NICE Guidelines for Bipolar Disorder- a Missed Opportunity

Joanna Moncrieff, MD
22
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There are some things to applaud about the recently released update of the NICE bipolar guidelines1,2, 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 (one group of researchers suggested that 5% of the population have bipolar 1 and 11% bipolar 2)3,4, classical bipolar disorder (the sort that used to be called ‘manic depression’) probably affects more in the region of 1 in 1000 than 1 in 1005. 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, 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 months6. 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’7.

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 for 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 it8,9. Studies of long-term lithium treatment consist of taking some people off lithium (or other long-term sedative drugs) and putting them on to a placebo. The fact that most (although not all) of these studies find higher rates of relapse among those on placebo cannot be taken to indicate the effectiveness of lithium, however, since it may simply demonstrate the risks of coming off lithium. Whether going on lithium in the first place has any benefit has never been established.

Lithium therapy was described by a psychiatrist in the 1960s as ‘the treatment of manic patients by lithium poisoning’10. 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 unpleasant11, 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 20thcentury 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 worse12.

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.

* * * * *

This article first appeared on Joanna Moncrieff’s personal blog.


UNE Center for Global Humanities and its founding director, Anouar Majid, host Joanna Moncrieff on “The Myth of the Chemical Cure: The Politics of Psychiatric Drug Treatment.”
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Interview with Joanna Moncrieff, author of “The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment”


References:

(1) 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 http://www.nice.org.uk/Guidance/CG185.

(2) Kendall T, Morriss R, Mayo-Wilson E, Marcus E. Assessment and management of bipolar disorder: summary of updated NICE guidance. BMJ 2014;349:g5673 http://www.bmj.com/content/349/bmj.g5673.

(3) Angst J. The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord 1998 Sep;50(2-3):143-51.

(4) Angst J, Gamma A, Benazzi F, Ajdacic V, Eich D, Rossler W. Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003 Jan;73(1-2):133-46.

(5) Healy D. Mania: a short history of bipolar disorder. Baltimore, MD: John Hopkins University Press; 2008.

(6) Royal College of Psychiatrists. Information leaflet on Bipolar Disorder. 2013 http://www.rcpsych.ac.uk/expertadvice/problems/bipolardisorder/bipolardisorder.aspx

(7) 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

(8) Suppes T, Baldessarini RJ, Faedda GL, Tohen M. Risk of recurrence following discontinuation of lithium treatment in bipolar disorder. Arch Gen Psychiatry 1991 Dec;48(12):1082-8.

(9) Baldessarini RJ, Tondo L, Viguera AC. Discontinuing lithium maintenance treatment in bipolar disorders: risks and implications. Bipolar Disord 1999 Sep;1(1):17-24.

(10) Wikler A. The Relation of Psychiatry to Pharmacology. Baltimore: Williams & Wilkins Co; 1957.

(11) Judd LL, Hubbard B, Janowsky DS, Huey LY, Attewell PA. The effect of lithium carbonate on affect, mood, and personality of normal subjects. Arch Gen Psychiatry 1977 Mar;34(3):346-51.

(12) Moncrieff J. The Bitterest Pills. 2013 London: Palgrave http://www.palgrave.com/page/detail/the-bitterest-pills-joanna-moncrieff/?K=9781137277428

 

22 COMMENTS

  1. I was on Lithium for about 15 years and had a full and productive life, gainfully employed, getting BS and MA, healthy marriage, no disability. Still, it led to a lot of problems, and especially, it kicked off panic attacks (adrenaline surges), which led to dual diagnoses and more meds.

    When I finally got off the Lithium (along with other meds that had piled up), I was able to recover, heal, and get on with things. No Lithium, no meds of any kind, no panic anything, no bipolar. Grounded, clear-headed. Hard to analyze, but that’s how it went. My uncle died from kidney failure, after taking Lithium for 20 years.

    That’s my experience with it.

    • A Missed Opportunity
      I consumed Lithium in the early 1980’s. I was put on this drug for no special reason, it was one of a cocktail. When I stopped the Lithium I went straight ‘up’. The ‘high’ did level off eventually, but this shows that Lithium itself can cause the mood swings.

