Comments: Notes For Psychiatrists: Labels Matter
I've already said here that I prefer the term "maniac-depressive psychosis".
I don't understand bipolarity 2 and people who are not familiar with diagnoses are confused.
Now there's bipolarity 3?
Great!
It's a good way to mix it all and prescribe same drugs.
Antidepressants to bipolarity 1.
Thank you Philip for this post and I hope people understand the consequences of "renaming" diseases.
This is very serious!
Posted by Ana at February 23, 2009 11:48 PM
I had that whole "you aren't depressive, you're bipolar" thing a bit over a year ago and they totally changed up all my medication. My question is this: for the people that have to live with this, does it matter what they label the condition? Isn't what matters the most that the medications help increase your quality of life? I mean, besides the question of prejudice by the general populace where you lose your job and friends because they're afraid of you. Besides that fear of telling people my diagnosis, my ability to cope and get through my day has improved substantially. Using just antidepressents destroyed every relationship and employment I've ever had. Why should I personally care what the doctor calls it as long as the new bipolar treatment is working?
Posted by Laura at February 24, 2009 04:50 AM
Laura,
Some dxs are more stigmatizing than others. I believe that's the one and only issue Philip's addressing in this posting. You are correct--who gives a hooey about dx if the tx works? But... so many people are on SSRIs these days--perhaps including the HR person interviewing you--that depression is a far less stigmatizing label to sport than BP or BPD, say.
And sadly, we have almost no privacy these days. The chances of an employer or prospective health insurer finding out your dx is pretty high. The label carries social issues that are quite apart from tx issues. Well, except for those dxs that are codes to other pdocs... Then your tx can be impacted indeed.
Sherry
Posted by Sherry at February 24, 2009 08:43 AM
Spot-on, Philip. You are touching on an issue I confront almost daily as a public mental health therapist. All too often the "Bipolar" label is assumed to imply disability. While I welcome aspects of the spectrum model, this issue looms large. Many folks come here touting a BP II diagnosis and the disability determination forms show up before the second appointment. The sources of these diagnoses are usually suspect, coming from an on-line search or a four item quiz in a magazine. No history of mania or hypomania to be found. How is this Bipolar? It is definitely pharma-driven with no concern for the consequences beyond quarterly profits. Naturally, I piss a lot of people off when I say that, while I can complete the determination form, my evidence is not likely to be supportive of disability. And Bipolar III? Lots of folks have adverse reactions to antidepressants, event those who are truly depressed. Diagnosis on such a basis is a classic example of the error of "post hoc ergo propter hoc."
Posted by Dark Jay at February 24, 2009 10:11 AM
Dr. Schneck asks: "are these cases of refractory unipolar depression that require more aggressive antidepressant treatment, or are there sufficient bipolar symptoms to introduce a mood stabilizer?"
There's a third possibility: is this a consequence of "taking multiple antidepressants for many years"? I am aware of NO clinical studies on the effects of five, ten or twenty years of daily antidepressant therapy. I do know at least one respected researcher, Giovanni Fava, who has repeatedly called for such studies on the grounds that there are good reasons to believe that long-term use of these meds is "depressogenic". That is, it resets the brain's threshold for depression, creating a chronic problem where it might not have existed previously.
The problems in getting funding for such a study are obvious: who the hell would profit from it? Only patients, I guess. Given the rising numbers of people on SSI disability for depression in the Age of Antidepressants, however, I think it would be well worth doing.
Posted by Johanna at February 24, 2009 10:35 AM
What Schneck is arguing in this editorial is a return to Kraepelin who categorized the diagnosis of manic-depression to include everything we call bipolar disorder and recurrent unipolar depression as outlined in Goodwin and Jamison's book. Often those with recurrent unipolar disorder are better treated with the same medicines for bipolar disorder. Many argue that there is a spectrum of manic-depression running from recurrent unipolar depression to bipolar I. This is where bipolar II and "bipolar III" come from. The point of the return to Kraepelin is that these recurrent illness may require medicines which stop cycling as opposed to medicines, like AD, that treat acute episodes. The labelling becomes important in that respect.
