Open letter to Jo Revill, Health Editor, The Observer, re her article "Doctors fail to spot manic-depression"

I welcome your article's support for the Manic-Depression Fellowship's attempts to obtain more funding for services and research for bipolar disorder. I would, however, question whether it is right that, "Once it has been identified, the condition can be treated with medication and most patients go on to lead relatively stable lives, with little need for hospital services." The patient that you quote, Sally Earl, who is largely stable taking the mood-stabilising drug lithium, says "it is a constant battle to stay well, and maintain a steady, quiet lifestyle to avoid the symptoms recurring".

However unintentionally, I think your article gives the impression that treatment is only about medication. In fact, there may be adverse outcomes of the use of medication, as you note in the example of switch to mania in the case of the use of antidepressants in bipolar disorder. I am sure there is evidence of delayed diagnosis and misdiagnosis of bipolar disorder, and that this evidence is demonstrated in the survey you mention. However, I contend that the issue is more about appropriate treatment for bipolar disorder once diagnosed.

Medication may have a role, but it may not, and there is bias in favour of medication in controlled trials. Although, as you say, "there does not appear to be one single cause", many patients are told that they have a "chemical imbalance" in the brain, which can be corrected by medication. Many psychiatrists take a biomedical view of mental illness assuming that the causes are biological. There is said to be evidence for this view, but the evidence is not conclusive. Personally, as a psychiatrist, I practise with a different hypothesis that the kinds of processes that underlie mental illness at the biological level may be no different from those that produce thoughts, feelings, and behaviour among "normal" people. I think it is important to put people's symptoms into a personal and social context. I believe that only by having such views about bipolar disorder can we offer treatment that is truly effective.

You may be interested in the Critical Psychiatry Network ( This group of psychiatrists provides a network to develop a critique of the contemporary psychiatric system, which is largely based on the biomedical model of mental illness.

Duncan Double
Consultant Psychiatrist