Moodswing - Dr. Fieve on Depression: The Eminent Psychiatrist Who Pioneered the Use of Lithium in America Reveals a Revolutionary New Way to Prevent Depression
By Ronald R. Fieve, M.D.
When I wrote the first edition of Moodswumg, it was to tell the story of my search for antidepressant treatments for those suffering from manic and suicidal feelings and of the breakthrough that my use of lithium achieved.
In the years since Moodsuring was first written, the treatment of mental illness has undergone major changes. No longer are most depressions treated with long and expensive courses of psychotherapy. A wide array of safe and effective antidepressants is now available to treat chemical imbalance.
New modes of health care have sprung up. Practitioners known as psychopharmacologists, who are experts in using medications to treat chemical imbalance, now treat depressions, panic and anxiety disorders, eating disorders, attention deficit disorder, alcoholism, and addictive disorders. Today these disorders are better understood by the general public, and they are best treated by the psychopharmacologist rather than by the general psychiatrist or clinic.
The hour spent weekly talking to the psychiatrist is largely obsolete. It has been replaced by a fifteen-minute visit with a psychopharmacologist-once a week in the beginning, and later once a month. During these visits the blood levels of drugs are measured if necessary, side effects are checked, and medications adjusted. In addition, the patient may discuss stresses and problems with a psychologist or therapist and meet with a peer support group. The cost of this treatment is far less than that of traditional psychotherapy, and quality care is available to all segments of society, including patients in remote areas.
We continue to search for biological markers to give the clinician a blood or urine test by which to determine whether a major depressive disorder or manic-depression is present. The genetics of mood disorders and behavior responses to medications are also being studied in a number of clinical laboratories throughout the world. These include my own at the Atchley Pavilion, Columbia-Presbyterian Medical Center, and groups we collaborate with in midtown Manhattan, elsewhere in the U.S., and abroad.
There have been major advances in diagnosis, including the concept of dual diagnosis, the notion that the patient has an underlying major psychiatric illness, superimposed on which is another major illness, such as alcoholism or drug abuse. One of the most common problems seen by physicians in the 1990s is substance abuse. But many people suffering from such abuse are actually victims of an underlying depression or panic disorder they may be trying to medicate on their own with addictive substances. In most cases, once the underlying disorder is treated with antidepressants, the addiction, which is usually slow and difficult to cure by itself, can be eradicated more easily with the help of twelve-step programs, such as Alcoholics Anonymous, and support group treatments.
The concept of depression has been expanded to include more than a blue mood or suicidal thoughts. Today we are seeing more and more patients with mild chronic depression, lack of pleasure in life, low energy, and low self-esteem. These individuals are often shy, with a tendency to social phobia. Such men and women suffer from a very harmful form of depression called dysthymia, literally "bad mood." These people, who often have been in psychotherapy for years, are usually chronic underachieves, unhappy on the job and at home. They and their physicians usually do not recognize that they have a treatable depression.
As for lithium, it has gained worldwide use and popularity since Moodswing was first written. It is now the standard treatment for manic-depression and many other forms of depression, and it is used by most psychopharmacology specialists throughout the world. Lithium has helped patients and their families avoid untold weeks and years of disruption and emotional suffering. I would estimate that the use of psychotherapy and psychoanalysis alone to treat depressed patients has decreased by at least 50 percent.
With each year, researchers come closer to understanding how brain neurotransmitter hormones (such as seratonin and norepinephrine) control the nervous system and affect mood and behavior. It is now widely accepted that much of our behavior is affected by our individual biochemical profile. As the stigma is removed from mental illness many new issues need to be addressed. Will our judicial system eventually be more forgiving of behavior that is biogenetically caused (and which eventually can be biochemically corrected)? How accountable for his or her behavior is an individual with a biochemical imbalance? How do we monitor the mental health of some of our national leaders?
Surprisingly, some mood disorders can be at times highly beneficial. As I pointed out in the first edition of Moodswing, there have been throughout history and are today many highly productive and creative individuals who suffer from manic-depression or depression. Outstanding figures in government, finance, the arts, business, and science often succeed because they have what I call the bipolar llB advantage. These men and women have a milder form of bipolar manic-depressive illness. They benefit enormously from the periods of high mood and high functioning that often accompany this form of the mood disorder. One day researchers may demonstrate that this beneficial form of bipolar illness has its own biogenetic and behavioral profile. In my practice I have seen hundreds of outstanding men and women who contribute enormously to society who suffer from mild moodswings. However, these often spectacular achievers only come to see me for help when their beneficial highs have cycled into a low.
Today the outlook for a patient suffering from depression is bright, for he or she is experiencing a treatable biochemical imbalance. Researchers are constantly looking for new antidepressants that work faster, more effectively, and with fewer side effects, and many new medications continue to appear on the market each year.
No one needs to live with depression. Most depressions are curable with the right treatment. If you or someone you care about is suffering from painful or even suicidal depressed feelings, I recommend consulting a psychopharmacology specialist.
There is more hope than ever for the millions who suffer from the debilitating emotional illness of mood disorders- and in this revised edition I have tried to share it all with you.
The Biochemical Revolution
What is being done today for people who are overcome by feelings of low energy and depression? What happens to the superachievers in business, politics, and the arts whose extremes of elation become irrational and psychotic? What is the promise of the revolutionary chemical treatments now available in psychiatry for depression and elation?
Depression is the most common psychiatric problem for which people seek help, and it may have caused more anguish and suffering throughout the world than any other medical or psychiatric illness. Because of its pleasurable aspect, elation has been less talked about, and regarded as an illness only in its most immoderate forms.
