The bipolar diagnosis is on the rise. You can read it in the media and readily observe it by talking to people you know. More people than ever (and significantly more children than ever) carry the label. According to results of a study published in the Archives of General Psychiatry (September, 2007) entitled, “National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth,” we’ve seen a 40-fold increase in the diagnosis of bipolar disorder in children and adolescents between 1994 and 2003. During this same period, the bipolar diagnosis in the adult population nearly doubled.
The estimated annual number of youth office-based visits with a diagnosis of bipolar disorder increased from 25 (1994-1995) to 1003 (2002-2003) visits per 100 000 population, and adult visits with a diagnosis of bipolar disorder increased from 905 to 1679 visits per 100 000 population during this period.
From Archives of General Psychiatry, Vol. 64 No. 9, September 2007
This sudden and dramatic increase in the diagnosis of bipolar disorder generates concern as well as questions. Consumers begin to wonder whether bipolar disorder is a real illness or just a diagnosis du jour. Is this increase in diagnosis good or bad? Does it mean more people who need help are getting it or that patients are being mis-diagnosed and receiving the wrong treatment?
Although these questions may ruffle the feathers of anyone who’s had to deal with the often brutal reality of bipolar disorder, they’re important questions to address. Let’s look at factors that could be contributing to the sudden and dramatic rise in the bipolar diagnosis:
The question of whether bipolar disorder is over-diagnosed does not presume that bipolar is a phony diagnosis or that people (including children and adolescents) diagnosed with bipolar disorder have something else entirely. Patients and parents who battle this often devastating illness on a daily basis can benefit significantly by receiving an accurate diagnosis and the required medications and therapy to level out their mood fluctuations.
Ultimately for those with classically defined bipolar disorder or a broader problem with mood regulation, heightened awareness and improved understanding by the public – that this is an illness and not just “an excuse” or a moral failing – can only be positive. Shining a light on this range of painful illnesses is the only way to ensure that patients will be more able to seek help comfortably, and professionals will be more likely to make as accurate a diagnosis as possible and provide help to those who are suffering.
On the other hand, if the diagnosis is a misdiagnosis (as I believe it often is in the case of children and adolescents), then it can potentially prevent patients from receiving proper treatment and perhaps expose them unnecessarily to powerful psychotropic medications used to treat bipolar disorder. (Visitors to the Bipolar Blog are already aware of what I see as the potential problems posed by over-diagnosing bipolar in children, as I discuss in “Bipolar Disorder Overdiagnosed in Children?“)
What does this mean for providers and consumers? It simply means that an accurate diagnosis is the key first step in receiving the proper care. Doctors should take care to rule out other possibilities first, and consumers should seek an accurate diagnosis from a psychiatrist experienced in diagnosing and treating bipolar disorder.
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thalia at 4:46 am on
October 2nd, 2008I think this misses the boat a little. The main reason the diagnosis is exploding is because people are being shifted out of the “unipolar depression” category and into the bipolar category. This isn’t about taking well people off the street and telling them their highs are too high. This is about what is really the correct diagnosis and treatment for that huge category of people who have already been diagnosed with depression and are now being prescribed SSRIs.
The argument being that antidepressants will make depressives with a bipolar tendency worse. And nobody really knows how many depressives have that tendency.
From that perspective there’s nothing “conservative” about having an extremely high evidence bar before diagnosing bipolar. The higher the bar, the more people will be treated with unopposed antidepressants, the more potential iatrogenic illness and disability.
Theoretically. It’s still a big unknown. But this is about whether people who would otherwise be treated with an antidepressant would be better off being treated with an anticonvulsant. If the person’s depressions aren’t bad enough to warrant antidepressants – then they shouldn’t be diagnosed as bipolar. It’s an easy call.
So the question isn’t whether hypomanias and thus bipolar are being overdiagnosed. Because the hypomania only comes up if major depression has already been diagnosed. The question is still the age-old are depressions being overdiagnosed. Once you’ve concluded (rightly or wrongly) that the depression is bad enough to treat with psychotropics, there’s nothing inherently safer about diagnosing unipolar over bipolar.
The only reason anyone would have that bias is because the pharmaceutical industry has been so effective in convincing us that SSRIs are as safe as candy.
Also you’re conflating bipolar I and II. Nobody’s arguing that these new bipolars have bipolar I. That’s a separate illness.
I think this whole idea of SSRI’s “unmasking” bipolar disorder is a little dubious. I’ve seen and heard about many cases that follow an identical pattern:
Patient seens doctor and reports feeling depressed or anxious.
Doctor diagnosis depression and prescribes anti-depressant.
Patient becomes manic.
Doctor diagnosis bipolar disorder… and patient now has to look forward to a lifetime of powerful psychotropic meds.
Looking at this common scenario from a perspective of common sense, any rational human being would probably conclude that the anti-depressant caused the shift from depression to bipolar disorder. It changed the course of the illness. We did a post addressing this topic called “Are You a Victim of Bipolar Diagnosis by Prescription?”
What I’d like to see is a study complete with a chart showing the increase in SSRI use over the past 20 years compared to an increase in the diagnosis of bipolar disorder over the same period of time. I’m no research scientist, but such a study/graph couldn’t be all that difficult to create, could it?
I’d also venture to guess that if such a study/graph were put together, it would show a close correlation between the growing use of SSRI’s and the increasing diagnosis of bipolar disorder.
I’m speculating here and not speaking on behalf of Dr. Fink and myself… only myself.