      When I came off strong drugs, I went to see professionals and asked if they could help.

      One Psychologist told me when she was young, about 19 or 20 she was out in the rain, and suddenly it stopped and the sky opened and the sun shone through. So when she went home she asked her flatmate to enter in her diary exactly 9 months from the day. She felt sure she might have been visited by the Holy Spirit. She said “You see – I had no defense against irrational thought”. – What she meant was that she thought she could help.

  2. Hello,

    David Moyer, LCSW is an example of a fine, caring person. He is author of Four Generation Bipolar Odyssey about the learning quest he embarked on, presented with his son Chris’ sudden life-derailing Bipolar disorder.

    David Moyer “I Knew Little” http://www.youtube.com/watch?v=kY3fuiRMZc8

    David Moyer http://beyondmentalillness.us/about

    “This site is about my family’s struggle to ensure that various biological disorders that affect my son and others like him are identified and treated as effectively as possible. This site is about moving beyond mental illness by changing the assessment and treatment paradigm. Psychotropic medications should be the last alternative saved for those cases where exhaustive diagnostic procedures have failed to identify treatable biological markers. ”

    Natasha Campbell-McBride, M.D. Neurologist is a remarkable speaker with new information on how people are becoming progressively sicker (multi-generationally).

    She speaks here at Weston Price Foundation. Price wrote the outstanding, seminal “Nutrition and Physical Degeneration.”

    The point to emphasis here (at commentary on diagnosis and Bipolar) is not the marijuana actually being a precipitant to a break down. That is secondary information in her very in depth presentation. We have always known hallucinogens like cannabis and LSD can cause trouble. It is everything else Natasha states – the people do not get treated for the ongoing Medical problems they do have as children – which have a number of contributing harms accounting for them Then, once they go from struggling along, over the years, the best they can, to having a destinct breakdown – then, these unfortunate youngsters, again, still do not receive the needed help from the Medical profession, instead have an ersatz “psychiatric diagnosis” (psychosis, schizophrenia, Bipolar…) applied, and are given powerful drugs – a slippery slope to a sentence of lifetime debilitation – once the “Psychiatric” label and the powerful drugs are inflicted on such already Medically struggling youngsters.

    This again shows the need for responsible current state-of-the art differential diagnosis in Medicine.

    Psychiatry is particularly in the hands of those who rig the system. DSM3 through 5 allow descriptive category labeling to represent “Psychiatric diagnosis”, and stating the catch phrase “we are employing the Medical model” they preceed to give polypharmacy with patent drugging chemicals as current, official “Psychiatric treatment.” Very lucrative con for certain players.

    Gut Psychology Syndrome GAPS Talk by Natasha Campbell-McBride

    2011 Presentation – https://www.youtube.com/watch?v=hp90DngfBwc

    50:10

    “A precious time wasted when the child could have been treated”

    “Which means that those toxins had enough time to bombard the brain. and to cause organic damage in the brain.”

    “When we do scanning — there’s a very sophisticated scan called PET Scan — when we do PET Scan on severely autistic children of the age of 3 to 5, we find perfectly normal brain.”

    “These children are born with perfectly normal brains.”

    “But when we do the same scan

    “To reverse this is much harder.”

    “When these children grow up — GAPS doesn’t disappear, unless it hasn’t been treated.”

    “And, then they get to teenage years, and the young adulthood — and substance abuse is one of the venues these children usually take.”

    “I’m sure you all know teenagers who go to parties, smoke cannabis, and they’re fine.”

    “But these are GAPS children. They’re vulnerable.”

    “Cannabis can start a psychotic episode, in these children, and that then leads to diagnosis of schizophrenia, being sectioned, being put on very potent medication – and that’s a slippery slide – for the rest of your life.”

    “Once you get hooked on those medications, it is very difficult to get off those things.”

    Label and drug as supported by the drug company and investors is poor practice. People need thorough differential diagnosis, and valid restorative (typically multimodal) treatment and information. Label and drug is fast and lucrative. Vincent Bellonzi, O.D. with PsycheTruth makes some excellent videos commenting on the current conditions in Medicine.

