The Infinite Mind; No. 32; Manic Depression; Part 2

I'm Dr. Fred Goodwin, and we're talking about manic depressive illness today on The Infinite Mind, produced by Lichtenstein Creative Media in association with WNYC New York. With an untreated suicide rate of 25 percent, manic depressive illness is one of the most fatal of all medical illnesses. But at the same time, we've heard a lot recently about some of the more creative aspects of the illness. So much, in fact, that some are considering bipolar disorder, kind of a trendy diagnosis to have. In fact, today there's a whole range of disorders that fall into the spectrum of bipolar mood disorder. Here to help us make sense of it all is Dr. J. Raymond DePaulo, professor of psychiatry and director of the Affective Disorders Clinic at Johns Hopkins School of Medicine in Baltimore. Welcome to The Infinite Mind, Dr. DePaulo. Thanks, Fred. It's great to be here. Why don't we start out by helping our listeners understand what we're talking about these days when we talk about bipolar? There are several types of bipolar disorder that we're we're confident that are related to one another.

The classical manic depressive illness with the pathological depressions and pathological periods of elation or irritability are certainly the most typical form. Now, of course, in that in that case, the manic patient would overspend. They'd have to often be hospitalized. They could even be psychotic. Everyone would know that there was something wrong here. Absolutely. These are obviously severely ill people. And this has now, in our new kind of terminology, been called bipolar type one. The second form, if you will, bipolar type two, as it's now called, are patients that perhaps 20 or 30 years ago we didn't recognize his bipolar at all. These are patients that have severe depressions, usually multiple episodes of major depression and but will have brief and mild elevations in mood or brief in my milder periods in which they're unusually irritable or unusually distractible.

OK, so they have the severe depressions with these milder states that are related and or irritable. Absolutely. And so that they have usually will have the racing thoughts, the increased energy, the decreased need for sleep that severely manic patients will have. But they usually do not have the grandiosity. They usually don't believe that they're Jesus Christ or about to be elected president. They don't usually spend all their money, although they might spend a bit too much and spend a little bit more on a purchase than they would have ordinarily. But it's not something that usually is very noticeable, at least to people who are casual acquaintances. Now, what about the looking at these people just from the overall amount of disruption in their life? Is it clearly always worse to have bipolar one than bipolar two? No. In fact, bipolar two for many patients is a more impairing condition, at least over a period of years. Is that because I spend more of their total amount of time in one state or the other?

I believe they do. Overall, I think they spend a lot more time depressed than do patients with more typical or classical forms of manic depressive illness. Even in their depressions, they may not be as obviously depressed. And in one sense that that can be a disadvantage, and that is that people don't immediately say, look, you need help and they might be quite angry at them, are quite disappointed in them, or judge that the person is just not up to doing a particular job or sustaining a particular relationship, or the person might judge themselves as just a weakness of character. Absolutely. It's a lot easier in one sense to recognize yourself as ill if you can't get out of bed. What about cycle time? In the cycle time, I think is right on the same spectrum. It's hard in some ways to distinguish cycle time year from bipolar to at least in where the hypomania is in that mildest form that I talked about. But these are patients who wouldn't meet at least today's current criteria for either a major depression or a hypomania.

But they clearly have brief elevations in their mood and brief depressions in their mood that just don't last as long or cause as much impairment. I guess we both seen people like this who when you look at a cross-section, they don't look like they're not doing too bad. But when you look at their whole life, they don't hold steady jobs. They don't stay in relationships. It's as if they don't count on how they're going to feel from one moment to the next, that they never really are able to commit to something. That's right. And I think that that in a sense, the more subtle the impairment the it is in, the more subtle or sophisticated or integrated steps in life that they have the most problem. Of course, we we use a word dysthymia to indicate sort of chronic low grade depression. Which has that same potential as sort of a cumulative effect on your life, even though it doesn't look so dramatic across actually what happens when you treat somebody with, let's say, bipolar to depression with a antidepressant? A couple of things can happen. Again, this gets into this issue of what

