Bipolar Revisited

Will The Real Bipolar Please Stand Up 

One of my favorite game shows during my formative years was To Tell The Truth, hosted by Garry Moore. The show consisted of a panel of celebrities...Remember Kitty Carlisle, Peggy Cass, Bill Cullen, and Orson Bean? They were all regulars, and definitely brighter than the average Hollywood star today.  Anyway, the show would begin with 3 contestants introducing themselves by the same name.  This was followed by an interesting biographical sketch of that individual.  The challenge for the celebrities was correctly identifying the actual person from the imposters by hurriedly querying the contestants, and then making an educated guess. At the conclusion, Garry Moore would dramatically request, “Will the real ‘so and so’ please stand up.” I found it entertaining because the celebrities would often guess wrong.  Looking back at some of the original clips on You Tube, it’s easy to see why...They simply could not obtain enough information within the unreasonable time frame to form an objective opinion. 

At this point, you’re probably wondering how the heck a game show is relevant to Bipolar Disorder, which is mentioned in the title. Just this…For years, I've pontificated about the over-diagnosis of Bipolar Disorder and the difficulty in disproving this phenomenon.  Who are the misguided calling themselves “Bipolar” and who are the true manic-depressives?  Now this is not to suggest that patients who think of themselves as having Bipolar Disorder are being deceptive.  Rather and more often than not, patients are simply repeating what they’ve been told they have by their doctors or what they’ve read or watched on the internet or TV.

Well, at the APA annual meeting in May of 2008, Dr. Mark Zimmerman, Associate Professor of Psychiatry at Brown University, played a little “to tell the truth” himself.  He presented a study involving 700 adult psychiatric outpatients, about 20% of whom had been diagnosed with Bipolar Disorder.  The patients completed a questionnaire that asked whether they had ever been diagnosed with Bipolar Disorder by a health care professional.  Then they were examined by blinded researchers, using a standardized and comprehensive diagnostic tool called the Structured Clinical Interview for DSM-IV (SCID).  The results of the study suggested that the previous diagnosis of Bipolar Disorder could not be supported by the SCID in 50% of the patients. According to Dr. Zimmerman, the significance of these findings should be obvious...that there are significant dangers in over-diagnosing, including unnecessary exposure to psychotropic medications with potentially harmful side effects as well as stigmatization of being labeled with a lifelong serious mental illness.  The report is from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project, for which Zimmerman is the principal investigator.  Zimmerman said, “The MIDAS project is unique in its integration of research quality diagnostic methods into a community-based outpatient practice affiliated with an academic medical center.”

Asked about Zimmerman’s study, Dr. Michael E. Thase, Professor of Psychiatry at the University of Pittsburgh Medical Center and the Western Psychiatric Institute and Clinic, said that he, too, has seen people diagnosed with Bipolar Disorder who don’t meet the criteria.  “I’m not surprised or shocked by these findings,” Thase said of Zimmerman’s study. After many years of hearing that bipolar is under-diagnosed, he said, “the pendulum has swung the other way.”

Dr. Gary S. Sachs, founder and director of the Bipolar Clinic and Research Program at Massachusetts General Hospital in Boston says that Zimmerman’s study goes to the heart of “a serious issue for our field”: inaccurate diagnoses, arrived at through casual impressions rather than the careful application of formal criteria.  "This is the sacred duty of a caretaker — to make sure they have the diagnosis right,” he said.

While we all know that no litmus test exists for accurate psychiatric diagnosing, Dr. Zimmerman should be commended for his tedious research, which appears to endorse a highly structured and thorough examination of patients subjectively presenting with bipolar identities.  The consequences to patients of being less investigative are much greater than guessing wrong on a game show. 

Scott Zentner