Tuesday, October 13, 2009

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV


Elizabeth said...

Well that's just depressing, John! How many more people are going to have to go through what you and I and many others have--the no-effect or disastrous-effect of the wrong med? It's good advice you're giving about bringing along someone that really knows you to the psychiatrist.

John McManamy said...

Hi, Elizabeth. I was fortunate. Within 48 hours of my misdiagnosis, my antidepressant flipped me into mania, which made a correct diagnosis a no-brainer. But suppose my antidepressant had a more subtle effect. Suppose it gave me a temporary feeling of relief before pooping out or making me feel agitated. Then they would have tried me on another antidepressant, then another and another, ad infinitum.

Unfortunately, this happens to way too many people, and it goes on for years and years. Off the top of my head, it takes someone with bipolar II ten or eleven years to get a correct diagnosis. And heaven help if you've never experienced hypomania. There you are cycling in and out of depression with no relief and bad treatment.

The STAR*D trials from a few years back found that after two failed tries on antidepressants the chances of success on yet another went way down. This suggests to me that after two failures the initial diagnosis needs to be revisited. A third antidepressant may be warranted, but at this stage - and this is only my opinion which is not supported by any hard data - I would submit that a mood stabilizer needs to be considered as the next med.

I've seen first hand too many people needlessly suffering for years. There are no easy answers, but psychiatry does need to correct an uncorrected 29-year-old error, and accurate information needs to get out to the public.

I try to do my bit ...

Lucy Talikwa said...

You used my life-story as a case-in-point for this article and for your answer to Elizabeth, correct? (Ha.) I may order the Goodwin/Jamison book (Manic Deprsive Illness,you mentioned him above), having tossed An Unquiet Mind & Touched By Fire years ago when they were just telling me "Oh, you're just depressed," and the anti-depressants were as effective as sugar pills and the marriage was sliding down the tube….hummmm….. I was in denial (“I’m not BP cause they say I’m not even though I sure seem to be a lot like her. But I’m not THAT manic… so whaaaaat am I?”) And they were just missing the diagnosis, ‘cause I was leaving out the happy-happy joy-joy parts. What a muddle all this was. Is. Gonna be? Ante up on the next part.

John McManamy said...

Hey, Lucy. Glad this struck a chord, even if that chord is bitter experience and years of suffering. The best cure for stupid doctors is smart patients. Here's to learning from each other. :)

Gina Pera said...

"The best cure for stupid doctors is smart patients."

Amen John! And thanks for all you to do educate your readers.

It's so easy to go off on tirades and paint all medication as profit-driven and all diagnoses as profit-driven and all....well, everything as profit-driven.

How much harder it is to educate with intelligent posts, carefully developed.

Keep up the great work!


John McManamy said...

Thanks, Gina. I'm doing my best. :)

kimbriel said...

I don't see how this would help on a broad basis. It would help some people but hurt others. Psychiatry will still be a game of hit or miss, trial and error. For instance, a friend of mine was depressed, and was trialed on an anti-depressant AND lithium, just IN CASE she was Bipolar. From that moment on, every psychiatrist she visited assumed she was Bipolar because of the Lithium, even though she had never, and even to this day, had a manic or hypomanic episode. She still feels like crap, decades later.

And furthermore, I don't think all manic reactions to anti-depressants are "unmasking Bipolar disorder". SSRIs have double the rate of causing Mania as do the older tricyclics. Or are we to believe that the rate of Bipolar (3) disorder has inexplicably doubled in the last 20 years?

John McManamy said...

Hi, Kimbrel. I think we're both in accord with the main point that the DSM and clinical reality don't always align, and that it is dangerous for both clinicians and patients to uncritically accept the DSM as Gospel.

Also, we're both in accord that antidepressants - particularly SSRIs - raise a strong risk of manic switch for those in the bipolar spectrum, whether we call it bipolar or not.

I'm not as concerned what we wind up calling patients who fall into the Terra Incognita where depression meets bipolar, so long as we are able to pinpoint what is driving every patient's condition and that we treat it appropriately. Bipolar III? Highly recurrent depression? Okay with me.

Mogens Schou, right up to his death, advocated lithium for recurrent depression. I would hate to think pdocs don't use it for that just because other pdocs might label the patient with bipolar.

kimbriel said...

I tried Lithium and it made me want to die. I honestly cannot fathom how it works for the "depression" pole.. I was really rooting for Lithium, too. It's (sort of) natural, I understand it better than the others, and it doesn't make Pharma rich. It just didn't work for me. But everyone is different, so to each their own.

John McManamy said...

Hi, Kimbriel. I appreciate your point. We need much more research on what works best for you and others in your situation. In the meantime we're operating in the dark.

Gledwood said...

I cannot take antidepressants. Prozac made me ridiculously agitated "like a cat on hot bricks"...

Mirtazapine made me so hyper I didn't sleep at ALL for 4 days... then after a week went crashing down far lower than I had been before...

But to complicate matters these highs, if you want to call them that, have not happened every time and on every antidepressant. (I took Cipramil for a month and nothing at all. Still depressed.)

So does this mean I am bipolar?~???