Feelings color all our experiences, and for some people the filter of emotions can go from rose to purple to black as quickly and subtly as the setting of the sun. Once referred to as manic-depressive illness, bipolar disorder is a baffling condition that affects close to three million Americans.
The most distinctive feature of the disease is precisely what it makes it most elusive: patients "cycle" between major episodes of depression and mania. Sometimes the dips and climbs can be rapid and confusing, and patients themselves may have no idea whether they are manic or depressed.
Clinicians also find bipolar disorder hard to spot because it combines two of the world's most diagnosis-immune illnesses. On the one hand, the World Health Organization recently acknowledged that depression is internationally underrecognized and thus treatment is far from adequate. On the other hand, there's mania, defined as a "distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week." Unlike the victims of colds or headaches, who know something is awry, people in the manic phase of bipolar disorder often don't hear that message. While the rest of the world crawls, they feel energetic, confident, in control.
"That was the frightening part of it. I thought I was complete and whole," recalls 62-year-old Francesca Dodd, of South Yarmouth, Massachusetts. When she was diagnosed with bipolar disorder at 45, she says, "It was like a bomb dropped on me. It's hard to admit you're manic, because it's so wonderful. It's like the story in Mary Poppins where they go up and fly with the balloons."
Mania, indeed, has been described as a "key to genius," a disorder that has led
to some of the world's greatest artistic
and intellectual achievements. Van Gogh and Freud, Charlie Parker, Cole Porter, Georgia O'Keeffe, and Emily Dickinson may all have had bipolar disorder. Who would take medication to curb the kind of imagination, elation, and energy that would put one in such a class?
But mania for most sufferers is no ticket to fame. Gary Sachs, director of the Harvard Bipolar Research Program at Massachusetts General Hospital, reports that bipolar illness is often compared to another Mary Poppins episode: the visit to her Uncle Albert, who loves to laugh. When Mary and her young charges arrive, they find the old man whooping uncontrollably and hovering near the ceiling. If only they'll laugh with him, he says, they can join the fun. Everyone has a wonderful time until the guests have to leave, and the whole party crashes to the floor.
"People tend to think of mania as being like that infectious good mood," observes Sachs, who is also assistant professor of psychiatry at Harvard Medical School. "But mania is no laughing matter. In fact, most people are irritable and argumentative during their manic episodes. They're impulsive and impatient, and the people around them often just want to duck out and get away."
Bipolar patients like Francesca Dodd have found that their high-strung manic episodes often repel the close family members who could help keep their behavior in check. Alone and unsupervised, a manic person can be a serious hazard to herself and others. In An Unquiet Mind, Kay Redfield Jamison writes about the "wild blue yonder" of mania, the invincible hours and days when she did the inexplicable, like buy 12 snakebite kits, or a horse, or 20 books on Arthurian legend simply because she had caught a glimpse of a brook that reminded her of a passage from Tennyson's Idylls of the King. As the whirlwind of wakefulness and confusion whips harder, manic people lose all the perspective that could let them see themselves as sick.
Although poorly understood, bipolar disorder's saving grace is its relative treatability. Lithium, which has been available for many years, or newer drugs, such as divalproex, carbamazepine, and antipsychotic medications, can treat most cases of mania effectively. Unfortunately, since bipolar patients seldom complain to their doctors about their manic episodes, nonspecialists often interpret the underlying problem simply as depression--and treatment with standard antidepressants often has the unfortunate effect of provoking manic episodes.
The problem, then, isn't that there aren't drugs to treat bipolar disorder; it has more to do with identifying the people who need treatment and persuading them to take it. As Jamison writes, "That I owed my life to pills was not obvious to me for a long time; my lack of judgment about the necessity to take lithium proved to be an exceedingly costly one."
The best way to gain perspective over the "siren call of mania," as Sachs terms it, is to emulate the plan Odysseus implemented on his voyage home from Troy. Knowing that he would sail within hearing range of creatures whose intoxicating song lured men to destruction, Odysseus filled the ears of his crew with wax and lashed himself to the ship's mast after ordering that no one was to let him go, no matter how he pleaded. Bipolar disorder sufferers must have their own posse of friends who can be trusted to recognize manic episodes and suggest, or even insist, that they take their medication.
"Involving friends and family in the process allows patients to remain captain of the ship," Sachs says, "yet recognizes that they're not always going to be well. It's a concept that's hardwired into all kinds of arrangements: even the U.S. Constitution has a provision for the vice president to take over if the president isn't able to perform. When this is part of the patients' plan, it protects them and all the people around them."
Now psychiatric researchers will try out this approach more widely in a large-scale clinical trial of the treatment of bipolar disorder that will enroll some 5,000 patients at 20 treatment centers across the country. Although such mammoth trials are relatively common in the study of heart disease and cancer, this will be the largest clinical trial ever undertaken by the National Institutes of Mental Health (NIMH). Its inclusive design will enable researchers to examine the effects of a variety of approaches on many different types of patients with bipolar disorder.
Equally important, all the psychiatrists involved will receive training in best practices for treatment of bipolar disorder. Sachs hopes that improved recognition and treatment of the disease will encourage more patients to come forward and identify themselves. Enrollment for the study has already begun, and Sachs says that patients' families have welcomed the opportunity to become more involved in helping to manage relatives who have the disease.
"It seems to be a powerful idea," he says. "We can help patients with bipolar disorder to continue to set the course of their own lives. They're no longer in a subordinate position, and that makes navigating this disease a whole lot less frightening."
To Volunteer
To learn more about the Systematic Treatment Enhancement Program for Bipolar Disorder, a study committed to improving treatment of patients with bipolar disorder, contact Dr. Gary Sachs's office in Boston at (617) 724-6545, or visit the study website at www.manicdepressive.org to find out about other study centers nationwide.
John F. Lauerman, of Brookline, Massachusetts, writes about health for Harvard Magazine.