the level of hypomania is. If these are folks whose hypomania is, have it had at least the potential for a significant causing significant problems in their life? That is, they do maybe overspend in their hypomania as they do get more irritable and have somewhat disrupted relationships, even if they don't look obviously mentally ill at the time. Antidepressants given without a mood stabilizer in combination may throw them into a full blown mania, which could with disastrous consequences. On the other end, there are some patients who are like this who have the very, very mild hypomania, who can take antidepressants and do as well with them as people that we call unipolar. That is, people who have only recurrent depressions. I do think where to draw that line is probably the most difficult thing that we've got to do clinically. OK, now I'd like to take a call now. Our first caller is Mike from San Antonio. Mike, how can we help you?

Hi. Yes, I have a question about the suicide rate for manic depressive. Mm hmm. I've heard that it does not decrease after treatment. Well, actually, there is a new study that reviews 28 different studies of lithium treatment showing a very astounding six fold reduction in those patients who are on lithium compared to patients, not on lithium. What was interesting about that study is that all 28 studies, which covered a total of sixteen thousand eight hundred suicide, all twenty eight studies went in the same direction. And I've always said that if you had a six fold reduction in death rate from any medical illness, it would be on the front page of every paper in the country. But this study has been not gotten very much attention. All I wondered if Ray had some comments on it as well. I absolutely agree. And I just want to underline how powerful that effect is with the antidepressants that are on the market today. They are very powerful indeed. They've been very helpful to us. But in the placebo controlled studies, fully

25 to 30 percent of the studies will show no difference between a placebo and a truly effective antidepressant. For twenty eight studies all to go in the same direction is truly remarkable. OK, well, thank you for calling me a friend of mine. I hope this has been helpful to you. All right. Thank you very much. And I'd like to take a call from Theresa from New York. Theresa, how can we help you? OK. My name is terrific and I'm taking lithium for the last 17 years and I've had a very successful time with it. My question is twofold, since I've had no mood swings at all since I'm taking it. And prior to that, when I was much younger at two hospitalizations, one for me and one for depression, would it be feasible to divorce for a while? Which I did actually. I went on for a year. I just to my body, rest of this tremendous amount of salt. I'm now back on because I was getting slightly depressed. But isn't it a good idea to go off once in a while? And also, is it true that a person of manic depression in all categories gets worse as one gets older?

Let's see what Dr. DePaulo thinks about that, and then I might have some thoughts about it. What do you think about? Well, I think two things, Theresa. Those are both good questions and they're ones that our patients or my patients certainly frequently bring to me. Firstly, I think in a sense, you've already done an experiment, number one. That is, you went off the medication and you saw that at least some of the symptoms came back. That's quite predictable and that's usually what happens. The fact that you've done so well for 17 years, therefore, is underlined that lithium clearly probably had a significant role in that. And so as long as you have no side effects from it, there is no evidence that, quote unquote, there is a salt buildup. Lithium is excreted by your kidneys very, very efficiently, as efficiently as sodium is OK. And we table salt every day. And I'm not worried about it building up. There are certainly some long term side effects that you need to monitor, but if you're free of those you're in, you're in good shape. So certainly if your kidney function is OK and your thyroid function is OK, then

I would say the evidence is very good that you could go 30 years or more on lithium without adverse problems. To the second question, does manic depressive illness get worse as you get older with age? And again, as a topic that's been talked about for a century now. And statistically, if you look at take 100 people, there will be a slight statistical increase in the number of episodes and their duration and perhaps even their severity. But that. Lee is not the case for everyone or necessarily even most individuals, the illness seems to run and certainly runs an episodic course, but there seem to be periods of time in people's lives where it gets better and periods of time when it's worse, a lot like asthma or migraine headaches that seem to come in clusters. But statistically, there is a slight tendency for them to get worse. And it's Fred can talk about in others, too. There are a number of theories about why that might be.

