Anatomy of an Epidemic (29 page)

Today, bipolar illness is a far cry from what it once was. Prior to the psychopharmacology era, it had been a rare disorder, affecting perhaps one in ten thousand people. Now it affects one in forty (or by some counts, one in twenty). And even though most patients today—at initial diagnosis—are not nearly as ill as the hospitalized patients of the past, their long-term outcomes are almost incomprehensibly worse. In his 2007 review, Baldessarini even detailed, step by step, this remarkable deterioration in outcomes. In the pre-drug era, there was “recovery to euthymia [no symptoms] and a favorable functional adaptation between episodes.” Now there is “slow or incomplete recovery from acute episodes, continued risk of recurrences, and sustained morbidity over time.” Before, 85 percent of bipolar patients would regain complete “premorbid” functioning and return to work. Now only a third achieve “full social and occupational functional recovery to their own premorbid levels.” Before, patients didn’t show cognitive impairment over the long term. Now they end up nearly as impaired as those with schizophrenia. This all tells of an astonishing medical disaster, and then Baldessarini penned what might be considered a fitting epitaph for the entire psychopharmacology revolution:

The Transformation of Bipolar Disorder in the Modern Era

This information is drawn from multiple sources. See in particular Huxley, N. “Disability and its treatment in bipolar disorder patients.”
Bipolar Disorders 9
(2007): 183–96.

We are now coming to the close of our examination of the outcomes literature for the major psychiatric disorders (for adults), and a return to Martin Harrow’s fifteen-year study on schizophrenia outcomes brings it to a climactic end. In addition to following schizophrenia patients, Harrow studied a group of eighty-one patients with “other psychotic disorders” that would have been described by Kraepelin as a manic-depressive cohort. There were thirty-seven bipolar and twenty-eight unipolar patients in this group, and the remaining sixteen had various milder psychotic disorders. Nearly half of this group stopped taking psychiatric medications during the study, and thus Harrow really had four groups he followed: schizophrenia patients on and off meds and manic-depressive patients on and off meds. Before we review the results, we can run a quick check of our own thoughts: How should we expect the long-term outcomes of all four groups to stack up?

Go ahead—take out a pencil and jot down what you believe the results will be.

Here are his findings. Over the long term, the manic-depressive patients who stopped taking psychiatric drugs fared pretty well. But their recovery took
time
. At the end of two years, they were still struggling with their illness. Then they began to improve, and by the end of the study their collective scores fell into the “recovered” category (a score of one or two on Harrow’s global assessment scale). The recovered patients were working at least part-time, they had “acceptable” social functioning, and they were largely asymptomatic. Their outcomes fit with Kraepelin’s understanding of manic-depressive illness.

The manic-depressive patients who stayed on their psychiatric medications did not fare so well. At the end of two years, they remained quite ill, so much so they were now a little bit
worse
than the schizophrenia patients off meds. Then, over the next two-and-one-half years, while the manic-depressive and schizophrenia patients who were off meds improved, the manic-depressive patients who kept taking their pills did not, such that by the end of 4.5
years, they were doing markedly worse than the schizophrenia off-med group. That disparity remained through the rest of the study, and thus here is how the long-term outcomes stacked up, from best to worst: manic-depressive off meds, schizophrenia off meds, manic-depressive on meds, and then schizophrenia on meds.
⁶⁹

Schizophrenia, of course, has long been the psychiatric diagnosis with the worst long-term prognosis. It is the most severe mental illness that nature has to offer. But in this NIMH-funded study, two groups of medicated patients fared worse than the unmedicated schizophrenia patients. The results tell of a medical treatment gone horribly awry, and yet they do not come as a surprise. Anyone who knew the history of the outcomes literature in psychiatry, a history that began to unfold more than fifty years ago, could have predicted that the outcomes would stack up in this way.

In terms of contributing to our modern-day epidemic of disabling mental illness, the bipolar numbers are staggering. In 1955, there were about 12,750 people hospitalized with bipolar illness. Today, according to the NIMH, there are nearly six million adults in the United States with this diagnosis, and according to researchers at the Johns Hopkins School of Public Health, 83 percent are “severely impaired” in some facet of their lives.
⁷⁰
Bipolar illness is now said to be the sixth leading cause of medical-related disability in the world, right behind schizophrenia, and in the near future, as more and more people are diagnosed with this condition and put on drug cocktails, we can expect that bipolar will climb past schizophrenia and take its place behind major depression as the mental illness that fells the most people in the United States. Such is the fruit, bitter in kind, born from the psychopharmacology revolution.

15-Year Outcomes for Schizophrenia and Manic-Depressive Patients

In this graphic, the group labeled “manic depressive” consisted of psychotic patients with bipolar illness, unipolar depression, and milder psychotic disorders. Source: Harrow, M. “Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications.”
The Journal of Nervous and Mental Disease
, 195 (2007): 406–14.

