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The Bipolar Bamboozle

Article

Stephen Ray Flora and Sarah Elizabeth Bobby

Volume 32.5, September / October 2008

With the broadening and softening of the criteria needed to label someone with bipolar disorder and aggressive marketing campaigns by pharmaceutical companies, millions of people are being told they have a severe psychiatric disorder and are being prescribed powerful antipsychotic medications. In fact, most are normal people dealing normally with everyday life issues.

“Bipolar disorder,” originally known as manic-depression, has been acknowledged as a problem for centuries. However, until very recently, it was considered a very rare and severe condition. Now diagnoses of “bipolar spectrum” disorders are reaching epidemic proportions. Nothing has changed in humans’ biology or natural environment to account for this rise in diagnoses. What does account for the increase is a “softening” of the criteria needed to diagnose a person with bipolar, an increase in aggressive marketing of new profitable prescription drugs for bipolar, and psychiatrists “upcoding” problems to get higher insurance reimbursement rates. A likely outcome of this increase in labeling people “bipolar” is not that more people in need of help are getting it but instead that millions of people are unnecessarily being put on powerful antipsychotic medications.

As the name suggests, people labeled bipolar are believed to alternate between the emotional extremes, or poles, of mania and depression. Prior to the publication of the third edition of psychiatry’s Diagnostic and Statistical Manual (DSM-III) in 1980, a patient would have to be hospitalized with a manic episode before a diagnosis of manic-depression was made. At that time rates of mania were estimated to be 0.4 to 1.2 percent of the population; prior to that, rates were estimated to be even lower. Currently some estimates of bipolar are as high as 10 percent of the population (Angst, et al. 2003), but rates of hospitalization for mania have not increased. What happened?

Just as a child with a hammer discovers new things that “need” to be hammered, when psychiatry finds new drugs it discovers new people who “need” to be treated with them. In 1949 Australian doctor John Cade reported that lithium salts could be effective in the treatment of “psychotic excitement” or mania (Cade 1949). As knowledge of this finding spread, so did the diagnosis of mania, as noted by Philip Mitchell:

One of the major driving forces determining the livelihood of particular diagnoses in medicine has been the availability of effective remedies. Psychiatry has not been exempt from this phenomenon, with the introduction of lithium into clinical practice in the late 1960s and early 1970s leading to substantial increases in the diagnosis of bipolar disorder over that time. For example, in Australia, Parker et al. demonstrated that in New South Wales, the diagnosis of bipolar disorder increased dramatically (with a concomitant decrease in the diagnosis of schizophrenia) from the mid-1960s to the mid-1970s, despite there being no overall change in the total number of those with “functional psychoses.” (Mitchell 2006, 279)

While there was no change in the number of people with “functional psychoses,” by 1968 more than 200 psychiatrists had applied to the FDA to study and use lithium for mania. Concurrently, three companies applied to market lithium. The FDA approved the applications and in 1970 approved the use of lithium to treat manic episodes of manic-depressive psychosis (Johnson and Gershon 1999). With the publication of the third edition of the DSM in 1980, the “mania” diagnosis was replaced with “bipolar disorder,” and the rates of bipolar remained stable.

In the last decade, rates of children being diagnosed with bipolar has increased by forty times, and the rates of diagnosis for adults almost doubled (Morero, et al. 2007)! Nothing overtly changed in American culture—not dietary practices, there was no mass exposure to toxic waste, and neither parenting nor educational practices were overhauled. Instead a culmination of less than scientifically justified factors resulted in the current explosion of people, many of them children as young as four years old, being diagnosed and misdiagnosed as “bipolar.”

