Furious Seasons

May 28, 2008

From The Frontlines Of Bipolar Disorder Overdiagnosis

Earlier this month, a study came out asserting that bipolar disorder was being overdiagnosed. About 50 percent of the patients diagnosed with bipolar disorder in a study in Rhode Island turned out to have been wrongly diagnosed once they were put through an appropriate clinical interview. This study hasn't generated anything close to the press response I would've expected to date, but it did lead to this interesting blog post at Psychology Today by Nassir Ghaemi, a psychiatrist at Emory University, asserting that the methodology behind the Rhode Island study was flawed. You can read it for your self and see if you can understand what he's talking about. (here's what I also wrote earlier about the Rhode Island study.)

But the bigger question is of how this sort of thing is playing out in the America the rest of us live in. J. R. White at Brain Blogger offers his own account of himself and some co-workers being misdiagnosed with bipolar disorder and how it happened.

"Let me illustrate this [the sloppiness of some diagnosing] with a pretty 'funny' situation that happened a few years ago. I visited a mental health facility for the first time and was seen by someone we’ll call Wanda. She was not a doctor; she was working towards some certificate or degree and was being 'mentored' by a psychiatrist at the facility. Well, after talking to me she gave me a brand new diagnosis, one that had never even been suggested to me before. It was a type of low-level bipolar disorder and she prescribed medicine to treat it. Turns out I didn’t feel comfortable with this diagnosis and didn’t continue with her suggested treatment plan.
"I became friends with two people who worked at my company and had been seen by Wanda within the same time frame. (Since we all lived in the same part of town and had the same insurance company, this wasn’t too odd.) What was odd about it was that after talking we realized that all three of us had been given the exact same diagnosis. And, stranger yet, none of us believed in the diagnosis so we all three stayed away from the medication and promptly either found someone else to see or found other ways of coping with the anxiety/depression/mood swings."

That's some nice mentoring there by the psychiatrist. It's interesting and not a bit funny that this happened to three separate people in the same town with the same caregiver, one who was still in training. It's just as interesting to me that all three newly-minted bipolars turned their backs on the diagnosis and the treatment. Since White does offer any information to the contrary, I assume they are doing fine.

What's discouraging to me is that this situation is roughly what the researchers in Rhode Island highlighted in their paper. People presenting to docs with symptomologies that spoke of depression and a certain unsettled moodiness and they wind up getting diagnosed with either bipolar disorder 2 or bipolar disorder NOS (not otherwise specified), get prescribed meds, and, later, learn that they aren't bipolar at all.

From where I sit, this speaks to what a bad idea it was to rebrand manic-depression (which generally required full-blown mania for someone to get the diagnosis) as bipolar disorder in DSM-IV in 1994 and, then, create several subtypes of the disorder--BP1 (the old school manic depression), BP2, BP NOS and cyclothymia (which had always kind of been around as a proxy diagnosis). The non-BP1 subtypes are much softer forms of the disorder, somewhere between depression and BP1 on the mood continuum. Part of the idea of rebranding manic depression back then is that the name change would be magical and would lead to less social stigma for people diagnosed with the disorder versus the really intense stigma that greeted folks diagnosed with manic depression. I think we all know how that bit of wishful thinking has turned out.

Even more troubling is how a misdiagnosis of bipolar disorder can lead to many years of treatment with medications that aren't particularly kind to the human body. Any doctor or mental health worker who does not recognize that this is an appropriate concern should get out of the business of diagnosing--especially the casual diagnosing that seems to be afoot in the land--until they get their bearings straight.

Why is this important? Because many millions of people in this country, from the young to the middle-aged, have been diagnosed with one of the types of bipolar disorder in the last decade or so. They've been put on very aggressive medications, including antipsychotics which are being handed out like candy in our culture (how else would Seroquel be winding up as a street drug?). Some of those diagnoses are now clearly in doubt, and so are the treatments these people are taking, in many cases unnecessarily. That's why.

Posted by Philip Dawdy at May 28, 2008 10:48 AM

del.icio.us Digg it reddit

Comments

What is disturbing too is that the meds for the 'mild' form of bipolar are the same as they would be for the 'severe' form. And then their side effects end up making some act even more classically bipolar in the end...