Posted by Tony at February 24, 2009 11:35 AM
Hi. In the only TV ad here in NZ which addresses Bipolar Disorder, the protagonist seems to stress a history of depressive-type symptoms. Hmmm.... it is a difficult thing: the subtleties of a subject and public perception. But the ad campaign seems well-intentioned in its aim to foster wider understanding. And as far i can tell, it is in no way influenced by Pharma.
Ads for depression featuring an ex All black (National rugby team) won best not-for-profit advertising campaign 2007 at the New Zealand Advertising Effectiveness Awards. The TV ads show former All Black John Kirwan, speaking openly about his experiences of depression. The ads were so 'effective' there was a spike in the number of males reporting depression.
Good post, Phil.
Posted by richey at February 24, 2009 06:12 PM
the term "mixed depression" doesn't make sense to me. depression mixed with hypomania? "mixed" as in mixed states of bipolar disorder? "agitated depression" was identified by Kraepelin around the early 20th century as an aspect of bipolar disorder, an aspect of which (sort of a full out mixed state) we don't have an accepted diagnostic term for now. it's a very strange, dangerous thing to be overwhelmingly depressed with an enormous amount of energy. to be angry and depressed is one thing, the mixed states they're discussing are a completely different matter and can't really be understood unless you've experienced one.
bipolar II, while generally won't make you run around thinking you're jesus, can very much impair occupational functioning and quality of life. hypomania is often written off as nothing, but it can devastate lives with impulsive spending and behavior. i've been manic as well as hypomanic, and while the hypomanias were occasionally fun, both destroy things in their own ways. it's demeaning to say that one disorder isn't valid in the way you do. suicide is higher for people with bipolar II when compared to MDD and bipolar I, it's a different beast.
additionally, as tony said, proper diagnosis can helpfully steer treatment which gives it value. categorizing disorders based on their similarities and treatment makes sense. what purpose it serves to try to say that various mixed states are simply "depression," i'm not sure. traditional depression treatments only aggravate the agitation and grant more energy, making the situation more dangerous (as you noted). not many treatments are much help for acute mixed states but the best bet is a temporary low dose of antipsychotics.
i agree that there has been far too much overdiagnosis of bipolar disorder, but i don't think the remedy for that is to eliminate a genuine facet of bipolar disorder.
Posted by sarah at February 24, 2009 07:36 PM
Philip:
Like anyone visiting this site, I'm 110% for more accurate diagnosis.
But honestly, attitudes like yours are what perpetuate stigma, not begin to erase it. Because until people can be made less scared of our symptoms and our conditions, you could call bipolar 2 "greatest person in the world" and then people would start stigmatizing the greatest people in the world ...
Posted by Larry at February 24, 2009 08:26 PM
Bipolar II, agitated depression, mixed states. A rose by any other name would be as excrutiating.
I went to the psychiatrist the other day because i've been what I call "wound up" for a few weeks now. Call it what you want but I call it being "wound up". Kinda hyper, blurting out things that then kind of embarass me (usually outrageous jokes), other "behaviors" that are not the most comfortable but by no means life-threatening or harmful, just amped up more than usual, sleeping about 5-6 hours a night. She wanted to start me depakote and I said no way. She assured me a depressive collapse would inevitably follow this feeling. Well, I take Lamictal for the depressive side of things already.
I'm not blacking out and ending up in Paris with 5 credit cards maxed out. I'm not naked running down the street psychotic. But, since I supposedly have a version of bipolar I should probably take the same meds as psychotically bipolar people just at lower doses, right? What harm can it do? From my experience, for me: LOTS of harm. (i.e. "low doses" of Zyprexa turning me into a zombie after 3 months)
So, instead i'm being mindful. Taking a lot of hot showers. Avoiding overly stimulating music. Trying to get a regular sleep schedule. I started eating better (I wasn't eating very much which makes me hyperactive as well). And I'm cutting down on the caffeine (I was drinking three cups a day). I take a small amount of Valerian root or an antihistamine (Vistaril) if I'm feeling really wound up and agitated and it takes a little bit of the edge off. And I've been going to my support meetings a lot. And the "hypomania" has pretty much passed. I started a new job yesterday and I'm doing really well at it, can focus and accomplish things.