The Tenuous Analogy: A Pharmaceutical Sleight of Hand

Without exclusive rights to a patented pharmaceutical, and with bipolar still a relatively rare “disorder,” sales of lithium, or any drug to treat this problem, could not be profitable. This rapidly changed when psychiatrists started to use epileptic, anticonvulsant, antiseizure medications in attempts to control mania (Healy 2006). Seizures occur in epileptics when there is sudden excessive firing of neurons; the initial firing is known as “kindling.” Anticonvulsants work by “stabilizing” the neurons and preventing or at least reducing the frequency of kindling and thus seizures. Perhaps because both seizures and mania appear to involve a high state of “excitability,” Robert Post (e.g., Post and Weiss 1989) suggested that manic states might be prevented with antiseizure medications analogous to how they prevent seizures in epileptics. But there is a difference in the excitability of neurons during seizures and the emotional excitability of mania. There is no evidence that nerurons fire uncontrollably and excessively during states of mania as they do during seizures.

Nevertheless, with this analogy, the term “mood-stabilizer” came into vogue, and in 1995 Abbott Laboratories’ Depakote became the first anticonvulsant approved by the FDA for treating mania. Yet, there is no agreement on what the term “mood stabilizer” means (Healy 2006), and although they may be called “mood-stabilizers,” anticonvulsants have never been shown to actually stabilize moods; rather, their use is simply based on an analogy, not science. Using anticonvulsants for mania, even though not developed for it, and calling anticonvulsants “mood stabilizers” though they have never been shown to stabilize moods, are just more examples of drug companies’ well-worn strategy of finding new, profitable “indications” for selling old, less profitable, drugs (see Flora and Sellers 2001 for another example). In the study “The Impact of Mood Stabilizers on Bipolar Disorder: The 1890s and 1990s Compared,” North Wales researchers found that despite the wide-spread use of mood stabilizers, rates of readmission for bipolar patients is higher now (77 percent) than it was one hundred years ago (8 percent). In the 1890s, 81 percent of the discharges were recovered, but only 17 percent in the 1990s were recovered. These findings forced the researchers to conclude: “These data are incompatible with simple claims that mood stabilizing drugs ‘work’” (Harris, Chandran, Chakraborty, and Healy 2005). Indeed, these findings indicate that not receiving treatment works better than pharmaceutical intervention. Similarly, University of Illinois researchers recently found that only 5 percent of medicated schizophrenia patients recover, but 40 percent of non-medicated patients recover (Harrow, Grossman, Jobe, and Herbener 2005; also see Harrow and Jobe 2007). In other words, schizophrenia patients are eight times more likely to recover if they are not on medications!

“Softening” Bipolar Sickness

According to Webster’s New Riverside University dictionary, “bipolar” is defined as “1. Relating to or having two poles. 2. Relating to or involving both of the earth’s poles. 3. Having or expressing two contradictory ideas or qualities” (1988). Thus, if “manic-depression” is “bipolar,” then the states of mania and depression need to be polar opposites as are the Earth’s north and south poles. Consisting of the polar states of mania and severe depression, the original notion of “bipolar disorder” matched the dictionary definition of “bipolar.” However, disregarding the very definition of bipolar, the psychiatric notion of “bipolar disorder” has been broadened and “softened” to include milder, decidedly nonpolar mood states in the now-called “bipolar spectrum disorders” (e.g., Akiskal, et al. 2000). Consequently, an individual who is simply very happy at times may be said to have periods of “hypomania” rather than mania; and if sometimes they are sad too they may be labeled “cyclothymic” within the bipolar spectrum. “Softening” is analogous to (geologically) studying Brazil and Mexico and claiming to be studying Earth’s poles. While this is merely ridiculous in geology, it is actually harmful in psychiatry. Yet this is exactly what is happening, because it is profitable for psychiatry and pharmaceutical companies. Even though normal life events expected to elicit happiness and sadness are recognized as contributing factors by psychiatrists, people experiencing happiness and sadness are nevertheless labeled cyclothymic in the bipolar spectrum, opening the door to reimbursable psychiatric care and unnecessary pharmaceutical prescriptions. For example, Akiskal et al., report:

