In the Daily Mail today UCL’s Dr Joanna Moncrieff warns that bipolar has become a “fashionable” mental health diagnosis, partly because of its apparent link with celebrity. “Once considered rare and seriously disabling,” Moncrieff frets, “bipolar disorder has been transformed – under pharmaceutical industry influence – into a vaguer notion of ‘mood swings’ that can apply to almost anyone.” It’s a concern that was aired a couple of years back by Robin Lee in his charmingly-named HuffPo article, Bipolar… My arse. The result of this over-diagnosis, warns Moncrieff, is that people are agreeing to prescriptions for potent antipsychotics without understanding what they are letting themselves in for. A troubling proposition, I’m sure you’ll agree.
Yet in the Telegraph there is a rather different tale of bipolar. Glenn Close, who has pledged her support to the Time to Change campaign, discloses the huge impact of the condition on her sister Jessie’s life. She describes her own shame in not having taken Jessie’s distress seriously – with hindsight it is evident Jessie has been symptomatic from childhood – and speaks of the “tragedy” of doctors’ failure to diagnose Jessie’s bipolar until she was 47.
Two newspapers, two bipolar narratives. Moncrieff’s UCL bio says that she analyses “all aspects of psychiatric drug treatment, including subjective experiences.” Sadly there is no voice for the bipolar person in her article, but after all she does have a book to sell. We wouldn’t want bipolar people’s positive or mixed experiences of antipsychotics cluttering up her article, or (heaven forbid!) preventing the Mail from expressing faux concern. Moncrieff’s opinions of antipsychotics were formed when “as a junior doctor 20 years ago I worked in one of those vast asylums that was in the process of being closed down.” Although two newer drugs (Seroquel and Zyprexa) are mentioned early in the piece, Moncrieff makes no clear differentiation between the effects of older generation drugs likely to have been prescribed a couple of decades ago and “new generation” drugs. Disappointingly for someone who spends their working life critically examining psychiatry, Moncrieff buys into the myth that the bipolar diagnosis is stretched so thin that almost anyone who is “a bit moody” gets diagnosed bipolar these days.
There is a spectrum of bipolar conditions and I don’t think anyone really disputes that. Those who would once have been called “manic depressives” but are now referred to as “bipolar I” find themselves at the furthest point from what is considered “normal”. Even with treatment the impact of their symptoms will be huge; their experience will include true mania, perhaps including psychosis or mixed mood, often necessitating hospitalisation. This is the group most likely to be treated with antipsychotics in the hope of slowing mania and dampening psychotic symptoms. Far closer to normal human experience is cyclothymia (occasionally known as bipolar III), yet the people I know with this condition really do have an experience outside the norm, their mood shifting almost continually back and forth with little respite. They struggle and they suffer as unimpaired people do not, even though they are nowhere near as impaired people with bipolar I. And somewhere between these conditions is bipolar II, defined in the DSM as bipolar causing less functional impairment as bipolar I. Depression tends to feature more prominently in this variant, with hypomania sometimes presenting as irritability or panic, rather than elation.
I accept that the position in the USA may be different; some clinicians there claim to be able to identify bipolar IV, V and even VI. Yet I have never heard of any of these being used in the UK (indeed I have heard of people in distress being told, “If you were in the US you would probably receive a bipolar diagnosis, but I am not going to do that”). In fact, the robustness of diagnosis is reflected in the time it takes for bipolar to be diagnosed. It is shocking that Close’s sister struggled on alone for decades before receiving a diagnosis, but in no way exceptional. Indeed, the average gap between onset and diagnosis is between 8 and 15 years, depending on which study you read. This suggests that, in complete contrast to Moncrieff’s assertion, a bipolar diagnosis is actually rather difficult to obtain.
The number of people diagnosed with bipolar may be rising, but I see no need to single out bipolar, nor malign its treatments. The number of people being diagnosed with other conditions is also on the rise; why is bipolar referred to as “fashionable” but not other conditions? The Royal College of Psychiatrists, which ought to have as good a handle on diagnosis as anyone, still estimates the prevalence of bipolar in the UK to be 1:100. Even the wildest, widest estimate I have seen for the wildest, widest possible bipolar spectrum only suggests that 1:20 people might have some form of bipolar or another. Meanwhile, almost 1:5 of people are identified as experiencing depression and anxiety. In the mental health fad stakes it is depression that is “going viral”.
In similar vein to Giles Fraser, Moncrieff takes her personal discomfort with antipsychotics and assumes that overdiagnosis must be at fault without drawing on the direct experience of taking these drugs. Conflating the “largactil shuffle” patients on long-closed hospital wards with the experience of bipolar people currently taking new generation antipsychotics tells us nothing at all. Neither does fretting about the sometimes brutal side effects of antipsychotics (and goodness knows I have written thousands of words on those) without assessing their advantages. Sad to say that when it comes to discussing bipolar and to mental health drugs, it’s lazy journalism that seems to be really in fashion.