The Diagnostic and Statistical Manual of Mental Disorders (the DSM) is frequently called psychiatry’s “bible.” I, however, would not pen it that way. I would suggest that the DSM is simply a guideline for the diagnosis of mental illness. It lists the criteria one has to have in order to be diagnosed with a mental illness.
And, as the name of this post suggests, the DSM is releasing its fifth major version – the DSM-5 – in just a couple of weeks.
Now, the DSM-5 has been controversial from the get-go and I have said that much of this controversy is overstated, but some of the changes do have fundamental nosological implications. In other words, some of the changes in the DSM-5 can change how people fundamentally think of certain mental illnesses.
The DSM-5 Cuts the Chord between Depression and Bipolar
And one of the changes in the DSM-5 is the separation of major depression and bipolar disorder into their own chapters. No longer is there a chapter called “Mood Disorders” with both disorder types listed (Can we still call them mood disorders?). Now they each represent a separate category.
This may seem like a small change, and I’m not going to have a fit over it, but I will say that I think it was the wrong move.
Depression and Bipolar Disorder – Separate but Equal
You see, it is my belief that bipolar disorder is not so much separate from major depression as much as the two are at either ends of a spectrum, like so:
Because it’s clear to me that bipolar disorder doesn’t just come in three flavours: bipolar I, bipolar II and cyclothymia, it also comes in a myriad of textures in between. I think it’s entirely possible to be diagnosed with depression with just a soupçon of bipolar disorder thrown in there for colour.
Indeed, the fact that we have multiple versions of bipolar disorder, each “less manic” than the next, suggests that depression is the outstanding feature of all and the mania is the variable. So we all have depression but some of us have these other odd moods too – to varying degrees.
So it makes all the sense in the world to group these disorders together. But, as I said, they are no longer grouped.
The Problem with a Depression / Bipolar Dichotomy
What I’m saying is that the idea of a depression / bipolar dichotomy is false and this matters because of the implications to treatment. If depression really were completely separate from bipolar disorder then why would anyone with depression have a beneficial reaction to anything other than antidepressant medication? (And this is often the case. Many people with depression are on effective medications other than antidepressants.) And should anything but antidepressants be tried on just a straight major depressive population?
Now, I suppose when it comes down to it, it’s a philosophical difference because I highly doubt it will change prescribing practices one bit. Nevertheless, I think forgetting that bipolar and depression are on ends of a spectrum does a disservice to patients and to research where this concept could be critical to our understanding of affective disorders in general.
And moreover, it has never been made clear to me what the advantage of the separation is. If we admit that patients do not fit nicely into boxes (and we do admit that, that is why there is a diagnosis of “not otherwise specified”) then why are we just creating higher walls on said boxes? It’s silly. I don’t get it. And I don’t think it reflect the reality of patients, doctors or treatments at all.
DSM remains important largely for financial, political, and bureaucratic reasons : the area it affects ts surprisingly little, unless you have a little bit of direct experience in the field, is clinical work. With few exceptions, we treat symptoms, and DSM guidelines & diagnoses contribute little to treatment decisions. One prominent exception : those prone to mania, whom we do not treatwith antid epressants apt to bring it on. Regardless of how they’re presented in any book, nothing real will change on the groundunt il science offers us some real way to distinguish actual biologically distinct ailments responding in predictably different ways to different treatments. Committees can surmise until the end of time without much if any real progress: look at philosophers’ millennia of musings until real physics came along. DSM remains largely committees of prominent well intentioned philosophers arguing with too little real evidence to approach real truths.
Considering that bipolar can be diagnosed with a single isolated episode of mania or hypomania, coupled with depression, it seems to me that bipolar and depression remain closely related. I don’t see the rationale for characterising them so differently now. I’m thinking this new DSM is largely a “make-work” project, rather than the refinement it ought to be.
Hi Natasha,
Perhaps the discussion should be centred on the difference between recurrent depression and major depressive disorder.
There is a good discussion as you probably know in Manic-Depressive Illness by Frederick K. Goodwin and Kay Redfield Jamison.
For me there seems to be a difference in many areas specifically family history, symptomatology, as well as treatments. Might even go into provocation resulting in major depressive episodes which may last as long as the person has not come to terms with, for instance a tragic loss, whereas recurrent depression will come and go with or without provocation.
Major Depressive disorder responds very favourably to antidepressants as you rightly say. Recurrent depression can be treated the same way as bipolar depression with the use of mood stabilisers particularly lamotrigine for long term maintenance and prevention.
Bipolar depression for people with bipolar I and mixed states/rapid-cycling should never be treated with antidepressants.
Antidepressants have little evidence of effectiveness for the long term maintenance treatment of bipolar depression.
There seem to be clear differences hence experts such as the aforementioned authors and Dr. Phelps and both the Affective Disorders Outpatient Service (Maudsley Hospital) and the Spectrum Centre for Mental Health Research http://www.lancs.ac.uk/shm/research/spectrum/ here in the UK, for instance, have suggested separating bipolar and major depressive disorder Hopefully it will become clearer that recurrent depression should be grouped within the spectrum of the other manic depressive illnesses, the scale you rightly show above.
I happen to agree with Dr. Phelps and the information he gives on his site:
http://www.psycheducation.org/depression/frameset.html
I agree with David. I think bi-polar depression is a different creature than unipolar depression. I had been struggling on a cocktail of an anti-psy and anti-convulsant. It kept me relatively stable for three years, then I spent another two years of ups and downs. I went on Lamictal and the depression went away. I take the occassional anti-psy, but I have been med free for 18 months. I am feeling and doing much better now than I ever have.
I think mania is some brains deal with depression. In other words, I think my bi-polar brain creates its own solution to depression. The better solution was to pull out of the depression with the Lamictal to the point where I could make the lifestyle, health and nutrition changes I needed to tame my depression. My theory is that if I can tame my depression that I don’t have to worry too much about mania. If I feel a slip into mania, I have a good support system and I’m also not shy about taking an anti-psy when needed.
As someone diagnosed with depression for years, and for whom it was recurrent (with clinicians occasionally using that word), but who has recently had that diagnosis revised to BP2, this makes perfect sense to me. The defining difference is the variability, to my mind.
I’ve not made up my mind about this but while I can accept there is a scale of Bipolar Disorder, I am not yet convinced unipolar depression is on it. One marked difference with unipolar depression and a Bipolar depression is that the former can be successfully treatable with anti-depressants; but many (most?) anti-depressants can trigger a manic phase (euphoric or dysphoric) in someone with Bipolar Disorder. So, clearly, there is some difference between them. And to complicate this further, I understand that most people who have Bipolar Disorder (active or sleeping) usually have some element of comorbidity (in my case, as an example, Dysthymic Disoder) and each may be treated best by different means, but only if one or other(s) are inactive.