    As most readers here at Mad in America are well aware, label and drug, in Medicine today, is not the result of people wanting the easy fix, or of Doctors being lazy. That’s ‘transferring the blame.’

    Powerful political forces are at work. The news revelations over the last decade on Harvard’s pediatric Psychiatry department leadership’s actions being of key relevance.

    Harvard “Veritas”
    https://www.google.com/?gws_rd=ssl#q=Harvard+pediatric+psychiatry++Biederman++pringle+OR+sharav+OR+whitaker+OR+boring

    “When you’re not well you go the doctor who takes a history of your symptoms. Based on these symptoms, you are assigned a name for a disease. With this diagnosis, a therapy or procedure is prescribed or, more likely, a drug is prescribed to suppress the symptoms. Nosology is the classification and naming of disease.”

    Functional Medicine
    http://www.youtube.com/watch?v=qeq6xRU2ASQ

    Functional vs. Mainstream Medicine
    http://www.youtube.com/watch?v=99INrbeiCwA

    S.P. Mahadik when people go psychotic use an antioxidant cocktail then, immediately, because oxidative harm is probably happening at or before first onset, and such a simple obvious non-harmful move may affect longterm prognosis.
    http://www.ncbi.nlm.nih.gov/pubmed/11370992

    Nutrition and Physical Degeneration by Weston A. Price
    http://gutenberg.net.au/ebooks02/0200251h.html

    Book Review “In the country of the blind the one-eyed man is king.”
    http://www.soilandhealth.org/02/0203cat/020305ppnf/ppnf.html

    Daniel Burdick, Springfield Eugene Antipsychiatry

    Eugene Oregon, USA

  3. Thank you, Dr. Moncrieff for speaking out against the massive increases in “bipolar” diagnoses, especially in children in the US, and for trying to prevent such in the UK. And, since I know from personal experience, and Robert Whitaker was kind enough to to point out, most of the “bipolar” diagnoses are actually misdiagnoses (according to the DSM), largely thanks to Dr. Joeseph Biederman, of the adverse effects and withdrawal effects of antidepressants and ADHD drugs.

    As a mom on the front lines in the US, whose spent nine years researching the psychopharmaceutical industries, I’m personally heartbroken and disgusted by what the psychiatric industry is doing in my country.

    Please do what you can, as a “professional,” to prevent more iatrogenic harm from happening worldwide. Since, the US psychiatric community claims, according to my medical records, that moms are “irrelevant to reality,” “w/o work, content, and talent” and “unemployed” … oh, and our lives are a “credible fictional story.”

    I don’t personally agree it’s “proper medical care” to create iatrogenic illnesses, especially in children, for profit. And believe that’s what anything over a .05% of the population occurrence of bipolar / manic depressive illness is.

  4. ” most (although not all) of these studies find higher rates of relapse among those on placebo cannot be taken to indicate the effectiveness of lithium, however, since it may simply demonstrate the risks of coming off lithium. Whether going on lithium in the first place has any benefit has never been established.”

    Never been established – a dangerous treatment which is practically forced on people whose effectiveness has never been established.

    At this point I question whether Dr’s, or rather psychiatrists, have any credance left

  5. Lithium was “discovered” as a psychiatric agent after it was noticed, subsequent to another study, that it made guinea pigs sedate, but not drooling and lethargic like phenothiazines make people. So voila! Those inpatient units looked so much nicer without the overt zombies!

    Something I remember from my college days.

    • You’re right.
      And that’s not all… It takes out the thyroid and the kidney for many folks….
      When taken in conventional psychiatric doses of 900 – 1,200 mg per day.

      In SMALL doses at 5-20 mg per day (no more than 100), this naturally occurring mineral seems to show benefit – particularly with alcoholism, emotional health, ie, anxiety, depression, moods. Most recently, studies indicate benefits for alzheimers.

      http://www.livestrong.com/article/316987-lithium-aspartate-vs-lithium-orotate/

      I’ve been taking small amounts for 6 years, with no side effects, other than better overall well-being.

