I accept that bipolarity may be overdiagnosed. I often wonder about my own diagnosis until I go off my meds and flip out. But it strikes me there are a few points to be made here:

1) Is cyclothemia not a valid diagnosis?
2) Bipolarity is progressive. Manias (in particular) and depressions are neurotoxic.

If you answer yes to 1, and accept 2, then:

3) Cyclothemia has a lower therapeutic phamacologic threshold.

So if cyclothemia (or bipolar-lite, if you like) is a valid diagnosis, it increases the possibility of full blown bipolarity by serving as a kindling agent. Yet treating it pharmacologically might cost less and might be an effective preventative step. I read some article somewhere with the conclusion that 250mg of valproate daily might be effective for treatment of cyclothemia.

20 or 30 years ago would we have been as critical of BP2?

While I totally agree that treating subthreshold bipolar disorder is overkill, I wonder if the concept in an informal sense, not a diagnosis, could be useful as a warning—to say to patients, "hey, keep an eye on this and if it gets worse or impedes your functioning then come back and we'll do something about it."

Or does it not work that way?

It is interesting to me that the one person who does not benefit from these pseudo-disorders is the patient. And who is, on the whole, least informed about the issues and most susceptible to being influenced by direct to consumer ads. Turf and money are the name of this game. And the patient is the loser.

mind hacks mind hacks
The Washington Post has a timely article about the psychology of believing news reports, even when they've been retracted - suggesting that if false information is presented early, it is more likely to be believed, while subsequent attempts to correct the information may, in fact, strengthen the false impression.

oxstu -- I don't know if mania and depression are neurotoxic or not. I think the psychiatric community tries to propagate this idea. On the other hand I do know for sure that psychiatric drugs are neurotoxic. Just read Grace Jackson's book Rethinking Psychiatric Drugs: A Guide to Informed Consent. It's much more likely that the treatment is permanently neurotoxic than the "disease". It boggles my mind that clinicians can stand up there and talk about mania and pyschosis being neurotoxic and not breathe a word about Zyprexa, Risperdal and Seroquel. The evidence is so much easier to get at about their neurotoxicity like hair falling out in some people -- this is chemotherapy in action right before your very eyes. When did mania ever make hair fall out? I don't care how bad your psychiatric symptoms are; the real way to healing is not with chronic long term use of psychiatric medications. As for zapping "prodomal" symptoms with meds before they even "blossom" this is the recipe for getting a full blown "disorder" in no time flat -- much better to see what circumstances might be triggering these problems and do something about it while you still have some control. Don't mess up your brain further with mind altering medications. View any attempts to label you with some DSM "disorder" with a very jaundiced eye.

Yes, deal with your life. As if your symptoms had something to do with what happens in your life.

Sara,

I don't mean to be rude, but the bulk of scientific research disagrees with you. There is considerable mounting evidence suggesting both lithium and valproic acid prevent prefrontal grey matter loss associated with bipolarity:

http://www.psycheducation.org/depression/meds/ManjiLithium.htm

http://www.bpkids.org/site/PageServer?pagename=lrn_004

"What our research and other peoples' research has recently shown is that mood disorders, while they do entail mood swings or emotional changes, are also associated with changes in important structural areas of the brain."

"Wayne Drevets' group published a finding in Nature about five years ago that in a part of the pre-frontal cortex of bipolar patients or patients with familial recurring unipolar depression, there was almost a 40% reduction in the amount of gray matter. That was a remarkable finding that you have such a reduction in a discrete part of brain. We spoke to him about our lithium findings and asked him to reanalyze the data. He had a small group of patients who had been treated with lithium for a long time and they did not show the brain atrophy compared with the bipolar patients. Interestingly all of the patients with unipolar depression, whether or not they had been treated with antidepressants, still showed the atrophy. That was a suggestion that bipolar treatments might have a protective effect. Valproate (Depakote) in the prefrontal cortex seemed to have the same type of neuroprotective properties. Lithium and depakote do not have identical effects in every brain area, but in this area they did. Brains treated with chronic lithium or valproate seemed not to have the atrophy in the prefrontal cortex."

