Okay, this is really interesting. One can argue that the most trenchant criticism of DSM-5 bipolar comes from none other than the chair of the DSM-5 Task Force, David Kupfer. This requires some explanation:
Until 2009, Dr Kupfer was the chair of the department of psychiatry at the University of Pittsburgh and Western Psychiatric Institute. He is one of the leading experts on mood disorders, having authored more than 800 articles and book chapters, and the recipient of numerous awards and honors.
Personal disclosure: Dr Kupfer has been one of the organizers of the two-yearly International Conference on Bipolar Disorders. In 2007, at the Conference, he presided over an awards ceremony where I was one of the awardees (for Public Service). His wife, Ellen Frank, also a leading mood disorders expert, wrote a glowing blurb for my book, Living Well with Depression and Bipolar Disorder.
In the May 11 Lancet, Dr Kupfer co-authored (with Mary Phillips) an intriguing article: Bipolar Disorder Diagnosis: Challenges and Future Directions. (Abstract here. The full article costs $31.) Let’s take a look:
The Misdiagnosis Problem
Despite being one of the most disabling illnesses, bipolar is misdiagnosed as recurrent unipolar depression in 60 percent of those seeking treatment for depression. Only 20 percent of those experiencing bipolar depression are correctly diagnosed within the first year of seeking treatment, with the mean delay between illness onset and diagnosis being five to ten years.
The most obvious reason for misdiagnosis is that the criteria for unipolar depression and bipolar depression are exactly the same. Clinicians naturally look to tell-tale mania or hypomania, but here the problems begin. Those with bipolar I experience manic symptoms only nine percent of the time while those with bipolar Ii experience hypomanic symptoms only one percent of the time.
Muddying the waters even further are mixed episodes, which blur the line between depression and (hypo)mania and are far more common than once thought.
Just to make matters interesting, there is a good case that for many people unipolar depression is bipolar waiting to happen. Twenty percent develop a manic or hypomanic episode in five years. Many with so-called “treatment-resistant depression” probably have unrecognized bipolar. The consequences of misdiagnosis can be disastrous, as this can result “in the prescription of inappropriate drugs, such as antidepressants in the absence of a mood-stabilizing drug, which might lead to switching to mania ...”
The authors emphasize that the boundaries between depression and bipolar is not clear-cut. For example, hypomanic symptoms that do not meet DSM-IV criteria for bipolar II are present in 40 percent of those with recurrent unipolar depression. Further, when certain threshold cut-offs for (hypo)mania are relaxed, those meeting bipolar criteria increases to nearly 50 percent. A good case, therefore, can be made for “the spectrum approach, in which clinical measures of dimensions of lifetime affective pathology are assessed.”
A picture tells a thousand words. Below are mood changes tracked over time in bipolar I, bipolar II, and recurrent unipolar depression. Note the similarities in the three cycling patterns. The only main difference between the three is the degree of “up.” So - three different illnesses or one phenomenon?
Neural Circuits and All That
In the opening to their Lancet article, the authors note that:
The identification of objective biomarkers that represent pathophysiologic processes that differ between bipolar disorder and unipolar depression can both inform bipolar disorder diagnosis and provide biological targets for the development of new and personalised treatments.
The catch is we are not there yet. Co-author Mary Phillips directs neuro-imaging psychiatric research at both the University of Pittsburgh and Cardiff University. A major part of her research includes the identification of biomarkers for bipolar disorder. A 2007 article (this one is free) in the Dec 2007 Current Psychiatry (Matthew Keener, co-author) identifies some of the challenges. Fast forward to 2013:
A suitable focus for analysis in neuroimaging studies of bipolar disorder and unipolar depression is the neural circuitry that supports emotion and reward processing, and emotion regulation, since these are key processes that are abnormal in all affective disorders.
As for differentiating bipolar from unipolar depression, there appears to be more irregularities in white matter (involved in neural connectivity) in the brains of those experiencing bipolar depression.
So there you have it: Explicit acknowledgement from the Chair of the DSM-5 Task Force that the DSM-5 (which was published in May this year) does little to help clinicians correctly diagnose bipolar disorder, plus recognition of the consequences of making a wrong diagnosis. We also have explicit acknowledgment that we need to look at bipolar from a dimensional standpoint (one that overlaps with depression) and to reconceptualize the illness in terms of its underlying biology.
In other words, Dr Kupfer would be the first to recognize that we need to blow up the DSM and start over. It’s just that, in his view, we are years away from making it happen. I would say blow the whole up right now, but let’s not quibble. Conceptually, at least, we’re all on the same page.
Published On: July 07, 2013
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