Misdiagnosis and Antidepressants: Any Progress?
"It is still astounding to me that so many psychiatrists seem to not know that treating someone with (undiagnosed) bipolar disorder, in a severe depression, can cause a 'tipping' into mania."
So we might ask: how bad is this mis-or under-diagnosis problem? Is it still as bad as it was? And how many psychiatrists really are unaware that antidepressants can precipitate a manic episode?
As we proceed, we might also wonder if there is any evidence that the pendulum swing toward increased diagnosis of bipolar disorder has gone too far, causing unintended consequences on the opposite side -- people being treated with medications for bipolar disorder, with their known risks and side effects, who really do not need this treatment.
Taking each of these questions, and summarizing very briefly (one could write nearly an entire book summarizing the research and opinions on each of these questions):
1. How bad is the problem? A few years ago, it was this bad (the graph below reflects one study, but several showed a nearly identical result):
To my knowledge, there have been no similar studies published more recently that might show us changes in this problem.
2. Is there any evidence that the pendulum has swung too far in the opposite direction?
If judging simply on the basis of public outcry,certainly there is reason to worry.There is a lot of noise these days about overdiagnosis of bipolar disorder, particularly in children. There is one study (Soutullo et al) which seriously questions the rate of diagnosis of bipolar disorder in children in the United States.
In talking with doctors who are worried about overdiagnosis,it seems that the main concern isabout exposing people -- especially children --to the risks of medications we use for bipolar disorder. In particular, the risk of weight gain, which comes along with so many of the medications for bipolar disorder, is concerning -- given the prevalence of weight gain even without such medications in our society, and the evidence that severe mood disorders themselves seem to be associated with weight gain. This is a very valid concern.
Nevertheless, we should probably not be positioning our diagnostic pendulum based on medication risks, or at least that is not supposed to be another process works. Alternatively, if we are to let medication risks influence our diagnostic judgment, then the issue of how much risk antidepressants pose in the short and long run is a very important variable. Readers who have gotten this far might be interested in my essay for psychiatrists along these lines, which appeared in a journal called Psychiatric Times.
3. How many psychiatrists are unaware that antidepressants can trigger manic episodes?
Frankly, I think this number is probably quite low. The problem lies more with the primary care providers who are struggling to cope when they cannot refer patients to a psychiatrist (because in many regions of the country, particularly here in the West, it is difficult to find a psychiatrist who can see a patient within a few weeks, and for many it is months, and some not at all). These current care providers have not had good training in the diagnosis of bipolar disorder. And they have very little experience in using the mood stabilizers for this condition. That makes them reluctant to make the diagnosis, because they are reluctant about being led into having to treat it. The result is an over-reliance on antidepressant medications, which makes them perhaps reluctant to look at potential risks of these medications.
All of this was the basis, in part, for writing my website on bipolar II (PsychEducation.org). Since that time, six years ago, I think there has been substantial improvement. But it is slow, and there is a long way to go. On top of all this, we now have to counter that concerned that greater diagnosis of bipolar disorder will lead to many children being placed on medications that will lead to massive weight gain and other problems. If all we did was simply demand that anyone who is about to receive an antidepressant medication be screened with accepted instrument for bipolar disorder, such as the Mood Disorders Questionnaire, that would be a big step forward.
Dr. Phelps
posted by PsychEducation | This post's link
9 Comments:
Thanks very much for your responsiveness. I recall from your .org article on BP II, that you included links at the end to the writings of Dr. Simon Sobo, who offers a sobering assessment of the difficulties inherent in proper diagnosis and treatment in the current 'medical model'. The risks at either end of the treatment pendulum seem to be high.
The fact that SSRI's often do little to help BP-related depressive cycles seem to point to some fundamental 'physiological' difference in the basis of BP vs uni depressive episodes. The depressions experienced by 'BP folks' seems more intractable, more difficult to treat properly.
I can't remember if you cited ref's re: genetic differences in the two populations: I hope they are still up at .org.
What is the difference common genetically, between bipolar and unipolar disorder? You think there should be a good answer to that, at this point.
However, think about it: in order to study the two groups, you have to differentiate between an extremely well in order to be able to identify genetic differences. That differentiation is getting in the way, because different diagnosticians called the split differently.
Here is the most recent example of this problem, which speaks specifically to this difficulty of diagnostic differences at different diagnostic centers in a multi-site study: Saunders EH et al, 2007.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17525972&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
It's a very fair and important question, however.
I spent 7 years misdiagnosed with everything from one of the several anxiety disorders to, of course, depression. Each new doc I saw pushed antidepressants, and often suggested that I just needed to "push-through" what I now know to be BP II rapic cycling. I suffered terribly, until I discovered your web site in 2003. Since then, neither of two docs I've had seemed to believe this was a real issue (I didn't stay long). Hence, I was surprised at your suggestion the pendulum may have swung too far. I didn't know it had really started in the other direction at all. But, I recognize I'm only one of (way too) many, and other's experiences vary.
