The forces behind mood disorders

Psychiatry has a PR problem. It seems that every week or so, an article or a book comes out revealing how yet another top academic has accepted drug company money, creating the impression in the public’s mind that all psychiatrists are on the payroll. For more than two decades, Dr. David Healy, a professor of psychiatry, has been telling us what is wrong with psychiatry and in the process taking a lot of heat. His books include Let Them Eat Prozac, The Antidepressant Era, and The Creation of Psychopharmacology. Healy argues that academia’s role has changed radically as a beacon of sober analysis in the face of frivolous claims and trends, as research and clinical care is increasingly dominated by pharmaceutical interests and market-driven imperatives.

Mania looks at historical and contemporaneous forces shaping the construction of mood disorders in general, the bipolar brand and the controversial issue of pediatric bipolar disorder. It traces the presentation of serious mood problems across different eras and shows how physicians have historically struggled with similar clinical challenges, recalibrated periodically to technical and professional changes. Even when manic–depressive illness was finally recognized as a type of insanity category in its own right (circular insanity or folie circulaire) in 1854, the condition remained relatively rare in asylums. And the belief that manic depression or bipolar disorder was relatively uncommon remained current up until the early 1960s.

The strongest claim to a continuity between today’s construct of bipolar disorder and earlier classification systems is a link to the turn-of-the-century system proposed by German psychiatrist Emil Kraepelin. A cornerstone of his approach was dividing the major psychoses into those with a progressive deteriorating course and the less disabling intermittent disorders such as manic–depressive illness.

Image courtesy of Johns Hopkins Biographies of Disease

This distinction would later set the stage for the Diagnostic and Statistical Manual (DSM), the hugely popular “bible” of biological psychiatry that has come to dominate classification internationally since the 1980s. Healy explains that “While the ideal type of a manic–depressive patient now seems compelling, it did not seem obvious through the lens of early 20th century clinicians.” Classification systems in psychiatry, rather than being accurate facsimiles of “carving nature at the joints,” reflect in part the idiosyncrasies of their makers, as much then as nowadays.

Why should anyone care about sterile academic debates about dead psychiatrists and ancient nomenclature? If the results were inconsequential then it would not matter. Across time, psychiatrists have invented concepts, whether they were biological treatments or systems of psychotherapy, and defended them rigidly as the only viable truths. This is our imperfect human nature. However with blockbuster drugs garnering billions in revenues for their companies, Healy demonstrates how, over the last 30 to 40 years, commercial interests have come to dominate all aspects of psychiatric practice in journals and conferences under the guise of addressing the mushrooming prevalence rates of DSM-based psychiatric disorders.

Manic–depressive illness, Kraepelin’s own term and with a very precise meaning, was supplanted with bipolar disorder, a concept that lends itself better to diagnostic elasticity as it can include the mood fluctuations of personality disorders; then it was just a short step away to the bipolar teen, the bipolar child and finally the bipolar toddler.

In a doctor’s mind there is a very tight association between diagnosis and treatment. If a mood is perturbed then it makes sense to use a “mood stabilizer.” Or does it? Healy shows that by using branding, companies promote the marketing of certain drugs as necessary “mood stabilizers” creating an aura of specificity, coupled with the need to prevent future hypothetical episodes of illness. Anxious parents and professionals alike are made to feel remiss if they question this withholding of apparently “necessary” treatment. Imperceptibly the older mood stablilizers such as lithium and sodium valproate have been replaced with the improved brand, the atypical antipsychotics, which nonetheless have their own serious side effects.

This book is an excellent exposé of the history of bipolar disorder, but its brevity precludes a more comprehensive treatment of the history of psychopharmacology, a book written by the same author.1 Healy demonstrates that a rigorous analysis of the history of psychiatry is critical to its integration as a science and a humanistically based clinical practice. Forget all the chatter out there about this author: Read him!