (it is what produces the runny nose, weepy eyes, and other signs of inflammation in an allergic reaction), in the brain, histamine functions as a neurotransmitter.
Dr. Pfeiffer found that he could reverse or alleviate schizophrenic symptoms by giving supplements that normalized the histamine level, lowering or raising it as needed. He concluded from the effectiveness of this approach that histamine, as a neurotransmitter, might very well be the decisive factor in schizophrenia, recalls Dr. Walsh. “A lot of time has passed since his death, and there's a lot more evidence. It appears that histamine is actually a marker for methylation. People who are high histamine are undermethylated. People who are low histamine are overmethylated. What Pfeiffer did was accidentally stumble on the right treatment, on an effective treatment. He thought he was adjusting histamine, but what he was doing was adjusting the methyl-folate ratio.”
What do undermethylation and overmethylation mean? Methyl is one of the more common organic chemicals in the body; methyl groups are present in most enzymes and proteins. Methylation is the process by which methyl groups are added to a compound, making methyl available for the many reactions for which it is needed in the body. Both methyl and histamine are major, ubiquitous chemicals in the body, and they compete with each other, Dr. Walsh explains.
With too much methyl, the body overproduces the three neurotransmitters dopamine, norepinephrine, and serotonin. With too little methyl, the neurotransmitter levels are too low. Folates are the various forms that folic acid takes in the body. Folic acid, a member of the B-vitamin family, aids in the manufacture of brain neurotransmitters and thus needs to be available in the proper ratio with methyl.
On the basis of his research since the 1970s, Dr. Walsh now knows that the methylation factor operates not only in schizophrenia but in bipolar and other mental disorders as well. For example, high histamine and its attendant low methyl are also associated with obsessive-compulsive disorders. Like people with schizophrenia, most people with bipolar disorder have a methyl imbalance—either too much or too little. “The methylation factor highlights the importance of knowing what is happening in a person biochemically,” observes Dr. Walsh. “For people who are overmethylated, taking drugs to raise neurotransmitter levels will be detrimental.”
Treatment for low histamine and overmethylation consists of supplements to reduce methyl, notably folic acid, vitamin B12, and vitamin B3 (niacin or niacinamide). Many people in this category also have a metal-metabolism problem, as evidenced by high levels of copper in relationship to low zinc, so that problem needs to be addressed as well (see the section on metal metabolism to follow).
The supplements used in treating high histamine and undermethylation are the amino acid methionine, calcium, magnesium, and vitamin B6. These supplements increase methyl in the body and/ or assist in methylation. Calcium is an important supplement for those who are undermethylated because it helps lower histamine levels. For those people who do not efficiently convert methionine to SAMe (S-adenosyl methionine), a necessary step in making methyl available to the body, SAMe supplements are part of their program.
With this protocol,“neurotransmitter production will become more normal,” Dr. Walsh explains. However, reversing undermethylation is “a slow, gradual process that takes four to six months to complete.”
In addition, the nature of high-histamine, undermethylated people sometimes interferes with treatment. It is important to note here that this biochemical characteristic exists not only among people with bipolar disorder or other “mental” illness, but widely in the general population as well. Those who manifest bipolar have a more severe imbalance, genetic vulnerability, or other factors that combine to produce the disorder. “High-histamine, undermethylated people are intrinsically noncompliant,” says Dr. Walsh. “High-histamine, undermethylated people are the kind of people who don't want to go see a doctor for anything. If they have a splitting headache, they won't even take an aspirin. They tend to be averse to treatment of any kind.”
While the supplements to correct these biochemical trends tend to be the same, there is no standard protocol at the Pfeiffer Treatment Center. Treatment is based on individual biochemistry and dosage is determined according to a person's metabolic weight factor. This is a method of calculating dosages based on metabolism, Dr. Walsh explains. It is far more accurate than figuring dosage as a mere percentage of the standard 160-pound person. The latter method results in underdosing small people and overdosing big people. If you have someone who is 320 pounds, for example, it is not correct to give them twice the dose of a 160-pound person, says Dr. Walsh.
