1996 Article

 

Reprinted with permission from THE SATURDAY EVENING POST, March/April '96, pp. 46-80

The Post Investigates

MANIC-DEPRESSION

Dr Kay Redfield Jamison, a brilliant researcher, author, and professor of
psychiatry at Johns Hopkins, is also a manic-depressive.

by Cory SerVaas, MD.

Illustrated by Don Trawin

Manic-depression, also currently known as bipolar disorder, has baffled medical practitioners for thousands of years. Observers as far back as Plato have written of its strange behaviors and its apparent link to creative genius. Only in the last 40 years have doctors been able to treat manic-depression effectively, using lithium and other drugs. Yet, of the estimated 2.2 million Americans suffering from the disorder, more than two thirds are not receiving medical attention today: a fifth of these untreated manic-depressives will end their lives in suicide.

*Bipolar I: Because manic-depressive patients suffer from different degrees of mania, psychiatrists classify the severe and heightened mania with swings to depression as bipolar I. The cyclical, recurrent episodes of mania can range from moderate euphoria to inappropriate excitement, exaggerated feelings of grandiosity, and dangerously poor judgment.

*Bipolar II: With less exaggerated forms of mania (hypomania) before swings to depression, patients are classified as bipolar II.

*Unipolar: The name is given to patients with the hereditary form of mood disorder in which the illness is characterized by recurrent episodes of depression without mania.

All the above categories of patients differ in the length of time between episodes, a phenomenon referred to as cycling.

It is important to recognize and diagnose these forms of hereditary mood disorders. Once diagnosed properly, patients can be treated with lithium and other drugs that have been shown to be effective for bipolar and unipolar illnesses.

In this issue, the Post calls attention to this very different kind of mental illness because it has its own special medical treatment. Manic-depression is a lethal disease that is very treatable. It is found in a family's genes. We are inviting readers who recognize some manic-depressive symptoms in family histories to help further research by sending in the questionnaire on page 51.

Dr. Kay Redfield Jamison, professor of psychiatry at the Johns Hopkins University School of Medicine, is herself a manic-depressive patient. In her new book, An Unquiet Mind, she tells in beautiful prose what manic-depression does to the mind. Only patient could so exquisitely describe the roller-coaster life and the helplessness to control emotions that manic-depressive patients endure. Her interview with the Post follows:

Dr. SerVaas: You mention in your book that it is hard for someone, even for a physician who isn't a manic-depressive, to understand the problem as well as one who is. How old were you when you first realized that you were different from your friends? Did you start as a preteen or as a child having episodes of euphoria or depression?

Dr. Jamison: No, I don't think so. I think it was more that I was always a very intense child. I was really pretty normal until I was about 17, which is not uncharacteristic for a manic-depressive. A lot of people have problems earlier, but a lot also don't really get sick until their late teens or early 20s. When I first got really sick, like a lot of people, I didn't put it in terms of having an illness; I just knew something was very wrong with me.

Dr. SerVaas: A lot of children are given drugs such as Ritalin for attention deficit disorder. Do you think that quite often it may be the beginning of manic-depression instead?

Dr. Jamison: Certainly, children can get manic-depressive illness, and sometimes some of the symptoms of hyperactivity can look like mania and the other way around. That's one of the reasons why you should really be evaluated by somebody who knows what he or she is doing. The medication and treatments are very different, depending on whether you have a mood disorder or attention deficit.

Dr. SerVaas: Lithium is the best known treatment for manic-depression. Is it true that lithium is more likely to be effective in cases where there is a family history of manic-depression?

Dr. Jamison: Yes. That's certainly true, and there are certain kinds of manic-depressive illness where you have generally more euphoria in your manias and certain other patterns within the illness itself in which you're more likely to respond to lithium. What's great now is that there are several treatments available, whereas before there was only lithium. Two other major drugs that are used in manic-depressive illness are Depakote, manufactured by Abbott Laboratories, which was developed for epilepsy but turns out to work well on manic-depressive illness, and Tegretol [Basel Pharmaceuticals], another drug that has also been used for seizure disorders.

Dr. SerVaas: Are there countries where there is less manic-depression because of a higher lithium content in the soil?

