Part of what you describe in your new book Mania: A Short History of Bipolar Disorder is a fair amount of "biomythology" about the illness. What aspects in particular do you have in mind?

Biomythology links to biobabble, a term I coined in 1999 to correspond to the widely-used expression psychobabble. Biobabble refers to things like the supposed lowering of serotonin levels and the chemical imbalance that are said to lie at the heart of mood disorders, ADHD, and anxiety disorders. This is as mythical as the supposed alterations of libido that Freudian theory says are at the heart of psychodynamic disorders.

While libido and serotonin are real things, the way these terms were once used by psychoanalysts and by psychopharmacologists now—especially in the way they have seeped into popular culture—bears no relationship to any underlying serotonin level or measurable chemical imbalance or disorder of libido. What's astonishing is how quickly these terms were taken up by popular culture, and how widely, with so many people now routinely referring their serotonin levels being out of whack when they are feeling wrong or unwell.

In the case of bipolar disorder the biomyths center on ideas of mood stabilization. But there is no evidence that the drugs stabilize moods. In fact, it is not even clear that it makes sense to talk about a mood center in the brain. A further piece of mythology aimed at keeping people on the drugs is that these are supposedly neuroprotective—but there's no evidence that this is the case and in fact these drugs can lead to brain damage.

How does our understanding of "mania" differ today from earlier conceptions of the phenomenon?

Bipolar disorder itself is a somewhat mythical entity. As used now the term bears little relation to classic manic-depressive illness, which required people to be hospitalized with an episode of illness, either depression or mania. The problems that currently are grouped under the heading "bipolar disorder" are akin to problems that, in the 1960s and 1970s, would have been called "anxiety" and treated with tranquilizers or, during the 1990s, would have been labeled "depression" and treated with antidepressants.

How did we move so rapidly in the 1990s from a psychotherapeutic treatment model for children to a largely drug-related one?

I think a key factor in this shift has been the availability of operational criteria. These were introduced in 1980 in DSM-III, the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders. The idea was to bridge the gap between the psychotherapists, on the one hand, and the neuroscientists on the other. It was hoped that if both camps could ensure that patients met 5 of 9 criteria for depression, for instance, then at least the patient groups would be homogenous, even if the views on what had led to the problems weren’t.

It was still assumed, however, that there was a place for clinical judgment, so that a patient who met 5 of the 9 criteria for depression but had 'flu or was pregnant would be diagnosed as being pregnant rather than depressed. But in the face of company marketing, and with the advent of the Internet, clinical judgment has been eroded. Patients going on the Internet or faced with drug company materials now all too easily find that they meet criteria for a disorder and there is often nothing or no-one to tell them this is not equivalent to having the disorder.

In the extreme, I have had patients with highly social careers come to me and say they think they have Asperger’s Syndrome because they've been on the Internet and find that they meet the criteria for this when, in fact, almost by definition, such a person cannot have Asperger’s Syndrome. In the absence of clinical judgment there is a default towards a biological option and a drug solution. Criteria create a problem for which a drug is all too often the answer, in just the same way that measurements of your lipid levels create a problem that a statin is the answer to.  

Operational criteria are interacting here with a certain loss of medical authority. It is not possible for a doctor today to say to a patient, "Based on my 15 to 20 years experience, you do not have PTSD," or whatever. She cannot say, "We do not need to continue this conversation; come back when you’ve had a medical training and 15 years of clinical experience."

The doctor has to engage with the patient on the level of the material that's out there in popular culture, and when she tries to do this she will find that she's up against an extraordinarily skilful deployment of those materials by pharmaceutical company marketing departments who are masters at populating the wider culture to suit their interests.

In the mid-1990s, you note, roughly half of all mood disorders were redefined as bipolar disorder rather than depression. What do you think accounts for that dramatic shift in perspective?  

The key event in the mid-1990s that led to the change in perspective was the marketing of Depakote by Abbott as a mood stabilizer. Before that, the concept of mood stabilization didn't exist. And while in a popular TV series we can accept that Buffy the Vampire Slayer gets a new sister in Season Five that she had all the time but we didn’t know about, we don’t expect this to happen in academia. 

The introduction of mood stabilization by Abbott and other companies who jumped on the bandwagon to market anticonvulsants and antipsychotics was in fact quite comparable to Buffy getting a new sister. Mood stabilization didn’t exist before the mid-1990s. It can’t be found in any of the earlier reference books and journals. Since then, however, we now have sections for mood stabilizers in all the books on psychotropic drugs, and over a hundred articles per year featuring mood stabilization in their titles.  

In the same way, Abbott and other companies such as Lilly marketing Zyprexa for bipolar disorder have re-engineered manic-depressive illness. While the term bipolar disorder was there since 1980, manic-depression was the term that was still more commonly used until the mid-1990s when it vanishes and is replaced by bipolar disorder. Nowadays, over 500 articles per year feature bipolar disorder in their titles.

You just have to look at Lilly’s marketing of Donna from the Zyprexa documents on the Internet to see what is going on here: "Donna is a single mom, in her mid-30s, appearing in your office in drab clothing and seeming somewhat ill at ease. Her chief complaint is 'I feel so anxious and irritable lately.' Today she says she has been sleeping more than usual and has trouble concentrating at work and at home. However, several appointments earlier she was talkative, elated, and reported little need for sleep. You have treated her with various medications including antidepressants with little success. . . You will be able to assure Donna that Zyprexa is safe and that it will help relieve the symptoms she is struggling with."

Donna could have featured in ads for tranquilizers from the 1960s to the 80s, or for antidepressants in the 1990s, and would have probably been more likely to respond to either of these treatment groups than to an antipsychotic, and less likely to be harmed by them than by an antipsychotic. What company marketers are so good at doing is framing the common symptoms people have—we almost all have—in a manner most likely to lead to a prescription for the remedy of the day. It flies in the face of a century of psychiatric thinking to see conditions that patients like Donna have as bipolar disorder. But while a century of psychiatric thinking used to count for something, it doesn't any longer.