If you’ve been around as long as I have, you may remember a time when the diagnostic label “Bipolar Disorder” was relatively unknown. Although that term has been around since the 1950s, it came into common usage only in 1980 when the APA released its third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III); before then, mental health professionals discussed and wrote about Melancholia or Manic-Depressive Illness. It was considered quite rare. As you may know, that revision to the prior version of the DSM sought to eliminate its psychoanalytic/psychodynamic bias and replace it with a supposedly more “scientific” approach, thereby embedding psychiatry within the medical model of treatment.
According to the 1969 book, Manic Depressive Illness by George Winokur of Washington University, Bipolar Disorder used to be fairly rare. In 1955, only one person in every 13,000 was hospitalized for it. Today, by contrast, according to the National Institute of Mental Health, Bipolar Disorder affects an astounding one in every forty adults in our country!!! It’s also worth noting that, before psychiatric medications were introduced, the long-term outcome for those patients was fairly good. Only 50% of the people hospitalized for a first attack of mania ever suffered a second one. Studies have found that, in the pre-drug period, 75-80% of hospitalized patients recovered within a year and only half of them had even one more attack within the next 20 years. Today, Bipolar Disorder is a chronic illness, with patients spending years and years on psychiatric medications. In other words, Bipolar Disorder was comparatively rare before 1980 and the prognosis for hospitalized patients was fairly good; today it’s 325 times more common than it used to be and has become a lifelong illness.
How are we to account for this change, from a rare and acute illness to one that is pervasive and chronic?
Four possible explanations occur to me. (1) Manic-Depressive Illness was actually more common than believed at the time and clinicians unfamiliar with its features failed to recognize it. (2) Bipolar Disorder is currently “in vogue” and therefore over-diagnosed. (3) The threshold for diagnosis has been lowered and our conception of the illness has been expanded. (4) Something social or environmental has occurred that has actually increased the incidence of Bipolar Disorder. I believe that all four explanations are true to varying degrees. Let’s begin with No. 3
Over the years of my practice, I’ve noticed a steady increase in the use of the term Bipolar Disorder. With the introduction of additional diagnoses such as Cyclothymic Disorder, the division of Bipolar Disorder into Types I and II, as well as a juvenile form of Bipolar Disorder, a reduction in the severity of symptoms needed to meet the diagnosis, plus the identification of a new rapid-cycling form of Bipolar Disorder, this category of mental illness has expanded its reach to cover an ever-larger population. At the same time, I’ve seen exponential growth in the use of psychiatric medications as the primary form of treatment.
As for No. 1, I’m sure that years ago when mental illness was more of a taboo subject, many cases of Bipolar Disorder went undiagnosed. Regarding No. 2, I believe it’s quite true that many people who receive the diagnosis today don’t merit that label, especially when under-informed general practitioners rather than psychiatrists assign the DSM-IV code and write a prescription for psychiatric medication. None of these factors can fully explain the astronomical increase in the incidence of Bipolar Disorder or its transformation from an acute into a chronic illness.
Robert Whitaker, whose book The Anatomy of an Epidemic I covered in several recent posts, has a disturbing explanation. He begins with a study from researchers at Mt. Sinai Medical School, who found that “nearly two-thirds of the bipolar patients hospitalized at Silver Hill Hospital in Connecticut in 2005 and 2006 experienced their first bout of ‘mood instability’ after they had abused illicit drugs.[footnote omitted] Stimulants, cocaine, marijuana, and hallucinogens were common culprits.” Another study from the Netherlands found that marijuana use increased the risk of first-time diagnosis of bipolar disorder five times, and that one-third of that country’s new bipolar cases resulted from such drug use. In other words, these illicit drugs kick some people into a manic or depressive episode they might not otherwise have experienced. Illicit drug use has been on the rise since the 1960s, which might partly account for the increase in the incidence of affective disorders such as bipolar illness.
Whitaker likens the stimulant effect of anti-depressants to those of elicit drugs; he goes on to offer the unsettling results of various studies: one from Switzerland which found “that the percentage [of patients] with manic symptoms jumped dramatically following the introduction of anti-depressants.” They also reported more frequent manic episodes. Another study from the Yale University of Medicine reviewed the hospital records of 87,290 patients who had been diagnosed with depression or anxiety during the period from 1997-2001. They “determined that those treated with antidepressants converted to bipolar at the rate of 7.7 percent per year, which was three times greater than for those not exposed” to those medications. As Whitaker explains, “This is data that tells of a process that routinely manufactures bipolar patients.”
To make matters worse, the conversion to bipolar disorder is often permanent, even after medication is withdrawn. As Fred Goodwin, in a 2005 interview with the journal Primary Psychiatry, explains, “that patient is likely to have recurrences of bipolar illness even if the offending antidepressant is discontinued. The evidence shows that once a patient has had a manic episode, he or she is more likely to have another, even without the antidepressant stimulation.” Giovanni Fava, a prominent Italian researcher, believes that “antidepressant-induced mania … may trigger complex biochemical mechanisms of illness deterioration.”
Now we have a better understanding of the factors that have brought about this change in the frequency and severity of Bipolar Disorder: Better diagnosis by mental health professionals, an enlargement of our notion of what constitutes the illness, the rise of illicit drug use, and finally, the creation of a whole new class of bipolar patients whose biochemistry has been altered by the use of antidepressants.
Finding Your Own Way:
Many people one might consider “moody” have ups and downs that wouldn’t meet the criteria for a diagnosis of Cyclothymic Disorder much less Bipolar Disorder. Many people cycle occasionally from undue optimism to feeling gloomy. Is it possible that Bipolar Disorder is the extreme of an emotional condition we might consider “normal” in less pronounced forms — that we are talking about a spectrum rather than discrete categories? I believe many people given the diagnostic label and prescribed drugs might once have been considered “moody” instead.
Do you consider yourself “bipolar” and why? Read the actual diagnostic criteria here and see if you meet them. How do you feel about this diagnostic label? If you’re taking psychiatric medication and have actually had a full-blown manic episode that meets the DSM-IV criteria, did it happen before or after you started the meds?
Do you know other people who consider themselves to be or have been diagnosed as bipolar? Do you think they actually suffer from Manic-Depressive Illness, or is it something similar to it and less severe? Do you know whether they’re taking psychiatric medication and whether it might have had a role in the onset of their manic symptoms?
I don’t know about you, but I find this all deeply disturbing. To me, the worst part is the medicalization of this emotional difficulty, to the point where hardly anyone considers the psychotherapy of Bipolar Disorder at all viable. The psychodynamic interpretation of Manic-Depressive Illness has fallen completely out of favor, and now, people who might once have discovered the meaning behind their cycles of exuberance and despair now routinely receive medication that makes them worse and perpetuates their illness.