In Dr. Walsh's experience, essential fatty acid (EFA) imbalances play a much greater role in bipolar disorder than they do in either unipolar depression or schizophrenia. “That might be the differentiating factor between them,” he notes. “Of the 300 major fats in neuronal tissue and the myelin sheath, four of them make up more than 90 percent of all this fatty material at brain synapses and receptors. That has to be important.” The four fatty acids are EPA (eicosapentaenoic acid), DHA (docosahexaenoic acid), AA (arachidonic acid), and DGLA (dihomo-gamma-linolenic acid). The first two are omega-3 essential fatty acids, and the second two are omega-6s.
As others have observed, the standard American diet, with its generally poor nutrition and emphasis on junk food, tends to result in an overload of omega-6 and a deficit of omega-3 EFAs, notes Dr. Walsh. Both the low- and high-histamine categories of bipolar disorder fit this profile. The main EFA therapy for these people is omega-3 supplementation, specifically EPA and DHA. Fish oil contains both and is therefore a helpful form of supplement, but Dr. Walsh also uses products that are pure EPA and DHA. For bipolar, he does not use flax oil as a source of omega 3s because, being primarily EPA, it does not supply enough DHA.
With pyroluria (see section in this chapter), the problem is not omega-3 deficiency, but rather, low levels of omega 6, specifically, arachidonic acid. This is less common in bipolar disorder than the methyl factor. In these cases, the EFA supplement needed is primrose oil or borage oil. Dr. Walsh observes that people with bipolar disorder and this biochemistry have the typical skin problems associated with omega-6 deficiency, which are very dry skin, inability to tan, and vulnerability to sun poisoning.
With people who demonstrate the omega-3 deficiency, a fascinating fact is that DHA and EPA address the opposing poles of bipolar disorder. DHA works to calm the manic phase, and EPA helps to lift the depressive phase, says Dr. Walsh. Taken together, they act as a mood regulatory system and help prevent mood swings. Both are needed, which is a further explanation as to why fish oil, which contains both, produces results in treating bipolar disorder, while flax oil does not, as research shows.
Hypothetically, says Dr. Walsh, people who only experience mild hypomania rather than full-blown mania in their bipolar disorder and who want to avoid only the depressive phase could take EPA alone, but he typically recommends the combination of the two essential fatty acids.
A problem with metal metabolism (the regulation of metals, which include both necessary minerals and toxic heavy metals such as mercury) in the body is also frequently present in bipolar disorder, as evidenced by high levels of copper in relation to zinc. This indicates that the body is unable to control the mineral levels in the bloodstream. Normally, the body can maintain homeostasis (the proper ratio) of copper and zinc in the blood, regardless of diet or other factors, because this ratio is so crucial to many functions. This mechanism of homeostasis relies upon a vital protein called metallothionein; thus, an inability to maintain homeostasis indicates a metallothionein deficiency or malfunction.
Metallothionein is involved in many functions of the body, including immunity, brain and gastrointestinal tract maturation, and the regulation of metals. A deficiency in or inability to utilize this substance is associated with an impaired nervous system; mental difficulties; weakened immunity; and digestive problems, including malabsorption, nutritional deficiencies, and the development of allergies. Dr. Walsh has also discovered a link between autism and metallothionein dysfunction; in fact, his research suggests that such dysfunction may be a primary cause of autism.
For more about the autism-metallothionein link and Dr. Walsh's work, see my book The Natural Medicine Guide to Autism.
Since there is no commercial test to measure metallothionein in the body, PTC relies on the ratio of blood levels of zinc, copper, and ceruloplasmin (a substance in the blood to which copper attaches) as indicators of malfunction of this protein. Treatment then consists of supplements to stimulate the function of metallothionein.
PTC has long been expert at correcting disturbances in metal metabolism. “We've known for more than 25 years that two-thirds of people with behavior disorders have a metal metabolism problem,” states Dr. Walsh. “And we've known for all that time that it was almost certainly a problem with metallothionein. The reason we were sure was that all of the metals that are managed by metallothionein are the very ones that are abnormal in these people.”
For example, people with obsessive-compulsive disorder tend to have very low copper levels, he explains, as do sociopaths (people with antisocial personality disorder). In bipolar disorder, the undermethylated type also has low copper, while the overmethylated type has high copper levels, and the pyroluric type has severe zinc and metallothionein deficiencies. Dr. Walsh emphasizes that it is the ratio of copper to zinc that is important here. “We learned awhile ago that you have to measure the ratio to get solid data. If you look at the individual elements, you can get fooled.”
