Bipolar Disorder – A BRIDGE to nowhere?

By Neuroskeptic | June 6, 2012 6:10 pm

Last August I blogged about a research paper that claimed that almost half of all people suffering from depression actually have features of bipolar disorder – including me: So Apparantly I’m Bipolar

It was called the BRIDGE study. I took issue with it for various reasons, including the fact that it counted as ‘bipolar features’ any periods of irritable or elevated mood, even if they were associated with drug treatment:

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…

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

Now a crack team of psychiatrists have written a Letter to the Editor criticizing BRIDGE and they say… pretty much what I said: BRIDGE Study Warrants Critique. They do make a couple of new points also.

The 8 authors of the Letter include David Allen, David Healy, Peter Parry and Jon Jureidini, all major critical voices in psychiatry. However… while this A-Team make an excellent case that BRIDGE is a step in the direction of overdiagnosis and overtreatment of bipolar, they drop the ball slightly when they say:

The article concluded with an appeal to use “mood stabilizers,” presumably atypical antipsychotics, which are less efficacious than lithium. The sponsor has a medication in this class.

Sanofi does make the atypical antipsychotic amisulpiride, but it’s not generally referred to as a “mood stabilizer”, and I’m not sure why you’d assume that Sanofi had amisulpiride specifically in mind. The BRIDGE team exploit this in their rebuttal letter:

Allen et al cast unseemly aspersions that the BRIDGE study was a vehicle to promote sales of an antipsychotic drug sold by sanofi-aventis. sanofi-aventis has no antipsychotic with an indication for bipolar disorder. We know of no evidence that this was the case at any stage of development and execution of the BRIDGE study.

Maybe so, but as I said in my post, Sanofi also make some popular brands of valproate/valproic acid, a prototypical “mood stabilizer” which is widely used in bipolar disorder. I’d have said that was the more likely candidate…

Fundamentally, we know that Sanofi “was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.” We also know that Sanofi is exists to make profit by selling drugs. So either Sanofi thought that this study would make them a profit eventually, by selling more drugs… or they threw money and time at this for no commercial reason. Hmm.

The reply concludes with the frankly bizarre statement that:

Allen et al view their position as part of a “debate” about the “ever-widening bipolar spectrum.” We consider data, not debates, as central to the progress in the scientific understanding of mood disorders…

But science is a debate about data. Data by themselves are just numbers; to be useful, they must be interpreted, and scientific debates aim at arriving at such interpretations. No-one is questioning the BRIDGE data as such, we’re questioning what it means.

ResearchBlogging.orgDavid M. Allen, et al (2012). BRIDGE Study Warrants Critique Archives of General Psychiatry, 69 (6) DOI: 10.1001/archgenpsychiatry.2012.118

  • DS

    “We consider data, not debates, as central to the progress in the scientific understanding of mood disorders… “

    Neuroskeptic

    Indeed that was a truly bizarre statement. Weasel words IMO.

  • Peter Parry

    As one of the authors of the critical letter – I'd just like to highlight a quote of Eistein's:

    “NOT EVERYTHING THAT COUNTS CAN BE COUNTED, AND NOT EVERYTHING THAT CAN BE COUNTED, COUNTS.”

    If you google around for Einsteinian quotes you'll find that Albert was prolific with pithy drops of wisdom. He liked this particular aphorism of his so much he had it hung on a plaque above his office at Princeton. It was his motto.

    It darn well should be hung as a plaque over every research institution of the planet.

    Hmm thanks for allowing me to get that off my chest – and thanks for the positive writeup Neuroskeptic.

    Dr Peter Parry
    child & adolescent psychiatrist

    PS – used Einstein's motto as a central basis for paper on related topic – http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826 and whilst I'm at some self promotion – the geography of pediatric bipolar – http://www.tandfonline.com/doi/pdf/10.1080/15299732.2011.597826

  • http://www.blogger.com/profile/06280912088483192599 David M. Allen M.D.

    Thanks for a great post. What weasels. “They don't have an atypical antipsychotic with an indication for bipolar.” But they do have an atypical antipsychotic, although it's not available in the State. I'm about to post another example of a drug company fined by the US Department of Justice for off-label marketing.

    There's been 8 or 9 different companies – I've lost count – with fines in the BILLIONS of dollars. Perhaps the Bridge Study authors weren't aware of that. NOT.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Thanks for the comments.

    Peter Parry: Regarding that Einstein quote I think that in psychiatry and psychology it needs an addendum:

    “…and even if it counts and can be counted, your self-report measure might not count it very well”.

