The Bipolar Bamboozle
ANOTHER EXAMPLE OF HOW TO MAKE MORE PROFITS-while ruining
peoples lives. What is said about
bipolar disorder and its treatment can be generalized to all the major
psychiatric disorder and their treatments:
statistically it has been shown that long-term drug treatment has a much
Found in the September/October 2008 issue of Skeptical
Inquirer, Vol. 32, No. 5 and on the web at
The Bipolar Bamboozle
With the broadening and softening of the criteria needed to label
someone with bipolar disorder and aggressive marketing campaigns by
pharmaceutical companies, millions of people are being told they have a severe
psychiatric disorder and are being prescribed powerful antipsychotic
medications. In fact, most are normal people dealing normally with everyday
STEPHEN RAY FLORA
and SARAH ELIZABETH BOBBY
Stephen Ray Flora is a psychology professor and behavior analyst at Youngstown
and author of Power of Reinforcement (SUNY Press 2004) and Taking
America off Drugs: Why Behavioral Therapy is More Effective for Treating ADHD,
OCD, Depression, and Other Psychological Problems (SUNY Press 2007).
E-mail: srflora [at] ysu.edu. Sarah Elizabeth Bobby is a psychology
graduate of Youngstown
“Bipolar disorder,” originally known as manic-depression, has been
acknowledged as a problem for centuries. However, until
very recently, it was considered a very rare and severe condition. Now
diagnoses of “bipolar spectrum” disorders are reaching epidemic proportions. Nothing
has changed in humans’ biology or natural environment to account for this rise
in diagnoses. What does account for the increase is a
“softening” of the criteria needed to diagnose a person with bipolar, an
increase in aggressive marketing of new profitable prescription drugs for
bipolar, and psychiatrists “upcoding” problems to get higher insurance
reimbursement rates. A likely outcome of this increase in labeling
people “bipolar” is not that more people in need of
help are getting it but instead that millions of people are unnecessarily being
put on powerful antipsychotic medications.
As the name suggests, people labeled bipolar are believed to alternate
between the emotional extremes, or poles, of mania and depression. Prior to the
publication of the third edition of psychiatry’s Diagnostic and Statistical
Manual (DSM-III) in 1980, a
patient would have to be hospitalized with a manic episode before a diagnosis
of manic-depression was made. At that time rates of mania were estimated to be 0.4 to 1.2
percent of the population; prior to that, rates were estimated to be
Currently some estimates of bipolar are as high as 10 percent of the population
(Angst, et al. 2003), but rates of hospitalization for
mania have not increased. What happened?
Just as a child with a hammer discovers new things that “need” to be
hammered, when psychiatry finds new drugs it discovers new people who “need” to
be treated with them. In 1949 Australian doctor John Cade reported that lithium
salts could be effective in the treatment of “psychotic excitement” or mania
(Cade 1949). As knowledge of this finding spread, so did the diagnosis of
mania, as noted by Philip Mitchell:
One of the major driving forces determining the livelihood
of particular diagnoses in medicine has been the availability of effective
remedies. Psychiatry has not been exempt from this phenomenon, with the
introduction of lithium into clinical practice in the late 1960s and early
1970s leading to substantial increases in the diagnosis of bipolar disorder
over that time. For example, in Australia,
Parker et al. demonstrated that in New
South Wales, the diagnosis of bipolar disorder
increased dramatically (with a concomitant decrease in the diagnosis of
schizophrenia) from the mid-1960s to the mid-1970s, despite there being no
overall change in the total number of those with “functional psychoses.”
(Mitchell 2006, 279)
While there was no change in the number of people with “functional
psychoses,” by 1968 more than 200 psychiatrists had applied to the FDA to study
and use lithium for mania. Concurrently, three companies applied to market
lithium. The FDA approved the applications and in 1970 approved the use of
lithium to treat manic episodes of manic-depressive psychosis (Johnson and
Gershon 1999). With the publication of the third edition of the DSM in 1980,
the “mania” diagnosis was replaced with “bipolar disorder,” and the rates of
bipolar remained stable.
