There are some things to applaud about the recently released update of the NICE bipolar guidelines (1,2), not least the recognition that the diagnosis has been inappropriately applied to children with behavioural problems. Hopefully this will help curtail the worrying trend of using toxic bipolar drugs in this age group. As usual, however, the Guidelines overlook glaring problems with the evidence base for drug treatment in general, and miss an opportunity to stem the diagnostic creep that has come to the UK and Europe via the United States.
Although NICE does not refer to the inflated prevalence figures suggested by some (one group of researchers suggested that 5% of the population have bipolar 1 and 11% bipolar 2) (3,4), classical bipolar disorder (the sort that used to be called ‘manic depression’) probably affects more in the region of 1 in 1000 than 1 in 100 (5). But NICE’s concept of bipolar disorder is likely to be stretched well beyond 1% of the population. NICE defines manic and hypomanic episodes as lasting for a minimum of seven and four days respectively, but I have never seen anyone with classical bipolar disorder whose mania did not last for several weeks, and sometimes months. The Royal College of Psychiatrists information leaflet on bipolar disorder also specifies that mania lasts for weeks or months (6). As soon as it is suggested that a few days of elevated mood constitutes a manic episode, all sorts of life difficulties can start to be defined as ‘bipolar’ (7).
NICE also fail to mention that research on drug treatment has been conducted almost exclusively in people diagnosed with bipolar 1 disorder. Therefore, quite apart for the questionable validity of concepts like bipolar 2 and ‘rapid cycling’ bipolar disorder, the evidence base cannot be generalised to people with these other diagnoses.
It is welcome that NICE highlight the option of psychological treatment in some situations, but the Guideline recommendations on drug treatment still fail to acknowledge the serious methodological problems of drug trials in bipolar disorder. Having previously promoted the use of atypical antipsychotics, NICE now strongly emphasises the role of lithium, stressing that it has the strongest evidence base. It has been recognised for decades now, however, that the evidence for lithium is fatally flawed by the fact that you are more likely to have a relapse of your bipolar disorder after stopping lithium treatment than you were before you started it (8,9). Studies of long-term lithium treatment consist of taking some people off lithium (or other long-term sedative drugs) and putting them on to a placebo. The fact that most (although not all) of these studies find higher rates of relapse among those on placebo cannot be taken to indicate the effectiveness of lithium, however, since it may simply demonstrate the risks of coming off lithium. Whether going on lithium in the first place has any benefit has never been established.
Lithium therapy was described by a psychiatrist in the 1960s as ‘the treatment of manic patients by lithium poisoning’ (10). As well as acute toxicity, long-term use frequently impairs the thyroid gland and inevitably damages the kidneys to a greater or lesser extent. Lithium’s brain-dampening effects are usually experienced as unpleasant (11), and there are safer sedatives if this is the desired effect.
Comparing relapse rates in recent trials and follow-up studies with those found in the first half of the 20th century suggests that modern drug treatment such as lithium and antipsychotics has not improved the prognosis of manic depression or bipolar disorder, and may even have made it worse (12).
NICE missed its opportunity to take a more critical view of the evidence, and stem the diagnostic creep that is spreading drugs that are certainly toxic, and probably ineffective, to ever greater sections of the population.
(1) National Institute for Health and Care Excellence. Bipolar Disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. NICE clinical guideline 185. London: National Institute of Health and Care Excellence; 2014 http://www.nice.org.uk/Guidance/CG185.
(2) Kendall T, Morriss R, Mayo-Wilson E, Marcus E. Assessment and management of bipolar disorder: summary of updated NICE guidance. BMJ 2014;349:g5673 http://www.bmj.com/content/349/bmj.g5673.
(3) Angst J. The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord 1998 Sep;50(2-3):143-51.
(4) Angst J, Gamma A, Benazzi F, Ajdacic V, Eich D, Rossler W. Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003 Jan;73(1-2):133-46.
(5) Healy D. Mania: a short history of bipolar disorder. Baltimore, MD: John Hopkins University Press; 2008.
(6) Royal College of Psychiatrists. Information leaflet on Bipolar Disorder. 2013 http://www.rcpsych.ac.uk/expertadvice/problems/bipolardisorder/bipolardisorder.aspx
(7) Moncrieff J. The medicalization of “ups and downs”: The marketing of the new bipolar disorder. Transcult Psychiatry 2014; 51: 581-598 http://tps.sagepub.com/content/51/4/581.full.pdf+html
(8) Suppes T, Baldessarini RJ, Faedda GL, Tohen M. Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Arch Gen Psychiatry 1991 Dec;48(12):1082-8.
(9) Baldessarini RJ, Tondo L, Viguera AC. Discontinuing lithium maintenance treatment in bipolar disorders: risks and implications. Bipolar Disord 1999 Sep;1(1):17-24.
(10) Wikler A. The Relation of Psychiatry to Pharmacology. Baltimore: Williams & Wilkins Co; 1957.
(11) Judd LL, Hubbard B, Janowsky DS, Huey LY, Attewell PA. The effect of lithium carbonate on affect, mood, and personality of normal subjects. Arch Gen Psychiatry 1977 Mar;34(3):346-51.
(12) Moncrieff J. The Bitterest Pills. 2013 London: Palgrave http://www.palgrave.com/page/detail/the-bitterest-pills-joanna-moncrieff/?K=9781137277428