  • http://www.blogger.com/profile/13415130945771174088 Measy

    About 10 years ago…I was misdiagnosed with bipolar disorder…lost my health insurance – no more drugs … no more “bipolar symptoms” … no more hallucinations … no more suicidal thoughts…Thanks for this post

  • http://www.therapyconsumerguide.com Marina

    Just thanks for the post. If I elaborate further, I'd go on forever:) You can see some of my philosophy about mental health in general on my website http://www.therapyconsumerguide.com

  • http://www.blogger.com/profile/12057537399918684119 ItsTheWooo

    I wonder if the criteria for mania/depression will become so wide, that eventually the poles will meet each other and we will arrive at “unipolar disorder” haha. No more unipolar depression, or bipolar disorder…just unipolar disorder. If you are alive, you have unipolar disorder.

    I've been assaulted several times with the bipolar stick, and the funny thing is there are people WAY LESS bipolar than I am who are being diagnosed with this. I mean at least a case for bipolar makes somewhat sense in my history, I've had significant depression, I've had energy/euphoria/crackout timez. The idea that people are being called manic because of irritability alone is ridic!

  • http://www.blogger.com/profile/06832177812057826894 pj

    A view from the coalface.

    The growth of bipolar 2 disorder as a diagnosis is really pernicious, and is at least partly driven by a particular subset of academics with interests in the expansion of the bipolar label. It confuses GPs who end up referring everyone to secondary care because they don't think they understand bipolar anymore. And, in my experience many, perhaps a majority of these people have problems with emotionally unstable/borderline personality traits – and calling them bipolar and putting them on medication isn't going to help with that.

    And many of the remainder just have simple unipolar depression, and if you treat them as if they have bipolar 1 disorder you're ignoring the evidence base for unipolar depression on an ideological whim.

  • http://www.blogger.com/profile/14107632038306560194 Sidereal

    I agree with pj. In my experience, the majority of patients with a bipolar II diagnosis either have an Axis II disorder or a history of major depression but no hypomania or mania, just irritability. Such people are then “treated” with ineffective cocktails of mood stabilisers and atypicals. It's really worrying how these silly academic fads have trickled down into clinical practice.

  • http://neuroautomaton.com neuroauto

    @Sidereal

    One must wonder why overdiagnosis, as nothing more than a “silly academic fad”, has so profoundly affected clinical practice. If physicians are really any better than their academic counterparts at determining best practice, then why don't the latter take a stand? Physicians are all members of a power professional organization, the idea that they have no ability to counteract the pernicious trickle-down effects from academia is ludicrous.

    The problem of over-diagnosis is endemic within the entire system, and its failings must be actively addressed by each and every individual if change is to come about successfully. The blame game is a waste of time.

  • http://www.blogger.com/profile/06832177812057826894 pj

    “Physicians are all members of a power professional organization, the idea that they have no ability to counteract the pernicious trickle-down effects from academia is ludicrous.”

    At the head of the medical profession stand the academic medics, they get to set the agenda, whether that be by dominating the research literature or packing NICE committees. While front line clinicians do recognise the limitations in a lot of what they say, they have to pay attention to it.

    When you're standing in court defending why you said that someone didn't have bipolar disorder but was in fact just irritable and aggressive with anti-social tendencies, and they then go and kill someone you're going to have to justify why you ignored the 'silly academic fad' and defend your approach against some eminent academic who will happily turn up as expert witness against you.

  • Peter Parry

    Copies of internal industry documents reveal how Big Pharma pushed the widened bipolar boundaries from the late 1990s when they saw the SSRI patents due to expire and needed extra markets for their new batch of atypical antipsychotics (increasingly being called “mood stabilizers”) – bottom of page are powerpoint files that include excerpts relating to bipolar disorder promotion –

    http://www.healthyskepticism.org/global/news/int/hsin2009-12

    Also a retired psychiatrist investigated a similar phenomena with pediatric bipolar from internal industry documents –

    http://1boringoldman.com/index.php/2012/01/28/a-mess/

  • http://www.blogger.com/profile/06280912088483192599 David M. Allen M.D.

    PJ – in the case of bipolar, my ass disorder, a doc can merely stick to the duration criteria in the DSM and any “expert” testifying – who no doubt will not have examined the patient himself – will look like an idiot. It helps immensely if the doctor has documented his or her reasoning.

    No need for cowardice. I'd certainly rather go to court if I had to than damage some patient's life forever. (You could get sued for that as well. If you do right, the odds of being sued are low, and the odds of losing a suit extremely low).

  • http://www.blogger.com/profile/06832177812057826894 pj

    Unfortunately someone has already invented the concept of ultradian rapid cycling bipolar (=borderline PD to most clinicians).

    In the UK we don't rely on tick box criteria like the DSM in quite the same way* (so the ICD-10 criteria for research are just that, for research) so there is plenty of scope for expert opinion I'm afraid.

    * Which, incidentally, I think is a good thing, and means the controversies around DSM are less of an issue for us.

  • http://survivingantidepressants.org Altostrata

    It is absolutely heinous that adverse reactions to antidepressants or other psychiatric medications are diagnosed as emergence of a vague new psychiatric disorder calling for additional drugs.

    I've always wondered why psychiatrists en masse accept this twisted logic. It doesn't speak well for their training or ability to think independently.

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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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