I interviewed more than sixty people with psychiatric diagnoses for this book, and roughly half at some point had been diagnosed as bipolar. Yet of the thirty or so who got that diagnosis, only four suffered from what might be called “organic” bipolar illness, and that is to say they were hospitalized for a manic episode and had no prior exposure to illicit drugs or antidepressants. Now that we know what science has to tell us about the modern bipolar boom, we can revisit the stories of three people we met in
Chapter 2
, and see how their stories fit into that story of science. Then we can hear from two people diagnosed with bipolar who, if they had been enrolled in Harrow’s fifteen-year study, would have fallen into his “off-meds” group.

If we look at Dorea Vierling-Clausen’s story now, we can see that she has good reason to believe that she should never have been diagnosed with bipolar illness. She went to see a therapist in Denver because she cried too much. She had no history of mania. But then she was prescribed an antidepressant and starting having trouble sleeping, and soon she had a bipolar diagnosis and a prescription for a drug cocktail that included an antipsychotic. A bright teenager
had been turned into a mental patient, and Dorea would have continued to be one for the rest of her life if she had not weaned herself from the drugs. When I last spoke to her, in the spring of 2009, she was aglow with the blush of motherhood, as she had recently given birth to a son, Reuben. She and Angela were busily raising their children, with Dorea planning shortly to resume her postdoctoral research at Massachusetts General Hospital, the memory of her “bipolar” days receding into an ever-more-distant past.

During the time that I worked on this book, Monica Briggs was the one person who, after an initial interview, got off SSDI (or SSI). She secured a full-time position with the Transformation Center, a peerrun organization in Boston that focuses on helping people “recover” from mental illness, and if you parse her medical story, it’s easy to see that her return to work was related to a change in her medication.

When we first met, I mentioned to Monica the risk of antidepressant-induced mania, and as she remembered back to her breakdown at Middlebury College, a light went on: “I got manic within six weeks of being put on desipramine,” she said. “I’m sure that’s what happened to me.” After that initial manic episode, she was prescribed a drug cocktail that included an antidepressant, and she spent the next twenty years cycling in and out of hospitals, struggling constantly with depression, manic episodes, and suicidal impulses. Psychiatrists put her on eight or nine different antidepressants, and she also went through a series of electroshock treatments. None of this worked. Then, in 2006, she “casually” stopped taking an antidepressant. For the first time, she was on lithium alone, and bingo—the suicidal feelings went away, as did the depression and mania. That symptom relief is what enabled her to work full-time, and now, as she looks back on the horrible twenty years, she is stunned by what she sees: “I have not yet recovered from the immensity of the likelihood that my roulette game with antidepressants exacerbated my illness.”

Steve Lappen, who is a leader of the Depressive and Bipolar Support Alliance in Boston, was diagnosed with manic-depressive illness in 1969, when he was nineteen years old. He was one of the four people I interviewed whose manic-depressive illness was “organic” in kind, and on the first day we met, he was in something of a hyper state, talking so fast that I quickly put my pen away and took out a tape recorder instead. “OK,” I told him, “fire away.”

Raised in Newton, Massachusetts, in a family he describes as dysfunctional, Steve got tagged with the “bad apple” label early in life, both by his teachers at school and his parents at home. “I was disruptive in class,” he says. “Every day, during the pledge of allegiance to the flag, I would go sharpen my pencil. I would also get up without provocation and just spin around until I was overcome with dizziness. I would announce that I was a tornado.” He struggled with mood swings even as a kid, and at age sixteen, while hospitalized for fainting spells, he jumped out of bed one night and donned a white coat. “I went around to patient rooms and had conversations as if I were a doctor. I was manic.”

During his first year at Boston College, he was hit by a bout of severe depression. His was a classic case of true manic-depressive illness, and Kraepelin would have recognized the course his illness took over the next five years. “I didn’t take medication,” he explains, and while he suffered several bouts of depression, he did well in between those episodes, particularly when he was in a slightly hypomanic state. “When I was feeling well, I would read more, and I would write papers that weren’t due for two or three months,” he says. “When you are hypomanic, your output is remarkable.” He graduated with a double major in philosophy and English, with nearly a straight-A average.

However, in his first year of graduate school at Stony Brook in Long Island, he had a full-blown manic episode followed by a plunge into depression that left him suicidal. It was then that he was put on lithium and a tricyclic antidepressant for the first time. “I didn’t have mood swings after that, but instead of having a baseline of functioning normally, I was depressed. I was in a state of depression
the entire time I was on the medication. I stayed on it for a year and said, ‘No more.’”

Over the next two decades, Steve mostly stayed away from psychiatric medications. He married, had two sons, and divorced. He worked, but skipped from job to job. His life was proceeding down a chaotic path, a chaos that was clearly related to his manic-depressive illness, and yet his life was not marked by vocational disability—he always found work. In 1994, seeking relief from the mood swings that plagued him, he began taking psychiatric medications regularly. He cycled through an endless number of anti-depressants and mood stabilizers, none of which worked for long. Those drug failures led to fourteen electroshock treatments, which in turn left his memory so impaired that when he returned to his job as a financial planner, “I could no longer recognize my best client.” In 1998, he was put on the tricyclic desipramine, which promptly turned him into a rapid cycler. “I’d wake up and feel great, completely emancipated from the demon of depression, and then two days later, I am back into depression,” he explains. “Two days after that, I’m feeling well again. And there is nothing in my external environment that would account for that change in mood.”