I'm certainly not a health care practitioner, but did wonder whether overdiagnosis of bipolar in children may be more related to yet one more reach by society to explain those things we find hard to control. Just a thought.
In any case, this is the first time I've posted to your site, and wanted to thank you sincerely for your site, and to tell you how deeply I appreciate it and your blogging.
Mike
Thank you for the note, Mike.
I definitely agree, the concern about overdiagnosis in children does reflect, at least in part, a reluctance to admit that sometimes kids can be really sick and it is not the fault of the parents.
The problem is, sometimes it is easier to haul out a label, and then haul out a pill, then it is to really figure out what is going on in the child's life and/or help the parents create a different environment for that child -- which is unfortunately also very commonly the basis for a child's symptoms.
In other words, one has to hold on to both of these explanations (nature and nurture, roughly) in consideration of any given child's situation. That does not make for such good headlines. Too nuanced.
Thanks for the comment --
Jim Phelps
I found my copy of the article on .org re: 'antidepressants that aren't', ie, a review of antipsychotics and their ups and downs (sorry) wrt things like weight gain and 'antidepressive' power. Again, you may have written about this already in a link to this, but could you talk a bit (or repeat the link) about Lithium's role as an 'antidepressant'? You indicated in your clinical ex's that it is often coupled with an antipsychotic (ie, seroquel), for 'BP II' cases. Is there such a thing as low-dose Li having AD efficacy alone? What would such a dose be (roughly, for ~ 200 lb male). Curious if there has been any further work reported in this area since you wrote the article. Thanks.
An important source of statistical bias in any attempt of trying to pin a number in bipolar misdiagnosed as unipolar is treatment abandonment. I anecdotally know of three cases of mild, "tolerable" depression where psychiatric treatment was once attempted, but antidepressants resulted in manic breakthroughs. These people just stopped taking the drugs, seeing the shrinks and basically took the "psychiatry is bunk" attitude. No stats on that,
In reply to the last two comments:
1. What about lithium as an antidepressant? Is there such a thing as low-does lithium having an antidepressant effect?
Lithium has definitely been used in this role. Small doses, well below the 900-1200 mg we commonly used to prevent manic episodes, can have benefits. Usually this has been studied in the context of an antidepressant, already in place, where the role of lithium is "add-on". All by itself, lithium is not quite as reliable for an antidepressant effect, although in some patients I would definitely consider it, used that way.
2. Treatment abandonment as a source of statistical bias -- you are absolutely right. I could not agree more. I think that is a missing piece of data in many contexts.
Perhaps most importantly, I fear that clinicians may prescribe antidepressants and then never see that patient again, because the patient had such a negative reaction they not only do not continue the medication but they do not return to that doctor. This form of "Treatment abandonment" would be extremely hard to measure. But those patients end up in my practice quite commonly. If one was to judge based on my patients' comments alone, one would think that this is a very common phenomenon (but I have a very select group of patients in my practice, who have made their way through several other providers or treatment options, generally, before they get to me, so this is not a very good way to judge either). Thanks for the comment, which is an important one.
Dr. Phelps
I've been misdiagnosed as "depressed" for the since I was 20 years old was given the treatment of choice, antidepressants for many years. I can't even keep track of how many times I have tried to commit suicide anymore. I know how many times I would beg my doctor to take me off of them, I knew they were making me crazier (I always heeded the warning to not stop taking without physicians approval for some reason). He assured me I needed them, then I would get crazier, then I would be back in the ER. Then we would try a new one and the cycle would repeat. Finally I just said no more and have been living with the symptoms of the disease. It's better than the wrong medication. I have an appointment with a new doc coming up soon (I'm 46 now and have lots of other problems and need some help) and I'm still terrified of getting even more screwed up. What happens if one just refuses treatment?
A couple of thoughts --
A) unless you say something indicating that you are potentially dangerous to your self or other people, generally you would be able to simply walk out of a new psychiatrist's office and say no thank you to the treatment which was being offered.
B) however, you might want to check with your significant others and see what they think about your need for treatment. If the relationship matters to you, their input will be worth taking into account. There might be a trade off between preserving the relationship and exposing yourself to yet another treatment.
C) finally, from your comment it sounds like it might be possible that you have not really had treatment with medications other than antidepressants. Nothing in your text suggests that you have "bipolar disorder", but if you did, antidepressants could indeed have made things worse at the time -- but the good news is, there are many other treatment approaches for you to consider that could very possibly work much better. You might want to try learning about Bipolar II, for example, to see if that might fit you to some degree. If so, that may well make Parts A and B above quite moot.
JP
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