Maggie's Farm

Some random observations on a subject with which I probably have too much experience as a family member and friend to be dispassionate about....

IMHO the increased diagnosis of bipolar in recent years may reflect an increase in symptoms by members of families prone to this disorder as everyday life becomes less ordered, less predictable, and a higher premium is placed on conformity and social skills for career success. It's a disorder that can be helped by structure, predictability, nurture (no matter how much the stereotypical and rather rare manic may rail against these things as boring).

In other words, time was when hyper Junior could be set to ploughing the back 40, hewing wood, hunting, milking cows, etc. and mood cycles might be both regulated and/or less troublesome than say, on a trading floor where he may sell a lot, and be a whiz at cold calls but mauy crash and burn when it comes to schmoozing with loathsome supervisors and rivals. Then think of military service today: a Viking berserker was valued a thousand years ago, but would be useless in a modern army, where discipline, technical savvy, as well as courage, etc. are now essential.

But to return to my hunch (which may be a bunch of malarkey) I believe that more people in families prone to bipolar disorder are getting out of whack these days, because family life, work life, social life, etc. are less stable. I am not romanticising the "good old days." Perhaps people who are better nourished, less ravaged by physical disease, who are less exhausted by a daily struggle to survive (as, say, medieval peasants were) have the time and energy to become aware of mood disorders. In a grim time when death and disease stalked one, depression or even mania probably seemed less serious than the plague or starvation.

We all know that modern life is way more stiimulating that building stone walls on a New Hampshire farm and digging out potatoes....To take one more example: think of an old style classroom, bare walls except for a president or two, map of the US and the blackboard and clock. Silent except for the drone of the teacher and dutiful answers of called upon students. Now? Pictures, projects, dangling mobiles, sound effects from the computer, bickering over group projects, the gurgle of the fish tank,etc. A blooming, buzzing confusion. If a child were at all prone to anything---whether ADHD or bipolar or just normal fidgets---they would be distracted, made restless by a modern classroom.

But the stigma of a diagnosis is never going to go away, and that is my beef with all these kids getting labelled. One boy I know well wants to serve in the Army, but sadly reflects that "They will never want me because I have been on meds."

The one advantage to a greater focus on childhood bipolar is that many parents and penny-pinching HMOs were far too quick in recent years to dose kids hastily labelled ADHD with stimulant medication. Partly this was simple denial. ADHD not unduly threatening as a diagnosis. But some studies have suggested that as many as half the kids labelled ADHD are actually bipolar, and that being dosed with stimulant meds worsens bipolar disorder, can bring on mania and psychosis prematurely in the genetically susceptible.

If you consider that it is cheaper to send a fidgetty , raging, out of control kid to a regular pediatrician for a five minute visit and put him on Ritalin, than to have him evaluated by a psychiatrist who might even (gasp!) suggest a trial of therapy and behavior and environmental changes to see if things improve, you can imagine that many, many kids in the last 15 years or so have been put on stimulants who should not have been. And so we could be seeing a rash of medication induced manias. Not that the meds turn someone bipolar who doesn't have it somewhere in the family tree, but that they can hasten the worsening of symptoms.

I have seen it at first hand in several misdiagnosed children.

But probably even more common, and perhaps the reason for the overdiagnosis of bipolar in women, is the ever wider prescription of SSRIs for depression. These drugs have lifted millions out of despair, and I have no use for jackasses like certain celebrities who urge the depressed to tough it out. But certainly there are those (usually with a bipolar family background) whose unmedicated symptoms are mostly depressive, who are moved into agitation, aggression, hypomania by being prescribed SSRIs by a doctor who wants only to alleviate the abject misery of a desperately depressed female. Many more women present as depressed, and admit to being depressed, so many more women are prescribed SSRIs, and at least some of these women will go on to be diagnosed bipolar. Could this be part of the reason for more women being diagnosed bipolar recently? Also, it is possible that many of the women are simply being labelled bipolar who actually have personality disorders, but that health insurance reimbursement policies rather than clinical judgment may be driving what their doctors are writing down on the forms. You have a patient who needs care, you will give them whatever label will get that care paid for by an insurance company that may reimburse for bipolar but not for personality disorders.

Also, there is the whole phenomenon of diagnosis following a response to medication. Not so long ago, clinical texts used to assert that a favorable response to lithium was by definition diagnostic of bipolar. These days, shrinks will try whatever med might work on a give patient, and the various ones work on a variety of disorders. But there is still the presumption that if someone is on a mood stabilizer , that diagnoses them bipolar.

Too much close contact with this. Enough of my opinions....

Hi, Apple Pie! I do sympathize! I could tell you a tale or six about rotten marriage counselors, but will spare the gory details!

I know several admirable social workers socially who are good counselors, but IMHO that is because they have the brains that, had circumstances been different, they could have become doctors. The ones I know chose the shorter route knowing that they wanted to be full time mothers when they had a family.

Americans have the best medical care in the world IF: 1) They can afford to pay for their own choice of a professional and/or 1a) They have the luck to find and character to listen to a doctor who will tell them what they need to hear,not just want they want to hear, and/or 2) (if not billionaires) they can figure out how to get their insurance to help pay for it and/or 3) their psychologist or psychiatrist can afford to give them a break on fees (hard, given the insurance bite most of these take themselves these days).

The ONLY family members who have recovered or stayed in remission from illness have been those who have negotiated the above maze and got extremely expensive professional care on an ongoing basis. Send one of em in to see an MSW or in for a cookbook cognitive behavioral course of therapy and a WTF is about all the reaction one gets. Apologies to those non-doctors who do better than the ones my family has had to deal with, and been let down by. I know there are exceptions.

Of course, we joke that the Addans family look normal to us,so perhaps we are a tad more obnoxious and difficult to deal with than most salt of the earth Americans.....