Bipolar Mood Disorder (BMD), is a serious mental illness characterised by extreme shifts in mood, energy and functioning. Approximately 1% of the population is diagnosed with Bipolar 1 and up to 6% with bipolar spectrum disorder of which bipolar II is one.
Is it true that BMD is overdiagnosed?
Zane Wilson, founder of SADAG (the South African Depression and Anxiety Group), feels that these claims are unfounded.
“I think a couple of things have contributed to the view of bipolar being 'fashionable',” says Wilson.
“Firstly, it has had a lot more publicity and higher profile, both locally and with international celebrities, so the word, even the name of the illness, has become better known.”
The condition was previously known as “manic depression”. Wilson says that the name change to “bipolar disorder” might also make it easier for people to admit that they have the condition because many people didn’t want to be associated with the term “manic depressive”.
While the possibility exists that bipolar can be misdiagnosed in certain cases, Dr Stefanie van Vuuren, psychiatrist, says that it is incorrect to claim that it is overdiagnosed in South Africa.
“All mood disorders (i.e. unipolar depression and BMD) are in fact underdiagnosed. There are several reasons for the underdiagnosis. Patient factors include not utilising services for reasons such as fear of stigma, and ignorance. When they do utilise these services, symptoms are frequently underreported (confusing what is an “illness” with “I am just like that”). Under-diagnosis also happens because doctors and mental health professionals themselves don’t notice the subtleties of the diagnosis ('you can only see what you are looking for')."
Research has shown that it can take up to 10 years of coping with bipolar symptoms before a person is diagnosed with BMD. Diagnosis in children and adolescents can be even more tricky because bipolar symptoms are easily confused with normal teen behaviour or conditions such as ADHD.
"What people’s perception of the diagnosis is, and what psychiatrists mean by the diagnosis, are not the same. The concept is that there is a certain percentage of patients who present with symptoms of depression, who do better on mood stabilisers (usually used for the treatment of BMD) than on antidepressants. If we look at the group, there are certain clinical characteristics which distinguish them from the more classical depression. We as psychiatrists try to notice and diagnose these subtleties sooner," says Dr van Vuuren.
Dr Pieter Cilliers, Cape Town psychiatrist, also often finds that some depressed patients (especially those who are treatment-resistant) may react more favourably on a treatment regime augmented with medication such as lithium and certain antipsychotics, even though they do not have bipolar. The use of these medications in depressed patients may contribute to the impression that there is an increase in bipolar disorder.
Bipolar disorder also qualifies as a prescribed minimum benefit (PMB), but unipolar depression does not. This means that medical schemes have to cover the costs of treatment for bipolar disorder. It is understandable that some psychiatrists may motivate for depressed patients who are on mood stabilisers to benefit from this.
Bipolar disorder is currently diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The fifth edition is out soon.
"The DSM-V will be out shortly and then the current 'overdiagnosis' debate is likely to become a non-issue," says Dr Cilliers. In the new edition, mood disorders will be viewed according to a spectrum. The DSM-V follows a more dimensional approach as opposed to the categorical approach of the current edition.
State vs private
What further complicates the debate in developing countries such as South Africa, are system problems such as limited access to services, especially in the rural and state sector.
“I don’t think it is underdiagnosed in the state sector and overdiagnosed in the private sector. It is underdiagnosed everywhere,” says Van Vuuren.
She thinks that the possible discrepancy in private vs state diagnoses can be explained by the patient profile serviced.
Rural areas have their own challenges. Due to the lack of mental health professionals in the country, thousands of South Africans do not have access to mental healthcare and many who do, prefer to approach community leaders or traditional healers.
“There is a great need for bipolar awareness in rural communities and townships,” says Lefates Makunyane, senior trainer for SADAG, who has just completed training in rural Mpumalanga where access to mental health practitioners is minimal.
“Many patients, who came forward for individual counselling, have not consulted any medical professional regarding their feelings and symptoms. Some of the reasons included that they felt they could use their own ways to cope as these were perceived as life problems. Some of the causes were related to trauma (such as bereavement, crime, violence and accidents) and others were related to poverty issues.”
More harm than good
Many bipolar patients struggle to come to terms with the diagnosis due to the stigma attached to it. By believing that the condition is overdiagnosed, many patients may feel guilty or “irresponsible” and may even reject treatment.
Today treatment options for BMD have improved hugely, information is available and support groups exist.
“I still don’t believe the patients look for or wish for this diagnosis. It still has stigma, it is still frightening,” says Wilson.
“Our most common problem in our call centre, is from bipolar people who have come off their meds (either because of financial constraints or stigma, or feeling much better). They then of course dip so severely and need help again, and usually have to go back to their psychiatrist.
“Then there are also people in certain industries (music, advertising or writing) who almost embrace their illness because they believe they do their most creative work on a manic high.”
“The greatest danger of underdiagnosis is that patients don’t get the necessary help which will optimally treat their condition. Psychiatric symptoms have an impact on all levels of functioning – i.e. social, interpersonal, academic or career. It deprives patients of the opportunity to reach their full potential,” says Dr van Vuuren.
- Ilse Pauw, Mind Editor, Health24, May 2011
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