A metallothionein problem, which results in a failure to achieve homeostasis of copper and zinc in the bloodstream, is mainly a genetic disorder, according to Dr. Walsh. But a zinc deficiency can also create or further exacerbate the problem. “The primary nutrient needed in the formation of metallothionein is zinc, so if you're extraordinarily zinc deficient, that will disable the system,” says Dr. Walsh.
In any case, biochemical treatment is the solution to reversing the problem. “Zinc, manganese, and vitamins E and C are all aimed at inducing and promoting normal functioning of metallothionein,” explains Dr. Walsh, adding that selenium and glutathione (a relative of glutamic acid, an amino acid) are also very useful nutrients for this purpose. Vitamin B6 is also part of the protocol because “B6 and zinc work together, and B6 is directly involved in the synthesis of some of the neurotransmitters.”
Dr. Walsh has found this program to be “quite effective.” Typically, the copper and zinc level out and become normalized. “When the person achieves homeostasis of copper and zinc levels in the blood, you can conclude that metallothionein is operational,” he says.
As the supplement program gradually brings the metallothionein protein into proper function, metallothionein's detoxification work will resume. The emphasis here is on gradual. “We learned long ago that we don't dare suddenly bring it to life,” Dr. Walsh explains. “Because if that happens, the metallothionein works so well that it suddenly causes an excessive amount of toxics in the tissues to be released all at once. And that could cause nasty symptoms and stress the kidneys.” To prevent this, the dosages of the supplements that stimulate metallothionein are slowly increased over time.
In some cases of bipolar disorder, tests reveal a condition called pyroluria, which is characterized by extreme deficiencies in zinc, vitamin B6, and arachidonic acid, the omega-6 essential fatty acid discussed above.
A pyrrole is a basic chemical structure used in the manufacture of heme, which is what makes the blood red. Pyroluria is a genetic disorder in pyrrole chemistry, characterized by an overproduction of kryptopyrroles (meaning “hidden pyrroles”) during the synthesis of hemoglobin (the iron-rich component of the blood that carries oxygen). Since kryptopyrroles bind with vitamin B6 and zinc, which are then excreted in the urine, this leads to deficiencies in these two nutrients. People with pyroluria may have low levels of the neurotransmitter serotonin, as vitamin B6 is needed for its synthesis.176 Also, GABA is a zinc-dependent neurotransmitter, so a zinc deficiency may have negative repercussions on this neurotransmitter as well.
Pyroluria is known to scientists and physicians with a biochemical orientation for its connection to schizophrenia, says Dr. Walsh. But bipolar disorder is associated with it as well, and the two diagnostic labels are often confused when pyroluria is present. Pyroluria is a genetic disorder that may explode into mental imbalance as a result of a stressful event or period in one's life. “With the pyrolurics, not only do they have a high-stress onset, but also their relapses are almost always tied to stress. It's a cause and effect there, whereas with the other two groups [classic bipolar disorder and schizophrenia], it's not necessarily related to their life circumstances. They cycle also, but there's no rationale to it.”
The involvement of pyroluria in bipolar disorder and schizophrenia is consistent with the first breakdown typically taking place between the ages of 15 and 25. Dr. Walsh believes that puberty and the growth spurt of that time period exacerbate the pyroluria by consuming zinc and elevating copper and serve to trigger the mental disorders. “Hormones are related to copper,” he explains. “The higher your estrogen level, the higher your copper level. Copper is related to paranoid schizophrenia, so that's a direct connection. Also, for the pyrolurics, zinc deficiency is a problem. When you go through a growth spurt, it consumes a lot of zinc, so a pyroluric under a growth spurt may become severely zinc deficient.”
The classic signs of zinc and B6 deficiency, which tend to go together, serve as an alert for pyroluria. These include sensitivity to bright light, little or no dream recall, a tendency to skip breakfast, and preference for spicy food. Treatment for pyroluria focuses on supplementation with zinc, vitamin B6, and augmenting nutrients.
As part of gathering information for treatment design, PTC looks “for the symptoms that tend to accompany the various biochemical imbalances that our work over decades has taught us are associated with these disorders, and then we do a history that takes an hour to an hour and a half,” says Dr. Walsh. “We want to learn everything about that human being. We want to know their medical history, their symptoms, their personality, their life history, the kind of student they were, reaction to any medications they had. We want to know what happened at the time of their breakdown. We want to know what differences they felt and their family saw at the time of the breakdown.”
