Original article no longer available
March 25, 2008
Annie Maccoby Berglof
Annie Maccoby Berglof is a writer living in London. She is working on a book called The Bright Side of Melancholy
A big shift in our understanding of mood disorders is under way, with many depressed people now being reclassified as bipolar. But is trading antidepressant drugs for mood stabilisers a sign of progress, or just the latest diagnostic fad?
The recent Hull University report, which suggested that antidepressant drugs were no more effective than placebos for mild depression, was greeted as a welcome antidote to the age of pills. Yet missing from the media debate was an awareness of a new and fundamental shift in our understanding of mood disorders. Many of those who wrote articles lamenting their experiences on Prozac and Seroxat are, in fact, still taking psychiatric pills but mood stabilisers rather than antidepressants. They have simply traded in one diagnosis for another. Formerly depressed, they are now officially bipolar.
If trends in the original Prozac nation, the US, are anything to go by, bipolar disorder will be the next big mood disorder to hit Britain. All across the US, the chronically gloomy have been re-diagnosed as moody. If Woody Allen was neurotic in the 1970s, he would have been declared depressed in the 1980s and bipolar today (maybe he is). Even depression guru Andrew Solomon, who dissected gloom in his bestselling The Noonday Demon: An Atlas of Depression, revealed not long ago that he is bipolar.
First used in the 1960s and 1970s as a new name for classic manic depression, bipolar disorder has subsequently been broadened as a category to include a number of softer symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM), the American “bible” of mood disorders, officially lists four kinds of bipolar disorder. Manic depression has been recast as bipolar I, for extreme swings between “episodes” of depression and exuberance that can careen into mania. The second kind listed in the DSM, bipolar II, is a harder-to-spot version in which patients seesaw between depression and milder ups or “hypomania,” meaning, literally, “beneath” mania. The third type of bipolar disorder, which is characterised by milder but equally disruptive ups and downs, is called “cyclothymia.” A fourth type, NOS (or “not otherwise specified”), covers conditions that don’t conform to any of these labels.
Mood swings are not the only feature of the softer variants of bipolar disorder. The ups of “hypomania” are marked not just by brighter moods, but also by increased energy and quicker thinking. The hypomanic are more self-confident and decisive. These ups, however, last only a few weeks, days or even hours before there is a predictable return to gloom.
According to Hagop Akiskal, director of the International Mood Centre at the University of California in San Diego, while 1 per cent of the US population suffer from bipolar I or classic manic depression, 4-5 per cent could qualify as bipolar II. If cyclothymia is tossed in, the numbers creep up to 6 per cent or more, equal to national estimates of depression. Sixty per cent of people who have been diagnosed bipolar in the US were first diagnosed as depressed. And leading researchers like Akiskal say that bipolar disorder remains underdiagnosed or misdiagnosed: “Many cases are still missed.” Even more striking, experts are now suggesting that half to two thirds of all depressions may share characteristics with bipolar disorder, and should be renamed.
The reclassification of many formerly depressed people as bipolar has important public health implications. It is not just that the drugs used to treat the two conditions are different. Some experts say that as a concept, the bipolar “spectrum” can help explain many conditions and behaviours, including alcoholism, drug abuse, eating disordersand even suicide. But there is a danger here. If applied too broadly, bipolar could become just another diagnostic fad, a way for drug companies and doctors to “medicalise” all human behaviour. As the borders between sickness and health become increasingly blurred, the challenge will be to avoid viewing mood stabilisers as the next all-purpose treatment for everything from serious illness to ordinary moods.
When I was diagnosed with bipolar II in 1982, at the age of 21, hardly anyone had heard of the disorder, partly because it had only just been identified [read: invented – SSRI ED] by doctors at the National Institute of Mental Health (NIMH), a top US psychiatric research centre. Frederick Goodwin, David Dunner and Elliot Gershon had only developed the concept of bipolar II in a paper in 1976. So when I shuffled in to see Goodwin, then director of research at NIMHhaving just dropped out of Harvard with anxiety, low energy, insomnia and such severe concentration problems that I could no longer readI expected to be handed the latest diagnosis of the day: depression.
