Hating bipolar meds: The illness persists

My friend Tom Wootton makes excellent points about the limitations of the anti-medication attitude in bipolar illness, while pointing out the limitations of medications too. I'd like to add some comments that I hope clarify possible mistaken interpretations of this topic.

Tom describes someone who talked about being fine off medications for one year, to great applause. One whole year. Great. And the sun rises every day. And if you drop an apple from a tree, it will fall.

It is the nature of bipolar illness that it is episodic. The average patient has about an episode every year. In other words, without medications, it is the typical natural course of this illness that a person will go one year without symptoms. Then, the episode happens. (See the chapter on course of illness which I helped write for the classic text, Manic-Depressive Illness).

This is the problem. We have almost two centuries of good natural history evidence, from long before the advent of any effective medications. We know quite well, with almost no doubt, that if a person has a manic episode, there is over a 90% chance of repeated manic and depressive episodes in the future (this immense scientific literature is reviewed in chapter on Course in the text above). Those are long odds without treatment.

Now clearly there are good medications and bad ones. Unfortunately, most patients in the US and across the world receive the wrong medications: they get antidepressants, which are ineffective at best, and harmful at worst (causing more and more mood episodes over time). I've published and done research on this topic for two decades (see www.tuftsmood.com for my scientific articles). (I know many bipolar experts disagree with me on this issue, but I don't think the science supports their wishes to make antidepressants seem more effective than they are). With these wrong medications, patients do worse. No wonder they hate medications; it is fully understandable.

Unfortunately, they then conclude that all medications are harmful, whereas a few of them, the proven valid mood stabilizers, like lithium are quite effective and helpful. (This is a large topic, beyond the space of this post. Extensive detail can be found in Goodwin and Jamison's Manic-Depressive Illness).

So, the scientifically valid approach is to support taking some medications, like lithium, but oppose taking others, like antidepressants. It's not scientifically valid to take either extreme: to support, or oppose, all medications.

I would like to correct a point that Tom Wootton makes at the end of his post. He writes: "those who advocate medicine as the solution to Bipolar Dis-Order can only advocate making Bipolar go away. They need the illness paradigm to make medicine the central tool and are unwilling to consider that remission is far below what we are capable of. "

I advocate a medical illness paradigm for bipolar disease; it is a disease, and has been proven to be so with a century of biological research. But this does not mean that every single symptom of it needs to be treated away. Tom is right that many, if not most, bipolar experts take this view; but not all of us. In fact, this isn't the case with the medical illness paradigm in general. If you have an infection, does the doctor try to make every bacterium in your body "go away." You live with tons of bacteria in your intestines every day. It's only the one's that are harming your lung, say, in a pneumonia, that your doctor tries to make go away.

Let's not oversimplify and parody medicine, disease concepts, psychiatry, and medications. Science is a useful thing.