Dr. Jamison: No. People used to talk about that being true in parts of Texas-more lithium in the drinking water and so forth. But the concentrations are so low there, there wouldn't be any clinical impact.

Dr. SerVaas: How about areas where the suicide rate is high, such as in Scandinavian countries? Might lithium be playing a role?

Dr. Jamison: No. Just the rate of manic-depressive illness is probably higher there.

Dr. SerVaas: Are there any environmental factors that may be detrimental to manic-depressives? There's a doctor in West Palm Beach, for example, who is convinced that NutraSweet [aspartame] is bad for his epilepsy patients.

Dr. Jamison: There is nothing like that demonstrated for manic-depressive illness. It really seems to be genetic and sometimes, certainly the initial episode, can be triggered by drug abuse, but it doesn't seem to be the case that there is anything causative in the environment per se.

Dr. SerVaas: Is it true that manic-depression is very often apt to get worse as the patient gets older?

Dr. Jamison: Yes, if it is left untreated.

Dr. SerVaas: You have gone public about your disease. If you had a manic-depressive patient who wanted to go public and really help the cause, how would you counsel that patient?Post961.jpg (18743 bytes)

Dr. Jamison: In this age, I would counsel caution, because there is still a tremendous amount of stigma and discrimination. I think there is no question that is true. It is one thing to face your family and another to face the world and employers and so forth. Actually, one of the things that has been very nice for me is discussing this in more depth with my own family, nephews, and nieces. Not that we haven't talked about it before, but the book causes us to talk about it a lot more, and it has been wonderful. I think the younger people in the family have ended up feeling a lot more optimistic as a result of knowing that things can work out well.

Since manic-depression is genetic, you really want kids to know that there is a certain risk. If they start getting depressed, they know that they've got an illness that can be treated; they can go to a doctor and get good care. What was so frightening for me when I got sick and for so many other people whom I have treated is that they didn't have any idea what was going on. It just came out of the blue and was so awful, so devastating that there was no context in which to put it. To the extent that family members can be honest with one another, that can be enormously helpful to the younger generation.

There is no reason to have stigma attached to this disorder, but that doesn't mean that there isn't. One of my hopes in writing the book was that it would make it easier for people to talk about manic-depression. And one Of the things that has been very nice is that–at least in some situations–feel that there has been more public discussion about manic-depressive illness, than there was before. That is the whole point of doing it, because it is a very lethal disease if it is left untreated, and it is very treatable.

Dr. SerVaas: Patty Duke wrote about her manic-depression in Call Me Anna. Did she accurately describe the illness?Post962.jpg (25318 bytes)

Dr. Jamison: Yes. I think overall her book was very helpful, because it made people aware of an illness that they ordinarily didn't talk about. A lot of people paid attention to Patty Duke who wouldn't pay attention to someone else. Her reaction to lithium was that she took it, thought it was wonderful, and everything was great. My sense is that's true for some people. In fact, for myself that's true, but it's generally a lot more difficult than that. It's a very complicated illness. I think what she perhaps didn't address was some of the complexities and how the disease overlaps with personality and temperament. People need to hear from a whole lot of different types of people. My hope is that by having a professional reach out, it will take away some of the stigma by saying, "This is a doctor who has it."

Dr. SerVaas: You've written about the ongoing search for a manic-depressive gene. Could you tell us about the Dana Foundation and the Genome Project?

Dr. Jamison: It's the Charles A. Dana Foundation in New York. The chairman is David Mahoney, a very, big-time businessman who used to be chairman of the board of Norton Simon. He became interested many years ago in neuroscience and the study of the brain, and has given huge amounts of money to brain research, Both the center at Harvard and the one at the University of Pennsylvania are named after him. Presently, the Dana Foundation is funding a study of genetics of manic-depressive illness that is a collaborative research program between Johns Hopkins, Stanford University, and Cold Spring Harbor Laboratory in New York.Post963.jpg (16996 bytes)

Dr. SerVaas: You are on an advisory group there. Is that a very active group for you?

Dr. Jamison: Yes it is, and the Genome Project is an extremely active, ongoing scientific program in Washington, D.C.

Dr. SerVaas: What benefits do you see coming from the present gene research?