Moods of deep depression and elation were described by Old Testament writers and by early Greeks and Romans. Philosophers, historians, poets, and novelists have accepted mental depression that returns from time to time as a part of the human condition, ranging from inexplicable moments of misery or joy to prolonged periods of extreme despondency or elation indicating serious mental derangements. Disorders of mood throughout the centuries have been misdiagnosed and, at the very least, unsuccessfully treated until recently. Those that have not led to suicide have often remained uncontrollable, even in the hands of experts.
What I have to say in the pages to follow may startle many who believe primarily or exclusively in the psychological approaches to depression. Anyone who has kept abreast of the new biochemical advances for treatment and prevention of mood disorders, however, will know that we are now undergoing our third and most spectacular revolution in the treatment of emotional states. In particular, we have witnessed for the first time a major biochemical breakthrough with the use of lithium for the treatment and prevention of manic-depression and recurrent depression. These chemically treatable mood disorders can now be easily recognized in normal people, and are characterized by what I refer to as recurrent moodswing.
I have treated thousands of patients with moodswing, first as a psychoanalyst and in later years as a psychopharmacologist-a psychiatrist who approaches emotional disorders with drugs to alter or correct abnormal or faulty body chemistry. When the primary treatment of manic-depression or recurrent depression has required the patient to talk with me about his or her problems-the so-called psychotherapeutic or psychoanalytic approach-in my experience not very much has happened.
The first time I became aware of the perplexities of manic-depression was in the fall of 1954, during my fourth year of psychiatric clerkship at the Harvard Medical School. I was assigned to treat a thirty-three-year-old woman in a deep and uncommunicative depression. Since the principal teaching at that time was psychoanalytic, I spent most of my evenings in the library reading Freud, hoping that I would discover some explanation for the unwillingness of my patient to talk with me. Daily I sat with her for at least an hour, probing all the possible reasons why she might be so deeply hurt, saddened, and depressed, but all to no avail.
One morning I returned to have another psychotherapy session with her, and to my great astonishment she was not the same despairing, noncommunicative woman I had known. Instead, I was confronted with a wild, talkative, and seductive female. In her new, elated manic state, her activity was unstoppable. For two weeks nothing I did had any effect on calming her ecstasy, other than the use of heavy sedatives and restraints that were temporary and relatively ineffective. After several consultations with senior psychiatrists, electroshock treatments were ordered, and for the first time as a student I observed the effects of this therapy-a dramatic, although brief, one-month remission of her symptoms. Then once again she switched into her deep and suicidal depressed state. I remember feeling perplexed and confused, and I considered it a personal defeat. After months of my trying to help this patient, the cure I had hoped to bring about had not been achieved at all. Instead, a harsh, drastic, electric shock machine, rather than a warm, understanding human relationship, had been necessary to relieve her acute suffering; even so, no long-range cure had been effected, for her depression recurred.
During the years that followed, I completed a medical internship and residency in New York. While I was going through three years of psychiatric residency at Columbia-Presbyterian Medical Center and the New York State Psychiatric Institute, I rarely met with the diagnosis of manic-depression again. It had virtually disappeared. During the 1950s most cases of excitable, talkative, and elated behavior were being diagnosed as schizophrenia. The new phenothiazine tranquilizers, effective in schizophrenia and some excited states, were being given exclusively.
From 1959 until mid-1970 I was in charge of the acute psychiatric service at the New York State Psychiatric Institute, and word had spread from Australia and Denmark of promising results from the use of lithium carbonate in treating manic-depression. Researching the world literature on lithium was a relatively easy task in 1959, since it consisted of only a few reports from abroad. I soon read that lithium carbonate was a simple white powder found in mineral water and rocks, a naturally occurring salt. I found that it could be given to excited manic patients by mouth in capsule form. And according to the reports by its Australian discoverer, John F. Cade, it would calm manic excitement in five to ten days.
My first research trials of this drug on hyperactive and elated manics resulted in a dramatic calming of their symptoms. Furthermore, with the correct dosage of lithium, there seemed to be no side effects, unlike the chemical straitjacketing of the patient that often resulted from use of the major tranquilizers. I had seen this latter effect in acutely agitated patients for whom massive doses of tranquilizers were required to slow them down and induce sleep. In the process, side effects-retarded body movement, a masklike face with little expression, a zombielike appearance-were usually evident. Manic patients calmed on lithium, in contrast, were perfectly normal. Their overactivity, talkativeness, seductiveness, playful tie pulling, and high energy levels were quickly dampened, and they were ready for discharge in a few weeks. Previously, these same patients had received months or even years of electroshock therapy, multiple drugs, psychotherapy, and psychoanalysis. During the three years I spent in psychiatric training, the additional five years of formal psychoanalytic training, and the years I have spent in psychiatric research, I have not found another treatment in psychiatry that works so quickly, so specifically, and so permanently as lithium for recurrent manic and depressive mood states.
While working with lithium, I have also watched the alcoholic's high, followed by his or her crash into depression, which resembles and is therefore often confused with the manic-depressive cycle. Studies now indicate that manic-depression and alcoholism go hand in hand and may be related genetically. Furthermore, over the years, it has become apparent that cocaine, heroin, alcohol, marijuana, amphetamines, potentially addictive tranquilizers, and sleeping pills are frequently used by depressed people in our society in an attempt at self-treatment of their mood disorders. Instead of curing the depression, these drugs worsen it and add the dangerous problems of alcoholism and/or drug addiction.