The unfashionable truth

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.

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About purplepersuasion

40 something service user, activist, writer and mother living with bipolar disorder. Proud winner of the Mark Hanson Prize for Digital Media at the Mind Media Awards #VMGMindAwards 2013. Winner of the World in Mentalists Mood Disorder blog 2012. Regular guest blogger for the International Bipolar Foundation http://www.internationalbipolarfoundation.org/ Expert by Experience working with Mind training department. Working on The Incoming Tide, a bipolar memoir. Find me on Twitter @BipolarBlogger or at my Facebook page http://www.facebook.com/BipolarBlogger
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10 Responses to The unfashionable truth

  1. Becci says:

    Great post.
    The only thing that I really disagree with here is the idea that cyclothymia is closer to normal experience – it is very rare to be clinically cyclothymic and I would argue that naming bipolar III, IV, V etc is a better reflection of subclinical ‘ups and downs’ I.e. not diagnosable.

    • Well, I think my clinically cyclothymic friends – I have several – would vehemently disagree with you. They find the label useful for explaining what they are going through and acknowledging that their experience is something more than “just being a bit moody.”

      • Becci says:

        Hi guys, I should clarify – I absolutely agree with both of your descriptions of cyclothymia. By disagreeing that “cyclothymia is closer to normal experience” I meant that for people with clinical cyclothymia their experience is far from “normal experience” of people without mental health difficulties. I think that I had the impression that you were positing that cyclothymia was “normal” and “not problematic”.
        Sorry if my unclear comment caused any upset!

      • OK, well, really not sure how you got the impression that I was saying cyclothymia was “normal” and “unproblematic” since my words in the post were “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.” So….yeah.

    • EhOhSaysYes says:

      I have to agree with PurplePersuasion’s reply to your comment. As someone with cyclothymia I can tell you that it very much exists and it does affect my everyday life.

      While I have not experienced the severe mania associated to BP I or II, I can reach extreme states of hypomania which can affect my thought processes and actions. While not placing myself or others in bad situations, I can agree to almost anything as I feel I can literally take on the world. Others are aware of my ‘highs’ with close friends even encouraging me to take a step back to ground myself again. The depression that I feel is also recognisable to the point of hopelessness and apathy of everything that is expected of me, or I place on myself.

      I am on medication (mood stabilisers) which allow me to function and lead a successful life. Without them I would not be in the position I currently am in (attending med school) as the illness would be farther out of my control than what it is now. I am happy with my diagnosis and the treatment/support I receive, which is what I would encourage anyone do to if they feel any sign of mental illness.

      Please feel free to contact me if you would like to know more about the illness, and I can confirm to you that it does exist, it is diagnosable and very much treatable.

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  3. phylor says:

    Thank you for pointing out how the media shapes issues to fit their agenda. It makes the stigma worse, stops people from seeking a diagnoses, and other detrimental results.
    I think that any article dealing with bipolar should include the voices of people dealing with it, new drugs and therapies, up to date discussions with mental health professionals, accessibility to resources, medications and nontraditional/alternative therapies. I think it’s unprofessional to misinform the public.
    There are other mental and physical health issues that are the disorders de jour, and big pharma’s pushing drugs originally to deal with a specific condition, now become something else, highly advertised toted as being the perfect med for x.

    It was add on drugs for depression, now it’s an antidepressant for certain kinds of physical pain, and a drug for diabetic neuropathy (I take if for referred pain from damaged nerves in my neck, and so far it’s meant not high doses of opiates like before) for the generalized pain from fibromyalgia. More and more people are being diagnosed with fibromyalgia — does that make it any less real a disorder?

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  5. Mike S says:

    I’m curious about this. As an ex-psych nurse I’ve seen bipolar diagnoses handed out pretty freely. and I’m often uncomfortable with that. And that’s in the UK. Rates in the states are a lot higher. The assertion that the diagnosis is difficult to obtain seem to rest on Glenn Close’s sister being delayed. The rate of bipolar diagnosis in the UK of 1:100 is considered not high (it sound’s terrifyingly high to be honest) and you equate rates of diagnosis bipolar with prevalence. The RCP represents practitioners who are trained to see distress through the viewer of illness labels. If you are looking for bipolar of course you’ll find it.

    There also seems to be an assumption that Moncrieff’s article is in some way not valid because of there being no user perspective. Why should that be so? I’m genuinely curious. Because people who’d received a diagnosis and medication would defend it? Perhaps they would. Except for all the ones who wouldn’t of course. I wonder what you make of the other side of the argument. Users who feel deumanised by getting diagnoses and damaged by medication are out there plenty.

    You know your experience and that of like minded people. Where does that leave people who don’t share your experience? The system in which I used to work is a complicated one and the fact that a highly medicalised view works for you leaves out a lot of problems.

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