When I begin my career in psychiatry, as an intern in 1994, there was a defined academic variation I understood, but it didn’t make sense to me in real time.

The “Bipolar” patients I saw were filled with anger, anxiety, and depression. They were at the end of their rope. When I would read their life stories, it made perfect sense where the fear and the sadness and the pain all came from.

How come these patients were labeled differently than every other patient who had these same basic painful psychological symptoms? After 30 years of full-time practice, I still wonder about this, but more so, with a sense of chagrin and defiance.

The emotional states of mania and melancholia have been recognized since the time of Hippocrates (460-370 BCE). He attributed these conditions to an imbalance of humors. The great foundational psychiatrist Emil Kraeplin (1856-1926), was instrumental in modern psychiatry by scientifically classifying mental disorders.

In detailed case studies, he described how some people with depression sometimes coped in a “manic” style. In addition to suffering the symptoms of depression, they would sometimes exhibit agitation, increased energy, and racing thoughts. He sensibly described this as “manic-depressive” insanity. He emphasized that the states were never cleanly separated.

Sometimes people with depression would act in melancholic ways and sometimes people would cope with depression by being agitated and grandiose. And this makes sense. It was the same illness, which people with different backgrounds and circumstances would cope with in different ways.

For some people, it was not an option to be sad, melancholic, and withdrawn. Mania or hypomania can be seen as a defensive, unconscious reaction against depression. Perhaps an exaggerated, yet futile attempt to run from despair and deny the unacceptable reality of depressed. “I’m not frustrated, sad and powerless. I’m in a great mood, positive, and capable.” This is described as Grandiosity.

There are ways people in different circumstances manifest the same illness. The term Bipolar Disorder became officially recognized by The American Psychiatric Association in 1980 with the release of DSM-III. Even then, the term was intended to differentiate the same illness from “Unipolar Depression”.

It’s very difficult to objectively measure emotional symptoms on a spectrum. The American Psychiatric Association attempted to make it more clear by introducing the concept of Bipolar Disorder, type II in 1994 with the release of DSM-IV.

The condition became classified then as bipolar I disorder if there has been at least one manic episode, with or without depressive episodes, and as bipolar II disorder if there has been at least one hypomanic episode (but no full manic episodes) and one major depressive episode. It is classified as cyclothymia if there are hypomanic episodes with periods of depression that do not meet the criteria for major depressive episodes.

As if this wasn’t messy enough, the concept of Bipolar I, Bipolar II and Cyclothymia were still not sufficient to describe the complex emotional states that Psychiatrists were observing in their patients. In an attempt to further squeeze more life out this concept, DSM-V in 2013 introduced the concept of ‘mixed features’. This specifier can now apply to mania, hypomania, or depression, if some opposite-pole symptoms are present, even if the criteria for the full opposite episode aren’t met. Huh? What a mess! What was intended to describe when a patient with depression was coping with anger and acting out verse when a patient with depression was coping by being sad and withdrawn, has evolved into a diagnosis with twenty different variations!

I don’t think this is practical.

Many of my patients carry a previous diagnosis of bipolar disorder. However, now in 30 years of practice, by striving to understand people’s life story and their understandable sources of fear, anger, and pain, I’ve not had a single patient hospitalized or suffer an episode of mania or even hypomania. I find it far more effective, and helpful, to treat them as suffering the anger/anxiety that has been recognized since the beginning of Medicine.

In my opinion, the influence of Big Pharma, has much to do with the diagnostic mess we find ourselves in today. More on this in my next blog.