Tuesday, March 22, 2005

Summary of Bipolar disorder article and additions since it was written

1. The definitions of "mood swings" and "mood stabilizers" have been radically changed since their original usage. Mood swings, in bipolar disorder, originally referred to the changes from mania (highs) to lows (depressions) and vice-versa that occurred in the course of manic-depression. Rapid cycling mood swings were defined as 4 changes in a year. Mood stabilizers were supposed to be drugs that were both antidepressants and anti-manic agents. There was, what I will call, a sentimental belief that mood stabilizers might get at the basic cause of the disease, and over the long term, prevent worse and worse rapid cycling. This reasoning was somewhat like good control of diabetes where it was hoped close monitoring might prevent later problems like diabetic induced blindness. Applied to "mood stabilizers" use in manic depression, it is a great idea if correct, but it is at best a guess. It has never been shown to actually happen, even in unequivocally diagnosed bipolar patients. We simply don't know

2. Moreover, the basic cause of the disease is not known and each of the “mood stabilizers” work in completely different ways. So there is no reason to think that any one of these drugs, or many of them used simultaneously, are curing the illness (as say, penicillin cures strept throat by killing streptococcus bacteria). It is more accurate to think of them as medications to help control symptoms, not a trivial accomplishment, but this is relevant if the "symptoms" are not creating a problem (such as some forms of hypomania) Essentially, as might be expected, most of the “mood stabilizers” are downers. They slow down neuronal discharges, about what you would expect from anti-seizure medication. Consistent with what they do, they also may be used in other conditions in which we might imagine incredibly active neurons firing away, e.g. people with explosive disorder ( who fly into uncontrollable rages) people with panic disorder (where patients describe extreme terror) as well as mania. There is no basis for calling them mood stabilizers. Anti manic drugs is more appropriate. A common side effect is what might be expected, somnolence, lack of energy, sleeping a lot.

3. One study of 13 classical bipolar I patients found that when their moods were measured every 2 hours, 5 of them had moods all over the map- high, low, what have you. This was not a discovery. It has always been recognized that bipolar patients can present with a “mixed” picture. What was a big deal was that these authors speculated that these mood changes represented “ultra rapid cycling.” This idea went completely unchallenged, even though there was no particular basis for this concept. Even more striking, the idea was embraced by many psychiatrists, particularly because another change in thinking had taken place regarding how we should define bipolar disorder. The idea of bipolar II came into being. It was possible to have bipolar disorder without ever being manic.

4. Diagnosing some people who have never been manic to, nevertheless, have bipolar disorder, is reasonable. Many genetic diseases have incomplete penetrance, meaning, some people have a gene for an illness, but for whatever reason, they don’t have the full illness. It is valid to assume this happens with bipolar disorder and keep this is mind when treating with antidepressants as they might send patients into a full manic episode. The problem is, that once "hypomania" became a criteria, it was so loosely defined that all kinds of patients might qualify, whether their hypomania was representative of an illness or not. Moreover, with this expanded use of the term "mood swings" patients with labile moods were being told they have mood swings and therefore were bipolar II. The phenomenon was so widespread that I decided to write my article, but so far there has been almost no discussion of this issue in the literature despite the radical shift in thinking that took place.

5. Bipolar II opened up a can of worms. All kinds of moody people, people with bad tempers, impulsive people, adolescents with poorly formed identities and labile moods , drug abusers, irritable people, and finally moody children were, and are, being assigned a bipolar diagnosis. Time Magazine ran a cover story on "bipolar children." Many people use newspapers, and news magazines and TV for health information. This is very unfortunate. In this case the story was written by a young reporter who admitted to me that she didn’t know that much about manic depression. She had only been working on the story for a few weeks. Reporters, such as her, might draw as her next assignment a story on bananas. This story, and an Oprah book, gave the impression that medicine had to be given to these kids early to keep the illness from “progressing.”
The other reason I wrote my article was that this diagnosis was often made by doctors at inpatient units after a suicide attempts by a moody or impulsive teenager. Thee psychiatrists who made the diagnosis had spent, in total, less than an hour with the patient. I would then see them as an outpatient when they were discharged and they were already complaining about enormous weight gain and the desire to sleep 14-16 hours a day. They, and their families, were convinced that they had to take the medicine for life in order to correct their "chemical imbalance." Bipolar patients can, and often do have labile moods, but so do many other conditions, that are not necessarily related to bipolar disorder, and should not be the basis for making the diagnosis, as appears to have happened. Furthermore, there is no particular reason to believe that "mood stabilizers" should be particularly helpful here even though the term implies it should be exactly what is needed. To reiterate, many "mood stabilizers" are depressants. They slow you down, a characteristic that makes them useful for mania, anxiety and other states of high excitement (including epilepsy, their original reason for being on the market.