The scientific basis for biochemical treatment, however, is gained from blood and urine tests. Blood testing is the key for determining high and low histamine, or undermethylation and overmethylation, respectively. In the case of pyroluria, it is a urine test. With this information, treatment can be tailored to the individual.
In addition to the Pfeiffer Treatment Center (see the listing for Dr. Walsh in the appendix), another clinic that specializes in this type of biochemical balancing is the Riordan Clinic, 3100 North Hillside, Wichita, KS 67219; (316) 682-3100; www.riordanclinic.org.
PTC has had good success with bipolar disorder in most cases, based on outcome studies, with most families reporting “remarkable improvement” or “partial improvement.” No improvement is uncommon with the biochemical approach, reports Dr. Walsh. Those who experience partial improvement can be divided into two categories: “those who did great and relapse once in a while; and those who got partially better and are still partially better.”
Partial improvement suggests to him that the chemistry is only partially corrected. “There is still some element of chemical imbalance present, and all it takes is an environmental trigger—it could be an emotional upset, a death in the family, an illness, an injury, a car accident,” he says. The relapses are almost never back to the pretreatment state, however. He describes it as going from zero to 100 percent with treatment, and then with relapse going down to 60 percent. Relapse seems to stem from a combination of stress and compliance problems, reports Dr. Walsh. The relapses are usually brief and, with resumed or temporarily increased dosage of supplements, the person is soon back up to 100 percent.
“We strike out 20 to 25 percent of the time in bipolar,” he says, citing compliance among older patients as a major issue. “We've done outcome studies of thousands of people, and we find that compliance is almost linearly heading downward from the age of three. So the older the person, the less likely they are to comply with your treatment.”
People with bipolar disorder are different from schizophrenics in this regard. The latter seem be more compliant perhaps because “they suffer so dramatically,” says Dr. Walsh. “Their pain is so enormous that they will do anything to get better. I think it's a matter of desperation for them.” This is not to say that people with bipolar disorder are not suffering extremely, but schizophrenics are further along the continuum of pain and dysfunction in life.
—KAY REDFIELD JAMISON, PHD
One of the reasons for noncompliance may be negative experiences with medications. By the time most of the people who are bipolar come to PTC, they have been on many medications and suffered through their negative effects. In a not uncommon occurrence, one young man recently told Dr. Walsh that he didn't think he could bear to live if he had to continue to take Zyprexa (an atypical antipsychotic) and Celexa (an SSRI). He was on a high dose of both and didn't think they were helping him. “He said he felt like he was a horse with blinders on and he could only see straight ahead when he was thinking about things,” recalls Dr. Walsh. “It was an interesting way to describe the differences in his mental functioning. He would try to focus on something and would lose all perspective.”
For many people, the effects associated with the drugs they have been given in an attempt to regulate their bipolar disorder have left them with an aversion to medication. “We give them capsules to swallow and it's hard for them to distinguish between medication and nutrient therapy,” observes Dr. Walsh, who views gaining compliance as a component of a successful therapeutic method. “You need to have a treatment that people can do and will do. That's part of the treatment.”
If people stop taking the supplements for a while, even a week or ten days, they begin to deteriorate. Then they are even less likely to take their supplements. “Sometimes it's a vicious circle. Once you get to a certain point, then you're not able to bring yourself back. It can happen quickly.”
Patients with bipolar disorder have to take more supplements than most PTC patients, an average of seven to ten pills, both morning and evening. Compounding the supplements (a compounding pharmacy prepares the formula in accordance with the individual's biochemical needs) makes compliance more likely, as it usually cuts the number of pills down to three to four, taken twice daily.
The following cases feature the two types of methylation problems in bipolar disorder and the efficacy of biochemical therapy in reversing the condition.
Elena, 24, had always been an excellent student and high achiever; she was valedictorian of her high school class and graduated summa cum laude from a prestigious university. After college, she went to law school. In her first year, she had a severe breakdown, was diagnosed with bipolar disorder, and had to go back home to her family. When her parents brought her to PTC, Elena had been sick for a year. She was on medication and undergoing counseling, but had cut off contact with all of her friends, was no longer able to work, and rarely left her bedroom.
