Which came first, the condition or the drug?

Mikkel Borch-Jacobsen

  • Mania: A Short History of Bipolar Disorder by David Healy
    Johns Hopkins, 296 pp, £16.50, May 2008, ISBN 978 0 8018 8822 9

Early in the morning on 13 December 2006, police officers from the small town of Hull, Massachusetts, near Boston, arrived at the house of Michael and Carolyn Riley in response to an emergency call. Their four-year-old daughter, Rebecca, had been diagnosed with bipolar disorder two years earlier. When the officers reached the house, they found Rebecca sprawled on the floor next to her teddy bear. She had died from an overdose of the medication cocktail prescribed by her psychiatrist, Kayoko Kifuji. At the time of her death, she was taking Seroquel, a powerful antipsychotic drug, Depakote, a no less powerful anticonvulsant and mood-stabilising drug, and Clonidine, a hypotensive drug used as a sedative.

Rebecca’s parents were charged with first-degree murder, but her doctor’s role must also be questioned. How could she have prescribed a two-year-old psychotropic medications normally intended for adults suffering from psychotic mania? Yet the medical centre where Rebecca had been treated issued a statement describing Dr Kifuji’s treatment as ‘appropriate and within responsible professional standards’. In an interview with the Boston Globe, Janet Wozniak, director of the paediatric bipolar programme at Massachusetts General Hospital, went even further: ‘We support early diagnosis and treatment because the symptoms of [bipolar] disorder are extremely debilitating and impairing … It’s incumbent on us as a field to understand more which pre-schoolers need to be identified and treated in an aggressive way.’ On 1 July 2009, a Plymouth County grand jury dropped all criminal charges against Dr Kifuji. Carolyn and Michael Riley were respectively convicted of second and first-degree murder earlier this year.

How did we come to this? In Mania: A Short History of Bipolar Disorder, David Healy goes back to the Greeks and Romans in search of an explanation. There are good reasons for this. Very few people had heard of bipolar disorder before 1980, when it was introduced in the DSM-III – the diagnostic manual of the American Psychiatric Association – and it was only in 1996 that a group of doctors from Massachusetts General Hospital, led by Joseph Biederman and Janet Wozniak, first proposed that some children diagnosed with attention-deficit/hyperactivity disorder might in fact suffer from bipolar disorder. But whoever googles ‘bipolar disorder’ today is likely to learn that the illness has always been with us. It’s just a new name, we are told, for what used to be called manic depression, a mood disorder characterised by oscillations between states of manic hyperactivity and deep depression which had already been described by Hippocrates and other ancient physicians. It is often added that Newton, Van Gogh, Schumann and Boltzmann suffered from the disorder, and even that they owed their genius to it.

Healy has no trouble demonstrating that this history is a retrospective illusion. While the Greeks did indeed speak of mania and melancholia, these terms covered all sorts of hyperactive deliriums and lethargic stupors, the majority of which were probably caused by infectious or post-infectious states, or perhaps by Parkinson’s disease or hypothyroidism. Ancient physicians limited themselves to the visible physical manifestations of the diseases they described, so we have no way of knowing if these corresponded to what we today categorise as bipolar disorder. Even when they established a link between melancholia and mania without fever, as Soranus of Ephesus and Aretaeus of Cappadocia did, they may well have been describing fluctuations of psychotic agitation unrelated to mood swings.

Bipolarity in the modern sense could not have emerged until it became possible to identify mood disorders without delirium or intellectual disorders; in other words, it required a profound redefinition of what had until then been understood as madness or insanity. This development started at the beginning of the 19th century with Esquirol’s ‘affective monomanias’ (notably ‘lypemania’, the first elaboration of what was to become our modern depression) and led in 1882 to Kahlbaum’s ‘cyclothymia’ and ‘dysthymia’, two mood disorders that he firmly distinguished from what he called ‘cyclical insanity’ (Irresein). The identification of bipolarity also required the researcher to be in a position to observe and compare the course of various psychical disorders over the long run, which, as Healy points out, could be done only once mentally ill people were gathered in asylums. Before this, it would have been impossible to identify, as Jean-Pierre Falret and Jules Baillarger did independently in 1854, a ‘circular insanity’ or folie à double forme characterised by a regular alternation of manic excitation and melancholic depression. In 1899, Emil Kraepelin wove all these threads into what he proposed to call ‘manic-depressive insanity’, to distinguish it from dementia praecox (later renamed ‘schizophrenia’ by Eugen Bleuler).

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