slightly under 10% of a mental health clinic’s patients conformed to subsyndromal [nonpolar] mood changes over extended periods of time. These where young adults who presented clinically because of social disruptions in their lives, such as romantic failure, financial extravagance, repeated change of line of work or college studies, frequent geographical moves, and polysubstance abuse. The underlying affective diathesis was validated on the basis of phenomenological criteria that involved biphasic subsyndromal [nonpolar] changes in energy, activity, mood, and cognition, each phase typically lasting from 2 days to a week; some oscillated more in a depressive direction, . . . [t]he subthreshhold oscillation of hypomanic and subderessive periods occurring in 6.3% of the population at large. (Akiskal et al. 2000, S10, emphasis added)

What Akiskal et al. are arguing is that even though emotions do not reach the level of being a psychiatric syndrome (“subsyndromal”) and are caused by common emotional life events (e.g., “romantic failure, . . . repeated change of line of work or college studies, frequent geographical moves, and polysubstance abuse”), a significant portion of the population with these normal emotions should nevertheless be labeled “bipolar.” Indeed, their original article in this line of work was titled “Cyclothymic Disorder: Validating Criteria for Inclusion in Bipolar Affective Group” (Akiskal et al. 1977, emphasis added). Thus normal happiness and sadness become disorders “treatable” with pharmaceuticals.

“Upcoding”

As if “softening” the diagnoses of bipolar to cast a wider net for paying clients wasn’t questionable enough, psychiatrists have been “upcoding” individuals, particularly children, to more severe “bipolar” diagnoses to get greater insurance reimbursement. SUNY-Stony Brook psychiatrists Joseph Blader and Gabrielle A. Carlson (2007) found that from 1996 to 2004 rates of bipolar diagnoses among adults increased 56 percent, increased 296.4 percent among adolescents, and increased 438.6 percent among children! They suggest:

higher rates of inpatient admissions among youth associated with BD [bipolar disorder] may reflect . . . “upcoding” to putatively more severe conditions for reimbursement (107) . . . [and that] Clinicians may have responded to the higher hurdles for obtaining payer’s authorization for inpatient care by “upcoding” severe behavioral disturbances to a major mood disorder that connotes a more pernicious illness. (111)

Apparently, to gain these increased diagnoses, children with behavioral difficulties and conduct problems are receiving “upcoded” diagnoses of bipolar disorder (Blader and Carlson 2007). Diagnosing children who have behavioral difficulties with bipolar disorder (or any psychiatric disorder) and subsequently medicating them is particularly disturbing. The evidence is conclusive that to correct conduct and other behavioral problems, behavioral management programs and parent training programs are superior to medicating children (Flora 2007).

Selling Sickness with Direct-to-Consumer Advertising

In 1997 the FDA began to allow direct-to-consumer advertising, making the U.S. and New Zealand the only two countries in the world that allow the practice. This change opened the door for self-diagnoses, medical-seeking behavior, and disease mongering. According to writers in the British Medical Journal:

Some forms of “medicalisation” may now be better described as “disease mongering”—extending the boundaries of treatable illness to expand markets for new products. Alliances of pharmaceutical manufacturers, doctors, and patient groups use the media to frame conditions as being widespread and severe. Disease mongering can include turning ordinary ailments into medical problems, seeing mild symptoms as serious, treating personal problems as medical, seeking risks as diseases, and framing prevalence estimates to maximize potential markets. (Moynihan, Heath, and Henry 2002, p. 886)

This is exactly what has occurred with bipolar disorder. Advertisements for Abilify and Seroquel, two antipsychotic medications approved for bipolar disorder, are ubiquitous in periodicals, daytime television, and even plastered on phone booths. Just as anticonvulsants were used as “mood stablizers,” the current drugs being pushed for bipolar were developed for schizophrenia. According to company press releases, Abilify was approved in 2002 for the treatment of schizophrenia, producing over 3.7 million prescriptions between 2002 and 2005. Seroquel was approved for the treatment of schizophrenia in 1997 and produced sales of $2.8 billion in 2005. Pharmaceutical patents typically last for seven years, but if “new indications” can be found, then the patent can be extended for several more years, which will protect and likely increase profits. Using this strategy, the makers of Seroquel gained FDA approval for the treatment of mania in 2004 and for depressive episodes in 2006. The makers of Abilify gained FDA approval for “maintenance treatment” of bipolar in 2005.

