The Problem with Bipolar Disorder

The Archives of General Psychiatry has an
open-access article about bipolar disorder in childhood ( href="http://archpsyc.ama-assn.org/cgi/content/full/65/10/1125">Child
Bipolar I Disorder).  I started to write
about that.  But then, as often happens, I stumbled upon
something else.



The LA Times has a consumer-oriented href="http://www.latimes.com/news/nationworld/nation/la-sci-bipolar11-2008oct11,0,5539685.story">article
about the journal article.  It is one of those OK-level news
articles.  One glaring error: the author cites the "Archives
of General Psychology," which is the wrong journal; it's in the
Archives of General Psychiatry.



That aside, I found an earlier article on the LA Times about the
subject: href="http://latimesblogs.latimes.com/booster_shots/2008/05/bipolar-disorde.html">Bipolar
disorder may be over-diagnosed (which is based on
an href="http://www.psychiatrist.com/abstracts/abstracts.asp?abstract=200806/060808.htm">article
in the Journal of Clinical Psychology
Psychiatry).  To be fair, it is on their health
blog; it is not a regular newspaper article.  So we shouldn't
hold it to the same standards.  (On a blog, the only standard
that matters, is the standard that the author sets for the blog.)



We do not know if bipolar disorder is over-diagnosed.  To know
that, we would have to know the true incidence of the disorder, and the
incidence of cases diagnosed as bipolar disorder.  If the
number of diagnosed cases is greater that the true number of cases,
then it is overdiagnosed.



The uncertainty about the is reflected in the conclusion of the JCP
article:

Conclusions: Not only is there a
problem with underdiagnosis of bipolar disorder, but also an equal if
not greater problem exists with overdiagnosis.

What matters to individuals, though, is not this esoteric statistical
rat fact.  What matters is the validity of the diagnosis, or
lack thereof, for a particular person.  We
do know that some people who have the diagnosis but do not have the
disorder; likewise, some people have the disorder, but not the
diagnosis.  How do you tell?  That is what matters.
 These questions highlight one of the most important problems
in psychiatry.



The LAT article mentions a couple of other problems:

The study's lead author, Dr. Mark Zimmerman of Brown
University,
suggests drug company advertising is leading doctors astray. Doctors
tend to believe they have arrived at a correct diagnose if the
medication they prescribe shows some benefit, says Zimmerman, adding:



"This
bias is reinforced by the marketing message of pharmaceutical companies
to physicians, which has emphasized the literature on the delayed and
underrecognition of bipolar disorder..."

Really, the professional literature does have a lot of articles the
purport to show that bipolar disorder is under-recognized.
 Mostly, though, this pertains to persons who already are
diagnosed as having unipolar depression, when in fact they have bipolar
disorder.  That is the focus of professional attention.
 There is less concern about the possibility that there are
people walking around with no diagnosis, when in fact they have bipolar
disorder.  (Not that it isn't a problem, just that it is
difficult to publish a study that is based upon people who have not
come in for treatment. Epidemiological studies, based upon phone interviews, will always leave a troubling degree of diagnostic uncertainty.)



Still, the point stands, sometimes drug company advertising can
influence the process of diagnosis.  That can be a problem.
 



Later, the author quotes another blog:

Or, as the author of the psych blog Furious Seasons
points out: "he's saying that doctors -- you know, those rational,
god-like creatures who do things based on Science --are being softened
up by all those pharma ads saying bipolar is wildly underdiagnosed."
Medication for bipolar often produces serious side effects.

There are some doctors who are god-like, but those are not the ones who
are influenced by advertising.  (There are no advertisements
in heaven; indeed, that is the definition of
heaven.)  No, the rest of us are influenced by advertising.
 Decent, but nongodlike, doctors avoid advertising and try to
counterbalance it, with varying degrees of success.



One other thing, the last sentence in that quote does not appear
anywhere in the post (on Furious Seasons) that is quoted.  The
author of the LAT post slipped that in, apropos of nothing.
 It happens to be meaningless, absent any guidance as to what
the author considers to qualify as "often."



