Drug industry is partly to blame for overdiagnosis of bipolar disorder, researchers claim
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39577.442650.DB (Published 15 May 2008) Cite this as: BMJ 2008;336:1092All rapid responses
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The paper by Zimmerman et al1, raises two important issues; namely the overdiagnosis of bipolar disorder and the role of direct to consumer advertising in the United States.
Although information was collected from 700 patients over a period of 4 years, there are a number of weaknesses in the study. All the data was collected from direct interviews using the Structured Clinical Interview for DSM-IV (SCID)2 without systematic review of case notes or discussion with psychiatrists. This would effect the validity of the study. Additionally, 23% of those diagnosed with bipolar were given a diagnosis of bipolar disorder not otherwise specified (NOS). This substantial proportion included those who reported multiple short, hypomanic episodes which could have been due to other aetiologies such as substance misuse or a primary personality disorder. Some of the patients may have been given only a differential diagnosis of bipolar disorder in the past and so would be overrepresented in the sample. Indeed, diagnosing bipolar disorder is difficult as many of its symptoms are shared with other conditions, and so it is frequently misdiagnosed in cases of agitated depression3 and substance misuse4. The distinction between bipolar disorder and atypical depression can be very difficult5 and it has been suggested that atypical depression is a variant of bipolar II disorder6.
The second point raised in the paper was of direct to consumer advertising (DTCA), a concept that has raised enormous debate in North America and New Zealand. DTCA is where pharmaceutical companies promote prescription drugs directly to the public. It can lead to patients suggesting to their Doctors that they have certain illnesses or would like a new drug they think will help them. Pharmaceutical companies argue that DTCA educates people and encourages them to seek early treatment for potentially chronic and disabling conditions that would ultimately lead to more cost to the economy in terms of hospitalisation and lost employment. However, it risks "pathologising" society and redirecting valuable and scarce resources in the health service. The European Commission is to allow drug companies to use the media to provide information on prescription drugs to the public, without explicitly promoting them. This is an almost impossible task and some argue that this could lead to "opening the promotional floodgates"7. If this legislation is pushed through, Doctors may have to invent innovative ways of saying "no" - probably to the detriment of the relationship with their patients.
References
1. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is Bipolar Disorder Overdiagnosed? Journal of Clinical Psychiatry. May 6, 2008. e1-e6.
2. First MB, Spitzer RL, Gibbon M et al. Structured Clinical Interview for DSM-IV Axis 1 Disorders. New York, NY. Biometrics Research Department. New York State Psychiatric Institute. 1995.
3. Benazzi F. Agitated depression: a valid depression subtype? Progress in Neuro-psychopharmacology and Biological Psychiatry. 2004 Dec;28(8):1279-85.
4. Stewart C, El-Mallakh RS. Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disorders. 2007 Sep;9(6):646-8.
5. Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. Diagnostic guidelines for bipolar depression: a probabilistic approach. Bipolar Disorders. 2008 Feb;10:144-52.
6. Akiskal HS, Benazzi F. Atypical depression: a variant of bipolar II or a bridge between unipolar and bipolar II? Journal of Affective Disorders. 2005 Feb;84(2-3):209-17.
7. Richards T. Purely medicinal? British Medical Journal. 2008;336:693.
Competing interests: None declared
Competing interests: No competing interests
Slipping editorial standards at the BMJ
Dear Editor
Those of us with obsessional personalities puzzle that you should choose in the print edition of the BMJ to adopt the traditional journalist's tradition of having subject's profile portraits facing the spine of the publication. Is the BMJ so hard up that it has only one library picture of Stephen Fry for your news item and prints it in reverse (page 103), yet prints the same picture the correct way around on the contents page of the same edition, presumably, to maintain compositors' preferences?
Yours faithfully
Michael G Bamber
Competing interests: None declared
Competing interests: No competing interests