If you do a PubMed search you'll find more recent articles backing this theory up.

Consider also the suggestion that SSRIs function by restoring the hippocampus, an area already known to regenerate cells. Research suggests that sufferers of unipolar depression have smaller hippocampal volumes, suggesting depression might stunt that regeneration. Last time I searched PubMed for this I found over 70 articles speaking to this.

The key here is neural plasticity, not chemical imbalances. That's what people have to wrap their heads round. Mental illness changes the structure of your brain in fundamental ways. The likely mechanism of the meds is to heal that, or to aid prevention of further damage.

Also, I should point out the FDA requires bipolar patients to be started on either valproic acid or lithium before moving to other meds or off label. Granted, some doctors ignore this, and you won't find me defending them. But neither will you find pharmaceuticals making scads of money off of either of these meds (you can get Lithium for $4 at Walmart). They've both been around forever and a day.

I'm also willing to bet you've never seen an ad for either one.

Oxstu, I agree with you that it is interesting that you don't see ads for Lithium or Valproic Acid. However, if you think there's some test to indicate that the brains of people labeled as having bipolar disorder are different from other brains, I think you are mistaken.

Reason took this matter up in July of 2007. Here's a bit:

"Steven Faux, chairman of the psychology department at Drake University, wonders how much neuroscience tools have really done for us so far. An fMRI scan, for example, attempts to measure neuronal activity by detecting blood flow in the brain. But as Faux told Scientific American in 2005, “The beautiful graphics fMRI produces imply much more precision than there actually is. It’s really a very gross, if not vague, physiological measurement that people are using to try to pin down some very complex behaviors. And in too many studies the authors way overinterpret the data.” Critics of fMRIs, such as William Uttal, an emeritus professor of psychology at the University of Michigan, question whether brain function is compartmentalized enough for information about blood flow to tell us much, condemning the process as “the new phrenology.” Dr. Jay Giedd, chief of brain imaging in the child psychiatry branch at the National Institute of Mental Health, told The New York Times in 2005: “I have been waiting for my work in the lab to affect my job on the weekend, when I practice as a child psychiatrist. It hasn’t happened. In this field, every year you hear, ‘Oh, it’s more complicated than we thought.’ Well, you hear that for 10 years, and you start to see a pattern.”

http://www.reason.com/news/show/120266.html

oxstu--where's the link that says FDA requires Depakote or Li to be a starting point for bipolar?

I stand corrected and apologise. I had in my head a conversation with my psychiatrist over a year and a half ago when I first went on Depakote. My memory is pretty fuzzy on the details. I thought I'd seen a link somewhere else, but I was either mistaken or it has been moved.

However, it was not an entirely off the wall statement. There are APA guidelines for treatment of bipolar disorder:

http://www.psych.org/psych_pract/treatg/pg/Bipolar2ePG_05-15-06.pdf

to summarise:

First, there are only four meds with official approval for treatment of bipolarity: Lithium, valproic acid, Lamitrogene (Lamictal) and Carbamazapene. Anything else is off label.

Starting with Acute treatment (assuming that's where most people start with bipolar treatment, though I'm supposing a lot of you would disagree) for:

Mania -- in the severest cases the first line is either Lithium plus an antipsychotic or valproate plus an anti-psychotic (suggested olanzipine or risperdone). I don't want to get into arguments over APs here. We're talking treatment of actual psychoses here. For less severe manias, monotherapy with lithium or valproate, or possibly an atypical AP. I would hope that the latter is rare, but accept that it isn't as much as I would like. Valproate is the preferred option for mixed states and rapid cycling.

Depression -- The first line drugs are lithium and lamictal. My understanding for the longest time was that you were supposed to be stable on something before starting lamictal, but that could be very wrong. Antidepressant monotherapy is not recommended, though they say some clinicians will prescribe one in conjunction with a stabeliser. There was a recent article questioning the efficacy of SSRIs, even with a stabeliser, in the treatment of bipolar depression. Bupropion is suggested as a second line drug in case of a breakout episode. I can say it has been an enormous help to me, and didn't leave me crawling the walls like SSRIs do.