But Goodwin surprised me by declaring that while my symptoms looked like depression, they merely masked the underlying biological root of my problems: my mood swings. It was true that while I was sunk in gloom I could also still laugh and make jokes. I could be animated in the evenings, even wired, entertaining friends with mimicry and hiding my true state of mind. According to Goodwin, my “ups” would have been missed or deemed sub-clinical by most doctors. Yet to him they were clear signs, along with my lows, that I was on the soft side of the bipolar spectrum, with symptoms triggered by stress.
In 1977, Hagop Akiskal, then also a researcher at the NIMH, had published a paper in the American Journal of Psychiatry proposing the “bipolar spectrum” as an umbrella for a much broader range of symptoms than those covered by classic manic depression. Akiskal was prompted to come up with the idea of a bipolar spectrum by his experience with patients whose ups and downs were dismissed as too insignificant to be considered illnesses. Manic depression was easy to see. Yet Akiskal had people coming to him in distress whose mood swings did not meet any standards of full-blown disease and yet “who had a tempestuous lifeeven more severe than that of manic depressive patients.” He noticed something else too: many people with milder but chronic swings went on to develop depressions that seemed to have more in common with the lows of manic depression than with clinical depression.
The implications of reclassifying over half of all depressions as bipolar were huge. Treatment of depression and bipolar disorder called for radically different classes of drugs: antidepressants in one case, mood stabilisers in the other. For my symptoms, Goodwin scribbled out a prescription not for the antidepressants I’d expected, but for mood stabilisers. It took me a few years to gather up the courage to try the pills. (Back in those pre-pharmacological days, all non-recreational drugs were suspect.) Yet when I finally did down them, the results were dramatic. Within three or four weeks I could concentrate again enough to read. My anxiety and insomnia vanished; I lost weight. I even started writing again. (That very summer, aged 24, I actually wrote a children’s play which was produced by the Kennedy Centre Lab Theatre that winter and still gives me royalties of $50 a year). I went back to Harvard.
Despite success stories like mine, Goodwin and Akiskal’s thinking went largely overlooked. By the late 1980s, the American rage, in every sense, was clinical or unipolar depression, treated solely with antidepressants. With the introduction of Prozac and other selective serotonin reuptake inhibitor (SSRI) antidepressants, the bipolar spectrum fell into the shadows, ignored by all but a few researchers. Bipolar II did not make it into the DSM until its fourth edition, in 1994; and even today, in the revised edition, my own symptoms would still be considered too mild to meet most of the criteria for the disorder. Diagnosis of bipolar II requires “episodes” of hypomania lasting four or more days, an apparently arbitrary number often disputed. Yet I never experienced any hypomanic “episodes”I never went on wild spending sprees or ran off to Mexico. I was simply prone to an under-the-radar mood instability.
As a newly diagnosed patient in the early 1980s, I discovered that if most psychiatrists and GPs were unaware of the bipolar 2 label, so too was the general public. Family and friends confused my condition with more dramatic manic depression (many still do). When I married a Swede and moved to Sweden in late 1980s, I figured that a country that had produced the brooding Ingmar Bergman would be more enlightened about mood disorders. I was wrong. The psychiatrist I rushed to consult on arrival brushed off my diagnosis: “This is not a real diagnosis. If we treated everyone in Sweden with this, we would have to put lithium in the drinking water.”
The moody Swedes may not have heard of bipolar in 1989, but then it took 20 years for Americans to wake up to the disorder. Ironically, the popularity of SSRI drugs was partly responsible for raising awareness about bipolar disorder. In the 1990s, doctors started to notice that over time, antidepressants did not just yield good moods, but often triggered the “ups” of hypomania, pushing some people into mild or even extreme overdrive. This had serious implications. If, as Akiskal argued, half to two thirds of people suffering from depression had some form of bipolar condition, then over time the antidepressants they were being handed could make them worse. Nassir Ghaemi of Emory University cited three double-blind, placebo-controlled studies in which, for anyone with even mild bipolar disorder, “antidepressants caused more mood episodes, more mania and more depression compared to placebos.” If they did not prompt hypomania, the drugs could make patients more agitated, or could just stop working. Yet these warnings took years to reach US medical circles.