In the last
decade, rates of children being diagnosed with bipolar has increased by forty
times, and the rates of diagnosis for adults almost doubled
(Morero, et al. 2007)! Nothing overtly changed in American culture—not dietary
practices, there was no mass exposure to toxic waste, and neither parenting nor
educational practices were overhauled. Instead a culmination of less than scientifically justified
factors resulted in the current explosion of people, many of them children as
young as four years old, being diagnosed and misdiagnosed as “bipolar.”
The Tenuous Analogy:
A Pharmaceutical Sleight of Hand
Without exclusive rights to a patented pharmaceutical, and with bipolar
still a relatively rare “disorder,” sales of lithium, or any drug to treat this
problem, could not be profitable. This rapidly changed when psychiatrists
started to use epileptic, anticonvulsant, antiseizure medications in attempts
to control mania (Healy 2006). Seizures occur in epileptics when there is
sudden excessive firing of neurons; the initial firing is known as “kindling.”
Anticonvulsants work by “stabilizing” the neurons and preventing or at least
reducing the frequency of kindling and thus seizures. Perhaps because both
seizures and mania appear to involve a high state of “excitability,” Robert
Post (e.g., Post and Weiss 1989) suggested that manic states might be prevented
with antiseizure medications analogous to how they prevent seizures in
epileptics. But there is a difference in the excitability of neurons during
seizures and the emotional excitability of mania. There is no evidence that nerurons fire uncontrollably and excessively
during states of mania as they do during seizures.
Nevertheless, with this analogy, the term “mood-stabilizer” came into vogue,
and in 1995 Abbott Laboratories’ Depakote became the first anticonvulsant
approved by the FDA for treating mania. Yet, there is no agreement on what the
term “mood stabilizer” means (Healy 2006), and although they may be called
“mood-stabilizers,” anticonvulsants have never been shown to actually stabilize
moods; rather, their use is simply based on an analogy, not science. Using anticonvulsants for mania, even
though not developed for it, and calling anticonvulsants “mood stabilizers”
though they have never been shown to stabilize moods, are just more examples of
drug companies’ well-worn strategy of finding new, profitable “indications” for
selling old, less profitable, drugs (see Flora and Sellers 2001 for another
example). In the study “The Impact of Mood Stabilizers on Bipolar Disorder: The
1890s and 1990s Compared,” North Wales researchers found that despite the wide-spread
use of mood stabilizers, rates of readmission for bipolar patients is higher
now (77 percent) than it was one hundred
years ago (8 percent). In the 1890s, 81 percent of the discharges were
recovered, but only 17 percent in the 1990s were recovered. These findings
forced the researchers to conclude: “These data are incompatible with simple
claims that mood stabilizing drugs ‘work’” (Harris, Chandran, Chakraborty, and
Healy 2005). Indeed, these findings indicate that not receiving treatment works
better than pharmaceutical intervention. Similarly, University
researchers recently found that only 5 percent of medicated schizophrenia
patients recover, but 40 percent of non-medicated patients recover (Harrow, Grossman, Jobe,
and Herbener 2005; also see Harrow and Jobe 2007). In other words, schizophrenia
patients are eight times more likely to recover if they are not on medications!
“Softening” Bipolar Sickness
According to Webster’s New
dictionary, “bipolar” is defined as “1. Relating to or having two poles. 2.