Dr. Jamison: From the point of view of somebody who is both a scientist and a patient, I think the answers to what causes so many illnesses are going to flow from the genetic studies. You can see almost every week that they are coming up with a new gene. It is a very exciting time in research.

Dr. SerVaas: Do you see gene treatment many decades away or maybe within our lifetime?

Dr. Jamison: Absolutely within our lifetime.

Dr. SerVaas: Will treatment be available in which we would manipulate the gene that causes manic-depression?

Dr. Jamison: Yes, or certainly there will be drug treatments based on what we find out about the causes of manicdepressive illnesses and other psychiatric illnesses.

Dr. SerVaas: In your book you mention MRI and CAT scans. Are these tools useful in diagnosing manic-depressive states?

Dr. Jamison: They are not so useful in diagnosing as in studying. The major way of diagnosing manic-depressive illness now is through a very extensive clinical interview. I think in the future, MRI and CAT scans may be used in diagnosis, but they are expensive, and we don't know enough at the moment. I think what is really interesting is to see what goes on with the brain when the brain is manic.

Dr. SerVaas: In diagnosing mental diseases, is it sometimes difficult to differentiate a schizophrenic action from a first manic episode?

Dr. Jamison: Yes, it can be. And certainly a lot of people get diagnosed as having schizophrenia who have manic-depressive illness. It's less common now to make that mistake than it used to be. It used to be thought that if you were at all psychotic and hallucinated and were delusional, that meant you had schizophrenia. People are much more aware now that you can be very psychotic and violent with manic-depressive illness. To a certain extent, it depends on what part of the country you are in and the level of expertise of the doctor who sees the person. That's where things like family history can be very important.

Dr. SerVaas: Does manic-depressive illness come more frequently from the maternal or paternal side of a family?

Dr. Jamison: I don't think anybody really knows the patterns yet. There are certainly suspected patterns. Dr. Raymond De Paulo and the Johns Hopkins group are studying quite carefully the kind of transmission patterns, the maternal and paternal and so forth.

Dr. SerVaas: This may be somewhat personal, but have you and your husband considered having children?

Dr. Jamison: My husband has three children, and I think that we sort of decided to leave it at that, but I certainly would not have refrained from having children because of manic-depressive illness. First of all, I'm glad my parents had me. It is a very treatable illness, and I hope that comes across. Of all the mental illnesses that exist, it is one of the most treatable. The real problem is getting people into treatment and getting them to stay on treatment, but certainly I wouldn't hesitate to have children. Fifteen years from now, we are going to know a lot more about the illness than we do now. Any child born now wouldn't really be at risk for 15 or 16 years, and that is an awful lot of time to develop good, new medication.

Dr. SerVaas: I was fascinated by what you said in your book about men and women and how women who are frequently thought of as being more passive are more frequently diagnosed with depression.

Dr. Jamison: I've always been struck by the fact that the notion of depression is more congruent with what people think about women, and the impression that men are more tempestuous and impatient. I also think a lot of women get misdiagnosed. That is a real concern of mine.

Dr. SerVaas: Misdiagnosed as depression when it's really manic-depression?

Dr. Jamison: Yes, or when they have very mild cases. When somebody gets as off-the-wall as I was, it's not hard to diagnose. It's the mild cases of mania where people get misdiagnosed.

Dr. SerVaas: Are you working on any other books at present?

Dr. Jamison: At the moment I have decided not to write. I am just trying to catch up on my correspondence and get my life in order a bit. I am sure I will write again, just because I like to write.

Dr. SerVaas: In your own case, you're so candid about your disease. I believe your books are going to be extremely helpful to patients. What do you see for your personal future? Do you think with the treatments now available that you pretty well have the demon licked?

Dr. Jamison: I am optimistic about my future. I think anybody who has manic-depressive illness has to have a certain concern that it may recur. I am lucky that I respond well to medication and that I have good cause to think I will do OK by it, but I think it is like any recurrent illness. There is always in the back of your mind the possibility that you can get sick again.

Reprinted with permission from The Saturday Evening Post Society, a division of Benjamin Franklin Literary and Medical Society, Inc. © 1996.

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