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Response to other letters

Posted by plosmedicine on 30 Mar 2009 at 23:56 GMT

Author: Nassir Ghaemi
Position: Psychiatrist
Institution: Emory University
Submitted Date: June 28, 2006
Published Date: June 29, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

I wish to provide some feedback to two other letters. Ms. Ryan notes that she had not responded well to antidepressants and doctors were not willing to stop them; when she did so, she felt better. Part of the rationale for the bipolar spectrum concept is to provide a context for stopping antidepressants, if bipolar illness is diagnosable. Now there are risks, including overdiagnosis of bipolar disorder, as Dr. Healy points out. But a shoddy approach to making a diagnosis does not invalidate the veracity of the diagnosis, as he also allows.

I think if someone has severe recurrent major depressive episodes, that are bona fide and problematic, and they fail to respond to antidepressants, then indeed a search for alternate diagnoses should be made, with bipolar disorder being an important one. It would be a shame if fears of bipolar overdiagnosis, which are not empirically supported yet, should lead us to avoid any treatment for severe recurrent depression in persons who indeed may have a bipolar spectrum condition. It is up to researchers to validate this concept empirically, and it is up to clinicians to apply it responsibly.

While potential misuse through pharmaceutical marketing should be acknowledged and guarded against, I simply do not think the bipolar spectrum concept should be rejected out of hand before sufficient scientific research is conducted to assess its validity. On the other hand, some individuals may not have clear recurrent major depressive episodes; the use of antidepressants for milder depressive and anxiety symptoms raises another series of questions which Dr Healy has addressed in his book The Antidepressant Era. In those cases, stopping antidepressants without replacing them with other medications, or never even using antidepressants in the first place, might be viable options.

The relevance of research that suggests good efficacy with some psychotherapies, such as cognitive behavioral therapy, in that context also should not be ignored. As I have described in my book The Concepts of Psychiatry, there are no simple answers here; it is not correct to view all these depressive presentations as disease-entities needing medication treatment, nor is it correct to say that none are. A pluralistic approach needs to tease out when disease is present, and when symptoms are due to social or other factors.

Regarding Ms. Liversidge's tragedy, I agree that there is risk in giving up agents which are well proven to be effective as mood stabilizers, such as lithium, in place of agents that are hardly proven in that role, like antipsychotics. Indeed, I agree that a great deal of marketing, by pharmaceutical companies, of quite limited data has led to confusion on the part of psychiatrists.

As I have written in journal articles, the evidence for long-term maintenance efficacy with antipsychotics is quite thin and hardly compares with lithium. This is why I have stressed the need for better defining what we mean by the term mood stabilizer. I and others have argued that prophylaxis should be part of, if not the whole of, the definition. Prophylaxis needs to be established much more stringently than is commonly accepted these days; on that point, I would agree with Dr Healy. Then we could better show how lithium (and probably some of the anticonvulsants) are much better established as mood stabilizers than the antipsychotics. However, I feel that giving up the whole concept of "mood stabilizer" is not necessary, that it predates pharmaceutical marketing for bipolar disorder, and that it can be used responsibly if we researchers reach consensus on it and if clinicians are educated about it. Ms. Liversidge's sad experience shows us how important it is to address this topic. She should know that some researchers have been making efforts in this regard but obviously more needs to be done.

Competing interests declared: previously stated