McMAN’S DEPRESSION
AND BIPOLAR WEEKLY (April 27, 2002 Vol 4 No 15)
EXUBERANCE
"We do not intend our natural resources to be exploited by the few
against the interests of the many."
Believe it or not, a Republican President said that, Theodore
Roosevelt. TR was not your average President. According to Kay Jamison, who
needs no introduction, speaking on Wednesday this week to a Depression and
Related Affective Disorders (DRADA) Conference at Johns Hopkins
Hospital in Baltimore, Teddy Roosevelt was "hypomanic on a mild day." He
suffered from depression, and mental illness ran in the family, including a
brother who had to be institutionalized and a son who committed suicide. He
wrote 40 books, and read a book a day, even as President.
The context of Dr Jamison’s talk was
exuberance, which is the theme of her next book. We have "given sorrow many
words," says Dr Jamison, "but passion for life few." Exuberance, she says,
"takes us many places," with "delight its own reward, adventure its own
pleasure." But exuberance and joy are also fragile, "bubbles burst, cartwheels
abort," all part of the yin and yang of emotion, as "joy with no counterweight
has no weight at all."
TR came
into the world in 1858 "a full-blown exuberant." According to a Harvard
classmate, "he zoomed, he boomed, he bolted wildly." A journalist said that
after you went home from a meeting with the President you had to "wring the
personality out of your clothes."
In 1903, TR teamed up with fellow exuberant, John Muir, for an
extended hiking trip in Yosemite. Nature was Muir’s deliverance
from his strict Scottish immigrant upbringing. Someone described his writings as
the "journal of a soul on fire." He literally spoke in tongues to wildflowers,
and his constant stream of letters to lawmakers ultimately attracted the
attention of the twenty-sixth President of the US. "Any fool could destroy
trees," Muir wrote. "They can’t run away." Muir saw God’s immanence everywhere
in
nature, particularly in the mighty
sequoias. "Unfortunately, "God cannot save trees from fools," he observed. "Only
the government can do that."
TR was a committed
conservationist long before he met John Muir, but after the
Yosemite trip he marshaled his exuberance with new urgency. When TR assumed
office in 1901, half of the nation’s timberlands had been cut down, the buffalo
and other species faced extinction, and special interests were teaming up to lay
waste to huge tracts of pristine wilderness. Thanks to TR, five national parks
were created, along with 150 national forests, 51 bird refuges, four national
game preserves, 18 national monuments (including the Grand Canyon which later
became a national park), 24 reclamation projects, and the National Forest
Service. Significantly, TR extended the concept of democracy to include future
citizens, arguing that it was undemocratic to exploit the nation’s resources for
present profit. "The greatest good for the greatest number," he wrote, "applies
to the number within the womb of time."
In 1912, a would-be assassin shot TR
in the chest. Faced with the prospect of premature death, he remarked, "No man
has had a happier life than I have led; a happier life in every way." The deaths
of his first wife and mother on the same day followed by a grieving period that
lasted two years seemingly belies that statement, but personal realization has
long been recognized as the reconciliation of opposites, and the same applies to
John Muir, as well, who wrote he only went out for a walk but stayed out till
sunset, for "going out was coming in."
FREUDIAN SLIP
At one point in her talk, Dr Jamison said John Muir "eliminated"
nature. She corrected herself to "illuminated" nature, then laughed, saying she
was thinking of George Bush, which drew an appreciative round of applause
from the audience.
DRADA CONFERENCE
DRADA packed a lot into one day, so this week’s Newsletter will
depart from its usual format and devote itself entirely to the conference. So
without further ado ...
A MOTHER’S DEVOTION
Ben Carson MD is the Director of Pediatric Neurosurgery at Johns
Hopkins. In 1998, he achieved worldwide renown for the first successful
separation of Siamese twins joined at the head. But growing up in a Detroit ghetto a poor student with a bad temper did not bode well for the
young Ben.
Dr Carson was speaking to the DRADA
Conference in an interview format hosted by Raymond DePaulo MD, newly-appointed
chair of John’s Hopkins Psychiatry and Behavioral Sciences Department.