Thalia -
Thank you for your comments. This conversation is so important – and there are many levels of concern. We certainly don’t want to miss bipolar disorder but we don’t want to over diagnose it either. In either case we want to avoid exposing people to medications that they don’t need or avoiding medications that they do need with an inaccurate diagnosis either way
The argument that antidepressants will make people wil bipolar tendency worse has not yet been supported with data. As Joe points out the SSRI’s may trigger a manic response as a side effect, but that is not the same thing as unmasking or triggering bipolar disorder. We do know that people with Bipolar I often don’t do well with antidepressants alone. But the idea that antidepressants will induce or worsen or speed up the onset of Bipolar II or even other bipolar spectrum disorders is quite controversial and not at all a given. The overdiagnosis is far beyond Bipolar II – Bipolar II looks a lot like Bipolar I – but with hypomania not mania. The spectrum concept is much broader than that.
We do know from epidemiologic studies that the lifetime prevalence rate of unipolar depression is between 5 and 12 % in men and 10 to 25% in women. It is far more common tham bipolar disorder at least according to the data that we have at this time. And there are many studies that feel this is even an underestimate.
There are many who believe that there are actually a lot more bipolar “type” individuals in that depression number – and while that is certainly possible we have no evidence to back it up. It is essential to screen very carefully for symptoms of mania or hypomania in someone presenting with a first episode of depression. But it would not make sense to assume that anyone who is severely depressed enough to need antidepressants is probably going to be bipolar. Whatever treatment path we end up choosing careful monitoring and good communication between doctor and patient will be essential to safe and effective outcomes.
And I agree with you about drug companies – they certainly oversell and under-warn about their products. But they have done an excellent job overselling the atypical antipsychotics as much or even more than the SSRI’s. And while the SSRI’s have their own significant risk factors they do not carry the same type of physical side effects that are common in the atypicals.
Our best hope is the evolution of biological markers – genetic, biochemical and structural – that will help us identify the underlying neuropathology of these illnesses so that we can move into more scientific diagnostic strategies and be far more effective in treatment as well.
Candida Fink MD
What are the general thoughts on duration of medication usage? I was diagnosed with Bipolar I in 2002. And, like most people, I’m sure, I was put on medication cocktail after cocktail. This went on for about three years with the last year seeming to work really well with that particular combination of meds. However, I grew tired of some of the side affects and really felt like I would do better without medication. It took three attempts, but I was able to wean myself off the meds. I went back to basics and made sure I took care of myself as a whole. I stuck to a bed time and made sure I had enough rest. I watched what I ate. I avoided putting myself into risky situations. I gave a lot of thought to my decision making process. This seemed to help reduce the number of impulse actions. That said, I have been experiencing symptoms over the past year for which I am now seeking professional medical assistance. I can’t help but compare my experience to cancer in that medical treatment is used until the disease is in recession. At the onset of a relapse, medical treatment is again sought and utilized. So, getting back to the question… Should someone with Bipolar disorder ALWAYS be medicated? And, if so, based on one of the above comments, would that person even be considered bipolar when well enough not to require medication?
Raquel at 1:43 pm on
May 4th, 2009I share a similar experience with Xander, I was diagnosed with Bipolar disorder when I was 21 but I have felt the symtoms since before I even knew they were symptoms of anything and believed that everyone felt the way I did but that for whatever reason I was just too weak to control myself or my moods. I’ve had an highs and lows and been riddled with anxiety attacks since I was in my high chair. When I first sought anti-depressants I was 19 but didn’t know to volunteer the high energy and rapid thought or mood changes to my doctor and she didnt ask. I thought that part was just my personality and the depression was only problem. I was put on a variety of anti-depressants ranging from paxil to welbutrin and so many other cocktails I couldnt even begin to list them and they all only worked for the max of about a year and then the dosage was played with so much that the dr. would ask me what dosage I felt I wanted to try.By the time my bi-polar disorder was actually diagnosed I had also created so much emotional damage in the process of my mani that now I had that to deal with in addition. I went to psychologist’s for the behavior and psychiatrist’s for the meds and still found little relief, and was basically told that this was how it was and I had to live with. It became near impossible to maintain a job because I was afraid for them to see me manic and frequently called in sick until I would quit before I felt they would fire me. Fortuantly I met a wonderful man who was able to support me so that I could basically start at square one and find out what form of treatment would work best for me. It has not been easy. If I could find a prescription med that worked for me and whose side effects were not as difficult for me to live with as the disorder itself, I would take it in a heart beat. But I have not. I applaud others who have and would never encourage or recommend that they change a thing. But for myself I felt like a guinea pig who was only checked in on every 6 weeks to see if I was still alive. For myself I made the decision to come off meds. which I would not and could not have done without my husbands help and understanding. For the past 2 years, it has not been easy, I have though found a regiment of Lithium orotate, Omega 3 fatty acids, B-complex, 5-Htp and Sage and Lavender that for whatever reason has helped me more than the perscriptions ever did andd I do not have the side effects. With my own research I am able to adjust as i keep my self aware of my symptoms with the help of my famly. I am still trying to figure it out. But I am now 32 and happier than I can ever remeber being, though I still have my moments, and have learned how to recognize my limitations, I rest when I need to rest use my manic times to productive ends. I no longer work in an office or customer service environment but have been still help support my family. I am not saying this would work for everyone, but it has been my continuing experience.
Bridgette Torre at 11:49 pm on
February 14th, 2010Bipolar disorder is a severe and complicated mental illness. Many doctors are unable or unwilling to diagnose bipolar disorder in children and young teens. It is important to get help and recognize the different treatment options available. The Silver Hill Hospital website has some helpful information and resources for adult and adolescent psychiatric treatment.
Bipolar Blog | Bipolar Disorder | Bipolar Spectrum | Overdiagnosis in Children and Adolescents (September 25, 2008)
Hear No Evil « biFACTOR (March 18, 2009)
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