Maintainance dosing is suggested after 6 months of stability on a first line drug. This can mean switching dosages or to a new medication regime. For instance, I switched from Depakote to Lamictal after a year as I tend to reside in the depressed part of the scale.

Similar suggestions, though from Canada, are here:

http://meds.queensu.ca/~clpsych/orientation/Mood%20stabilizers%20&%20adjunct.pdf

Finally -- Sally, you and I are talking apples and oranges. I'm not just discussing pictures of brain functioning. I'm talking about actual physical examinations of brains relating to synoptic growth or deterioration, spacing and functioning.

"Over the years, a large body of data (utilizing membrane, slice, and synaptosomal preparations from rat brain in vitro and ex vivo, peripheral cells from humans, and postmortem human brain tissue) has confirmed that lithium has significant effects on the cAMP second messenger generating system in rodents and in humans"

http://www.nature.com/npp/journal/v19/n3/full/1395205a.html
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1525098

And did you really just quote an article from the Cato Institute?

Yes, I agree that mood disorders may cause morphological changes to the brain over the long term, but I will also add that there is a lot of controversy surrounding the volumetric changes in the brain caused by medication. It is not clear that just because there is neuronal growth in the hippocampus for instance as a result of antidepressant use that this is actually beneficial. There is neuronal growth in the brain as a response to stress, strokes for instance. We cannot prove whether medication induced neuronal growth is actually healthy neuronal growth. It could be a response to a toxic agent. A lot of the volumetric studies that have been done on the brains of mentally ill people do not clearly distinguish between those who have been previously medicated and those who haven't been, thus invalidating a lot of it from my point of view anyway. I actually have read a lot about this and am indebted to Grace Jackson, author of Rethinking Psychiatric Drugs: A Guide to Informed Consent for much of the evidence that has shaped my point of view.

Oxstu, My understanding is that I quoted Scientific American and a psychiatrist from the National Institute of Mental Health as quoted in the Slate "In Other Magazines" section linked to Reason Magazine. What I'm concerned about is the idea that there is some evidence that the brain, either structurally or chemically or in combination of structure and chemistry, causes mood disorders. The links you sited do not indicate that there is any proof they do. That drugs and experience can change behavior and the structure of the brain, I don't doubt. And I'm still bowled over by the fact that there are no lithium ads.

I've never heard of "Subthreshold Bipolar" but I'm currently reading Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder
by Jim Phelps and it's excellent. I was skeptical at first especially with the term "soft bipolar" but not anymore. I agreed with the concept of the mood spectrum long ago but this puts things into much better focus.

I took the book in with me to show to my psychiatrist and she says it's the most up-to-date book out there about the bipolar spectrum. I think it's worth reading for anyone with bipolar and clearly for anyone who opposes the concept of the bipolar spectrum :)

More info:


Hard depression, soft bipolar


short review of the book at bphope

I'm not a subscriber to the website so I can't view the entire article that got you all riled up so I don't know what that author's assertions about the bipolar spectrum were, but I definitely think that there's a full spectrum to consider when dealing with bipolar. That's why Bipolar NOS exists right now.

Sorry for posting twice but I just found this after posting my earlier reply. This article has some interesting info related to the original "subthreshold bipolar" article that irked you.

This sums up nicely why I think this would be beneficial.

well Sally, don't worry I'm sure once the Lithium patch goes to market we will see plenty of ads, because Nemeroff owns the patent for it, surely it will be touted as the best of the best.

For further thought re: Lithium and advertising, start here:

Charles Nemeroff Lithium patch patent,Emory University

Stephany,

That's creepy and I'm just around the corner from Emory.

Sally

that's strange...I tried to post a link to this article in my earlier comment but the html was stripped out. Anyways, I'll try one more time.

Bipolar Spectrum Disorder May Be Underrecognized And Improperly Treated

Katy, how exactly is it that you think mild bipolar disorder differs from the normal human condition?