Another thing: the study that the author of the LAT article cites
mentions an additional factor, tangentially related to the
drug-advertising problem.  This is quoted, incidentally, by
the author of   href="http://latimesblogs.latimes.com/booster_shots/2008/05/bipolar-disorde.html">Furious
Seasons:

Clinicians are inclined to diagnose disorders that
they feel more comfortable treating. We hypothesize that the increased
availability of medications that have been approved for the treatment
of bipolar disorder might be influencing clinicians who are unsure
whether or not a patient has bipolar disorder or borderline personality
disorder to err on the side of diagnosing the disorder that is
medication responsive.

So, three problems have emerged.  Two are mentioned int he LAT
post: doctors can be influenced by advertising, and drugs have side
effects.  But neither of those qualifies as news.
 Advertising influences can be counteracted, as I've
mentioned; admittedly, the counteractions are variably effective.
 The fact that drugs have side effects is well-known, and can
be dealt with the way any professional deals with risk -vs.-benefit
problems.  Its a straightforward process.  The third
problem, that doctors tend to diagnose conditions that they are more
comfortable treating, is more difficult to deal with.



However, I contend that none of those problems is particularly close to
the top of the list.  The real problem with the way
psychiatrists deal with bipolar disorder is unrelated to any of the
problems mentioned in so far.



The real problem is this: time is scarce.  A corollary: time,
being scarce, is expensive.  



Sure, sometimes a person comes into the office, and it is perfectly
obvious that they have bipolar disorder.  Sometimes it is
obvious that there is no evidence to support such a diagnosis.
 Then there is a problem that remains, in that it is not
possible to prove that someone does not have bipolar disorder.
 A person can be completely free of clinically significant
symptoms one day, then wake up with a florid manic psychosis the next
day.  But even limiting the discussion to those who do not
have, and have not had, such symptoms, there is a problem with the time
involved.  



The problem is made worse by the fact that most people do not pay
enough attention to their own lives, to be able to fully and accurately
report the presence or absence of current and past symptoms.
 Furthermore, the disorder itself can impair one's ability to
observe and report such findings.  These problems can be
surmounted, by education of the patient, and the use of mood
charts/diaries.  That takes up time on the part of the
patient.  Perhaps more important, though, is the limitation of
doctor time.  



If you accept that about 2% of the population has bipolar disorder, and
that there are about 300,000,000 people in the USA, that means that
there are about 6,000,000 with bipolar disorder in the USA.
 There are about 50,000 psychiatrists.  That might be
enough, barely, if all the psychiatrists devoted all of their time to
assessment and treatment of bipolar disorder.  But that will
never happen.



The fact is, a really complete assessment takes hours.  I've
always thought that, ideally, one would devote at least two
--preferably three -- separate one-hour interviews to the initial
process.  That could be supplemented with psychological
testing, various somatic investigations (blood tests, imaging), and
interviews with parents, kids, spouses, etc.  Although
practices vary considerably, My opinion is that persons with bipolar
disorder should see their psychiatrist at least once a month, when
stable, and more often when they are not doing well.  Plus,
there is some evidence that adding family therapy to the individual
treatment can be helpful.



Few insurance plans will cover that much.  Many patients with
bipolar disorder do not have the spare cash to pay out of pocket for
the ideal level of treatment.



It takes a lot of time to be really thorough.  It costs a lot
of money.  And with each additional hour or dollar spent,
there are diminishing returns.  At what point does the doctor,
or the patient, feel that the additional diagnostic confidence is not
worth the additional investment?



In practice, no diagnosis is certain.  We all have to live
with an omnipresent spectre of possible misdiagnosis.  Of
course, there is a rational way to manage that, too.  First,
you build that into your assessment of risks and benefits or treatment
vs. nontreatment.  Second, you take it into consideration when
recommending follow-up.  If there is less confidence in the
diagnosis, then more frequent follow-up may be called for.  



But follow-up takes time and money, too.  At some point, there
are diminishing returns.  That dilemma is merely more grist
for the risk-benefit mill.



The main point is that ideal assessment and management of bipolar
disorder takes a lot of time.  It helps, to some extent, if
everyone realizes this.  But even a full awareness of the
problem will not solve the shortage of qualified specialists* relative
to need, or the shortage of funding.  



___________

*I realize that psychiatrists are not the only specialists who can
provide assessment and treatment of bipolar disorder.
 However, even if you add all the nurses, psychologists,
social workers, and others, it still is not enough.