“We found that she was one of the lowest histamine people we had ever seen,” Dr. Walsh reports. “That seemed to be her only imbalance. Everything else was normal, and because this wasn't completely consistent with her symptoms, we retested her and verified that in fact that was her proper diagnosis.” Her overmethylated state meant that “she had too much dopamine, norepinephrine, and serotonin, which explained why the SSRI she was taking was a failure.” The drug was prescribed to try and enhance serotonin activity, “but she was a person who already had too much serotonin.”
To address Elena's overmethylation, the Pfeiffer Center gave her folic acid, vitamin B12, and niacinamide with augmenting nutrients, including vitamins C, E, and B6. The B12 was delivered in the form of weekly injections. In the beginning, she wasn't well enough to give herself these injections, but when she had improved, PTC taught her how to do them herself, and thereafter she did. With such low histamine, she had to continue the shots.
Elena “responded marvelously” to this simple program. In the second month on it, she began to improve and by the fourth month was back to normal. Dr. Walsh notes that essential fatty acids were not part of her regimen because this was before the connection between essential fatty acids and bipolar disorder was known. Today, Elena is doing fine, has not had a relapse, and is working as an attorney, having earned her law degree in the interim.
In fact, she returned to law school after the fourth month of treatment, believing that she was cured. “She completely violated my recommendations,” recalls Dr. Walsh. “I wanted her to wait until at least eight months. She was just in a hurry to get on with her life and went back and struggled for a while. She put too much stress on herself during the biochemical transition period, before we had her chemistry completely fixed.”
Dr. Walsh always cautions people, when they start feeling better, not to be in too big of a rush to get on with their lives. “Most of these people have lost a few years, and they can't wait to get back. They feel behind. All their friends have graduated, are working, married … We always urge them not to jump into the deep end of the pool, but just to dip their toe in. We suggest that, instead of going through a difficult full set of college courses during the first year of recovery, they take one or two fairly easy courses and test out their brain and test out their ability to handle stress.” Elena ignored this advice, went back into a difficult, full-time course of study, and “toughed her way through it.” Fortunately, putting herself through tremendous stress did not have lasting repercussions on her condition.
Marcus was strikingly handsome—he looked like a movie star—and had a compelling personality. He had been diagnosed with classical bipolar disorder at 17 and when Dr. Walsh saw him at the age of 20, he had just spent a year in a penitentiary for forging his father's signature on checks during the excessive buying of a manic phase. His father was wealthy and had for a time paid the debts his son ran up on his manic shopping sprees. At some point, however, he cut his son off financially, thinking that he was enabling this behavior. Not long after, Marcus forged the checks and wound up in jail.
After his release from prison, his parents brought him to PTC. He had at various times been on the mood stabilizers lithium, Depakote, and Tegretol, but he didn't like any of them. While his parents thought the drugs helped, he said that they did not and refused to take them. On the other hand, “he seemed very interested in our treatment,” says Dr. Walsh.
Testing revealed that “he was one of the undermethylated bipolars, with very high histamine.” For this, the Pfeiffer doctors put him on the classic methylation program, that is, methionine, calcium, magnesium, zinc, vitamin B6, manganese, and vitamins C and E.
Marcus complied with the protocol, and in three months he was doing marvelously well. “Then at his six-month follow-up visit, he straggled in, looking sad. I asked him what had happened, and he said, ‘Well, I want to apologize. I stopped your program. Things were going so well I didn't think I needed all those capsules. I thought I could do it myself.’”
The result was relapse. He was plunged into a manic phase again, during which he bought two boats on false credit and was arrested a second time. He needed a lawyer, and his family had refused to help unless he came back to PTC.
Retesting revealed that his chemistry was as skewed as it had been before he started treatment. Marcus's program was adjusted slightly according to these results, but it was essentially the same regimen.
Marcus was sent back to prison for a second year. When he was about to be released at the end of that time, his mother called Dr. Walsh and told him that Marcus wanted to come to PTC. They drove there directly from the prison. Marcus told Dr. Walsh that he was never going to go through that again, meaning incarceration, and he vowed that he would be compliant. That was six years ago, and he is doing “remarkably well,” by his own and his family's report. He has had no more major episodes, has established a successful career in business, and, as far as Dr. Walsh knows, has stuck to his vow to be compliant.