Can a Diagnosis Be Epidemic, with Therapeutic Efforts the Catastrophe?

The diagnosis of bipolar spectrum disorders (BSD) given for office visits has risen 40-fold for children and has risen dramatically for adults as well. Some of the growth may have been fueled by recategorization of individuals who would previously have received diagnoses of major depression along with the widening of diagnostic criteria for BSD. Concomitant with the rise in BSD diagnoses, the number of adults and children receiving atypical antipsychotics has increased dramatically. Recent evidence finds that atypical antipsychotics cause considerable reduction in brain volume. It is thus imperative to ensure that those with diagnoses comprising BSD-bipolar I, bipolar II, and bipolar not otherwise specified (BP-NOS)-actually share a common etiology and are being appropriately treated. This article reviews the history, evidentiary support, and implications associated with the expansion of the bipolar spectrum. Keywords: bipolar I; bipolar II; pediatric bipolar; atypical antipsychotics In the years from 1999 to 2003, the diagnosis of bipolar given in office visits has increased 40-fold for children. Bipolar disorder diagnoses have increased during the same period for adults as well rising from 4.77% of office visits to 6.28% of office visits (Moreno et al., 2007). Alan Frances (2009), the chairperson of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV), has suggested that the sharp rise in bipolar diagnoses is attributable to the manner in which criteria for the disorders were written-that it was an issue of taxonomy rather than epidemiology. Obviously, diagnostic criteria have profound implications for who is diagnosed, at what age, and whether they are treated with psychotropic medications. Because psychotropic medications carry substantial risks-if not guarantees-of side effects, those decisions must be judicious and ever cognizant of Hippocrates' admonishment: First, do no harm. This review constitutes an audit of psychiatry's books, asking if they balance when the substantial risk of harm from such diagnoses and the regimen of medication they entail are taken fully into account. CREATION OF THE BIPOLAR SPECTRUM Over the years, those behaviors categorized under the bipolar label have expanded greatly. In the DSM-II (American Psychiatric Association [APA], 1968), manic depression, listed under the heading "affective psychoses," was the only bipolar-type diagnosis. With subsequent editions of the DSM, new categories of affect perturbations were included in manuals. The DSM-III (APA, 1980) provided descriptions of the behaviors required to meet criteria for mixed and manic episodes. The DSM-III-R (APA, 1987) added criteria for hypomania (specified in the next paragraph). The literature recognized that some persons who had experienced an episode of depression did have periods when they were enthusiastic, energetic, and animated to the extent that they met criteria for hypomania. Kupfer, Carpenter, and Frank (1988) had argued that such individuals, who were labeled bipolar II, should be viewed as experiencing a variant of major depression. Dunner (1993) disagreed, arguing that because in family studies, both probands with bipolar I and probands with bipolar II reported more family members with bipolar than did probands with major depression, bipolar II should be designated as a bipolar disorder. With the 1994 publication of the DSM-IV, the diagnosis of bipolar II was officially included in the manual under the heading of bipolar disorders. The conventions for diagnosing bipolar spectrum disorders (BSD) have basically been in effect since 1994. The diagnosis of bipolar I, as defined in the DSM-IV-TR (APA, 2000), requires an episode of mania or a mixed episode. Mania criteria are comparatively restrictive, requiring 1 week of "elated, expansive, or irritable mood" with three or more of the following (or four or more of the following, if irritable rather than expansive mood is present): inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas/ racing thoughts, distractibility, increased goal-directed activity, and excessive involvement in risky but pleasurable activities. …