Bipolar Epidemic?

Caution is in order when facing a new psychiatric "epidemic."

Posted Mar 18, 2010

About two years ago, within weeks of each other, two teenage children of dear friends of mine were diagnosed with bipolar disorder, one in the Midwest, the other on the East Coast. The diagnoses were given by psychiatrists whom their parents had consulted. I am not a physician, but I am deeply interested in diagnostic categories and have read extensively in the history of the subject. I knew both of the children in question very well. To be frank, the diagnosis of bipolar disorder amazed me. The label just didn’t seem to fit either child. I spoke to two psychiatrist friends of mine about these diagnoses and then, in conversation with the parents, I offered the only sensible advice I was in any position to give: Diagnosis is tricky. Make sure you get other medical opinions. Both children were seen by other doctors, and with those further consultations, the diagnosis was dropped. The two, now older adolescents, are doing fine. Neither one is taking any medicine. It seems that whatever they were suffering from at the time vanished with some growing up.

One child (I will call her P.), then fourteen years old, received her diagnosis after twenty minutes with the psychiatrist. He also wrote her a prescription for an anti-psychotic drug. If the circumstances had been slightly different, and P. had had parents more likely to fall under the spell of medical expertise, she might now be stamped with “bipolar” and frequenting the same psychiatrist to adjust her medication. Manic depression is a serious condition. The highs and lows of this mood disorder ravage lives, but identifying it is not like diagnosing, say, a urine infection or type 2 diabetes. Peeing into a cup or taking a blood test will get you nowhere.

Do we understand the physiology of bipolar disorder? The authors of a recent paper on neuroscience research into bipolar disorder write: “The heterogeneity of both imaging findings and neurotransmitter alterations has not yielded a single underlying hypothesis.” Although scientists hope to discover more, at the moment there is no consensus about the neurobiology of manic depression.

Not long ago, the disorder was thought to be very rare, far less common than schizophrenia. In the last decade the numbers of people diagnosed with this condition has grown enormously in the North America, especially among adolescents and children, although it was formerly thought to be an illness only of adults. In Europe, bipolar disorder remains an affliction of adults and is not diagnosed in children. What exactly does this mean? What has changed? Tracking the phenomenon of an exploding diagnosis is complex, but it interesting to note that we have been here before.

In his book Rewriting the Soul: Multiple Personality and the Sciences of Memory (1995), the scholar Ian Hacking traced the massive increase in diagnoses for multiple personality. As he points out, in 1972, the condition was regarded as extremely rare with fewer than a dozen cases reported over the course of fifty years. By 1982, psychiatrists found themselves in the middle of a “multiple personality epidemic,” and by 1992, “there were hundreds of multiples in treatment in every sizable town in North America.” Where are they now? No one speaks of an epidemic anymore. In Europe the epidemic never happened. Multiple personality is now called dissociative identity disorder in the DSM IV, and the number of people who “have it” has shrunk dramatically.

P.’s psychiatrist must have felt confident that he had come up with the right answer for her. He listened to her, looked at her, and in under half an hour had a diagnosis. Surely, he had his reasons. The two other physicians who saw her disagreed with him. No doubt, they also had their reasons. I do not know whether children can have this disorder. Those who insist on its legitimacy say that its symptoms look very different from those in adults. It is also clear that the disorder has been marketed in various ways. Drug companies sponsor mood disorder questionnaires on their websites. Even books for children have been published about the disorder. It has many professional defenders as well as convinced parents who cling to the diagnosis as the answer. In 2002 bipolar as a disorder in children made the cover of Time magazine.

My sense is that caution is in order whenever we are faced with psychiatric “epidemics.” As David Healy and Joanna Le Noury argue in a paper that was published in The International Journal of Risk and Safety in Medicine, “…a number of forces appear to have swept aside traditional academic skepticism with the result that an increasing number of children and infants are being put on cocktails of potent drugs without any evidence of benefit.” Children are not in a position to assess risk and safety; it must be done for them, and it must be done carefully.

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