Ben’s
mother was one of 24 children (no, that’s not a typo). She married at 13 and the
couple moved from rural Tennessee to Detroit, where they
managed to buy a house, but her husband got into drugs and turned out to be
a bigamist. Determined not to go on welfare, Ben’s mom worked two or three
jobs as a domestic, getting up at five and going to bed at 12. Dr Carson
explained that from working in other people’s houses, his mother realized there
was a different way of life, and that her kids need not be drawn into the morass
of the ghetto. Accordingly, she required both he and his brother to read
two books a week and submit two book reports to her before they could watch
TV. She would go over each report very carefully, and make check marks in
places that met her approval. It was only much later the brothers discovered
their mother couldn’t read.
At the time, Ben was at the bottom of
his class in the fifth grade and everyone called him Dummy. He resented reading,
but soon got hooked and started imagining himself doing lab experiments and all
sorts of other possibilities. In the space of a year and a half, he went from
the bottom of his class to the top.
There were
times when their mother would mysteriously go away for weeks at a time, and
relatives or people from their church would look after them. Later they found
out she was checking into a mental hospital. She knew she had to rebound, Dr
Carson explained, and she was a determined patient who thought "her relationship
with the owner of the universe gave her a special edge." Nevertheless, "I’m
certain she must have cried herself to sleep many a night."
Ben’s mother later got her GED, went to college, and received an
honorary doctorate. These days, she lives with her son, occupying the top floor.
UNIPOLAR VS BIPOLAR
People with bipolar depression are more likely to have psychotic
features and slowed-down depressions (such as sleeping too much) while those
with unipolar depression are more prone to crying spells and significant anxiety
(with difficulty falling asleep), according to Francis Mondimore MD,
assistant professor at Johns Hopkins and author of "Bipolar Disorder: A Guide
for Patients and Families", talking to the DRADA conference.
Are unipolar depression and bipolar depression two different animals?
We know what happens when an individual with undiagnosed bipolar is prescribed
an antidepressant without a mood stabilizer.
A study published in 1995 following 1000 individuals with all types
of mood disorders over 10 years found only five percent of the 381 unipolar
depressed patients who completed the study nearly half dropped out) developed
mania and only five percent developed hypomania. Less than 10 percent of those
with bipolar II developed mania compared to 66 percent of those with bipolar I
or schizoaffective disorder.
These results suggest bipolar and unipolar depression are
biologically distinct, but a number of family studies suggest the opposite, that
bipolar and unipolar share the same genetic base, with the illnesses running
together in families (though other family studies come to opposite conclusions),
and with studies into identical twins showing a predisposition to unipolar
when the other has bipolar. In one study that involved interviews with
1254 individuals of relatives with mood disorders, the more severe the illness
the greater likelihood of having multiple family members with mood
disorders (though once again other studies suggest the opposite). Meanwhile,
genetic research into chromosome 20 has turned up high readings for both
depression and bipolar.
PMDD
SSRIs work well for premenstrual dysphoric disorder (PMDD), according
to Karen Schwartz MD, assistant professor at Johns Hopkins, talking to the DRADA conference,
and they work faster than for classic depression, suggesting different
mechanisms at play. Women with PMDD may limit their SSRI medication to the week
before their period rather than remaining on the drug constantly. SSRIs work
"significantly better" for PMDD than TCAs.
PMDD is a distinct clinical syndrome, first described by Hippocrates
and finally receiving recognition in the DSM III under the name Late Luteal
Phase Dysphoric Disorder, and more recently in the 1994 DSM-IV by its present
name. The symptoms are similar to depression, but with breast
tenderness, headaches, and bloating and with symptoms remitting in the week post
menses. Women with dysthmia or major depression may also have symptoms that
worsen.
Dr Schwartz stressed the need for a complete psychiatric evaluation.
She displayed an ad for Serafem (Prozac with a Barbie color scheme, as
she described it) that ran in a women’s magazine with a symptom checklist to
take to one’s doctor, symptoms that hardly mean one has PMDD, she pointed out.
One of her patients, she learned, had earlier hypomanic episodes, so she gave
her a mood stabilizer instead of an antidepressant. "Had I just checked
for depression symptoms," she concluded, "I could have switched her into
mania.".
LITHIUM THEN AND NOW
Back in the mid-sixties, an old hand at Johns Hopkins told Ross
Baldessarini MD (now with Harvard), "Son, you’re going to dent your lance and
ruin your career by getting involved with lithium."
Lithium, he went on to say to the DRADA conference, is dirt and is as
cheap as dirt, with no marketing budgets. A recent myth about lithium is that it
is not as effective as it used to be, but Dr Baldessarini produced figures
to show this lesser response was "not significant."