6 Some of “bipolar II" patients will turn out to have bipolar disease. A good number of them won’t. Vanessa Grigoria addressed this issue in a cover story in New York magazine “Are you Bipolar?” She had noticed that many of her young and foolish friends in Manhattan were being told that they had bipolar disorder by doctors, who saw them every few months for 15 minutes, meaning they wouldn’t eventually mature and regret their young wild ways. The diagnois of bipolar disorder meant they would have this disease for life. They were not too thrilled that their drug induced lethargic behavior and thinking had grown to resemble the oldish doctors who made the diagnosis.

7. In addition to sloppy arguments about the nature of bipolar disorder there are many reasons for what I am claiming is the over diagnosis of this and many other conditions. I think the problem is DSM IV or at least the paradigm that has grown around it. I attack this notion in several of my articles. Not too long ago, it was believed that a secret to be revealed in the course of psychoanalysis, a forgotten event might free a patient of his or her symptoms. The same thing has happened with DSMIV diagnosis. Clinicians, family members, patients believe that if only the real diagnosis can be discovered, than an explanation will be available that explains the illness. Aha it was a cancer all along, or Lupus, or Lyme disease, or whatever. "Now we can treat it." A person may not appear to be obviously manic, or ADHD, or autistic (a topic I will address in the future) or whatever, but if we can make the correct diagnosis the problem is solved. The mystery is over. How this kind of categorization can get in the way of good treatment, or even thinking cogently about a particular patient’s problems, is the subject of many of my articles. Maslow's observation should be added. "If the only tool you have is a hammer, you tend to see every problem as a nail." Many psychiatrists have almost exclusively become medication doctors. The results of this practice follow. Give it a name and give it a drug. And if that doesn't work a different drug, or several different drugs.
I am not against the use of medication, even medication given when a diagnosis cannot be determined. Some of the drugs that have appeared in the last few years are fantastic, offering hope, and better than that, very satisfying results. However, I am against the self deception and deception of the public that "scientific" logic is being used by "experts" to describe what doctors are doing. True science will come to psychiatry when we understand the mechanisms behind the symptoms we are treating, and prove that the treatments we are using work. We do not have to apologize, nor should we be blamed for our state of ignorance. We can only know what is known. But this means we have to do a lot of guessing, hopefully educated guessing, because we have to try our best and sometimes drugs are quite helpful, when established through this trial and error approach to them.

8. When my article was written the consensus of “experts” was that mood stabilizers should be used as the first treatment for bipolar depressed patients and antidepressants used only as a last resort. There were reasonable concerns about sending depressed patients into mania. But this caution went too far. It was being issued as state of the art treatment despite the fact that no mood stabilizers had been shown to work for depression. On the contrary all the evidence pointed to their usefulness for mania alone. I was completely bewildered by this, especially since the vast majority of psychiatrists like me, doctors in practice spending most of their time treating patients, used anti-depressants and the experts were condemning the only treatment we could offer. Indeed Dr. Sachs at Harvard had been given a $28 million dollar grant in the hopes of trying to educate non-experts like me and other clinicians in the hinterlands to follow the experts like him. The discrepancy in practice between the experts and us dummies was not mysterious. I had learned when, as chief of the psychiatry at my local hospital, I would try to reach experts to give a talk at our hospital. I had great difficulty getting through to them. They were almost always out of town at conferences, or giving talks. Hence the mystery of their reason for advocating mood stabilizers as the mainstay of treatment was clear. Compared to us they had comparatively little actual contact with patients. So they weren’t confronted by the evidence, the failure of their recommended treatment (using drugs such as Depakote and other "mood stabilizers" to treat bipolar depression). Fortunately by 2002 the facts eventually won out. Anti-depressants were granted an important role to play in bipolar depression in revised protocols. It was admitted that previous warnings about their danger may have been overstated.