I don't think people, though, should assume that their death they're going to get worse. Well, I thank you very much. Great. Well, thank you very much for your call. Our next caller is Grace from Arizona. Grace, how can we help you? Well, I have the form of bipolar disorder, which is bipolar one form where you become psychotic. And I have very severe depressions that last nine months at a time. And I also have obsessive compulsive disorder. And my question is this. I became ill many years ago in the 70s, and it took a long time to get properly diagnosed and treated. And I think the only thing that kept me going to that time was my Christian trust and just plain stubborn determinism. But now are people getting diagnosed more quickly so they don't have to go through what I went through? And what can we do about the stigma about mental illness? There's so many people that suffer alone because they're just too ashamed or afraid of getting help because they'll lose the job or they'll lose friends or they'll lose family.

And I was just wondering what we could do to help those people. Well, first, Grace, people like you coming on the radio to talk about their own experience is very helpful in these stigmatization. And the efforts to do stigmatization are now extremely extensive throughout the country. There's still a long way to go. But I must say, just a few years ago, only one out of three people was getting treatment. Now, one out of two is seeking and getting treatment, which is still a long way to go, but a lot of progress. Dr. DePaolo was involved in a group in Baltimore that Depression Research and treatment group was called Durata. These patient run organizations, the National Depressive and Manic Depressive Association, the National Alliance of Mentally Ill, has been an explosion in these issues across the country. And a lot of prominent people coming out and pointing out that they they've had or have manic depressive illness or depression. And once you have people of real stature in the community, whether it's from the entertainment community or the political community, people in public life who come out and talk about their illness makes an enormous difference.

I wonder if Dr. DePaolo, he's been involved in this stigmatization effort for a long time. And perhaps you have some comments on that as well, right? Yeah, I'm delighted to hear Grace's call. And you're right on target, Grace. I would first point out that the National Depression and Manic Depressive Illness Association did a survey of their members and asked them when was what age they had their first symptoms of illness and then at what age did were they finally told by somebody they had manic depressive illness and the average delay was in excess of 10 years. And that is probably one of the biggest mental health problems we have one of the biggest public health problems we have, because if you don't make the right diagnosis, you really can't focus either the doctor's energy or your energy on specific treatments. And that's a great shame and causes a huge problem. But but that's not news to you. So but at least you know, and that's not good news, that you were not alone. As Fred said, it is getting better.

We can't tell you exactly how much better it's getting. I hope we'll be able to do some studies on that as well sometime soon. Well, that was very, very seriously ill. And my illness was a total disruption to my life for many, many years. And I would just like to tell people that if they get the right diagnosis and treatment, they can feel and function so much better and that there is hope if they just hang in there. Grace, thank you very much for calling in. And the mind has been very good questions. Thank you. OK, OK. Next on the line, we have Diane from Arizona. Diane, how can we help you? Hi. I was diagnosed with manic depressive disorder back in probably 90. And before that I would I've been seeking medical treatment since 85, but was never really diagnosed with manic depressive disorder till about 90. And I had a severe, severe breakdown in 92. A lot of stress in my life. I was losing my house and my kids are going to live with

their father. And I'm having a hard time getting back into society and enjoying, you know, life. And I was just wondering if you had any suggestions to make it, you know, maybe a little a little steps at a time. Dr. DePaolo might have some. Well, there are several things, Diane, that you want to go, there's almost a checklist you want to go down and to say, hey, look, why am I not getting back into the swing of things? I had this severe episode in 92. I had this stress at some point later. But but or I guess some point just around 90 to. But this is a long time from 92 to 98. And I would expect that if your illness were in complete control, that you probably would be back kind of under your own steam again. And and so the first question you want to ask you and your doctor is, am I depressed? Even when you have the illness, patients often don't recognize when their depression is back upon them. Many patients will define depression is only when they are

