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The Globalization of Biological Psychiatry and the Rise of Bipolar Spectrum Disorder in Iran

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Abstract

In recent years, psychiatry in Iran witnessed a dramatic increase in the use of the diagnosis of bipolar spectrum disorder (BSD). This qualitative study maps the journey of the BSD diagnosis from the West to Iran, examines the controversy surrounding the diagnosis and its treatment, and explores some of the structural factors that facilitate and maintain the widespread use of the BSD diagnosis in Iran and related practices of prescribing neuroleptic and mood stabilizers. The study methods include archival research and semi-structured interviews with 25 prominent Iranian psychiatrists in the field of mood disorders. Results show the importance of factors in addition to economics in driving changes in diagnostic fashion. Most psychiatrists interviewed reported what they viewed as an over-diagnosis of bipolar disorder and over-prescription of mood stabilizers and atypical antipsychotics among Iranian psychiatrists over the past decade. In addition to the influence of leading figures of American psychiatry, the dominance of Western psychiatric classifications and textbooks in Iran’s psychiatry, and indirect intervention by pharmaceutical companies, local structural and political factors have played a significant role in the Iranian psychiatric system’s embrace of the new concept of bipolarity. In Iran, the medicalization of social conflict has been embraced by government, families, and psychiatrists for cross-cutting purposes. These challenges and the continued controversy over the adoption of American psychiatric fads in a non-Western country like Iran point to the importance of elaborating a more ecosocial and cultural view of psychiatric practice to disentangle some of the complex trade-offs involved in adopting particular modes of diagnostic practice.

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Notes

  1. The term is borrowed from Emily Martin’s book (2009) and serves to emphasize our focus on the ways that the concept of bipolarity travels between and within societies.

  2. Mental health expenditures constitute only 3% of the total health budget (WHO 2006).

  3. According to the 2014 fee schedule set by the Iranian Ministry of Cooperatives, Labour and Social Welfare, the fee per session for seeing a psychiatrist in a university hospital was ~ $5 USD, and in a private setting was ~ $11 USD, per session (for a session of 30 min). According to the same source, seeing a General Physician in a public (governmental) setting is ~ $2.70 and in a private setting is ~ $5.50, a session which is supposed to be 15 min long. (http://en.ihio.gov.ir/Portal/Home/). Seeing a clinical psychologist costs ~ $15–25 USD per 45-min session (based on the fee schedule set by the Iranian Organization of Psychology and Counseling in 2014; http://pcoiran.org.ir).

  4. From 2003 to 2013, prior to her immigration to Canada, the first author completed her undergraduate and graduate degrees in clinical, general, and child psychology and worked in the field of mental health in Iran.

  5. The terms “wave” and “movement” were used by several psychiatrists to describe the pattern of changes in the diagnoses in general and in BSD diagnosis in particular. However, these were informal designations and, in this context, the wave or movement had characteristics of a psychiatric “fad” (Paris 2013)—that is, an intense and widely shared enthusiasm for something, especially one that is short-lived—although the enthusiasm for the BSD diagnosis has now persisted for one decade.

  6. In 2005, Dr. Yasamy left Iran to pursue his career as a Regional Advisor of Mental Health at WHO EMRO (Cairo) and then Senior Medical Officer in charge of prevention and management of mental disorders in Geneva. Recently, after he retired from WHO, he returned to Iran and continues his career as a Professor of Psychiatry at Shahid Beheshti University of Medical Science.

  7. Couple and Family Therapist and former Professor of Psychiatry at Shahid Beheshti University of Medical Science.

  8. Psychoanalyst and Professor of Psychiatry at Tehran University of Medical Science.

  9. Cluster B involves dramatic, emotional, and erratic behaviors and includes Borderline Personality Disorder; Narcissistic Personality Disorder; Histrionic Personality Disorder; Antisocial Personality Disorder (American Psychiatric Association 2013).

  10. Professor of Psychiatry at Shahid Beheshti University of Medical Science 2000–2010. Consultant Psychiatrist at Melbourne Health, Australia, since 2013.

  11. Professor of Psychiatry at Shahid Beheshti University of Medical Science.

  12. Nassir Ghaemi is an American Psychiatrist of Iranian origin and Professor of Psychiatry at Tufts University School of Medicine in Boston.

  13. At the time, Ghaemi was a Council Member of the ISBD, which was influenced by Dr. Hagop Akiskal’s views.

  14. http://tumspress.tums.ac.ir/books/detail.asp?bookID=162.

  15. Gender plays a crucial role in the dynamics of medicalization in general and is a crucial factor for understanding the increase in BSD diagnosis in Iran. A gender analysis will be the focus of a later paper.

  16. This critique of the shift in psychiatry from a biopsychosocial model to a “bio-bio-bio” model of mental disorders, which locates psychopathology within the individual’s biological constitution and limits treatment to psychotropic medication, has also been criticized by Steven Sharfstein in his American Psychiatric Association presidential address (Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly. Psychiatric News August 19, 2005, page 3, published by American Psychiatric Association).

  17. Patients attending the outpatient psychiatric clinics of the hospitals are mostly former inpatients who are seen for follow-up or people from lower socio-economic status who have no other access to mental health care. Stigma associated with mental illness is one reason that people who have economic resources try to seek help in private clinics rather than at psychiatric hospitals, which are more public places.

  18. Aftab-e-Yazd newspaper; May 5, 2010 (15/02/1389 AP).

  19. http://www.tebyan.net/newindex.aspx?pid=208060.

  20. In the same event, one of the keynote speakers, Dr. Gudarzi, who is identified as one of the prominent psychiatrists who influenced the expansion of bipolar spectrum disorder diagnosis to Iran, questioned the uncritical adoption of American psychiatric diagnostic fads, including bipolar spectrum disorder.

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Acknowledgements

The research was supported by a Grant from the Global Health Research Capacity Strengthening Program (GHR-CAPS), funded by the Canadian Institutes of Health Research (CIHR) and by the Quebec Population Health Research Network (QPHRN). We would like to thank our colleagues in the Iranian Psychiatric Association for their openness and generous collaboration with this study.

Funding

The research was supported by a grant from the Global Health Research Capacity Strengthening Program (GHR-CAPS), funded by the Canadian Institutes of Health Research (CIHR) and by the Quebec Population Health Research Network (QPHRN).

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  1. Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University, Montreal, Canada

    Fahimeh Mianji & Laurence J. Kirmayer

  2. Culture and Mental Health Research Unit, Institute of Community and Family Psychiatry, 4333 Chemin de la Côte Ste-Catherine, Montreal, QC, H3T 1E4, Canada

    Fahimeh Mianji & Laurence J. Kirmayer

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Mianji, F., Kirmayer, L.J. The Globalization of Biological Psychiatry and the Rise of Bipolar Spectrum Disorder in Iran. Cult Med Psychiatry 44, 404–432 (2020). https://doi.org/10.1007/s11013-019-09665-2

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