Bipolar disorder may be over-diagnosed

One of the most controversial topics in psychiatry over the last few years centers on the questions what is bipolar disorder, and how many people have it. Estimates on rates of the disease, which is marked by periods of depression alternating with episodes of euphoria, are heavily debated. A new study, however, suggests doctors are over-diagnosing bipolar illness.

The paper, presented today at the American Psychiatric Assn. meeting in Washington, D.C, and published online in the Journal of Clinical Psychology, found that fewer than half of the people who were previously diagnosed with bipolar disorder could be said to have the disorder when strict diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders-IV (the so-called bible for diagnosing mental disorders) were applied.

The study's lead author, Dr. Mark Zimmerman of Brown University, suggests drug company advertising is leading doctors astray. Doctors tend to believe they have arrived at a correct diagnose if the medication they prescribe shows some benefit, says Zimmerman, adding:

"This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder..."

Or, as the author of the psych blog Furious Seasons points out: "he's saying that doctors -- you know, those rational, god-like creatures who do things based on Science --are being softened up by all those pharma ads saying bipolar is wildly underdiagnosed." Medication for bipolar often produces serious side effects.

The study is rich fodder for the just-appointed members of the American Psychiatric Assn.'s Work Group who will soon begin writing the fifth edition of the mental disorders manual. DSM-V will represent the first complete revision of the text since 1994, a period in which, psychiatric association experts note, "may prove to be the most scientifically productive era in the history of psychiatry." The final text is expected to be published in 2012. Let's hope it makes huge strides in clearing up some of the astonishing confusion surrounding bipolar disease -- along with many other perplexing questions about the diagnosis and treatment of mental illness in children and adults.

--Shari Roan

Illustration: Darren Booth / For The Times

Comments

[John Pence]

As a psychologist working in the public schools sector, I have seen these fads come and go. In the late 80's and early 90's it was ADHD. Now we see a rise in bi-polar diagnoses. The new up-and-coming diagnosis is Autism. Some of these trends are due to the whole under-diagnosis-over-dignosis pendulum the authors of various article posit. However, I see no mention of the monetary gains provided by the rising rates of these diagnositc categories. Insurance company reimbursments for psychological services often depend on the patient having a major Axis I diagnosis. I see this unfold in a particulalry insidious fashion with kids who are in forster care. They go to a neuropsychologist who diagnoses them with one of their four favorite disorders (often without any information from anyone other than the fosterparent and Case Worker) and then send them on to a geneticist for genetic testing, who sends them on to someone else and the cycle goes on and on. So instead of spending money and time on therapy and skills training where you might make a difference, we funnel it into the hands of the medical community. Some of this is purely a medicaid/insurance scam.

Now I'm no saying that there aren't people out there who suffer from these dibilitating disorders and that psychotropic medications don't provide some measure of relief from these conditions. The problem with over-diagnosis is that it doesn't bring "awareness" of these disorders and improved care. It only cheapens the condition of those that truly have a serious mental health issue (i.e. ADHD, so what, everyone's got that). Another part of the problem is that we fail to appreciate that everyone has a personality and that getting past hard times and difficult situations takes hard work not a pill. In the late sixties and early seventies it was, "what's your sign?". Soon it'll be, "what's your diagnosis".