Since my bipolar article was written Lamictal has emerged as an excellent treatment for bipolar depression and probably for other forms of depression. This drug may cause me to eat my words and theories. For here is an anti seizure medicine that does work for depression. So is this a true “mood stabilizer”? Perhaps. It certainly shakes up my ideas that drugs are basically uppers or downers. Well not exactly. For now my perspective still holds. Lamictal has not been demonstrated as effective for mania (although it eventually might be) and many patients experience it as something of a stimulant. And, in fact, I have now seen 2 patients who appeared to become manic after they were started on Lamictal. for depression.
9. Also, in reviewing what I have written here, lithium must be mentioned as a true mood stabilizer. It is a far better antimanic drug than antidepressant. Some studies do not show effectiveness in depression but some do. It also should be noted that Depakote, and perhaps other anti manic drugs, may be thought of as mood stabilizers because if taken on a regular basis they may decrease the number of depressive episodes. My guess is that they may do this by preventing depressive reactions to manic behavior but I am guessing. It should also be noted that calming drugs (such as the anti- seizure drugs) may be useful in agitated depression by calming the agitation (or anxiety). This is not surprising when we consider that patients with panic disorder often become depressed as a result of their helplessness, hopelessness, and sheer desperation. If Xanax, or one of the other tranquilizers is given alone, and it works to control the panic, the depression may improve or go away. The tranquilizer is not an antidepressant any more than a drug that relieves congestive heart failure (thereby decreasing hopelessness and depression that goes with heart failure) but it is lessening depression.
In this context it should be noted that some people who see bipolar disorder everywhere, are ready to expand bipolar disorder to include patients who have never even been hypomanic, let alone manic They feel agitated depression, by itself, may warrant the diagnosis and back this up by the fact that "mood stabilizers" may help. But if you have been following my drift so will simple tranquilizers. This isn't to deny that a patient with (a still unidentified) gene for manic depression could present with agitated depression and might never become manic or hypomanic
The same consideration applies to someone who goes into rages, or acts very impulsively, but this is a big maybe. The fact that a drug like Depakote might be helpful here does not mean the patient is "really" bipolar. The same reasoning applies to "irritability." Some manic patients are not euphoric when they are high. They are irritable, or they can be euphoric, but easily bothered by people around them, or "irritable." There are many other reasons that people can be irritable, including depression, a bad marriage, a noisy home, a bad nights sleep, overcontrolling parents, an annoying sibling, and so forth through the spectrum of non bipolar experience. Since bipolar II loosened the criteria for the illness I have seen an unusual number of people who were diagnosed bipolar on the basis of irritability alone. They were then given "mood stabilizers" and came to me complaining of their tirednes.
10. I do not want to be misunderstood regarding the chronic use of anti-manic drugs even when it has been a long time since there was a manic episode. Consideration might be given to a trial off of them, especially if the side effects are awful, during pregnancy, etc, but this should be done extremely cautiously. Veryoften, with bipolar I patients, the result of stopping them is disastrous. The mania comes roaring back in no time. However, the issue is very relevant in bipolar II when the person has never been manic, especially when the hypomania has done little, or perhaps, no damage. The hypomania may even be a good thing (see 12 below). This reasoning especially applies when there has not even been hypomania, and the doctor has stretched the diagnosis of bipolar far beyond what I think is justified
Here is where the discussion above is relevant. If the reasoning is that the "mood stabilizer" is working on the level of warding off and controlling the basic disease process, chronic use might be justified with or without destructive symtoms. But there is no actual evidence for this belief. So here real questions can be asked about the risk/benefit ratio.
11. Blogs are terrific. I will add further ideas on these issues as they occur to me.
12. Here is an article from the 3/22/05 Science section of the New York Times which touches on many of these ideas : Hypomanic? Absolutely But Oh So Productive.” http://www.nytimes.com/2005/03/22/health/psychology/22hypo.html