Reminiscing on Rapid Cyclers

These posts examine modern psychiatry from a critical point of view. Unfortunately, mainstream psychiatrists usually react badly to any sort of critical analysis of their activities, labelling critics as “anti-psychiatry,” whatever that is. Regardless, criticism is an integral part of any scientific field and psychiatry is no different. As it emerges, there is a lot to be critical about.

If you like what you read, please click the “like” button at the bottom of the text, it helps spread the posts to new readers. If you want to comment, please use the link at the end rather than email me as they get lost and nobody sees them.

****

The American Psychiatric Association’s annual jamboree is on now in San Francisco. Psychiatric Times celebrated with an interview with Prof. David Dunner, the psychiatrist who, 50 years ago, invented the term “rapid cycling” in what was then manic-depressive psychosis, now Bipolar Affective Disorder (BAD). At that time, there was great excitement in the (new) bipolar camp as safer forms of lithium were available, as well as rapid laboratory tests, so there was pressure to put more and more people on it. Soon after, while at the NIMH, he and coworkers published their paper on Bipolar II Disorder, which extended the diagnosis in uncharted new directions. The net effect has been to extend what was once quite a rare diagnosis (about 0.2-0.5% of population) to cover 2-3% of the population, meaning about ten times as many people on drugs. Not long after, the bipolar diagnosis was extended to children, with as much as 8,000% increase in rates of diagnosis.

The interview was titled Rapid Cycling, Lithium, and the Landscape of Bipolar Disorder. The interviewer wanted the old chap to talk about how they came up with the concept of rapid cycling and what has happened since but that wasn’t clear. He was speaking without notes and had obviously given this type of talk hundreds of times, and kept talking more or less without prompting. In the early 1970s, people taking lithium were sent to a “lithium clinic” for their blood tests and prescriptions. I never knew why this was necessary but it meant that big centres had lists hundreds of patients available for research. Gradually, it emerged that people who had rapid swings of mood would not do well on lithium, which is where the drugs called “mood stabilisers” (actually anticonvulsants) found a niche. Their story is bizarre. In the 1960s, a Mr Jack Dreyfus (1913-2009), a very wealthy businessman who developed direct-sale mutual funds, was prescribed phenytoin (Dilantin) by his GP, even though he wasn’t epileptic. Dreyfus was a dreadful person with a truly filthy temper (politely described as “volcanic”) but the drug calmed him. He went on a sort of crusade to publicise it, writing a book and distributing it free to doctors, reputedly at a cost of $70million (about $600million today), and even gave a sample to Richard Nixon. From that, it was a small jump to using anticonvulsants to “treat” episodes of elevated mood. Over the years, anticonvulsants have gradually replaced lithium so that now, they and so-called 2^nd generation antipsychotic drugs are seen as the first line drugs for anybody given the diagnosis. Also, lithium tablets cost nothing to produce (US$2.00 a box in India), which may have something to do with it.

As the drugs have changed over the years, so too Dunner feels the clinical picture of bipolar has changed. Whereas once people in a manic or hypomanic state were elated and grandiose, now they are more likely to be irritable and paranoid. As the interviewer said, “The phenotype has changed” (for readers not familiar with the term, genotype and phenotype are biological expressions. Genotype specifies the actual genetic code in the DNA while phenotype is how it is manifest in life). There was no suggestion as to why this has happened or its significance.

I’m not sure what the interviewer intended from this rambling talk as it wasn’t educational in the usual sense, more an unfocussed reminiscence by an 86yo who really didn’t know anything apart from surveys from long ago and who said what in the various DSM committees over the years. He talked about “the serotonin mechanism and the dopamine mechanism and the noradrenaline mechanism” in depression and how difficult it is to get a drug that matches each one for each patient: “We’re very bad at predicting who’s going to respond to what sort of drug. It’s not clear why that should be” (at 51.20). Psychiatrists, he complained, generally don’t have a plan of management, unlike say oncologists who have different forms of chemotherapy available in case the first one doesn’t work. This produces difficulties as all too often: “Patients fail a whole bunch of drugs” (at 46.00). It’s a “failure of technology,” he said (at 54.10), in that we don’t have adequate genetic tests to work out which type of disorder the patients have and how to target them with the precise drug for that disorder. Treatment in psychiatry defaults to: “Try this, but if it doesn’t work, we’ll try something else.”

