Interesting. I guess Zimmerman was applying the strict criteria that are used in Europe for ICD10?

As I said in a comment on your previous post, I'm one of those people who has some mania stirred in there, but is not suffering from "Bipolar Disorder" - the mania is only a problem in terms of treating the depression and as a stressor - depression is the main "catastrophic illness".

I guess people like me are being categorised as "Bipolar 2" in the USA when we are not in fact?

I think it's possible to say, we have a bipolar spectrum, and to this side of this point on the spectrum, is where we have mania or hypomania as a serious problem in its own right, these people have Bipolar Disorder. The rest? They have recurrent depression, or whatever, with elements of "bipolarity" but are not suffering the extremes of mania or hypomania that characterise Bipolar Disorder.

In other words, the spectrum exists, what do we do with it. Here, it's not encouraged to mis-classify someone simply because ICD10 doesn't have a differential classification for recurrent depression with or without sub-threshold symptoms of mania.

What do you think?

Dee Dee, I am also concerned with the problem of over-diagnosis, but what does it mean for hypomania "to be a serious problem in its own right?" Hypomania by definition doesn't impair the person to the extent that severe mania does. The truly extreme problems may only come when the sufferer crashes from hypomania into depression. But only "treating the depression," as you suggest, is not an option, because many if not most of these people will still go bonkers on an antidepressant just as someone with bipolar 1 will, and if they are going to take any medication it probably needs to be a "mood stabilizer" (scare quotes duly added) just as in bipolar 1. So how does your proposal help them, exactly?

The answer to the problem of over-diagnosis, in my opinion, is not to add yet another arbitrary distinction to an already somewhat arbitrary set of diagnostic criteria. It is to challenge the shocking lack of rigor shown by many psychiatrists in making these diagnoses, and in pushing the still-nebulous concept of a "bipolar spectrum" beyond anything justified by current knowledge.

I certainly have to restrain myself when I say I believe Thase and Sachs are just finally coming to after being knocked out for so long by drug industry and highly influenced ways of thinking as a result.

I find this quite interesting since Thase's name(for example) comes up all over the place in so many ways regarding bipolar.

Go have a beer indeed!

People who don't aren't anywhere on the bipolar spectrum are and have been misdiagnosed with it for years now. People with PTSD and DID for 2 that have been missed with severe consequences for health and recovery both. The Treatment Advocacy Center has an insulting post calling this study "Oops, Wrong People". I'm really beginning to wonder if they are incapable of ordinary human feelings over there with that level of dismissal of tragic consequences that don't fit their agenda.

Garth>

What I'm saying is, I suffer a bipolar spectrum disorder but do not fit into the criteria for BP2 because my hypomanic episodes do not last 4 days or more. There are lots of people like me - it's not a figment of my or their imagination.

It was explained to me that the dividing line between bp2 and not bp2 is arbitrary because it is taking an arbitrary point on a continuum.

Currently, the only diagnosis to the "less manic" side of that divide that encompasses severe depression is Recurrent Major Depressive Disorder. There is no cyclothymia equivalent for mild mania and severe depression. They said that there would be eventually (DSM V?).

I am assured that there is plenty of detail included in my case notes to ensure that any future doctors who treat me are aware of the exact nature of my illness so I am not worried on that account.

In Europe doctors can prescribe a mood stabiliser if they want even if the Dx is recurrent depression providing they can produce a suitable clinical justification. No insurance companies to placate. So there is no obstacle to treatment.

However, I wonder if the reason for some of the increase in Dx in the USA is doctors who know their patient doesn't fulfill the bp2 criteria but who is more like me, BUT their insurance won't pay for a mood stabiliser unless the Dx is BP2 or BP1. See what I mean?

So, in order to give me lithium, my doctor didn't have to change my Dx. And believe me I needed that mood stabiliser!

Finally, it's easy to get worked up on the internet. After a decade, I am finally getting to be normal, and it's wonderful. I'd hate to think someone else didn't get that treatment because of a view that you are either 100% bipolar or not at all.

Finally, hypomania does not mean, necessarily, anti-psychotics. Did I mention that I hate anti-psychotics?

I truly believe that a major reason for the upswing in bipolar diagnoses is the need to explain the large number of depressed people not getting better -- or actually getting worse -- on antidepressants. Rather than cast a critical eye on the drugs themselves, the industry looks for a subset of patients who do not respond well because they do not "truly" have "unipolar depression." The other motivator, of course, is the lucrative market for atypical antipsychotics and new, high priced anticonvulsants.