Sally,

Read this and go see Nemeroff speak and take notes! He speaks with the Dalai Lama and he has pharma funding, as well as the patent for Li and antidepressant patches!

Let's not forget with 50% of Americans being mentally ill, and 46% of that is "any disorder" the sub-bipolar discussion is all part of the big NOS "we're all something attitude", carried into the psychiatric thought world by one of the highest cited scientists out there--the guy that wrote that 50% theory. Read it here at Furious Seasons, then read what Kessler says about his paper in an interview here: Kessler re: the 50% paper.

"The high prevalence estimates reported in the paper were initially met with a good deal of skepticism. Although subsequent clinical calibration studies showed that the estimates are accurate, this led to a deeper questioning of the accuracy of the DSM system itself. The thinking goes like this: It’s inconceivable that half the population is mentally ill. Therefore, there must be something wrong with the DSM system. The error in this thinking is that the term "mentally ill" is being taken too seriously. It wouldn’t surprise anyone if I said that 99.9% of the population had been physically ill at some time in their life. Why, then, should it surprise anyone that 50% of the population has been mentally ill at some time in their life?"-Ronald Kessler

The medicalizing of human emotions begins with this thought and it's all backed by Pharma, so in essence, we are being manipulated by an the pharmaceutical industry and the scientists who get paid by that industry.The "soft" diagnoses are dangerous, because there is no reason to medicate emotions. Severe mental illness is one thing, small blips on our emotional or sadness radar is another. Americans are buying into the DTC ads in magazines and on television, convinced by a marketing agency they need a pill for the blues or moods.That is not always the case.

That's not what this is about. It's Bipolar depression vs Unipolar depression. Bipolar mood disorder vs Borderline personality disorder and so on. If you are treated for major depression but in actuality you have bipolar type II disorder (or an even "milder" form than that as you characterize it) and you're treated solely with antidepressants you're not going to get better. You're going to get worse. It's unbelievable how many people have gone through this misdiagnosis-usually for about a decade-before getting proper treatment. By then it's so bad that it's even more difficult to treat. Type II is much more well recognized now than it was even 10 yrs ago as is cyclothymia.

I'm not sure why the immediate response to this is that all of a sudden doctors are going to go around saying you are moody therefore you are bipolar!!

Americans are buying into the DTC ads in magazines and on television, convinced by a marketing agency they need a pill for the blues or moods.That is not always the case.

I don't live in the US. I live in Canada. DTC ads are illegal here.

Katy, speaking only for myself, I'll explain my concern. Subthreshold Bipolar disorder is not a mental illness, and thus should not be treated. Personality Disorders are based on criteria more vague and less scientific than astrological signs and should not be labeled as illnesses. Isn't there some pretty serious talk in the bipolar spectrum disorder crowd about personality disorders and schizophrenia being in the same spectrum with bipolar disorder?

The idea of Unipolar vs. Bipolar depression is specious. Anyone who recovers from depression and experiences even the slightest sense of happiness under that model, is bipolar. Which means everyone who has ever been unhappy and is not anymore now meets the criteria for bipolar spectrum disordeer. As I'm sure you know, in this model, life events don't cause emotional responses and changes to personality (that can be further changed by psychotherapy if the psychotherapy is voluntary and anonymous), but instead, in the bipolar spectrum model, once you are labeled bipolar, all events are triggers for which you should be observed carefully and possibly hospitalized voluntarily or involuntarily.

I interviewed a psychiatrist re: the new DSM, and the psychiatrist commented that "It will change how we diagnose people from now on."

That's why this broad brush spectrum dx'ing thing can get out of hand. The first time my psychiatrist wrote a "code label" on my insurance receipt, it was "Mood Disorder NOS", but he called me "Bipolar 2".

Subthreshold Bipolar disorder is not a mental illness, and thus should not be treated.

As I said in my initial comment, I do not have a membership at the website where the original article about "subthreshold bipolar" was posted. Therefore I was not able to read the article that was linked. I've never heard of this diagnosis and I don't know what that particular article was advocating. I was commenting to add information about further reading regarding the bipolar spectrum, not to argue for or against "subthreshold bipolar". My point is there is far more to this.