In the late 1990s, psychiatrists started to acknowledge what Akiskal and colleagues had pointed out 20 years earlier: that not all depressions were alike. Akiskal and Goodwin continued to argue that many so-called atypical depressions, marked by extreme weight gain, night insomnia, day sleeping or, most importantly, agitation and mental paralysis, should be reclassified under the bipolar rubric. A major 20-year study of the population of Zurich, led by a distinguished Swiss psychiatrist, the suitably named Jules Angst, appeared to support the bipolar spectrum: half to two thirds of the population previously diagnosed with depression were found to qualify as either bipolar II or cyclothymicremarkable figures considering that most of these patients were on antidepressants, unaware of the possible health repercussions for anyone on the bipolar spectrum.
Akiskal insists that despite increased awareness, bipolar disorder remains misdiagnosed, often masked not just by supposed unipolar depression but by other conditions. Experts say that bipolar disorder often coexists with substance abuse. According to the NIMH, rates of alcoholism among the bipolar are five times the general population. Just as striking are possible links to suicide. A survey by Goodwin and Ghaemi showed that rates of suicide for bipolar II are the highest of any mental disorder.
Still, it is vital not to confuse a disorder that, as I can attest, can be so debilitating that it prevents people from functioning at all with normal adult or adolescent moodiness. One particular area of controversy is bipolar disorder among children and adolescents. The New York Times reported that between 1993 and 2004, diagnosis for bipolar disorder among under-20s in America increased 40 times. There are also troublingly high rates of diagnosis in US colleges, where the disorder seems to be almost a fad: “My son came home from college and announced he was bipolar,” one Washington DC lawyer told me. “All his friends are bipolar too.” At Harvard, according to one estimate, up to 20 per cent of students have sought psychiatric help for a mood disorder.
If there is no one kind of bipolar disorder, there is also no magic bipolar pill. Andrew Solomon was recently quoted in New York magazine describing his attempt to find the right mix of drugs for his condition, which had so far eluded him. Mood stabilisers fall into three categories: lithium (the old standby), anticonvulsants and atypical antipsychotics. Many of these are drugs originally devised for one kind of condition (epilepsy in the case of anticonvulsants) that were later discovered to have mood-stabilising effects. Antipsychotics are now being used to treat not just psychosis, but softer symptoms too. Most of these drugs have potential side-effects ranging from weight gain to horrific facial and body tics called tardive dyskinesias. (Lilly, the maker of Zyprexa, an antipsychotic targeted at people with mild bipolar, is being sued in the US for allegedly concealing data showing that the drug can lead to diabetes.)
Hagop Akiskal’s answer to all this is that in today’s world, drugs save lives: nobody protests when large segments of the population try to control chronic medical conditions. “Fifty per cent of the population of Italy takes drugs for diabetes; 50 per cent for blood pressure. And there is no controversy there.” Yet there is an important difference: diabetes and high blood pressure are conditions with clear physical foundations, and can, as a result, be firmly diagnosed. While evidence is growing that bipolar disorder is hereditary, hard diagnoses are still impossible. Gary Sachs, director of the Harvard bipolar research programme, says that diagnosis can be highly systematised, with detailed questionnaires that spot hidden “ups.” Yet there are still no CT scans, no blood tests. Diagnosis is based on doctors’ assessments of what patients (and their relatives) say about their symptoms, and medical and family history.
And as in most areas of psychiatry, definitions are still in flux and confusion abounds. For instance, the terms “mania” and “hypomania” are still used interchangeably, although they refer to very different states of mind. Bipolar I and II are also lumped together despite evidence, mentioned by Ronald Fieve in his new book Bipolar 2, that the “genetic, clinical and biochemical factors in bipolar II patients are different from those in bipolar I.” “The whole point of the bipolar spectrum is that the soft sides do not include psychosis,” says Akiskal. “We came up with the term bipolar for public health reasons.”