Over the past thirty years I've been variously diagnosed with manic-depression, depression, psychotic depression, recurrent major depression, dysthymia, cyclothymia, and of course bipolar II. I don't discount that last one entirely -- but it seems that when a clinician is determined to see a depressed person as bipolar, then anything at all will qualify as "hypomania" -- having once fallen in love, stayed up late cramming for final exams, or simply experienced a few weeks of happiness. Most of the diagnostic variation is due much more to changes in fashion, than to changes in the patient.

I agree with Johannas' assessment. I think the over diagnosing is an excuse to explain away the side effects of anti-depressants.

I also agree with Johanna.

I guess people don't realize that 4 [four] million people have been hospitalized since 1988 [the first year Prozac was on the market] due to an antidepressant induced mania and/or psychosis.

This statistic comes from a Yale University study. It was published in the Journal of Clinical Psychiatry 2001: 62: 30-33 and was titled "Antidepressant-Induced Mania and Psychosis Resulting in Psychiatric Admissions" and its two lead authors were Adrian Preda M.D. and Malcolm M. Bowers, Jr., M.D.

The most terrible part of this national tragedy is that the four million people were the lucky ones. Their physicians recognized what was happening to them and hospitalized them.

Not all were recognized. That is why there are over 2,300 cases involving antidepressants, mostly SSRIs, on www.SSRIstories.com/index.php
The full media article is available for each case so a person can read the details.

Johanna, you took the words out of my mouth. I've thought for a long that the increase in the number of folks dx w/ bipolar disorder is due to so many people loaded up on high doses of antidepressants or stimulants like Adderall, Ritalin, Provigil, etc.

Dee Dee, I wasn't saying your own experience or the over-diagnosis issue are figments of your imagination! I also agree that a lot of shrinks seem to be shoehorning patients who don't fit the criteria for bipolar 2 into that category just because it's expedient.

But all this may be moot pretty soon, because I saw an online working paper from one of the groups working on DSM-V that recommends reducing the minimum period of elevated mood for diagnosing hypomania from 4 to 2 days. So that will make it even easier for psychiatrists to do what Johanna mentioned - interpret any patient's case so it will fit a bipolar 2 diagnosis.

Which is too bad, because - this is in my personal experience - I think it is as legitimate a diagnosis as any for some people.

I too think that a lack of understanding of the side affects and withdrawal affects of all the psych meds currently in use have fueled the bipolar 2 diagnosis increase. I think these affects can continue for quite a while after stopping the meds.

The docs seem to believe without question that there are no long term affects of the meds that are similar to psychitric diagnoses. If I said I took meth for 10 years and thought I had some lingering neourological affects they wouldn't be so surprised but somehow saying I took psych meds for 10 years and think I am still affected a couple years off makes them shake their heads.

Those lying drug reps and pharma companies sure know how to peddle their product.

Camas

Don't forget the instant 25 year shorter life span with the diagnosis.

Wikipedia life expectancy , schizophrenia, bipolar disorder and major depression.

Mentally ill die 25 years earlier, on average LINK

Garth> Ah I see.

Well, if they change it to 2 days, my Dx changes and..... my treatment stays exactly the same. Mood stabiliser + anti-depressant.

I guess what I was saying was: don't throw the baby out with the bathwater. Those of us who are genuinely on the "spectrum" exist and benefit from mood stabilising medication.

It would worry me if anyone and everyone was being slapped with this diagnosis though - because mood stabilisers work for me, the potential health risks and the side effects are worth it. If they are doing diddly-squat for some (which they won't if you're not actually bipolar!) then it's NOT a good idea to overprescribe them.

I guess what this comes back too is waaaay too many scripts for Zyprexa? Which, even if it's the best thing in the world for you, is a b***h to have to take...

Mental health is pretty tightly regulated over here. And conservative caution tends to be the rule in diagnosis from what I can see. I think this is a good thing!

Dee Dee, I know people who have very debilitating symptoms that don't fit clearly into either bipolar 1 or 2, so I don't want to throw the baby out with the bathwater, either. Since the underlying cause of bipolar disorders is still vague, I think the main question is a pragmatic one: Does this category help identify individuals whose symptoms are "bipolar" enough and severe enough that the benefits of taking anti-manic drugs are likely to outweigh the risks for them?
If the bipolar-spectrum model helped a slightly larger minority of patients get better treatment, I think that would be a good thing.