At 48.50, he dropped a bombshell but the interviewer didn’t notice: “I don’t believe we know how depression comes about or how our drugs work.” Nonetheless, he was convinced mental disorder is a physical disease of the brain, because (at 52.20) “There’s probably a whole bunch of ways these people become depressed…” in terms of their biochemical mechanisms. Still, he was quite clear that these days, depression is a lot easier to treat than in the old days. Most cases are treated as out-patients, either at hospitals or in private practice, and only a few require admission and ECT as used to be the case. After an hour, it ended with the usual effusive thanks for a most interesting and informative talk, etc.

What did we learn? What used to be called manic-depressive psychosis was definitely uncommon so these people were often admitted but didn’t spend a lot of time in hospital. However, it was potentially dangerous as people in a true manic state did dangerous things or just became severely dehydrated. Now that it’s bipolar disorder, it’s become very common, everybody is put on drugs, it’s clinically different and treatment isn’t successful. In his Anatomy of an Epidemic from 2009, science journalist and critic Bob Whitaker puts the case that the spread of the diagnosis is due partly to the much looser diagnostic criteria that started in DSM III (1980) but mainly to the spread of psychiatric drugs, especially antidepressants and stimulants [1]. Today’s diagnostic criteria, especially for bipolar II, are so elastic they can cover almost every person who has a few ups and downs – and who doesn’t? There are, however, several groups who are especially prone to ups and downs. These include people with unstable personalities and people taking psychiatric drugs, who comprise an overlapping and ever-growing segment of the community.

Once a psychiatric diagnosis is made according to today’s loose standards, drug treatment is mandatory. This is not because the drugs are always effective, i.e. the patients will never “fail their treatment,” as the speaker put it, but because of the risks of being sued if something goes wrong. Instead, the much more powerful impetus is the urge in psychiatrists to prescribe drugs, to “do something doctorish,” because everybody expects it, that’s what psychiatrists do. In the main, psychiatrists don’t know how to take a history or don’t see any point (or both) because the theory says it’s all genetic, so why bother asking about how home and school were 30 years ago? Very few offer any sort of talking therapy these days because again, it’s genetic and talk can’t change genes. That’s why up to 16% of the adult population are taking antidepressants, and large and growing numbers of people are taking stimulant drugs.

Both of these groups of psychoactive drugs are seriously destabilising. Soon after starting SSRI antidepressants, up to 15% of people will experience a bout of agitation, irritability and overactivity, with poor sleep, emotional detachment, disorganisation, big ideas, etc. If this happened with any other group of drugs, it would be classed as a “drug side effect” but antidepressants are different. If it happens with these drugs, then by decree, it isn’t a side effect, it’s the drug “uncovering” a previously unseen “bipolar tendency”:

A full manic episode that emerges during antidepressant treatment (drugs, ECT etc) but persists at a full syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis [2, p124, also p133].

What is the “physiological effect” of a drug? Nobody knows, so it’s taken to be “significant blood levels,” but we know that psychiatric drug effects persist long after it is cleared from the blood. What happens is that some ordinary Joe is having a bit of trouble at work, a few family upsets, not sleeping very well, irritable, etc. the usual sort of thing that comes and goes in life. A well-meaning relative says “You’re depressed, I saw that in the notice in the public toilets. Go and see your doctor.” He sees the GP who promptly prescribes an antidepressant. In a week, the unfortunate person has reacted with what looks like a hypomanic attack, has lost his job, more family disputes, maybe a traffic fine for driving erratically. With no idea what is going on, the GP sends him to see a psychiatrist who confidently diagnoses bipolar disorder and prescribes a heap more drugs, but they induce further mental disturbance, in a self-reinforcing manner. Within a few days, this previously normal citizen has been converted into a fully-certified lunatic who is facing a life of iatrogenic entanglement in the psychiatric industry. It’s that easy.