I have to accept the fact that there are times in my life, many times, when I just won't be comfortable. Sadly, for me, I don't think drugs can really remedy that situation. I've probably tried all of them: legal and illegal. Usually, they seem to just make it worse or add a whole other set of problems to my life.
p.s. This is my personal experience, if you're bipolar II and take Depakote and it's saved your life then bless you. I just hope my experience resonates with someone similar to me and maybe they won't have to go down the road of psychiatric over-treatment that I did.
Posted by David at February 25, 2009 05:22 PM
My psychiatrist said that in the past year he has taken away more diagnoses of bipolar disorder than he has "bestowed". We never talk about whether I am bipolar I or II, but I'm pretty sure it is I. He also said that those euphoric manic types that you hear about are pretty rare. I was one of those people who was treated for unipolar depression rather unsuccessfully off and on for several years in the 90's before anyone figured out it was bipolar. So we go from under-diagnosing it then to over-diagnosing it now.
You'd think that my first experience with an AD (prozac) which caused agitation, overstimulation and actual first time panic attacks in crowds would have been a warning sign, but I guess in 1992 bipolar was thought to be rare. So I was given trazodone to mellow it out and help me sleep. No one noticed the irritable mania that followed because I am a relatively well-behaved and quiet person in general. Hmmmm... Hindsight.
Now I am trying to get life insurance. I'm not feeling good about my chances.
Posted by Jen at February 26, 2009 04:31 PM
Jen, forgive me if I am stating things you already are aware of but I still wanted to post this for whoever reads your post.
As I am sure you are well aware, BP reactions are side effects of many ADS. Just because you have one doesn't mean you are BP. Sorry, I am very sensitive about this issue as way too many people are medicated improperly due to this occurring.
Also, just because ADs don't work doesn't mean you have BP. Many of them didn't work for me but I am definitely not BP.
If you truly are BP, I don't mean to come across as minimizing your situation. But I decided to take the risk anyway and post because I am concerned about all the misdiagnoses.
I feel your pain about wondering whether you will get life insurance. I was turned down for health insurance a few years ago due to my psych med history even though I was tapering off of them. They are gifts that keep on giving. NOT!
Posted by AA at February 27, 2009 03:36 AM
So saying to someone that you are diagnosed with bipolar disorder type 2, especially a cautious employer, is tantamount to saying you have full-blown manic-depression because that's all the general public knows. You'll lose your job, or not get it in the first place, and that date you've got tonight will run for the hills. Some family members will make the same kinds of assumptions. So will the police, insurance companies and society as a whole.
The instant assumption people will make is that you are just like the manic guy they read about in the paper who went off his nut and shot a cop or stripped and ran naked down the street until the cops dragged him off to a psych unit.
I don't know about others, but I have Bipolar I, and I find these statements very stigmatizing.
How would you like to be that "manic guy" who "went off his nut" (great use of non-stigmatizing language there), wandered for days and nights talking to strangers and getting into dangerous situations (I'm surprised I haven't been stabbed or raped yet), was shoved in the back of a police car in handcuffs, driven to an emergency room, locked in observation, given a needle in the butt by four staff members holding him down, and thrown onto a locked ward? You know, people are AWARE at these times. They can feel intense fear.
You complain that you're being treated like us, that people discriminate against you the same way they do us, and that this is because you're labeled like us. In my opinion, you're saying that being called "bipolar" means you're being called a freak.
That really makes me feel great about myself.
Maybe they should get rid of the bipolar II diagnosis. I've had hypomania and full-blown mania, and the two are scales apart. I don't think someone with BP II, or "mixed depression", or whatever you want to call it, has suffered to the degree I have. I don't have the type of mania where I just crash and sleep afterwards. I have the kind where I don't sleep until I get medication. If I didn't get medication, I could just die from being up so long.
Posted by Sara at March 2, 2009 12:14 AM
Just to say Sara at March 2, 12:14 AM is not me, the Sara who's on here rather a lot (one of the "addicts").
Posted by Sara at March 2, 2009 10:31 AM