Why ARE so many people being labelled bipolar?

The article below is launching Dr Joanna Moncrieff's new book.
Making us think about how people's up and downs, happy and sad times, success and failures are currently dealt with.

Bipolar disorder has become the 'fashionable' mental health diagnosis - helped, no doubt, by the fact that many celebrities, including Catherine Zeta-Jones and Stephen Fry, have said they, too, are sufferers. 

But as a new book reveals, the readiness with which so many people are being diagnosed as bipolar means they're needlessly prescribed heavy-duty drugs - with serious consquences for their health...

Psychiatrists are interested in drugs because we use a lot of them. Most people who visit a doctor for a mental health problem will come away with a prescription for at least one.

Celebrity sufferers: Both Stephen Fry and Catherine Zeta-Jones are bipolar, contributing to its increasing vogue as a diagnosis

The most powerful and controversial are the antipsychotics. Heavyweight tranquillisers, they transformed the treatment of schizophrenia 60 years ago.

But remarkably for drugs designed for a relatively small number of very disturbed patients, antipsychotics are now among the most profitable drugs in the world, just behind statins and on a par with diabetes medications.

Indeed, newer versions of the drugs, such as Zyprexa and Seroquel, have become some of the most profitable drugs in history.

In the last ten years prescriptions for antipsychotics for adults in the UK have increased by 67 per cent - last year nearly 8 million prescriptions were written in England alone.

But only a minority of these prescriptions will have been for  schizophrenia, suggests the evidence - antipsychotics are no longer used only to treat severe mental disturbance, but have broken into the mainstream.

This rapid expansion of their use may be good news for the pharmaceutical companies, but often it's far from being in the best interests of patients and we should be worried about their increasing use.

For while antipsychotics can be useful for those who are severely psychotic, these are dangerous drugs.

The growing popularity of antipsychotics has occurred partly because of the newly fashionable diagnosis of bipolar disorder.

What do they have in common? Bill Oddie and Kerry Katona both suffer from the disorder

Once considered rare and seriously disabling, bipolar disorder has been transformed - under pharmaceutical industry influence - into a vaguer notion of 'mood swings' that can apply to almost anyone.

As a result, if you now visit your GP with depression or anxiety or if you have symptoms such as irritability, and moodiness, there is a significant possibility you will be given a diagnosis of bipolar disorder and prescription for an antipsychotic.

Worryingly, the drugs have also been suggested as a preventative measure in young people who are not psychotic, but might be 'at risk', and have been widely prescribed to elderly patients with dementia.

And these drugs are harmful. I first became aware of how harmful they can be 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.

Some of the old inmates were still shuffling stiffly and aimlessly along the endless corridors. They looked heavily doped up and it struck me that the drugs hadn't returned patients to normality, as we were told they did.

I got a strong feeling that as a doctor I was not being told the whole story about antipsychotics.

The text books had almost nothing about the experiences of the people who took them. I was determined to find out more about their effect.

THE MYTH OF A 'CHEMICAL IMBALANCE'

When these drugs were discovered - more than 60 years ago - they were embraced by psychiatrists.

Unlike the straitjacket or electric shock therapy, they were said to treat not just the symptoms of schizophrenia - dulling the voices and the visions - but also to correct the underlying disease.

Unwelcome side-effects: For many people, the dampening down of feelings that results from taking antipsychotics is intolerable

They did it, said leading researchers, by reversing a 'chemical imbalance' in the brain (although the evidence never really stacked up - a rival, and I believe far more plausible, theory said the drugs worked by damping down brain activity, but this was rapidly forgotten.)

As a result, the drugs came to be seen as a cleverly targeted and sophisticated, and essentially benign, treatment. It was a seductive claim, but it was a myth; one swallowed hook, line and sinker by the medical profession at the time.

The claim is still being propagated today, but it has been extended - now it's said that large numbers of people may need antipsychotics to rebalance the malfunctioning chemicals that cause bipolar disorder.

The notion that they can restore some form of biochemical harmony has allowed these unpleasant and risky substances to be misleadingly portrayed as essentially harmless.

These are some of the things that patient information leaflets should tell you, but don't.

Antipsychotics are likely to make you feel slow and groggy and they will sap your initiative, reduce your sex drive and dampen your emotions.

The bitterest pills: Antipsychotics are likely to make you feel slow and groggy

When I looked at how patients described the drugs' effect, typically they used terms such as 'sluggish', 'inhibited', 'feeling nothing', 'feeling weird', 'spacey', 'empty'.

(Not for nothing are antipsychotics also used as animal tranquillisers in veterinary medicine.)

For people who are acutely psychotic, the damping down of feelings may be welcomed, but for many they are intolerable. This is one patient's memorable description: 'Beware. This medication is Satan in a flipping pill.'

FEARS ABOUT BRAIN SHRINKING

Then you need to know about the variety of metabolic changes they can induce in your body; major weight gain, high cholesterol and other harmful fats, along with raised glucose that can lead to diabetes and heart disease (the drugs have been linked with 1,800 deaths from stroke and heart disease a year in people with dementia). 

Despite these now well-recognised effects, two years ago the British Medical Journal reported that out of 300,000 psychiatric patients on antipsychotics, fewer than half were getting a metabolic check.

