So Apparantly I’m Bipolar

By Neuroskeptic | August 8, 2011 11:50 am

According to a new paper, yours truly is bipolar.

I’ve written before of my experience of depression, and the fact that I take antidepressants, but I’ve never been diagnosed with bipolar.

I’ve taken a few drugs in my time. On certain dopamine-based drugs I got euphoric, filled with energy, talkative, confident, with no need for sleep, and a boundless desire to do stuff, which is textbook hypomania. So I think I know what it feels like, and I can confidently say that it has never happened to me out of the blue.

On antidepressants, I have had some mild experiences of this type. Ironically, the closest I’ve come to it was when I quit an SSRI antidepressant. I’ve also experienced periods of irritability and agitation on antidepressants. Either way, that’s antidepressants. Bipolar is when you get high on your own supply of neurotransmitters.

Well, it used to be. Jules Angst et al have got some new, broader criteria for “bipolarity” in depression. They say that manic symptoms in response to antidepressants do count, exactly like out-of-the-blue mania.

What’s more, under the new “Bipolar Specifier” criteria, there’s no minimum duration. Under existing criteria the symptoms have to last 4 or 7 days, depending on severity. Under the new regime if you’ve ever been irritable, high, agitated or hyperactive, on antidepressants or not, you meet “Bipolar Specifier” criteria, so long as it was marked enough that someone else noticed it.

All you need is:

an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment.

The bipolar net just got bigger. And they caught me in it. Me and 47% of depressed people in their study. They recruited 509 psychiatrists from around the world, and got each of them to assess between 10 and 20 consecutive adult depressed patients who were referred to them for evaluation or treatment. A total of 5635 patients were included.

Only 16% met existing DSM-IV criteria for bipolar disorder, so the new system with 47% identified an “extra” 31%, trebling the number of bipolar cases.

A cynic would say that this is a breathtaking piece of psychiatric marketing. You give people antidepressants, then you diagnose them with bipolar on the basis of their reaction to those drugs, thus justifying selling them yet more drugs.

The cynic would not be surprised to learn that this study was sponsored by pharmaceutical company Sanofi.

All investigators recruited received fees, on a per patient basis, from sanofi-aventis in recognition of their participation in the study….The sponsor of this study (sanofi-aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.

In fairness, the authors do show that patients meeting their criteria tend to have characteristics typical of bipolar people. And they show that their system is at least as good as DSM-IV at picking out these cases:

For example, DSM-IV bipolar patients had a younger age of onset than DSM-IV depressed ones. “Bipolar specifier” patients did too, compared to the 53% who didn’t meet the criteria. Same for a family history of manic symptoms, multiple episodes, and shorter episodes. All of those are pretty well established correlates of bipolar disorder.

That’s fine, and the results are better than I expected when I picked up this paper. But all this shows us is that the bipolar specifier was no worse than the DSM-IV criteria as applied in this study.

It doesn’t tell us whether either was any good.

DSM-IV criteria were used in a mechanical cookbook fashion – symptoms were assessed by the psychiatrist, written down, sent back to the study authors, who then diagnosed them if they ticked enough boxes. Is that a good approach? We don’t know.

Most importantly, we have no idea whether these people would do better being treated as bipolar rather than as depressed. The difference being that bipolar people get mood stabilizers. Maybe these people would benefit from mood stabilizers, maybe not. Existing literature on mood stabilizers in bipolar people can’t be assumed to generalize to these 47%.

In the discussion, the authors argue that antidepressants are not much good in bipolar people, whereas mood stabilizers are. Fun fact: Sanofi make many of the most popular formulations of valproic acid/valproate , a big selling mood stabilizer.

I think that is no coincidence. Maybe that sounds crazy, but hey, what do you expect? I’m bipolar.

ResearchBlogging.orgAngst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH, & for the BRIDGE Study Group (2011). Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study. Archives of general psychiatry, 68 (8), 791-798 PMID: 21810644

  • usethebrainsgodgiveyou

    Another G.D. label for me, too, I'm sure…

    There have been studies that the mother's use of Valproic Acid causes autism in the fetus. It's a giant circle. Nobody wins but the drug lords and ladies.

  • Brainduck

    I think it's worth having some way to note that antidepressants make some people hm / manic – I get properly life-threateningly manic on SNRIs for about a week (stopping or starting), & mildly so on SSRIs.

    Having worked this out, I now know to use neuroleptics & sleeping tablets for a short time, 'till the antidepressant effect starts working properly.

    I'm glad to see this being recognised, as hopefully it will be more easily dealt with in future. Not sure if bipolar is the right term though.

  • Neuroskeptic

    Brainduck: I agree that it's something that needs to be studied. But I think it should be studied as a phenomenon on its own.

    It's been known since the early days of antidepressants that they can cause mood elevation and/or that they can cause an increase in activity before they improve mood, leading to a period of agitated depression early in treatment.

    There are papers from the 1950s that cover this in detail e.g. this one.

