In his emmy-award-winning BBC documentary The Secret Life of the Manic Depressive, Stephen Fry observes that Hollywood seems to embrace the individual with bipolar disorder.
While stigma may exist in other domains, the entertainment industry is energised by the creativity and magnetism of the mildly elated. In one poignant scene, the actress Carrie Fisher (best known for playing Princess Leia in Star Wars) describes what it is like to be manic – the loss of sleep, the sense of power, the accelerated flow of ideas, the frustration with others who cannot keep up; what starts out as pleasant soon becomes intolerable and frightening.
And, of course, she is not alone. Ambassadors for the empowered patient include the actor Richard Dreyfuss and the late comedian Spike Milligan, while speculative diagnoses exist for historical figures such as Winston Churchill, Vincent van Gogh and the German composer Robert Schumann.
Schumann began to worry about his mental health from his early twenties. His writings suggest he suffered from melancholia (depression) alternating with periods of excessive exaltation (mania). As he became gradually more unwell, he increasingly heard voices and strange noises for which he could not account, and developed a worsening paranoia of metal instruments and certain types of music. At the age of 44, he jumped from a bridge into the Rhine and had to be rescued by a boatman. In 1854, he retired to a private asylum in Endenich near Bonn, where he died just two years later.
What does bipolar disorder feel like?
‘Manic depression’ – the old term for bipolar disorder – was first coined by the German psychiatrist Emil Kraepelin to describe a relapsing and remitting illness marked by distinct periods of mania, hypomania (a less severe and briefer form of mania) and depression, each usually lasting weeks or months and interfering with the ability to lead a normal life while unwell. The depressive episodes unsurprisingly involve a pervasively low mood, a diminished sense of pleasure, enduring fatigue, unwarranted feelings of guilt, an inability to sleep and a loss of appetite.
But what about the mania? Imagine for a moment that the last decent night sleep you got was a week ago. But instead of feeling tired, you feel more and more energised. What begins as a persistent sense of joy soon evolves into an increasing irritation. You are more creative, but soon so many new ideas flood your brain that your body cannot keep up. You talk so intensely that nobody can interrupt you.
On Tuesday, you shouted at your boss during a meeting and, on Wednesday, you began an illicit affair – both quite out of character. You feel invincible; you are the cleverest, most charismatic person you know. So much so, you placed a down-payment on that Ferrari you have always deserved.
But now you begin to wonder if the bank is monitoring your actions through your computer. Indeed, like Schumann, you are now one of the 20% of individuals with acute mania who experience psychotic symptoms such as delusions (fervently believing things that are not true) and hallucinations (hearing or seeing things that are not there).
What causes bipolar disorder?
So, why does bipolar disorder affect some people and not others? There is no definitive answer to this but well-researched theories do exist. Certain factors make you vulnerable but you will probably not develop bipolarity without significant stress.
Genetics probably plays a role; family members of individuals with bipolar disorder have an increased risk of both major depression and bipolarity. Some experts have suggested a bipolar advantage, in that exceptionally creative and successful people sometimes have close relatives with the disorder; indeed, people with bipolar disorder are often very talented individuals themselves. Other potentially-causal factors include sleep deprivation, street drugs and social stressors, especially interpersonal conflict.
According to the World Health Organisation, bipolar disorder is responsible for more years lost due to ill health, disability or premature death than cancer, epilepsy or Alzheimer’s disease. This is partly because bipolar disorder first affects people when they are young – typically between the ages of 15 and 40. One in every 100 babies born will acquire it at some point during their lifetime, and thus even conservative estimates suggest seventy million people worldwide have the disorder.
The tragedy is that 10-15% of such individuals die by suicide. Moreover, according to a recent international study, less than half of those with bipolarity receive mental health treatment, a figure that drops to 25% in low income countries. Significant social stigma and lack of adequate mental-healthcare funding are two obvious reasons for this.
Treating bipolar disorder
And yet, bipolar disorder is very treatable. Early intervention helps, involving an assessment by a multidisciplinary psychiatric team. Medication is important for targeting symptoms, but any decent strategy should be agreed with the individual so that their recovery goals are central. Short-term antipsychotics and longer-term mood stabilisers have a particularly good evidence base.
The Australian psychiatrist John Cade first used lithium to treat bipolar disorder in 1948 and the medication remains highly effective and widely prescribed today. Other useful mood stabilisers include lamotrigine and sodium valproate, but recent warnings implore they be used very cautiously in women of childbearing age.
And medication alone is not enough. Real recovery usually involves cognitive behavioural therapy (CBT), structured courses such as the Wellness Recovery Action Plan (WRAP) and the avoidance of street drugs. Support for family members is crucial. Knowledge of the early symptoms for a given individual will help avert a relapse. Finally, important lifestyle strategies include mindfulness, a healthy diet, regular exercise and a well-structured daily routine in which intense stress is avoided.
Can you live with bipolar disorder? Poignantly, Stephen Fry asked his interviewees whether, given the chance, they would forfeit their bipolar disorder. In the end, most said they would not. One went on to remark: “If you’ve walked with angels, all the pain and suffering is well worthwhile”. Many people with bipolarity are content with their lives. It has given them something positive they might not otherwise have had. Even Schumann, in his time, might have said the same.
Dr Stephen McWilliams is a consultant psychiatrist and author. He is clinical lead of the Psychosis Programme at Saint John of God Hospital, Stillorgan, Co Dublin. Useful websites: www.stjohnofgodhospital.ie / www.detect.ie / www.aware.ie /