Grossly exaggerated prevalence figures of bipolar depression
By Dr Marcel de Roos (Psychologist PhD, the Netherlands).
A mental disorder like bipolar depression (or for example “ADHD”) is a CONSTRUCT: it’s a definition made up by humans to describe certain symptoms. A heart disease can be identified with the help of blood tests and electrocardiograms. Diabetes is diagnosed by measuring blood glucose levels. But there is no blood test for depression and no x-ray test to measure bipolar disorder.
Bipolar depression is a very serious illness that should be treated with medication. But in my 30 plus years of practicing I have seen how the definition of “bipolar” has changed. More and more people have been included by transforming the definition in the Diagnostic and Statistical Manual of Mental Disorders (DSM) 3, 4 and 5 from dichotomous (yes/no) into “spectrum”, bipolar 1 and 2, and even into “sub-threshold”. Sadly enough they have even tried this with children too.
It’s NOT true that bipolar depression or ADHD “shows itself in subtle ways”; this is a prime example of how some psychiatrists make the mistake of so called reification. Reification is the fallacy of treating an abstraction as if it were a real thing. Bipolar depression is just a definition; there exists no “subtle signs” of it. Only if you change the definition into a broader sense then more people will be included.
Bipolar depression is a very lucrative business for the pharmaceutical industry. It’s any manufacturer’s ultimate fantasy: people are told to buy expensive products (medication) for the rest of their lives. The pharmaceutical industry is an extremely profit seeking and often immoral business where the stakes are high (trillions of dollars). In the stock markets the pharmaceuticals are doing exceptionally well for many years. Constant lobbying of the pharmaceutical industry in the past decades has increased the chance of being labeled as bipolar significantly.
Bipolar depression is a RESIDUAL category. That means that it’s imperative to make a thorough, comprehensive and time consuming assessment of other possible explanations of the symptoms. Psychiatrists have a tendency to go for “symptom hunting” and stop when the symptoms seem to fit in the category of bipolar depression. This is a gross mistake; a false positive diagnosis causes a lot of problems in terms of pointless lifelong heavy medications, strong side effects, having an unnecessary tainted quality of life and high costs.
According to a publication on the website of the American National Institute of Mental
Health the prevalence of bipolar disorder among adults in the USA is 2.6%. It’s very
interesting to have a look at the source of this information. The epidemiologist Ronald
Kessler is head of the World Mental Health Survey Initiative (WMH-survey) for research of the prevalence of psychiatric disorders in the population. The head office of this worldwide project is located at Harvard University where Kessler works as a professor, and it’s a project of the World Health Organisation. But most of the researchers are sponsored by the pharmaceutical industry.
Kessler himself works with Shire, GlaxoSmithKline, Lilly, Pfizer, Sanofi-Aventis, and other pharmaceuticals. This is mentioned only once in his many publications. His views regarding the focus of his research are not very neutral as is shown in an article in Nature (456, 7223, 702-705) about cognitive enhancing drugs. This is relevant because much decision making is needed for research of the prevalence of disorders in the population. There is a choice of classification systems (DSM5 or ICD10) and the design of the measurement instruments to determine if somebody meets the criteria for that particular psychiatric category. Subsequently a decision must be made about what kind of people will be examined, how much of them and in which setting the testing will take place. After all of these choices, the results need interpretation too. Because research groups take different decisions in all of these phases, the figures regarding the prevalence of for example bipolar depression and ADHD differ enormously.
The WMH-survey didn’t follow the DSM classification system’s restriction that the diagnosis bipolar depression can only be made after an extensive assessment by a psychiatrist/psychologist regarding the life of every individual patient, including interviewing the family and the social environment. Contrary to this, the survey was done by merely laymen who only had received an interview training. They asked the participants questions which are a far cry from what is meant by bipolar depression. The participants were of course volunteers, but this can cause a non-representative selection of people who already think in medical terms about themselves.
But most and for all, the symptoms in this survey that have been gathered, can NOT directly be translated into bipolar depression. They need further interpretation from a professional in a proper (lengthy) interview to assess if there is no alternative explanation. In my own psychology practice the majority of the clients who have been “diagnosed” before as being bipolar turn out to be NOT bipolar after a comprehensive (30 – 60 minutes) interview about their STORY and not just the symptoms. When the story explains in a valid alternative way the symptoms then there is of course NO bipolar depression. For example gambling, a bit of manic behaviour and depression can be explained by a lack of meaning in life; or a period of stress can cause all kinds of symptoms.
All these considerations make the prevalence figure of 2.6% for bipolar depression extremely questionable. The disturbing fact is that this and other prevalence figures from the WMH-survey (e.g. for ADHD) pop up in many policy papers. Psychiatrists are compelled to believe that these are “correct” prevalence figures; they translate these percentages to their own country and subsequently try to label more people with bipolar depression and other disorders.
N.B: A big thanks to the Dutch Professor Dr G.C.G. Dehue whose book “Betere mensen” was an inspiration to write this article. I have quoted freely from her critique on the WMH-survey.