Relating to or involving both of the earth’s poles. 3. Having or expressing two
contradictory ideas or qualities” (1988). Thus, if “manic-depression” is
“bipolar,” then the states of mania and depression need to be polar
opposites as are the Earth’s north and south poles. Consisting of the
polar states of mania and severe depression, the original notion of “bipolar
disorder” matched the dictionary definition of “bipolar.” However, disregarding
the very definition of bipolar, the psychiatric notion of
“bipolar disorder” has been broadened and “softened” to include milder,
decidedly nonpolar mood states in the now-called “bipolar spectrum disorders”
(e.g., Akiskal, et al. 2000). Consequently, an individual who is simply very
happy at times may be said to have periods of “hypomania” rather than mania;
and if sometimes they are sad too they may be labeled “cyclothymic” within the
bipolar spectrum. “Softening” is analogous to (geologically) studying Brazil and Mexico
to be studying Earth’s poles. While this is merely ridiculous in geology, it is
actually harmful in psychiatry. Yet this is exactly what is happening, because
it is profitable for psychiatry and pharmaceutical companies. Even though
normal life events expected to elicit happiness and sadness are recognized as
contributing factors by psychiatrists, people experiencing happiness and
sadness are nevertheless labeled cyclothymic in the bipolar spectrum, opening
the door to reimbursable psychiatric care and unnecessary pharmaceutical
prescriptions. For example, Akiskal et al., report:
slightly under 10% of a mental health clinic’s patients
conformed to subsyndromal [nonpolar] mood changes over extended periods of
time. These where young adults who presented clinically because of social
disruptions in their lives, such as romantic failure, financial extravagance,
repeated change of line of work or college studies, frequent geographical
moves, and polysubstance abuse. The underlying affective diathesis was validated
on the basis of phenomenological criteria that involved biphasic subsyndromal
[nonpolar] changes in energy, activity, mood, and cognition, each phase
typically lasting from 2 days to a week; some oscillated more in a depressive
direction, . . . [t]he subthreshhold oscillation of hypomanic and subderessive
periods occurring in 6.3% of the population at large. (Akiskal et al. 2000,
S10, emphasis added)
What Akiskal et al. are arguing is that even though emotions do not
reach the level of being a psychiatric syndrome (“subsyndromal”) and are caused
by common emotional life events (e.g., “romantic failure, . . . repeated change
of line of work or college studies, frequent geographical moves, and
polysubstance abuse”), a significant portion of the population with these
normal emotions should nevertheless be labeled “bipolar.” Indeed, their
original article in this line of work was titled “Cyclothymic Disorder: Validating
Criteria for Inclusion in Bipolar Affective Group” (Akiskal et al.
1977, emphasis added). Thus normal happiness and sadness become disorders
“treatable” with pharmaceuticals.
As if “softening” the diagnoses of bipolar to cast a wider net for paying
clients wasn’t questionable enough, psychiatrists have been “upcoding”
individuals, particularly children, to more severe “bipolar” diagnoses to get
greater insurance reimbursement. SUNY-Stony Brook psychiatrists Joseph Blader
and Gabrielle A. Carlson (2007) found
that from 1996 to 2004 rates of bipolar diagnoses among adults increased 56
percent, increased 296.4 percent among adolescents, and increased 438.6 percent
among children! They suggest:
higher rates of inpatient admissions among youth associated
with BD [bipolar disorder] may reflect . . . “upcoding” to putatively more
severe conditions for reimbursement (107) . . . [and that] Clinicians may have
responded to the higher hurdles for obtaining payer’s authorization for
inpatient care by “upcoding” severe behavioral disturbances to a major mood
disorder that connotes a more pernicious illness. (111)
Apparently, to gain these increased diagnoses, children with behavioral
difficulties and conduct problems are receiving “upcoded” diagnoses of bipolar
disorder (Blader and Carlson 2007). Diagnosing children who have behavioral
difficulties with bipolar disorder (or any psychiatric disorder) and
subsequently medicating them is particularly disturbing. The evidence is
conclusive that to correct conduct and other behavioral problems, behavioral
management programs and parent training programs are superior to medicating
children (Flora 2007).
Selling Sickness with Direct-to-Consumer Advertising
In 1997 the FDA began to allow direct-to-consumer
advertising, making the U.S. and New Zealand the only two countries in the
world that allow the practice. This change opened the door for self-diagnoses,
medical-seeking behavior, and disease mongering. According to writers in
the British Medical Journal:
Some forms of “medicalisation” may now be better described
as “disease mongering”—extending the boundaries of treatable illness to expand
markets for new products. Alliances of pharmaceutical manufacturers, doctors,
and patient groups use the media to frame conditions as being widespread and
severe. Disease mongering can include turning ordinary ailments into medical
problems, seeing mild symptoms as serious, treating personal problems as
medical, seeking risks as diseases, and framing prevalence estimates to
maximize potential markets. (Moynihan, Heath, and Henry 2002, p. 886)
This is exactly what has occurred with bipolar disorder. Advertisements for
Abilify and Seroquel, two antipsychotic medications approved for bipolar
disorder, are ubiquitous in periodicals, daytime television, and even plastered
on phone booths. Just as anticonvulsants were used as “mood stablizers,” the
current drugs being pushed for bipolar were developed for schizophrenia.
