Author: Prakash Gangdev
Position: Psychiatrist
Institution: Regional Mental HealthCentre, Lonodn Ontario
E-mail: prakash.gangdev@sjch.london.on.ca
Submitted Date: June 21, 2006
Published Date: June 22, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The explosion of literature on bipolarity parallels the numerous trials on atypical antipsychotics, based on the premise of the DSM (Diagnostic and Statistical Manual of Mental Disorders), and rating scales are specific for mania. The broad claims are that the atypical antipsychotics have mood stabilizing property and are effective in both acute episode and prevention of recurrence of manic episodes.

The US-UK diagnostic study - and to an extent the International Pilot Study of Schizophrenia - revealed that diagnostic practices are variable across nations. Also, the stability of psychiatric diagnoses has been demonstrated to be less than robust by various authors. While DSM was published with the hope of refining the business of diagnosing, this has not been borne out in actual practice. One only has to review the files of 10 patients with long psychiatric history. There is a high likelihood that the diagnosis would have not have remained consistent. Schizophrenia, schizoaffective disorder, and bipolar disorder, and more recently even borderline personailty disorder are the likely candidate diagnoses. A kind of multi-speak pervades clinical psychiatric parlance.

The patient's ethnic background and comorbidities may also further add to the variability of diagnosis and outcome.

In acute inpatient setting, managing the agitation and the clinical risks is often the first priority. It is possible that a patient with acute psychotic episode, unrelated to mood disorder, may be misdiagnosed as having a manic episode and then be prescribed the right medication (antipsychotic) and respond to it. This is likely to lead to an erroneous impression that the manic episode has responded to the antipsychotics. Conversely, a psychotic episode may be misdiagnosed as a manic episode and treated with traditional mood stabilizers without success, leading to an erroneous impression about their efficacy.

Psychotic symptoms in the context of a manic episode respond to antipsychotics. Conversely, it is possible that the appropriate affective response to hallucinations may be misdiagnosed as a manic episode. For example, patients with schizophrenia experiencing derogatory hallucinations feel angry or sad, and display behaviors (aggression, withdrawal ) in keeping with their experiences. There is no rule that says that patients with schizophrenia cannot experience pleasant hallucinations. In this scenario, patients may present as happy and cheerful in the context of their hallucinations, which may be taken as an indication of mania. In both circumstances there are neuroleptic responsive symptoms and if these symptoms are attributed to mania, antipsychotics will falsely acquire an anti-manic reputation. It is possible that in the former, while the psychotic symptoms and physical agitation lessen due to antipsychotic and nonspecific sedative effects, the core features of mania may continue unabated without a traditional mood stabilizer.

Cyclicity in bipolar disorder and efficacy for prophylaxis of
bipolar disorder is recognized as a cyclic disorder, with a variable cycle length and frequency of mood episodes. Most of the atypical antipsychotic trials in bipolar disorder compare them with lithium, run for up to 12 months, report on relapse/recurrence rates and take that as evidence of prophylactic efficacy. Taking the absence of recurrence/relapse as proof of the efficacy of the medication is questionable as it discounts the possibility that during the trial period the manic cycle could have gotten over and another episode may have been destined to occur at some unspecified date after the trial period.

Randomized controlled trials help us do the thing right, but doing the right thing is a separate and more crucial matter. It will be an immense advance if the core disturbance in mania is defined first, so as to assist the clinician to accurately diagnose a manic episode and appropriate research measures to test the prophylactablity of 'mood stabilizing medications' are developed.