April 29, 2008

Experts Weigh In On Bipolar Disorder

And they conclude there's a lot of bad information out there.  They try to set the record straight.

Bring a bottle.

From the article:

[The Diagnostic Guidelines Task Force of the International Society for Bipolar Disorder (ISBD)]  chairman S. Nassir Ghaemi, MD, MPH ... brought together some of the world's clinical experts on bipolar disorder and key researchers with the goal of having them develop a more systematic and coherent set of diagnostic guidelines.

In other words, what do the best minds in psychiatry have to say about bipolar disorder?  What says the latest data? 

Also expanded was the definition of bipolar depression, according to Ghaemi. "It is not just depression in someone who happens to have had manic episodes but rather specific kinds of depression with specific features," he said.

...Clinical features include early onset of first depression (before age 25 years), multiple (5 or more) previous episodes of depression, family history of bipolar disorder, atypical depressive symptoms (such as leaden paralysis), psychomotor retardation, psychotic features, and/or pathological guilt
That's based on the PET scans and the NIMH genetic studies which have so far cost a quadrillion dollars, right?  Well, here's a line from the actual Guidelines.  It's the kind of line that makes you, well, look upon the works, and despair:

The subgroup describes this as a 'probabilistic' approach to the differentiation of bipolar from unipolar depression, and offers a heuristic of operationalized criteria to be studied empirically. Areas of dissensus persist...

Got that?  No?  Good, it'll go down easier.  So it's soon to be official: Farewell, Depression.

What else does the team think?  Oh: schizoaffective disorder doesn't exist.

Most of the evidence, he explained, suggests that schizoaffective disorder does not represent a separate categorical disease entity; rather, it is "a variation on schizophrenia or a variation on mood disorder or co-occurrence of the two."  The subgroup recommended dropping the schizoaffective disorder diagnostic category altogether from DSM-V...
The question is, if the evidence has so far been indicating that schizoaffective is not real, why did we have to wait for the DSM to tell us it doesn't exist?  Why can't psychiatry simply make it happen? 

But the sleight of hand is saying that the schizoaffective is "really" a variation on a mood disorder (read: bipolar.)  It is equally plausible that bipolar disorder is a variation of schizoaffective disorder since neither one exist except synthetically. I don't mean the symptomatology doesn't exist, I mean the classification is completely empty.  We choose to call this thing schizoaffective, and now we choose not to.  We chose to call it depression, now we choose to call it bipolar depression.   It's not like you chose to call it a unicorn but later discover it's actually a rhinoceros.  A more accurate analogy is that you chose to call this a unicorn, and now choose to call it a ki-ran.  Wait-- what's a ki-ran, you say?  Exactly.

Or, you find an elephant's leg, and say, this is an elephant.  And next you find a horse's leg, so you say, this has much in common with an "elephant," same joint here, so this is an elephant also.  Which would be okay, except then we start making treatment decisions based on that logic: ah ha!   Antifungal cream is the mainstay of treatment for all elephant illnesses!  And meanwhile the elephant dies of throat cancer.  Does it make any sense that the best of our science suggests that the manipulation of four neurotransmitters is somehow involved in the treatment of every single psychiatric illness known, from anxiety to xenophobia?

What do we say to all of those patients diagnosed with schizoaffective disorder?  Oops?  Is it  any consolation to them, or their families, to hear that it's actually bipolar?  How about the criminal cases of schizoaffectives?  Should they get new trials?   Their new diagnosis of bipolar has more studies to draw from, it has more play in the legal system, and better known to jurors? 

As a final question, Ghaemi was asked if he believed bipolar disorder is being overdiagnosed. "While unipolar depression, personality disorders, and schizophrenia have each had periods of overdiagnosis, there has never been an era in which bipolar disorder has been overdiagnosed," he said, "no matter what skeptics claim."
He said that concerns about bipolar overdiagnosis are largely anecdotal, have not been empirically well-established, and ignore solid evidence of continued underdiagnosis.

And there's some more sleight of hand.  Empirically?  What's the test to see if it is actually bipolar or actually depression?  Especially when you have the power to change definitions?

The best is at the end:

The lack of focus on bipolar disorder has led to neglect and controversy, Ghaemi noted. "Our task force," he said, "is a step toward more consensus and less controversy."
Bipolar is the neglected diagnosis?  And this will cause less controversy?  Are you serious?