    The idea that antidepressants only ever cause “good” mood effects, and that any “bad” effects must indicate some underlying bipolarity, is very new. Maybe it's true, but it's a big claim, involving a major redefinition of bipolar as well as a re-evaluation of antidepressants.

  • practiCalfMRI

    I'm exercise-bipolar by the same logic. Stop me from getting a hard run or keep me from my bike for long enough and I'll stab anyone to death with my sharp vitriol. (Believe me, people notice. I can be difficult to take on holiday.)

    But as soon as I'm back from a solid workout I'm elated, almost human in fact. Mania time!!! So the exercise actually makes me bipolar, right? Bummer. Should I quit the bike to avoid the manic episodes and aim for straightforward depression with a dose of heart disease thrown in? Mmmm.

  • Anonymous

    So now a criterion for bipolar is if “anyone notices?” LOL. Scientific Psychiatry marches on! Psychiatry is becoming the laughing stock of the medical profession.

  • petrossa

    So now everything becomes a spectrum. Handy. One day all spectra can be unified under the Theory of Everything resulting in everyone being a candidate for psychiatric help. Most of all the psychiatrists unfortunately.

  • Neuroskeptic

    practicalfMRI: Exercise may only be the tip of the iceberg.

    A lot of people get hyper after consuming the popular drug caffeine (street names include “Starbucks” and “Joe”).

    Others become irritable and grandiose after exposure to ethanol (“Special Brew”, “Jack”).

    Even sugar has been reported to have this effect, especially in pediatric patients.

  • The Neurocritic

    Back in 1999 (and probably in earlier publications), Akiskal and Pinto identified “Bipolar III”:

    “Although observed by many talented researchers and clinicians worldwide, hypomania associated with antidepressant use solely (and other somatic therapies) is denied official bipolar status in DSM-IV and ICD-10. This has been a tragic fault of the formal diagnostic system because the evidence is compelling about the bipolar status of such patients, yet the failure to classify them as bipolar robs the patients of proper mood stabilization. As described later, these patients should be recognized as having a less penetrant variant of bipolar II, which can be provisionally categorized under bipolar III disorder. The same consideration should apply to patients who first exhibit hypomania on abrupt discontinuation of a mood stabilizer.”

    Also, they claimed Bipolar III 1/2 is “BIPOLARITY MASKED–AND UNMASKED–BY STIMULANT ABUSE”. So it seems you might have both Bipolar III and III 1/2 (if by “dopamine-based drugs” you meant stimulants). Honestly, who doesn't get euphoric on cocaine? Isn't that the entire point?

    Clinicians advocating for the so-called bipolar spectrum sure do have substantial ties to drug companies that manufacture mood stabilizers and atypical antipsychotics…

  • Neuroskeptic

    Woohoo! Bipolar 3 and Bipolar 3.5 means my total Bipolar Score is a cool 6.5.

    Or maybe it means I have 6 and a half poles? Hmm. Well… I won't go down that road.

  • Anonymous

    I have bipolar type one and let's just say that being out of your head manic and feeling as though you're on a 5 day meth bender on “your own supply of neurotransmitters” are good signs of bipolar type 1. It's hard to feel sympathy for people who complain about being irritable here and there when I vacillate between owning the world and being trapped in my own bedroom.

  • Anonymous

    I get agitated and irritable if I consume too much caffeine, either to counteract lack of sleep, or before I found out decaf isn't always decaf and I need to be careful with it too.

    The only time I've been properly manic is when I was put on Depakote to counteract the effects of the caffeine.

    My brain just doesn't get along with brain drugs.

  • Anonymous

    If not bipolar, you are not in company with Newton, Dickens, Beethoven, Mozart, Chopin, Byron, Keats, Mahler, Tschaikovsky, Rachmaninoff, Faraday, Darwin, Robert Burns, Leo Tolstoy,D.H Lawrence, Thomas Hardy, Winston Churchill, William Wordsworth, Rudyard Kipling, Virginia Woolf, Edward Lear, Shelley, and Sir Walter Scott, among legions of others. Bipolar may be found in many species, and subject to many variations. Valproic acid is expensive, lithium and generic antidepressants dirt cheap.

  • Anonymous

    valproic acid has been generic for a while and the ER won't rake in the cash forever…what people are forgetting is that Sanofi manufactures amisulpride, an atypical antipsychotic with international success…we don't have it yet in the U.S., but if you're looking to invest in CNS stocks, now is the time because the medication will obtain FDA approval if all goes smoothly

  • Anonymous

    To The Neurocritic:
    As for cocaine, I guess the point would be if it triggers mania that lasts long after the usual effects of cocaine (days, weeks or months). I have a relative whose psychiatrist (conflict of interest because they work at the same hospital) diagnosed him with “Bipolar 3”. The effect has been to encourage the relative to continue believing he is not really bipolar. He now risks losing everything.



No brain. No gain.

About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.


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