However, right now it seems as if the "bipolar spectrum" is sucking in a whole other range of people - depressed patients who don't respond to antidepressants, teenagers who have problems with rage, people who have mild depression and occasional insomnia and racing thoughts, etc. Are the benefits of taking bipolar meds, or maybe any meds, going to outweigh the risks for such a large swath of the population? That seems very far-fetched to me.

I'd also be fine with them lowering the cutoff for hypomania in bipolar 2 from 4 to 2 days - what's the difference? - if they compensated in other ways. Bipolar disorders are cyclical by definition, and that's one of the main characteristics that tend to distinguish them from unipolar depression. So why don't they explicitly include recurrence of symptoms - especially severe depressive episodes - in the description? (Doesn't ICD 10 do that?) That might cut down on at least some of the bathwater out there.

Garth> I think you and I agree actually.

My symptoms are definitely cyclical. Plus I have 5 zillion relatives who are all bipolar. Yep ICD 10 has different codes for recurrent v. non-recurrent mood episodes.

Hmm it never occurred to me that if someone had 2 days of supposed hypomania ONCE that they would get a bp diagnosis - I think you'd have to have a pretty long list of why you thought you were hypomanic, or actually experience it as an inpatient, to get a dx change over here. I have, like, 20 years of symptoms of depression and hypomania that I can catalogue and even then it's taken some years to go from ADs only to ADs and mood stabilisers.

I guess I understand now why such a conservative approach is taken. Thanks: you don't often get a new insight reading blog comments but you just did that!

A good doctor will spend an hour at least assessing someone for the first time before making any decisions and will take a lot of things into account. I don't think there's any substitute for that.

But yeah, the less bathwater the better.

I was labelled bipolar 2 in 1996. I did not follow the treatment plan, I was originally forced into (while hospitalized). The doc said, "you seem a little bipolar" and for that I got Depakote, Paxil, and Thiothixene (typical anti-psychotic).

I did not hear voices, I was maybe delsuional, but I was also tossed into a drug ward without being drunk or on drugs.

I was forced to fit a dx, with a hammer.

I stopped all the meds except paxil after only a week. The sky did not fall, the hallucinations (I was not having) did not return.

I have more of an anxiety disorder now (go figure) no bipolar. I thought I was maybe bipolar after all. I did eventually receive compassionate care, that unfortunately got cut by the govy.

I did see a psych recently. It's hard to say what is really wrong other than, bad treatment can lead to bad outcomes for a patient. This psych (unfortunately) was big on bipolar too. They tried to label me bipolar just to get me on mood stablizing treatment. I asked if they really saw bipolar in me, at all in their practice. They did not, they just wanted to go with my initial dx to label me.

They wanted to try me on lithium without hypomania or depression present.

Basically they thought they might dupe me into playing guinea pig.

You know what, with our failing health care system, particularly mental health care, I can see where tired frustrated patients get duped all the time. I've been on waiting lists for more appropriate treatment for ages. I can see why patients will eventually just say, screw it and take whatever pill a doctor doles out to them, even when their dx is not really bipolar. It just feels good to a patient to finally get an answer where there are none.

This blog post is as wrong as the actual study.

See why the study is wrong:

http://www.psychologytoday.com/blog/mood-swings/200805/relax-youre-not-bipolar

Nassir, did you *really* just cite your own article?

Nassir,

In your blog entry to which you post a link here, you write:

"...But many other studies show that when people actually have bipolar disorder, they are not diagnosed with it about half the time."

I'm not sure how you arrive at this conclusion since you go on to write:

"Reliability of clinical diagnoses for any psychiatric diagnosis is rarely more than 50%. In one large community-base study (the Epidemiologic Catchment Area study, ECA), reliability of psychiatric diagnoses ranged from 5-35%. Thus, all diagnoses are overdiagnosed!"

Then you go on to waive that data that you don't dispute away as apparently irrelevant with this:

"To claim the wrong diagnosis (whether over or under), we must claim validity. We must know whether or not the diagnosis is valid, before we can tell whether it is being over or underdiagnosed."

So here's my question, what exactly is the criteria for a valid diagnosis of bipolar disorder? And is there any concensus on this or is primarily your opinion?

For anyone interested in the subject of Bipolar Disorder being over diagnosed and/or are looking for help to overcome difficult times. Feel free to view my sites:

www.bipolarbeware.com
www.drjeffmdphd.com

take care.