According to company press releases, Abilify was approved in 2002 for the
treatment of schizophrenia, producing over 3.7 million prescriptions between
2002 and 2005. Seroquel was approved for the treatment of schizophrenia in 1997
and produced sales of $2.8 billion in 2005. Pharmaceutical patents typically
last for seven years, but if “new indications” can be found, then the patent can be
extended for several more years, which will protect and likely
increase profits. Using this strategy, the makers of Seroquel gained FDA
approval for the treatment of mania in 2004 and for depressive episodes in
2006. The makers of Abilify gained FDA approval for “maintenance treatment” of
bipolar in 2005.
Direct-to-consumer advertising coupled with happiness and sadness fitting
into “softer” bipolar categories made for fertile ground in which drug
companies could solicit for mental illness and thus increase sales. Because
sales of drugs require a medical diagnosis, drug advertisements suggest to
potential customers that they may have a “medical disorder” such as bipolar.
Advertisements tell consumers to focus on feelings, behaviors, and sensations
consistent with the disorder. Drug company-sponsored “educational” Web sites
offer self-tests designed to lead the taker to admit symptoms consistent with
bipolar. The test taker is encouraged to print out the results and share them
with a doctor who can prescribe medication. “The Mood Questionnaire” Web site
is nothing more than a promotion for Seroquel by its makers, AstraZeneca
pharmaceuticals. The site tells survey takers: “Regardless of your results,
we recommend that you print and share this questionnaire with a qualified
health care professional who can provide you with a full evaluation” (emphasis
Showing up at a doctor’s office with a printout and concerns about bipolar
will influence some doctors to prescribe medication. Previous research revealed
that when “patients” visited doctor’s offices unannounced with complaints of
adjustment difficulties, they received a prescription for medication 10 percent
of the time. But when they made complaints of adjustment difficulties and
mentioned a specific medication, they received a prescription for
antidepressant medication 55 percent of the time (Kravitz, Epstein, Feldman, et
al. 2005). Based on these findings, it is not hard to guess what will happen
when a patient shows up with a questionnaire on bipolar from drug makers.
Medicating people for happiness and sadness is not without consequence.
Antipsychotics used to treat bipolar work by interfering with the body’s
dopamine and serotonin systems. These neurotransmitters are known to be involved in one’s
ability to feel pleasure and initiate activities. Interfering with these
abilities are likely reasons why up to 75 percent of patients refuse to take
prescribed antipsychotics (Flora 2007, 113).
Common side effects of Seroquel include dry mouth (44 percent), drowsiness
(34 percent), high triglycerides (23 percent), headaches (21 percent),
agitation (20 percent), dizziness (18 percent), high cholesterol (16 percent),
weakness (10 percent), constipation (10 percent), and fatigue (10 percent).
Common side effects of Abilify include headaches (30 percent), anxiety (20
percent), insomnia (19 percent), nausea (16 percent), constipation (13
percent), vomiting (12 percent), and dizziness (11 percent) (eMedTV). Many
other common side effects occur in between 2 and 10 percent of those who take
these drugs. For example, significant weight gain occurs in 6 percent of people
taking Seroquel and in 6.8 percent of people taking Abilify. This weight gain
often leads to diabetes or morbid obesity. With the drug-induced decreased
ability to feel pleasure and numerous aversive side effects, eating may be one
of the only sources of enjoyment available for people labeled “bipolar.”
In conclusion, the broadening and softening of the criteria necessary to
label one with bipolar disorder coupled with aggressive campaigns by
pharmaceutical companies results in millions of people being told they have a
severe psychiatric disorder. These misled patients are being prescribed
powerful antipsychotic medications when in fact they are normal people dealing
normally with ordinary life issues.