Gerry Sachs cautions about expanding what qualifies as bipolar disorder too broadly. “You’re going to get a lot of people diagnosed who are going through divorce, have lost jobs. It won’t be constructive for us to say this person has bipolar XII. We have enough on our plate just identifying bipolar I and II.” The risk is that bipolar drugs will simply be thrown at the moody, much as SSRIs were thrown at the depressed, potentially with equally harmful results.
Akiskal is surely right that for those with bipolar disorder who face real dysfunction and even suicide, the risks of not taking mood stabilisers outweigh the drugs’ possible side-effects. As I and many others can confirm, drugs do save lives. In my case, a mood stabiliser allowed me to claw back on to life’s track after a few years on the sidelines. But I was lucky to be given the right mood stabiliser at first; it may have allowed me to escape years of trial and error on antidepressants. It took friends with similar symptoms another 20 years to reach the same diagnosis. I was also fortunate to have been treated by pioneers in the field who knew how to manage treatment and side-effects. In psychiatry, there is a large knowledge gap between, on one hand, researchers and, on the other, the armies of psychiatrists, psychopharmacologists (doctors who dispense drugs), psychologists, social workers and family GPs now tending to the western psyche. These gaps are usually filled in by drug company “educators” with an interest in blurring definitions and classifications for their own ends.
The stakes are huge. The success of a company can ride on the sales of a single drug. Bristol-Myers Squibb is banking on a mood stabiliser and antipsychotic, Abilify, to ensure future profits. American advertisements tout Abilify as an all-purpose pill for mood swings, although the drug is approved only for bipolar II. On top of its civil case, Lilly is also facing criminal charges for marketing Zyprexa as a treatment for soft bipolar disorder, a condition for which it has not been approved. American psychiatrists can prescribe any drug “off-label”in other words, for conditions for which it has not received official approval. And Ghaemi points out that there are shockingly few long-term studies on most drugs for bipolar disorder. “If you don’t force the drug companies to do the studies, they won’t do them.” In the absence of these studies, we may be performing the biggest drug experiment in history on a huge segment of the population. The only drug with a tested long-term record for bipolar disorder, lithium, has long lost its patent protection and, as a so-called “orphan drug,” has no drug company pushing it.
There are also problems with the psychiatric labels. There is no question that patients with bipolar I, or classic manic depression, need a lifetime of mood stabilisers to manage their extremes: the results of going off drugs for anyone afflicted with true mania can be catastrophic. Yet should those of us at the softer ends of the spectrum be handed a lifetime sentence as mentally disordered? In 1987, after just three years on my mood stabilisers, I tossed those big grey pills, plus the pills to ease the side-effects, into the Baltic sea. Despite doctors’ predictions that any minor stress would trigger a tumble back into gloom, I never suffered a relapse. I knew the drugs were around if I needed them.
While Askikal is aware of the consequences of pathologising all behaviour, the trend in America is to characterise all bipolar symptoms not just as signs of a lifetime mental disorder but as evidence of serious cognitive disability. “Bipolar disorder is the sign of a broken brain,” warns a popular guidebook.
But there is a more positive side to theories of bipolar disorder: the link between mood swings and creativity. In several studies, extremes in moods have been tied to the creative output of major figures in the arts, from Schumann to Gauguin. In one study, a high percentage of prizewinning poets were found to have bipolar I; playwrights were more likely to have bipolar II. Aristotle noted that great leaders were prone to extremes in mood.
Two thousand years after Aristotle, diagnosing the mind is still more art than science. And we should take care that as the trendy new diagnosis, bipolar disorder is not thrown around artlessly. Neurobiology has revolutionised our understanding of mood disorders. Yet the chemicals for treating them are still imperfectly understood. In treating symptoms, we should also avoid turning our backs on other optionsfrom exercise to good old-fashioned talk therapy. Why? Because in our rush to find another quick fix, we should watch that we don’t deprive ourselves of the most powerfuland human tool for managing our moods: finding meaning in them.