Posted by: molly g at May 28, 2008 01:27 PM

After carrying a unipolar depression dx for many years, I moved across the country and had to find a new mental-healthcare practitioner. I had insurance at the time, and went to a large, well-respected medical center where I saw a psychiatric nurse-practitioner. She talked to me for 20 minutes, during which time I mentioned that I sometimes had mood swings that seemed related to my menstrual cycle.

She decided that I was in fact, bipolar type 2, and wrote me a prescription for Depakote. She also wanted to take me off my long-time antidepresant, for fear that it might make me manic. She was very sure of herself, and said that the side effects of the Depakote were mild.

I went home and called my long-time psychiatrist on the other coast. He told me he wouldn't touch Depakote with a ten foot pole, noting that one of the side effects was possible death. He assured me that I was not bipolar and said he would continue to write my prescriptions until I found a new provider.

I shudder to think what might have happened if I'd listened to that nurse and switched meds. And it took me forever to get that dx off my medical records. Not good.

Posted by: bottlecappie at May 28, 2008 08:09 PM

Dr. Ghaemi's point seems to be that bipolar disorder could be both overdiagnosed in some places and underdiagnosed in others. His reference to a "control group" is somewhat confusing but I think he means to say: What about similar patients in the opposite situation -- those who were NOT diagnosed as bipolar, but SHOULD have been?

He's quite probably right... and the figure he gives of only 50% reliability for psychiatric diagnoses in general sounds scary but plausible. It could be that the Rhode Island researchers found so many dubious bipolar diagnoses because of a diagnostic fashion in one or two large medical centers nearby. (Like Mass General?)

Ghaemi has written at length on bipolar disorder. He tends to think a lot of people in treatment for chronic depression have some bipolar variant. He's been a big critic of antidepressant use for problems of this kind. He's also criticized use of antipsychotics as "mood stabilizers," seeing both lithium and anticonvulsants as sounder choices. He also advocates -- gasp -- existential psychotherapy. Check out this link:

http://www.medscape.com/viewarticle/557762_print

Posted by: Johanna at May 29, 2008 10:49 AM

I was wrongly diagnosed with Bi-Polar many years ago, and prescribed Depakote. However, I decided that I was NOT bipolar, and stopped taking the Depakote. I have never felt better after I stopped taking it. I have NEVER had any manic episodes, but I do suffer from major/situational depression due to losing my Mom, my job, etc., all at the same time. I still have no mood swings. I feel much better, more alert, and more able to concentrate. I also felt suicidal on the drug, but once off of it, I no longer have suicidal ideations.

Posted by: Nan at July 4, 2008 02:25 PM

Back in late April I went to my family doc. I have had anxiety for along time, but just kind of dealt with it for 15 years. I went to find out what my options were and to give it a shot. It was very hard for me to ask for help with something, I am very stubrin. So I went and I was put on xanax and antidepressant called lexapro. I never told anyone anything about depression, because I wasn't. I figured it was strange but trusted my doc. Well 1 month later I wroke up in a behavioral health hospital. I could not remeber almost anything from the month before, but there was a suicide atempt that got me there.I sayed there for 1 week. The doc there told me I was bipolar 2. Put me on 2 new meds and off I went. I have been seeing this N.P. now sence july and things starting getting worst again the meds make me really depressed. She will not listen to me about it, just wants to push more drugs on me. I did not get them filled instead I have gottin myself off them, and finally am back to myself. I don't think docs care anymore, if they did I would never have been giving a RX of suicide, and a lovely 1 week stay in the mental hospital. I went for anixety problems and in the process have nearly lost my job, tried to kill myself, and worst of all watched my wife, mom, and sister cry and I didn't know why or care. I do not belive I have anything wrong but anxitey, but I will deal with that on my own. I also belive docs do not care about our safety. So I would tell anyone to ? everything a doc wants to give you, do reserch on it. If it dosn't sound right DON'T take it.

Posted by: michael at September 26, 2009 08:29 PM

Michael, just wanted you to know I have a story similar to yours that occurred about a year and a half ago. I agree with you 100 percent. CBT-III and vitamin supplements have done more for my emotional issues than any bogus diagnosis and drug ever has. Good luck to you!

Posted by: Miranda at September 28, 2009 07:43 AM