- Akiskal, H.S., M.L.
Bourgeois, J. Angst, R. Post, H. Moller, and R. Hirschfeld. 2000.
Re-evaluating the prevalence of and diagnostic composition within the
broad clinical spectrum of bipolar disorders. Journal of
- Affective Disorders,
- Akiskal, H.S., A.H.
Djenderedjian, R.H. Rosenthal, and M.K. Khani.1977. Cyclothymic disorder:
Validating criteria for inclusion in the bipolar affective group. American
Journal of Psychiatry, (134): 1227–1233.
- Angst, J., A. Gamma, F.
Benzaai, V. Ajdacic, D. Eich, and W. Rossler.
2003. Toward a re-definition of subthreshold bipolarity: Epidemiology and
proposed criteria for bipolar-II minor bipolar disorders and hypomania. Journal
of Affective Disorders, (73): 133–146.
- Blader, J.C., and G.A.
Carlson. 2007. Increased rates of bipolar disorder diagnoses among U.S.
child, adolescent, and adult populations, 1996–2004. Biological
Psychiatry, (62): 107–114.
- Cade, J.F.J. 1949. Lithium
salts in the treatment of psychotic excitement. Medical Journal of Australia,
- eMedTV. 2008. Abilify Side
Effects. Available online at http://bipolar-disorder.
emedtv.com/abilify/abilify.html. Accessed Jan. 8, 2008.
- eMedTV. 2008. Seroquel Side
Effects. Available online at http://bipolar-disorder.emedtv.
com/seroquel/seroquel.html . Accessed Jan 8, 2008.
- Flora, S.R. 2007. Taking
America Off Drugs: Why Behavioral Therapy is More Effective for Treating
ADHD, OCD, Depression, and other Psychological Problems. State
University of New York
Press. Albany, NY.
- Flora, S.R. and M. Sellers.
2003. ‘Premenstrual dysphoric disorder’ and ‘premenstrual syndrome’ myths.
Skeptical Inquirer, (27): 37–42.
- Harris, M., S. Chandran, N.
Chakraborty, and D. Healy. 2005. The impact of mood stabilizers on bipolar
disorder: The 1890s and 1990s compared. History of Psychiatry,
- Harrow, M., L.S. Grossman,
T.H. Jobe, and E.S. Herbener. 2005. Do Patients with schizophrenia ever
show periods of recovery? A 15-year multi-follow-up study. Schizophrenia
Bulletin, (31): 723–734.
M., and T.H. Jobe. 2007. Factors involved in outcome and recovery in
schizophrenia patients not on antipsychotic medications: a 15-year
multifollow-up study. Journal of nervous and Mental Disease,
- Healy, D. 2006. The latest
mania: Selling bipolar disorder, PloS Med3 (4): e185.
- Johnson, G., and S.
Gershon.1999. Early North American research on lithium. Australian and
New Zealand journal of Psychiatry, (33): S48–S53.
- Kravitz, R.L., R.M. Epstein,
M.D. Feldman, et al. 2005. Influence of patients’ requests for
direct-to-consumer advertised antidepressants. Journal of the American
Medical Association, (293): 1995–2002.
- Mitchell, P.H. 2006. Bipolar
disorder 40 years ago: A critical period of transition. Australian and
Journal of Psychiatry, (40): 279–280.
- Moreno, C., G. Laje, C. Blanco, et
2007. National trends in the outpatient diagnosis and treatment of bipolar
disorder in youth. Archives of General Psychiatry, (64):
- Moynihan, R., I. Heath, and D. Henry. 2002. Selling sickness: The
pharmaceutical industry and disease mongering. British Medical Journal,
- Post, R.M., and S.R.B. Weiss.
1989. Kindling and manic-depressive illness. In: Bolwig T.G. Bolwig and
M.R. Trimble, editors. The clinical relevance of kindling. London:
- Webster’s II: New Riverside
University Dictionary. 1988. Boston,
MA; Houghton Mifflin.