Direct-to-consumer advertising coupled with happiness and sadness fitting into “softer” bipolar categories made for fertile ground in which drug companies could solicit for mental illness and thus increase sales. Because sales of drugs require a medical diagnosis, drug advertisements suggest to potential customers that they may have a “medical disorder” such as bipolar. Advertisements tell consumers to focus on feelings, behaviors, and sensations consistent with the disorder. Drug company-sponsored “educational” Web sites offer self-tests designed to lead the taker to admit symptoms consistent with bipolar. The test taker is encouraged to print out the results and share them with a doctor who can prescribe medication. “The Mood Questionnaire” Web site is nothing more than a promotion for Seroquel by its makers, AstraZeneca pharmaceuticals. The site tells survey takers: “Regardless of your results, we recommend that you print and share this questionnaire with a qualified health care professional who can provide you with a full evaluation” (emphasis added).

Showing up at a doctor’s office with a printout and concerns about bipolar will influence some doctors to prescribe medication. Previous research revealed that when “patients” visited doctor’s offices unannounced with complaints of adjustment difficulties, they received a prescription for medication 10 percent of the time. But when they made complaints of adjustment difficulties and mentioned a specific medication, they received a prescription for antidepressant medication 55 percent of the time (Kravitz, Epstein, Feldman, et al. 2005). Based on these findings, it is not hard to guess what will happen when a patient shows up with a questionnaire on bipolar from drug makers.

Side Effects

Medicating people for happiness and sadness is not without consequence. Antipsychotics used to treat bipolar work by interfering with the body’s dopamine and serotonin systems. These neurotransmitters are known to be involved in one’s ability to feel pleasure and initiate activities. Interfering with these abilities are likely reasons why up to 75 percent of patients refuse to take prescribed antipsychotics (Flora 2007, 113).

Common side effects of Seroquel include dry mouth (44 percent), drowsiness (34 percent), high triglycerides (23 percent), headaches (21 percent), agitation (20 percent), dizziness (18 percent), high cholesterol (16 percent), weakness (10 percent), constipation (10 percent), and fatigue (10 percent). Common side effects of Abilify include headaches (30 percent), anxiety (20 percent), insomnia (19 percent), nausea (16 percent), constipation (13 percent), vomiting (12 percent), and dizziness (11 percent) (eMedTV). Many other common side effects occur in between 2 and 10 percent of those who take these drugs. For example, significant weight gain occurs in 6 percent of people taking Seroquel and in 6.8 percent of people taking Abilify. This weight gain often leads to diabetes or morbid obesity. With the drug-induced decreased ability to feel pleasure and numerous aversive side effects, eating may be one of the only sources of enjoyment available for people labeled “bipolar.”

In conclusion, the broadening and softening of the criteria necessary to label one with bipolar disorder coupled with aggressive campaigns by pharmaceutical companies results in millions of people being told they have a severe psychiatric disorder. These misled patients are being prescribed powerful antipsychotic medications when in fact they are normal people dealing normally with ordinary life issues.

References

Stephen Ray Flora and Sarah Elizabeth Bobby

Stephen Ray Flora is a psychology professor and behavior analyst at Youngstown State University and author of Power of Reinforcement (SUNY Press 2004) and Taking America off Drugs: Why Behavioral Therapy is More Effective for Treating ADHD, OCD, Depression, and Other Psychological Problems (SUNY Press 2007).

Sarah Elizabeth Bobby is a psychology graduate of Youngstown State University.