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Practice Guidelines

Assessment and management of bipolar disorder: summary of updated NICE guidance

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g5673 (Published 25 September 2014) Cite this as: BMJ 2014;349:g5673

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There are some things to applaud about the recently released update of the NICE bipolar guidelines, not least the recognition that the diagnosis has been inappropriately applied to children with behavioural problems. Hopefully this will help curtail the worrying trend of using toxic bipolar drugs in this age group. As usual, however, the Guidelines overlook glaring problems with the evidence base for drug treatment in general, and miss an opportunity to stem the diagnostic creep that has come to the UK and Europe via the United States.

Although NICE does not refer to the inflated prevalence figures suggested by some, the prevalence of classical bipolar disorder (the sort that used to be called ‘manic depression’) is probably more in the region of 1 in 1000 than 1 in 100 (1). But NICE’s concept of bipolar disorder is likely to be stretched well beyond 1% of the population. NICE defines manic and hypomanic episodes as lasting for a minimum of seven and four days respectively (2), but I have never seen anyone with classical bipolar disorder whose mania did not last for several weeks, and sometimes months. The Royal College of Psychiatrists information leaflet on bipolar disorder also specifies that mania lasts for weeks or months (3). As soon as it is suggested that a few days of elevated mood constitutes a manic episode, all sorts of life difficulties can start to be defined as ‘bipolar’ (4).

NICE also fail to mention that research on drug treatment has been conducted almost exclusively in people diagnosed with bipolar 1 disorder. Therefore, quite apart from the questionable validity of concepts like bipolar 2 and ‘rapid cycling’ bipolar disorder, the evidence base cannot be generalised to people with these other diagnoses.

It is welcome that NICE highlight the option of psychological treatment in some situations, but the Guideline recommendations on drug treatment still fail to acknowledge the serious methodological problems of drug trials in bipolar disorder. Having previously promoted the use of atypical antipsychotics, NICE now strongly emphasises the role of lithium, stressing that it has the strongest evidence base. It has been recognised for decades now, however, that the evidence for lithium is fatally flawed by the fact that you are more likely to have a relapse of your bipolar disorder after stopping lithium treatment than you were before you started it (5). Thus all the placebo controlled trials of long-term lithium treatment are confounded by lithium-discontinuation induced relapse in the placebo group.

Lithium therapy was described by a psychiatrist in the 1960s as ‘the treatment of manic patients by lithium poisoning’ (6). As well as acute toxicity, long-term use frequently impairs the thyroid gland and inevitably damages the kidneys to a greater or lesser extent. Lithium’s brain-dampening effects are usually experienced as unpleasant, and there are safer sedatives if this is the desired effect.

Comparing relapse rates in recent trials and follow-up studies with those found in the first half of the 20th century suggests that modern drug treatment such as lithium and antipsychotics has not improved the prognosis of manic depression or bipolar disorder, and may even have made it worse (7).

NICE missed its opportunity to take a more critical view of the evidence, and stem the diagnostic creep that is spreading drugs that are certainly toxic and probably ineffective to ever greater sections of the population.

References:

(1) Healy D. Mania: a short history of bipolar disorder. Baltimore, MD: John Hopkins University Press; 2008.
(2) National Institute for Health and Care Excellence. Bipolar Disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care. NICE clinical guideline 185. London: National Institute of Health and Care Excellence; 2014.
(3) Royal College of Psychiatrists. Information leaflet on Bipolar Disorder. 2013 http://www.rcpsych.ac.uk/expertadvice/problems/bipolardisorder/bipolardi...
(4) Moncrieff J. The medicalization of "ups and downs": The marketing of the new bipolar disorder. Transcult Psychiatry 2014; 51: 581-598 http://tps.sagepub.com/content/51/4/581.full.pdf+html
(5) Suppes T, Baldessarini RJ, Faedda GL, Tohen M. Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Arch Gen Psychiatry 1991; 48(12):1082-8.
(6) Wikler A. The Relation of Psychiatry to Pharmacology. Baltimore: Williams & Wilkins Co; 1957.
(7) Moncrieff J. The Bitterest Pills: the troubling story of antipsychotic drugs. 2013. London: Palgrave Macmillan.

Competing interests: No competing interests

29 September 2014
Joanna Moncrieff
Senior Lecturer and Consultant Psychiatrist
UCL
Charles Bell House, Riding House street, London W1W 7EJ