      Be well,

      Duane Sherry, MS, Retired Counselor
      discoverandrecover.wordpress.com

    • Oldhead
      In 1980 in the Maudsley Hospital (/Kings College) I could not believe the amount of completely normal young people wandering around the place describing themselves as ‘Bi Polar’ and ‘Schizoprenic’.

      But several years later when I tried to withdraw from strong drugs I near enough believed I was myself. If I had not withdrawn from the drugs I would have remained chronically psychiatric.

      I would say that about 1 person per 1000 might be genuinely ‘schizophrenic’, the same as genuinely ‘Manic Depressive’.

      • “I would say that about 1 person per 1000 might be genuinely ‘schizophrenic’, the same as genuinely ‘Manic Depressive’.”

        Fiachra,

        Question: Why would you say that?

        Why?

        What would it be, to be “genuinely ‘schizophrenic'” or “genuinely ‘Manic Depressive'”?

        At what point is anyone’s life (or presumed life-condition) genuinely well-described by either of those labels (“schizophrenic” and “Manic Depressive”)?

        In my many years of considering them (and also the label “bipolar disorder,” which many people use interchangeably, with “Manic Depressive), I’ve never been able to view them as anything better than extremely blunt instruments.

        The divisions between the phenomena that they are supposed to suggest are vague (hence, there is the nearly all-purpose cross-over label, “schizoaffective disorder”).

        I have found not the least bit of credible, scientific evidence, which could lead me to conclude that there is a ‘genuine’ version of any of these supposed “mental illnesses.”

        I sincerely wonder why you or anyone else (including Dr Moncrieff, whose work I generally admire) who is (as you really obviously are) so basically well-informed on these issues, winds up concluding that such nosology is at all credible or positively meaningful.

        Respectfully,

        Jonah

        P.S. — In relation to my expressed questions and concerns, please, when you have a moment, consider the brief ‘Argument’ and ‘Conclusion’ of a paper titled “Psychiatric diagnoses are not mental processes: Wittgenstein on conceptual confusion” (2012) by coauthors Rosenman and Nasti — via the following link:

        http://www.ncbi.nlm.nih.gov/pubmed/22528975

  6. I love Joanna Moncrieff, she is a sincere warrior for justice. Many are deeply grateful for her work.

    However, I have to take issue with the title of this article. I do not believe that any of the policies, procedures and guidelines which come into being happen by chance and are “missed opportunities”, but rather, that they are deliberately corrupt and harmful stances, based on clearly predetermined vested interests and agendas.

    Nothing is opportune or happening by chance here. The drug companies are firmly in bed and in cahoots with the professional bodies, with many doctors and with the bodies who draw up the guidelines, as well as with the “healthcare” systems and the politicians. They all work together, all form part of a corrupt and sinister Orwellian system.

    Loren Mosher highlighted the corruption in psychiatry in his letter of resignation from the APA in 1998: http://www.moshersoteria.com/articles/resignation-from-apa/
    Nothing has really changed since then. If anything, things have got worse.

    The creeping corruption has spread its materialistic tentacles, with increasing influence and speed. The plan – to invade our healthcare systems internationally, with a view to complete domination, colonisation and control, to such an extent that evidence based medicine is broken: http://www.bmj.com/content/348/bmj.g22

    Health care is not about people and health, but about profit, greed, social control and corruption. Some argue that it is also about the infliction of harm, illness and depopulation.

    Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Health Care
    https://www.madinamerica.com/2013/09/deadly-medicines-organised-crime-big-pharma-corrupted-health-care/

    Drug Companies & Doctors: A Story of Corruption: http://www.nybooks.com/articles/archives/2009/jan/15/drug-companies-doctorsa-story-of-corruption/

    Thankfully, in the midst of this sad devastation, ongoing corruption, harmful practice and injustice, people like Joanna and the Council for Evidence Based Psychiatry continue to speak out for truth, justice, health and human rights.

    However, the questions remain – precisely how and by what means are things really going to change? Those with the vested interests and the hidden agendas will not want to give up their power, money and control willingly. Will change come about when enough people finally wake up and realise that we have all been conned, when the groundswell of opinion finally shifts… I would be very interested to hear Joanna’s views about this.