For acute mania, lithium is not practical, with other drugs doing a
better job, but after that is another story altogether. Lithium, he
says, "practically obliterates" hypomania. It is less perfect for mania, but is
as good as the other drugs, though most Americans are probably overdosing.
There have been virtually no studies of bipolar depression (as
depression was a reason to exclude patients from studies, believe it or not),
but it is a good prevention against depression. According to a study he did,
lithium was found to have a "ninefold" reduction of suicide risk. If he had
reported on a five percent lower risk of heart fatality, he went on to say, it
would be front page news in the New York Times. Yet the medical journals
weren’t interested (he has published some 1,300 scientific articles).
Eventually, a Scandinavian journal published his findings.
"It’s amazing," he concluded, "that there is little medical interest
that suicide is a medical problem. I can’t get my colleagues to talk
about treatment."
BP KIDS
Many of the symptoms of bipolar in children and adolescents overlap
with kids with ADHD and other disorders, and even with kids who are normal, but
there are certain core symptoms, according to Paramijit Joshi MD, Chair
of Psychiatry and Behavioral Sciences at the National Children's Medical Center in Washington DC, talking to the DRADA conference. These core
symptoms include: insomnia, pressured speech, grandiosity, and risk taking
(resulting in impaired functioning at school and home). Risk factors include
family history, a history of depression and suicidality, a hypomanic response to
an antidepressant, and depression with psychotic symptoms.
By contrast, kids with generalized
anxiety disorder or panic pervasively worry rather than experience euphoria.
Those with ADHD have no depressive episodes and no grandiosity while those with
behavior disorders usually react to limit setting. For kids with substance abuse
problems, it’s very important to find out what came first.
Dr Joshi
brought up two cases she handled involving young children with very similar
symptoms, but in one there was a family history of ADHD and other disorders but
not bipolar, while in the second child’s family depression and bipolar were
rampant. "Taking the family history is so very very critical," she stressed.
Dr Joshi told the conference she gets kids aged four and five on four
or five medications. "I’m spending more time taking kids off medications than
putting them on, as I don’t know what I’m treating," she related. Thus the
critical importance of a thorough diagnostic evaluation.
PARENT EDUCATION
In her talk and in an earlier experts panel, Dr Joshi stressed
parent education and involvement. Kids, she explained, unknown to their parents,
may not be taking their meds, and then the doctor raises the dose causing
further trouble. Dr Joshi will ask kids why they are not taking their meds. Last
week a patient replied he didn’t like the taste. She explained that you may have
a situation where the patient is doing quite well and then you have
the grandmother come in who says, you don’t need those drugs. Education,
she emphasized, is not just a one-time process, it is ongoing. By the same
token, "sometimes kids have to fall on their faces and pick themselves up."
The need for parent education is further underscored when a kid comes
home from residential treatment, where he or she may have behaved perfectly,
and then is exposed to stressors and triggers that parents need to be mindful
of.
DARKNESS REDUX
In 1986, when author William Styron experienced his first depression,
he could not find any first-hand accounts of the illness. Talking to the DRADA conference
in an interview format hosted by Dr DePaulo, he said he first tried to write his
now classic "A Darkness Visible: A Memoir of Madness" as a work of fiction.
The genesis of his book occurred when he read in the NY Times how a
group of scholars found personal weakness in holocaust survivor and chronicler
Primo Levy for jumping down a stairwell. "This aroused me to a kind of anger,"
he related, which found expression in a NY Times op-ed piece. Dr DePaulo saw
the piece and phoned him, inviting him to speak at the DRADA conference, and
the rest is history.
In 2000, William Styron suffered an even worse depression that
hospitalized him for four or five months. "The first one sort of slid up on me,"
he related, but this one resulted in an "almost immediate plunge into
suicidal fantasy ... This was like a marauder in an alleyway that seized me."
A course of 12 or 14 ECTs followed (after he became relatively
stabilized), though he couldn’t say whether they helped or hindered him (he
suffered no memory loss). "I recovered just in time," he reported, "to endure
the 2000 election. It was almost enough to put me back."
DRADA
Every year, DRADA hosts a conference at Johns Hopkins
Hospital, which is well worth attending. For more on DRADA, check out:
http://www.drada.org/
MCMAN'S WEB
Check out more than 170 articles on all aspects of depression and bipolar, plus
a bookstore, readers' forum, message boards, chat room and other features at: http://www.mcmanweb.com
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