The idea of Unipolar vs. Bipolar depression is specious. Anyone who recovers from depression and experiences even the slightest sense of happiness under that model, is bipolar.

That's ridiculous.
That's like saying your paranoia about it means you're a paranoid schizophrenic.

Katy, I don't think it's like saying you're paranoia about it means you're a paranoid schizophrenic. It's more like saying even the mildest paranoia is schizophrenia, and that all mental illness exists on a linear scale, with, maybe mental wellness at the very center. I tend not to like this idea but it is an interesting idea. The problem, if you accept that model, a spectrum if you will from catatonia to psychotically manic with normal in the very middle and dysthemia heading towards catatonia and hypomania heading towards psychotic mania, the point which is normal become a tinier and tinier dot on the line. But it's an interesting, sort of mainstream way of looking at things, and particularly interesting when you try and put ADHD and autism and post traumatic stress and such in the mix. I guess they get their own separate spectrums which seems to be how one person can end up with multiple diagnosis that seem to me redundant. I just don't think humans are that static.

Katy, Read this and you will see where this stemmed from; also everyone note the authors:[to name a couple]Kessler and Akiskal. Read my commment above re: the Kessler 50% of America is mentally ill--discussing what was written here, by Philip.

Then, it is imperative to understand that in the USA, we DO have DTC marketing, in the doc offices, on TV and in magazines, [even on phone booths]Abilify Phonebooth ad, so what happened when the broadbrush "everyone is bipolar" talk came about via Kessler, it was alarming, because in fact just about everyone, according to Kessler is mentally ill at some time or now, in America. Why is this alarming? because we have a PHARMA problem: they make money off of all of it, the more people who have a dx, the more $$ are made--and the main people writing these alarmist type of science papers receive money from PHARMA. It's about medicating simple agitation or sadness, and steps off of the real mental illness diagnoses platform, and can end up medicating people without cause. And yes, alarming as it sounds, sometimes psychiatrist DO dx people with wrong dx and medicate them, per the paranoia = schizo discussion. Hell, I was given Seroquel for insomnia.

It's out of control in the USA.Period.

Once it gets into a science journal and on/in the news, it's too late to retract--pharma reps hit the pavement running.[I'm no expert by any means, this is just my opinion on this topic].

I did read that. It's a two paragraph blurb that tells me not much at all which is the problem I'm having with the the article you linked. I'm sorry but I just don't have $15 US to blow on this article right now.

All I can go on right now is the book that I have read. I take it you've read the entire article linked here, so I wanted to also pass on the book info as it may be additional and perhaps less scary (to you) information. Ya never know, right?

Seroquel for 'insomnia' isn't exactly out of left field.

And yes, alarming as it sounds, sometimes psychiatrist DO dx people with wrong dx and medicate them, per the paranoia = schizo discussion. Hell, I was given Seroquel for insomnia.

It's out of control in the USA.Period.

Once it gets into a science journal and on/in the news, it's too late to retract--pharma reps hit the pavement running.[I'm no expert by any means, this is just my opinion on this topic].

Yes you're right. In the interest of making sure this doesn't adversely affect people in the US progress should be suppressed because the US system cannot handle it. Good plan. The rest of us--you know, the rest of the planet earth, we don't need the benefits of the expansion of the classification of bipolar in order to have customized treatment.

Depakote and other anticonvulsants are known to cause very serious atrophic brain changes: http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=3117347&ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=9578009&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

and apoptosis/neurodegeneration (death of brain cells): http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=12417760&dopt=medline

Also encephalopathy:
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15971646&ordinalpos=38&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15602119&ordinalpos=47&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12199737&ordinalpos=77&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

They also have been linked to lowered IQ: http://www.psychiatrictimes.com/Children-and-Adolescents/showArticle.jhtml?checkSite=psychiatricTimes&articleID=171201519

Lithium may actually help the apoptosis caused by taking anticonvulsants: http://jpet.aspetjournals.org/cgi/content/abstract/286/1/539