The Ups and Downs of Manic-Depressive Illness

by Food and Drug Administration (FDA)

German composer Robert Schumann led a life of extreme ups and downs. In 1833, at the age of 23, he attempted suicide; in 1840, he experienced a period of inexplicable, great elation. Then in 1844 he fell into another deep depression, with another "up," or "manic," period five years later. In 1853, his mental illness forced him to resign as musical director of the Dusseldorf Symphony Orchestra, and a year later, he tried to kill himself by jumping into the Rhine River. He was rescued and placed in an asylum, where he died two years later of self-imposed starvation.

Some of Schumann's musical compositions noticeably reflect his dramatic mood swings. One account of the composition "Carnaval" describes the part called Florestan as the product of an "emotional, impulsive, stormy extrovert," yet attributes another portion, called Eusebius, to a "quiet introspective dreamer."

Robert Schumann suffered from manic-depressive illness, also known as bipolar disorder. This condition affects 1 percent of the U.S. population at some time in their lives. Periods of expansive, hyperactive thinking and behavior with elevated mood occur in sharp contrast to periods of extreme despair and sadness. Either phase can greatly disrupt a person's life.

Other gifted artists, writers, poets, and composers who suffered from manic-depressive illness include Walt Whitman, Cole Porter, Tennessee Williams, Mark Twain, Edgar Allen Poe, Sylvia Plath, and Vincent van Gogh. The incidence among creative people is 10 to 20 times greater than that of the general population, according to Kay Redfield Jamison, professor of psychiatry at Johns Hopkins University School of Medicine, who has studied manic-depressive illness and its effects on the creative community.

But bipolar disorder also makes plenty of regular folk miserable. Two million people in the United States have the condition, and researchers estimate that a third of them receive no treatment. Untreated, the suicide rate is 15 percent.

Treatment Options

For many years, the standard treatment for manic-depressive illness has been lithium, a pure chemical sold under many brand names, including Carbolith, Duralith, Lithobid, Lithizine, Eskalith, and Lithane. It is the best-studied drug to treat manic-depressive illness, and is effective not only in the acute treatment of mania, but also in long-term prevention of relapses.

While effective in many people, lithium also brings significant side effects to some. In May 1995, FDA approved the anti-seizure drug Depakote (divalproex sodium) for a new use: short-term treatment of manic depressive illness. It is not yet known whether the drug is effective in preventing relapses over the long term.

"This is a different bullet in the armamentarium against this illness. It has been widely used to treat mania for years. What's new is clinical trial evidence showing that it's efficacious," says Steven Hardeman, consumer safety officer at FDA's division of neuropharmacological drugs.

Depakote has been approved in the United States to treat seizures since 1983. The formulation has since been altered slightly to minimize gastrointestinal side effects. The drug may be helpful for some of the 30 to 40 percent of people with manic-depressive illness who do not respond to lithium.

Eighteen-year-old Melissa Kluth, who lives in upstate New York, has been taking Depakote to treat manic-depression for a few months. While her experience may not run true for all persons who try Depakote, Kluth, who never took lithium, says she feels like a new person. "When I'm off the medication, if you say anything to me, I get angry. I scream and yell and kick and throw chairs. When I'm on the medication, I'm fine; nothing bothers me," she says.

Diagnosing Mania

Depakote and lithium treat the mania portion of bipolar illness. Jack Gorman, M.D., deputy director of the New York State Psychiatric Institute, describes mania's distinctive symptoms: "The patient becomes very hyperactive. He or she doesn't sleep, and doesn't need to sleep. Thoughts race, and they talk very, very fast. They may be hypersexual and spend huge amounts of money. They get in all kinds of trouble, fights, even car accidents. Most people are diagnosed in their early 20s after having a few depressive episodes, and then a manic one."

To diagnose manic-depressive illness, a psychiatrist compares a patient's symptoms with the diagnostic criteria for the disorder in the fourth (1994) edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. DSM-IV distinguishes two variants. Bipolar I consists of major depression and mania. Bipolar II includes major depression and a milder form of mania called hypomania. The manual classifies manic-depressive illness as a "mood disorder," a designation that also includes altered mood due to a medical condition or taking a mood-altering substance.

In diagnosing manic-depressive illness, sometimes psychiatrists also consult scales and behavioral assessment tests that are more commonly used in clinical studies. These tools help assess signs such as elevated mood, diminished need for sleep, excess energy and activity, grandiosity (feeling that one can do anything), racing thoughts, poor judgment, irritability, and fast speech.

As is the case for many mental illnesses, the causes of manic-depression aren't at all clear, although there are inherited components. Yale University professor of psychiatry Joel Gelernter, M.D., describes the causes of manic-depressive illness as "utterly unknown" in an editorial in the May 1995 issue of the American Journal of Human Genetics. But in some cases, the condition, or susceptibility to it, appears to be inherited. A flurry of research reports in 1987, 1994, and 1996 trace the illness to specific chromosomes in a few very large families, but different studies point to different chromosomes. This indicates that there may be several ways to inherit the condition.

Twin studies — another way of looking for genetic clues — also suggest an inherited tendency to manic-depressive behavior. Several studies show that if one identical twin has the illness, chances are from 70 to 100 percent that the other twin does, too. Among identical twins reared apart, the probability of both suffering from manic-depressive illness is two-thirds, suggesting an inherited predisposition that persists even when identical twins are raised in very different environments. Among fraternal twins, who, unlike identical twins, are no more closely related genetically than are any two siblings, the chance that the second twin is affected is only 20 percent.

About the Author

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