unable to get out of bed or when they feel so low they want to kill themselves. But there are many degrees of depression, as we've talked about before. And so if you don't have the energy, if you don't have the concentration or the stress resilience that you once did, that all those also might be signs of depression. So that's that's kind of one level. Yeah, I know. I know. Right now I'm dealing with depression. I my family, they like when I first started having mental illness and the doctor sent me home with pills, my mom came in, throw them away. She said, you don't need them that are. So it took a long time for her to come to realize that, yes, it is an illness and it needs to be treated. Is she supportive now? In a way. Yeah. She still doesn't understand it. I, I just fear that of that happening again in 92 because if I go through it again, Doctor, I, I won't make it. You know, it was, it was, it was very it's what I do to control my mania is I have I have very strong control and

it all builds up inside, you know, because I can feel that mania part in and kind of control. And it's it tears me apart. Let me underline slightly what I said before, but then let's go on to another thing that you might do to help. I mean, first off, I hear you and I know from your experience and others how painful it is to go through these illnesses and the and the stigma that people actually feel within themselves having. Yeah. Seen them themselves lose or control of their own ability to to to think or function emotionally. But it is also true that I often will tell my patients when they talk about that. I couldn't go through that again. If they mean by that that they are they think that they would take their life. That's when I say, gosh, I think that's your depression talking, OK? And if you're in a depression currently, I'd like to tell you, I think that your depression talking OK, the and I want you to get it, but I want you and your doctor to work hard to get that treated.

The other thing you might do, and this is something we talked about earlier, is to look for a support group. If you don't have enough support at home, sometimes you literally have to go out and find people that literally will be supportive of you for the particular problem you have. And the National Depression and Manic Depressive Illness Association, the Durata organization here in Baltimore, can both could help you direct you to support groups so that you could meet with other people and see that other people have gone through this and have survived not just two or three episodes, but five or six episodes and are still functioning. I think it's real important to know that that there is a tomorrow and this illness does have a tendency to relapse. We want to do everything we can to prevent it relapsing. But if it does relapse once, we want that to be the last relapse and relapse is twice. We don't want you to have three, OK? And as Dr. Goodwin said, it's something that literally I say word for word to my patients as well. The longer you're able to be stable, the greater the number

of forces are that keep you stable. That is, stability beget stability, so that every day that you work at this and are successful at it, that increases your durability of sustaining yourself in this illness. OK, well, thank you very much for your call. Thank you. All right. Bye bye. Bye. Right, the last caller talked about a fear of suicide, if this happens again, that's it. Why do you think that the suicide rate why do you think suicide is is so high in this illness compared to other illnesses in psychiatry? I think that the for those of us like yourself and myself who see patients almost exclusively with this illness, you know, from the experience of the patients, why it's so high, that is that the fundamental symptoms of the illness are ones that one cloud your thinking and particularly cloud your view of yourself. And they tend to take things that are neutral and turn them into disastrously

negative things and things that are good and turn them into modestly bad things so that there's a great distortion of things towards the negative. In particular, people at their worst tend to feel worthless and hopeless. That's pretty bad. And and that certainly is what motivates the suicidal behavior. And then you have these mixed states where they have all that hopelessness of the depression and all the energy of the mania is which is a very lethal combination. Absolutely. And in fact, to kind of review that for our listeners is that when patients get to a certain degree of depression that's unalloyed with any manic symptoms, they may not have the energy to or even the concentration to figure out a way to kill themselves. But as you point out, particularly with bipolar patients, if they get back their energy first and that they still have the self-loathing ideas, that suicide becomes a much more accessible to them. One of the things I've noticed, too, and I think you alluded to this, is that the fall

from that, from the mania, the hypomania, that sudden contrast when you can fall into the depression is so stark. You have sort of no no middle way station. I think that's what Diane was referring to. Yeah. That the despair of oh, my God, here I go again. And and particularly if they're if they're falling down in from a kind of hypomanic state, that that that degree of contrast is just so, so stark. And also there's the issue of substance abuse. It's we know now that over around 60 percent of bipolar patients will, at some time in their life, meet criteria for substance abuse, alcohol or drug abuse, which, of course, can diminish judgment or can increase or decrease impulse control, increase aggression, all of which can increase the risk of suicide. It can simply worsen the depression as well so that you've got the worst of all possible worlds, I think, in terms of suicide, when you have somebody with manic depressive illness and substance abuse.