Problem is, as the speaker said, we don’t know what these drugs do. We may call them SSRIs or SNRIs or MAOIs but what are they doing to the brain, the most complex thing in the known universe? There are over 100 neurotransmitters in the brain, and each of them can be excitatory or inhibitory; serotonin alone has 14 different receptors. The idea that a drug works on just one of them and not the others is ludicrous. In addition, there’s the effect of the brain itself in trying to maintain its equilibrium when drugs interfere with normal function. Nobody knows any of this. Psychiatrists talk of “neural circuits” but that’s just talk, on a level with the talk from 75 years ago when psychiatrists talked of “cutting the brain tracts that are causing the mental disorder.” Add to this the explosive growth in the numbers of people taking stimulants for their (largely self-diagnosed) “ADHD” and we have a psychiatric industry essentially out of any control but which is both highly adept at denying it’s causing any problems – and hostile to any suggestion that they could be.

In every western country, the numbers of people taking psychiatric drugs unnecessarily is growing rapidly, largely as a result of another trend in psychiatry: rediagnosing people with unstable personalities as “bipolar” and putting them on drugs. Personality disorder is real, it’s very significant, for the subjects, their families and for the larger community [3, Chap. 8] but psychiatry doesn’t know what to do about it. This is a failure of psychiatry, not a “failure of the patients.” In the main, orthodox psychiatrists know nothing about personality or its disorders. They don’t have a theory of personality or a model of personality disorder, and therefore have no rational treatment for personality problems. This means they have no idea where personality disorder stops and frank mental disorder takes over, plus they don’t get paid if they can’t provide treatment, so the scene is set to stop giving personality diagnoses and label everybody “mentally ill” and put them on drugs. Prescribing relieves the need to be seen to “do something” * and drugs are where the money is. When the unfortunate patients react badly, as most will because they aren’t “mentally ill” in any meaningful sense, they will get more drugs with or without a forced trip to the local nuthouse. After a while on the psychiatric treadmill, they’ll fall in a heap and be put on a pension. This is how mental disorder is manufactured in the 21^st Century.

The whole talk was just a rambling and unfocussed trip down memory lane which took an hour to say precious little. Essentially, it was pseudoscience, science-sounding talk but unburdened by the ballast of a formal model of mental disorder. I certainly don’t believe things have changed as much as he said. Mayer-Gross’s textbook of psychiatry from 1969 (edited by Slater and Roth) specifically said that irritability and paranoid thinking were prominent in elevated moods. If it’s worse now, it could be because more essentially normal people are forced to take very unpleasant drugs with a host of adverse side effects against their will. The thing that always impressed me was how so many of these people lied, and the lying got them into trouble. My teachers dismissed this behaviour as “delusional, caused by his illness,” that it would get better when the drugs did their job. But it didn’t. It became more subtle, a personality factor, which leads back to the question of distinguishing between personality disorder and “mental illness.” However, as long as there’s no money in treating personality disorder and lots to be made from treating bipolar disorder, that’s a non-question.

What the speaker describes is a failure not of a “technology of mental disorder,” but of ontology, a failure of basic understanding directly caused by the lack of a formal model of mental disorder. Mainstream psychiatry won’t admit that it doesn’t actually know what it’s doing but the illustrious speaker gave it away at 48.50:

I don’t believe we know how depression comes about or how drugs work … We don’t actually know what causes depression or what our drugs do … We’re very bad at predicting who’s going to respond to what sort of drug. It’s not clear why that should be.

It’s clear to me but what he didn’t say was: “But we’re absolutely convinced it’s all biological and drugs are the only way to go.” Can he prove that? Of course not, but he also believes that anybody who wants proof is “antipsychiatry” and must therefore be silenced.

*The politician’s syllogism applies equally to psychiatry: “Something must be done. This is something. Therefore, this will be done.”

References:

1. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.

2. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. Washington DC: APA Publishing.

3. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London: Routledge. Amazon

****

My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.