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I'll Give You Two Wishes
News from the Department of Psychiatry and Behavioral Science
Mood disorders experts tell what’s needed. No hedging.
It was billed as an update on depression and bipolar disorder. But the talks that a panel from Hopkins’ Mood Disorders Center gave last November at the Dana Foundation’s offices in Washington reflect psychiatry’s wish list for the 21st century. They ranged from broad—Ray DePaulo’s declaration of an attack on mood disorders akin to the ongoing war on cancer—to James Potash’s suggestion of specific genes to target for such an attack. The speakers were passionate. “Prospects for ground-breaking discovery,” exclaimed Potash, “have never been better!” And like all wishes with a hope of getting realized, the additional two we report here are rooted in ability.
“For depression or bipolar disorder, the median time between the onset of patients’ symptoms and their getting appropriate treatment is six to eight years,” says psychiatrist Karen Swartz. “You can imagine the chaos that unleashes.” Swartz wants to whittle away that interval, starting with more universal, higher quality diagnosis.
“Say you go to your primary care doctor, as many first do for mood disorders, and are asked if you feel depressed. If you don’t think that applies to you—and only 50 percent of people with depression describe themselves as depressed—you’re far less likely to get the right diagnosis,” she says. Likewise, depressed patients without obvious symptoms, the numb and emotionally absent rather than the sad and teary, often slip through.
Because no biological markers exist for diagnosing mood disorders, clinicians rely on interviews. Carefully done, they’re accurate, Swartz says, but they require time and experience. “The vast difference in length of time that clinicians at specialized mood disorders centers spend with patients, compared with primary care,” she says, “can be crucial.” Misdiagnosed bipolar patients, for example, can slip into mania given standard drugs for depression. “An overall raising of patients’ and physicians’ awareness,” says Swartz, “will go a long way.”
A Magical Orange Grove
“American poet Robert Lowell, hospitalized 20 times for mania, spoke of that state as ‘the magical orange grove in a nightmare.’ He was describing mania’s early stages,” says psychologist and best-selling author Kay Jamison, who herself has bipolar disorder. “I nearly died from it on several occasions. It’s a very serious condition, one I’m not trying to romanticize. But moods don’t exist in a vacuum and it’s rare in life not to have some advantage along with disadvantage.” So begins Jamison’s wish for better, more sensitive medications for bipolar illness, ones that don’t damp creativity and energy as they calm mania.
Several years ago, Jamison’s study of 47 eminent visual artists and writers found that a striking number had been treated for mood disorders. Three-quarters had been prescribed lithium or antidepressants. As a group, poets were most at risk; fully half had been on medication or hospitalized. Research elsewhere shows those with bipolar illness or their families are more likely than others to score high on scales of creativity.
“Exactly what happens in these people with increased originality?” Jamison asks. “You don’t just speed up normal minds and get this.” She believes, instead, that changes occur in brain function and cognitive processing when episodes of mania break long periods of depression; they may spark a different kind of imagination or insight. Of course, she explains, the resulting glimmers appear only in mild depression or mania. “Clearly, no one is creating when they’re psychotic or lacking in restraint or severely depressed.”
Patients sometimes see psychiatrists “as enemy forces seeking to squash creativity,” Jamison adds. “Some say the medical community isn’t sensitive enough to their needs. Lithium and other mood-stabilizing drugs are, of course, essential. But in a minority, high doses can dampen thought and limit the range of emotion or perception.” That pushes patients to stop medications, she says. And with that, bipolar illness typically worsens. “The real task of imaginative, compassionate treatment is to give all patients meaningful choices, ones that don’t sacrifice crucial emotions and feelings.” With better understanding of the biology, she says, that will come
MORE THAN A CLINIC
Breadth and diversity mark mood center.
For more than 25 years, clinicians with the Johns Hopkins Mood Disorders Center have offered excellent care to thousands of patients with depression or bipolar illness. With an unusual breadth, the Center offers specialized inpatient, outpatient and day hospital services for adults, adolescents and children—the latter especially in demand as U.S. primary care mental health services have dwindled for those under 20.
Research vitalizes the Center. Its bench scientists investigate the genetics and biology of depression, suicide and bipolar disorder, helped by access to Hopkins’ core facilities in the basic sciences and brain imaging expertise. Its clinical researchers tackle understudied but key areas such as treatment noncompliance, effects of mood-altering medications on thinking ability, ties between temperament and mood disorders, depression linked with cardiac illness and suicide prevention.