Yeah. And of course, the good news is that recent lithium treatment data that I think we don't pay enough attention to, even just in the general field, that the fact that psychiatry has a treatment that saves lives and there may be many others that come along, and it may be that some of the newer treatments, the newer anticonvulsants, will be able to do the same thing. But right now we have a 30 year, thirty five year record with with this treatment that we need to remind ourselves of. That's absolutely right, Fred. I don't I don't think there's any way to overemphasize that. You know, what we'd like to do, of course, is to have data on all of our treatments and the ones that have been around the longest are the ones we do have the most data on. And I think there's some similar data on ECT that even though it's a treatment, that electroconvulsive therapy for severe depression or severe mania, that it also can prevent suicides, even though its impact is only last, probably for a matter of months. So if we can protect patients through these very difficult periods, that also is important. So there's there's a short term and a long term perspective as well.

All right. I want to have you back some time and talk about your genetic work. That sounds great, Fred. OK, thank you very much for having me. You can write to Dr. Ray DePaulo at Johns Hopkins University Medical Center, 600 North Wolseley Street, Baltimore, Maryland, zip to one to age seven. For more information on suicide prevention, you can call the American Foundation for Suicide Prevention at one 888 three three three two three seven seven. That's one eight three three three 23 77. We also want to repeat the number we gave earlier for depression screening. Free Screening for Depression is available to the National Depression Screening Hotline at one 800 five seven three four four three three. That number again is one 800 five seven three. Forty four. Thirty three. Log on to our website at WAFB, dot, the Infinite Mind dot com for more information about depression, manic depressive illness or anything you hear in the show, you can

reach us toll free at one eight eight eight three five oh mind to comment on today's show or to be a caller on a future program. That's one eight three five oh six four six three. Next week on The Infinite Mind, we'll take a look at humor. What makes it funny? Well, funny. And where in your brain does funny little? With comedian Margaret Cho, former Saturday Night Live writer and Beats and some other very funny people come to life with us next week on The Infinite Mind. Each week, we explore the new frontiers of the infinite mind right here on this public radio station. I'm Dr. Fred Goodwin. Thank you for joining me on this journey. If you have a comment about the infinite mind or would like to be a caller on an upcoming program, please call us toll free at one 888 three five oh mind. That's one eight three five oh six four six three.

The executive producer of The Infinite Mind is Bill Lichtenstein. The show was produced by June Peoples. Production manager Tamira Burgess, Associate Producer Eva Newberg Technical Direction by Gregory Seaton, Development and Outreach. Dan Miner with Kuduro Sawyer Original Music Art Labriola special thanks to Ceder Reiner and Elizabeth Alvarado intern Marianne Jaga, Legal Services, David Lubell, Accounting Services Akerman and Associates webmaster John Growe Hall announcer Catina Calan for a copy of this program called Birrell's Transcripts at one 800 777 text. That's one 800 seven seven seven eight three nine eight. You can visit our award winning website at one of the Infinite Mind dot com underwriting for this week's The Infinite Mind comes from the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, the American Foundation for Suicide Prevention, the Sage Foundation, and in the form of an unrestricted educational grant from Eli Lilly and Co.

additional support provided by Abbott Laboratories in the form of an unrestricted educational grant. And from the Dr. Eugene Garfield Foundation special thanks to Quintiles Specific Inc. Suicide Awareness, Voices of Education and listeners like you for providing additional support. This program was produced in association with WNYC New York and the New York Foundation for the Arts. The Infinite Mind is a nonprofit production of Lichtenstein Creative Media, Inc.. Copyright 1998.