Psychiatrist David Healy is the author of over 120 articles and 14 books, including Mania: A short history of Bipolar Disorder.
In the mid-1990s, you note, roughly half of all mood disorders were redefined as bipolar disorder rather than depression. What do you think accounts for that dramatic shift in perspective?
The key event in the mid-1990s that led to the change in perspective was the marketing of Depakote by Abbott as a mood stabilizer. Before that, the concept of mood stabilization didn't exist. And while in a popular TV series we can accept that Buffy the Vampire Slayer gets a new sister in Season Five that she had all the time but we didn’t know about, we don’t expect this to happen in academia.
The introduction of mood stabilization by Abbott and other companies who jumped on the bandwagon to market anticonvulsants and antipsychotics was in fact quite comparable to Buffy getting a new sister. Mood stabilization didn’t exist before the mid-1990s. It can’t be found in any of the earlier reference books and journals. Since then, however, we now have sections for mood stabilizers in all the books on psychotropic drugs, and over a hundred articles per year featuring mood stabilization in their titles.
In the same way, Abbott and other companies such as Lilly marketing Zyprexa for bipolar disorder have re-engineered manic-depressive illness. While the term bipolar disorder was there since 1980, manic-depressionwas the term that was still more commonly used until the mid-1990s when it vanishes and is replaced by bipolar disorder. Nowadays, over 500 articles per year feature bipolar disorder in their titles.
You just have to look at Lilly’s marketing of Donna from the Zyprexa documents on the Internet to see what is going on here: "Donna is a single mom, in her mid-30s, appearing in your office in drab clothing and seeming somewhat ill at ease. Her chief complaint is 'I feel so anxious and irritable lately.' Today she says she has been sleeping more than usual and has trouble concentrating at work and at home. However, several appointments earlier she was talkative, elated, and reported little need for sleep. You have treated her with various medications including antidepressants with little success. . . You will be able to assure Donna that Zyprexa is safe and that it will help relieve the symptoms she is struggling with."
Donna could have featured in ads for tranquilizers from the 1960s to the 80s, or for antidepressants in the 1990s, and would have probably been more likely to respond to either of these treatment groups than to an antipsychotic, and less likely to be harmed by them than by an antipsychotic. What company marketers are so good at doing is framing the common symptoms people have—we almost all have—in a manner most likely to lead to a prescription for the remedy of the day. It flies in the face of a century of psychiatric thinking to see conditions that patients like Donna have as bipolar disorder. But while a century of psychiatric thinking used to count for something, it doesn't any longer.
Between 1996-2001, you explain, there was a fivefold increase in the use of antipsychotics (Zyprexa, Risperdal, Abilify, Seroquel, and others) in preschoolers and preteens. What role did DSM-IVplay in that, with its introduction of the still-controversial category Bipolar II disorder?
The concept of juvenile bipolar disorder flies even more in the face of traditional wisdom in psychiatry than does calling Donna bipolar. As of 2008, upwards of a million children in the United States—in many cases preschoolers—are on "mood-stabilizers" for bipolar disorder, even though the condition remains unrecognized in the rest of the world.
I am not sure how much DSM-IV played a role in this switch. I think the companies would have found a way to engineer the switch even without the introduction of Bipolar II disorder in DSM-IV.
So then how much of that shift is attributable to SSRI antidepressants coming off patent while the antipsychotics were still major revenue earners?
I think this was in fact central to what happened. The antidepressants were due to come off patent whereas the anticonvulsants were older drugs that could be repatented for this purpose, and the antipsychotics—which also could be (and were) marketed as mood stabilizers—were early in their patent life.
A related point that’s worth bringing out is that the switch happened because companies weren't able to make new and more effective antidepressants. Had they been able to do so, I think they would have probably stuck with the depression model rather than made the switch to bipolar disorder.
In terms of what is happening in the US, I think we have to look at how skillfully the drug companies have exploited doctors. Doctors have wanted to help. While the drugs are available on prescription only, doctors tend to see giving a medicine as the way to go, where previously they had been much more skeptical about the benefits of drug treatments.
The drug companies have engineered a situation in which academics have become the primary spokespeople for the drugs. We see the sales rep in the corner and think we can easily resist his or her charms—but we still let them pick up the drinks tab. But it's the academics who sell the drugs. Doctors who think they are uninfluenced by company marketing listen to the voices of academic psychiatrists when these, in the case of the antidepressants or antipsychotics given to children, have talked about the data from controlled trials, and by doing so have been witting or unwitting mouthpieces for company marketing departments.