This is the third in our discussion of psychiatry’s diagnostic bible, the DSM. In May this year, an updated edition - the DSM-5 - will replace the current DSM-IV, which has been the last word since 1994. How influential is the DSM? In response to last week’s piece, Psychiatric Incompetence and the DSM, Tabby, who works in a clinic, reports that the manual is regularly consulted by the therapists and psychiatrist who work there. When they can’t seem to put a finger on the condition, she reports, she finds them “pouring through ‘the book,’ or huddle, two or three of them, in a circle discussing and arguing what each other thinks it is.”
There is one catch: Using the DSM to arrive at a precise diagnosis is like relying on Apple Maps to arrive at your destination. As I pointed out in my previous post, the DSM-IV has no way, practical or impractical, of differentiating bipolar depression from unipolar depression. Why it is critical to do so is that an antidepressant, which may work just fine for treating unipolar depression, may possibly be the worst drug a doctor can prescribe to someone in the bipolar spectrum (where the risk of the pill inducing a switch into mania or in speeding up the cycle is very high).
Another way of phrasing this: If an antidepressant worked the same for both bipolar depression and unipolar depression, diagnostic mistakes would not have the major consequences they do now.
So, imagine Tabby’s clinicians huddling over their office copy of the DSM-IV. Under “Major Depressive Disorder,” they are referred to “Major Depressive Episode,” where they mull over the nine-symptom checklist. First, one of two symptoms must be checked off: “Feeling depressed” (which we can loosely interpret as feeling sad) or “Loss of pleasure” (which is another way of saying you don’t necessarily have to feel sad to have depression). Then we have an additional seven symptoms to choose from. In all, at least five of nine symptoms need to be checked off.
Fine, Jim Dandy. But what if one of the clinicians suspects bipolar? The catch is the patient is presenting as depressed, with no sign of mania. Indeed, the patient in her depressive state might not even recall feeling good at any time in her life. I am guessing that Tabby’s clinicians know better than to look up what bipolar depression involves. This is because DSM-IV bipolar depression is an exact cut and paste of unipolar depression.
But are the two the same? Let’s think this through: The same antidepressant that may be beneficial for one condition may do a serious number on your brain for the other. Clearly, there is a different biological basis to the two depressions. On my website, mcmanweb, I quote Alan Swann of the University of Texas, Houston in support:
The differing biological properties of unipolar and bipolar depression suggest that treatments that were originally intended for unipolar depression may not be optimal for bipolar depression.
Fine, but we have no biological test for diagnosing psychiatric illness, much less in separating out different types of depression. But can we at least, through careful clinical observation, pick out some tell-tale symptoms? Can we at least have an assist from the DSM?
Goodwin and Jamison in the second edition to "Manic-Depressive Illness" (2007) acknowledge that the research on the topic is extremely thin, which would absolve the DSM to a certain degree. Nevertheless, they point out a number of features of bipolar depression, namely: irritability, high relapse rate, pronounced and pervasive sleep difficulties, fatigue and psychomotor retardation, loss of appetite and sexual drive, and feeling worse in the morning and better in the evening.
Perhaps these symptoms are too subtle or too ambiguous to rate being set in concrete by the DSM. But then Goodwin and Jamison bring up mixed states, where symptoms of depression and mania present simultaneously. Way back in 1921, in his classic "Manic-Depressive Insanity," Emil Kraepelin devoted considerable attention to this phenomenon, which he saw as closer to the rule rather than the exception, and with many fine shadings, including “depressive mania,” “excited depression,” and “manic stupor.”
To over-simplify, we are talking about agitated depressions and dysphoric manias that present a lot differently than your classic “pure” depressions and manias. Perhaps you experience road rage, even if you’re not driving. Perhaps you are feeling highly energized, but without the thinking parts of your brain booted up.
The research base is very solid on this. These states are clearly observable. It is not rocket science for a clinician to ask his or her patient: Have you ever had those moments when you wanted to wring the whole world by the neck? Let’s once again direct our attention to Tabby’s clinicians huddled over their DSM-IV. They flip the pages, but all they find is “mania, mixed.” That’s it - full-blown mania (M) combined with full-blown depression (D) to get MD. Not full-blown mania with a lower case depression (Md) or severe depression with a bit of mania or hypomania (Dm) or a little bit of both (md or dm).
Keep in mind, these conditions are very common, more like the rule rather than the exception, yet in the incomprehensibly surreal Apple Maps world of the DSM they don’t exist, except in one rare instance. So, heaven help if your depression has something a little extra. To the DSM-IV, you have a garden variety depression. And a garden variety depression presumes treatment with antidepressants.
If clinicians were smart enough to light a match to the DSM this would not be a problem. But Tabby’s clinicians are all too typical. At this very moment, they may be huddled together over their DSM-IV, studiously making the wrong call.
The DSM-5, to its credit, makes sweeping changes in this area. Thus, we have various shades of mixed depressions, mixed manias, and mixed hypomanias. The catch is, last time I looked, the DSM-5 has not risen to the challenge of using mixed states as a way of differentiating unipolar depression from bipolar depression. Until this happens, the distinctions are academic. Here is the $64,000 question:
If the depression is mixed, should the condition be regarded as bipolar, regardless of whether there is a history of mania or hypomania?
You tell me. Comments below ...