Antipsychotics can also shrink the brain. This had long been suspected but it was difficult to prove because schizophrenia is believed to have the same effect.

However, earlier this month a long-running brain scanning study, reported in the American Journal of Psychiatry, concluded that 'the higher the antipsychotic medication, the greater the loss of both grey and white brain tissue'.

'This is one patient's memorable description: "Beware. This medication is Satan in a flipping pill."'

Long-term treatment can also cause an irreversible form of brain damage called tardive dyskinesia which results in embarrassing involuntary movements and may be associated with some mental decline.

This was clearly recognised in the early days of the drug, but as the idea that antipsychotics could treat disease became more widely accepted, psychiatrists increasingly dismissed or downplayed these involuntary movements, saying they were an effect of the disease and that anyway they were infrequent and unimportant.

But these disturbing side-effects - jerky uncontrolled movements, particularly around the face, mouth and tongue - do occur, and I regularly see patients who suffer from them.

Some will claim that the benefits of the drugs outweigh such risks, and point to 'good' evidence that antipsychotics are an effective treatment for bipolar disorder.

However, the trials testing the effectiveness of antipsychotics on bipolar disorder have been done on patients suffering from manic depression.

What we now call bipolar is a greatly expanded version of this rare condition, which is characterised by a manic period lasting weeks (but possibly months), when the patient becomes hyperactive, elated, disinhibited; they don't sleep, barely eat and act quite out of their normal character.

This is often followed by a crash and a period of deep depression.

TOO EASY TO END UP ON THESE DRUGS

The symptoms that can get you a diagnosis of bipolar disorder today are quite different from those of classic manic depression.

It's all so vague you can now be diagnosed as bipolar simply as a result of going through changes of mood caused by the ups and downs of daily life.

But a diagnosis of bipolar disorder can lead to lifelong prescriptions for heavyweight drugs that should be reserved for serious psychiatric conditions. And yet almost all the drug trials testing antipsychotics have been conducted on people suffering from classic manic depression.

This means they tell you nothing about what the drugs will do for people with milder emotional problems. 

Brain damage: Long-term treatments can cause tardive dyskinesia, which results in embarrassing involuntary movements and may be associated with mental decline

Another serious problem with the trials done to test the effectiveness of antipsychotics in general is that the patients who go in the placebo group - those given a 'dummy' pill to compare against the patients having the real treatment - will virtually all have been on drug treatment prior to the study, often for years, since they have serious long-term conditions such as schizophrenia and manic depression.

They then have to come off their treatments to be part of the drug trial, usually quite abruptly.

But coming off antipsychotics, like many other mind-altering drugs, is known to have all sorts of very unpleasant effects - agitation, insomnia, anxiety, restlessness and irritability.

In other words, the group getting the drug is being compared with a group who are in a state of cold turkey.

These flaws mean you can't be certain the trial results are reliable, even for the classic version of manic depression. Given the brain damage, diabetes and heart disease associated with these drugs, not to mention the sexual impairment, weight gain, mental clouding and emotional suppression, trends towards this unfounded and increasingly unrestrained prescribing represent a serious threat to public health.

Other senior psychiatrists share my reservations about the value of expanding the definition of bipolar disorder so widely.

The editor of the Canadian Journal of Psychiatry has described it as 'bipolar imperialism', while journalist Robert Whitaker sums up the recent history of antipsychotics like this: 'Behind the public façade of medical achievement is a story of science marred by greed, death and the deliberate deception of the American public.'

I think it is going to be seen to be just the latest in a series of scandals that have engulfed these drugs in recent years.

'Bipolar imperialism': Several senior psychiatrists share Dr Moncrieff's reservations about the value of expanding the definition of bipolar disorder





THERE ARE ALTERNATIVES

So what are the alternatives for people who might be offered antipsychotics for emotional problems? What will work is going to be different for each person.

It depends on why they are feeling the way they are and what is going on in their lives that has led to this.

Therapy might be the best thing, some sorts of short-term medication might be appropriate but most importantly, you have to look at the circumstances. Antipsychotics have not been properly tested on people troubled by milder emotional issues.

They can be helpful in reducing the symptoms of an acute attack of schizophrenia or classic mania,  but the benefits of long-term treatment are less certain, even in these serious conditions.

Going on any drug for a psychological disorder is a serious step. Patients need to be very clear about what is involved. What is the benefit, what are the risks? There's a long history of failing to warn people about all the effects of antipsychotics.

If an antipsychotic drug is suggested for you, make sure you ask your doctor some hard questions before starting a prescription. Such as: How is this drug meant to work? How will it make me feel? Will you be monitoring me for any metabolic changes? How much weight is it safe to put on?

Your doctor probably won't have the answer to all of these questions because the research hasn't been done. And that is the problem.

There just hasn't been enough attention paid to the toxic effects of these drugs and how they impact on people's everyday lives.

But what we do know indicates they are often unpleasant and can be dangerous. You may decide you are better off without them.

Dr Moncrieff is Senior Lecturer in Psychiatry at University College London. Her book, The Bitterest Pills: the Troubling Story of Antipsychotic Drugs, is published by Palgrave Macmillan £19.99.

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