Wednesday, September 05, 2007

Subthreshold Bipolar: Told You So!

I Said: This is one of those "you heard it here first" moments that you might read about at times on a site like Peter Rost's. On May 10 of this year, I wrote a lengthy post about an Archives of General Psychiatry article that pushed the common existence of a new form of bipolar disorder, which the authors called "subthreshold bipolar disorder." Not only was this condition relatively common -- it required treatment! I strongly encourage you to read the post. Other also chimed in wisely, including Furious Seasons, Polarcoaster, and Dr. X. Ruth introduced us to a hilarious song regarding the new diagnosis. Others were less pleased and threatened to rip myself and others new orifices.

I pointed out several notable issues with the study and its conclusions. One of my main issues of contention was as follows:
Now pay close attention. Only 3.2% of people who had a subthreshold diagnosis during their lifetime, but had not experienced an episode during the past year received “appropriate medication maintenance” treatment. WHAT?? Back up. There is scant, if any, data, saying that people with this newfangled diagnosis of “subthreshold” bipolar benefit from short-term treatment and there is not a *blanking* shred of evidence to say that people with “subthreshold” bipolar benefit from treatment with antipsychotics, mood stabilizers, or lithium in the long-term. How the hell did this section sneak through peer review? So it is now officially “appropriate” for people to receive Zyprexa or Seroquel for their “subthreshold” bipolar disorder in the long-term, even when they are experiencing no symptoms? Incredible. The paper also implies that people with bipolar II should receive constant treatment – again, where is the data to support such a recommendation. The long-term data on bipolar I treatment is also not great, but it dwarfs the data on bipolar II and “subthreshold” BP.
They Said: The September issue of the Archives of General Psychiatry contains a correction from the authors, which reads in part:
"...the reference to inappropriate pharmacological treatment of bipolar disorder should have been restricted to bipolar disorders I and II and not included subthreshold bipolar disorder."
In other words, they were wrong to imply that subthreshold bipolar disorder required pharmacological treatment. Well, thank you very much -- I told you so. The authors also noted a couple of small errors in the some tables, and that disclosures were left out for some of the authors. In addition, I noted earlier that the authors mentioned that "preparation of [the] article was supported by AstraZeneca." The authors have now indicated that "AstraZeneca did not provide any financial or scientific support for this study."

I heartily thank the authors for making the corrections. Errors in tables are easily understandable, but I am still struck that nobody caught the subthreshold bipolar treatment issue, including the authors, the peer reviewers, and the editor. Perhaps that says something about the state of academic psychiatry or perhaps it was just an oversight. One more thank you to deliver. This one goes to Dr. Bernard Carroll, who is credited in the correction with having alerted the study authors to the problem with their statements that subthreshold bipolar required pharmacological treatment.

The Bad News: Here's the problem. News stories have already circulated indicating that subthreshold bipolar is real and requires treatment. Not a single news story will cover the latest turn in events, in which the study authors retract their conclusion that subthreshold bipolar requires drug treatment. The damage has already been done. This reminds me of a post I wrote in June where I wondered how we could amplify news such as this? A major conclusion of a study is withdrawn but who will ever know? Let's face it, not many people read the Archives of General Psychiatry (even including psychiatrists), and those that read it don't usually skim through the bottom of a page at the end of a reference section (where the current retraction was located) looking for corrections. Might journals want to post corrections in a more accessible manner? Might the so-called health media want to report on these corrections?


nab said...

Allright . . . this is beyond ridiculous.

Can someone just stand up to one of the "professionals" who lend this crap its faux-credibility and just challenge them?

"Sir, you are either a damned fool or a damned liar. Which is it?"

Sandra said...

Is there any way to get a copy of that song? Ruth's blog is private.

Stephany said...

nab I believe we are all standing up and challenging them, and they are taking note.
ANY time I write the word Seroquel in a post, AstraZeneca reads it immediately. [and I'm a no body]

Anonymous said...

from Ruths blog
21 Ways to be Subthreshold Bipolar

(with apologies to Paul Simon)

"The problem is all inside your head", he said to me
The answer is easy - you just take it orally
I'd like to help you in your quest for normality
For there are 21 ways to be subthreshold bipolar

Have you increased your goal-directed activity?
Are you subject to distractibility?
Engaged in an unrestrained buying spree?
There are 21 ways to be subthreshold bipolar

You been flat on your back, Jack
Making grand plans, Stan
Cheatin' on your boy, Roy
Well, listen to me
Hop on the shortbus
We don't need to discuss much
Just drop this off at the pharmacy
And get yourself free

He said that your pleasure-seeking can cause you so much pain
I wish there was something I could do to calm you down again
I said that's diagnostic bracket creep and I am not insane
In any of your 21 ways

He said I'll give you something to help you sleep tonight
And by the morning you'll have developed some insight
He patted my arm and I realized he probably was right
There must be 21 ways to be subthreshold bipolar
21 ways to be subthreshold bipolar

You been flat on your back, Jack
Making grand plans, Stan
Cheatin' on your boy, Roy
Well, listen to me
Hop on the shortbus
We don't need to discuss much
Just drop this off at the pharmacy
And get yourself free