Dr.Ashoka Jahnavi Prasad| The News Minute| September 21, 2014| 10.30 pm ISTWhat do Vincent Van Gogh, Ludwig von Beethoven, Wolfgang Mozart, Winston Churchill , Ludwig Wittgenstein, and Vivien Leigh have in common? The answer is that all of them in all probability were victims of a condition known as Bipolar Illness-probably as in some of the names mentioned, there is no concrete evidence of a formal psychiatric consultation having taken place. The symptoms recorded though suggest a strong likelihood of this disorder.Van Gogh's biography describes vividly how he used to lapse into 'long phases of injudicious lapses which alternated with severe melancholia.' Churchill has described himself his 'dark moods' which were further elaborated by his very close friend Lord Beaverbrook . Only in Vivien Leigh's case can we identify a psychiatrist who treated the famous star after the diagnosis was made.Van Gogh Self-Portrait, August 1889, Oil on canvas, National Gallery of Art, Washington D.C, uploaded by ScewingThere is some topical interest in the illness following the very unfortunate recent suicide of the famous comedian ,Robin Williams.Again there is no conclusive evidence of Williams having ever been diagnosed as a bipolar but from the symptoms reported in the media, there is a more than even chance that it was this illness which lead to his demise.Bipolar illness is one of the earliest illnesses to have been identified by the medical profession. In different Ayurvedic texts ,there is a vivid description of a condition called 'unmada' that corresponds nicely with our present day concept of mania. Aretaeus ,a very well known physician of Cappadocia detailed the symptoms of mania way back in the 1st century and was perhaps the first to draw the link between mania and depression.He is also reputed to have commented on the efficacy of 'lithium salts' in calming the manic when used in the bath. This is truly remarkable as it took nearly 2000 years for modern medicine to draw the same inferences when my colleague John Cade and later on Mogens Schou popularized lithium treatment for bipolar illness which caught up in a big way.For nearly 25 years following their path breaking researches, lithium treatment ruled the roost as the only specific malady in psychiatric practice. The situation changed somewhat when von Emrich in Germany and this author reported on the comparable efficacy of valproate which now ranks alongside lithium as the first line treatment.These developments have had a significant impact on the prognosis. But the legitimate question that remains is why did it take nearly 2000 years for us to arrive at this juncture. Aristotle had described melancholy in great detail in his erudite expositions and even suggested that this condition may in some ways be related to enhanced creativity while calling for a very humane approach in dealing with the sufferers.It would appear that his pleadings fell on deaf ears as in the very deeply religious ambience of the times, the sufferers were subjected to death as it was believed they were possessed by the devil.This unfortunate state of affairs persisted for centuries until the revolutionary French psychiatrist Pinel took up cudgels on behalf of these unfortunate sufferers and called for a humane and scientific approach.It was left to another genius called Jean Pierre Falret who published a paper in 1851 which described 'la folie circulaire' (circular insanity) in which he described rapid switches from mania to depression and vice versa. This is commonly believed to be the first known diagnosis of bipolar disorder in modern medicine. Falret also commented that this condition tended to run in families. It is noteworthy how Falret's insights correspond to our present understanding.This truly remarkable piece of observation was followed by another spectacular declaration by Emil Kraeplin, the father of modern day psychiatry, that all mental illnesses had a biological basis.Although Kraeplin published his observations nearly a 100 years ago, it is his basic precepts which still continue to guide us in our clinical practice even today.Emil Kraepelin in his later yearsWhat is a bipolar illness?Bipolar disorder is a condition which leads to serious shifts in mood, energy, thinking, and behavior—from the highs of mania on one extreme, to the lows of depression on the other. More than just a fleeting good or bad mood, the cycles of bipolar disorder last for days, weeks, or months. And unlike ordinary mood swings, the mood changes of bipolar disorder are so intense that they interfere with the ability to function.During a manic episode, a person might impulsively quit a job, charge up huge amounts on credit cards, or feel rested after sleeping two hours. During a depressive episode, the same person might be too tired to get out of bed, and full of self-loathing and hopelessness over being unemployed and in debt.Ronald Kessler, one of the pre-eminent researchers in this field has found that one out of 45 people in the US are afflicted with this illness. Other psychiatric epidemiologists have found comparable prevalence in other countries.That would mean that about a staggering 25 million people in India suffer from this malady.Symptoms of bipolar illness:The commonest known manic symptoms in a bipolar illness are:Feeling unusually “high” and optimistic OR extremely irritableUnrealistic, grandiose beliefs about one’s abilities or powersSleeping very little, but feeling extremely energeticTalking so rapidly that others can’t keep upRacing thoughts; jumping quickly from one idea to the nextHighly distractible, unable to concentrateImpaired judgement and impulsivenessActing recklessly without thinking about the consequencesDelusions and hallucinations (in severe cases)Some of the commonest symptoms in bipolar depression are:Feeling hopeless, sad, or empty.IrritabilityInability to experience pleasureFatigue or loss of energyPhysical and mental sluggishnessAppetite or weight changesSleep problemsConcentration and memory problemsFeelings of worthlessness or guiltThoughts of death or suicideNot infrequently patients present a mixed picture of mania and depression which includes depression combined with agitation, irritability, anxiety, insomnia, distractibility, and racing thoughts. This combination of high energy and low mood makes for a particularly high risk of suicide.Treatment:The treatment approach is usually multipronged where pharamcotherapy is coupled with supportive psychotherapy and counseling. The first line of drugs are lithium and valproic acid derivatives . Antidepressants are needed where depressive symptoms are prominent.Since bipolar disorder is a chronic, relapsing illness, it’s important to continue treatment even when you’re feeling better. Most people with bipolar disorder need medication to prevent new episodes and stay symptom-free.The most effective treatment strategy for bipolar disorder involves a combination of medication, therapy, lifestyle changes, and social support.Therapy can be useful in helping the client understand the illness and it’s consequences and be better able to know when a manic or depressive episode is imminent and to prepare for this.As with all disorders, poor coping skills and lack of support will make the illness more pronounced, and this is often a focus of therapeutic treatment.Prognosis:Many people with bipolar disorder have successful careers, happy family lives, and satisfying relationships. Living with bipolar disorder is challenging, but with treatment, healthy coping skills, and a solid support system, one can live fully while managing the symptoms.As stated here,although the illness has been known for centuries, the stigma associated with the diagnosis has not completely evaporated which has considerable treatment implications. Kay Redfield Jamison, a psychiatric researcher and a bipolar sufferer herself adumbrated her own battle with the illness in a volume authored by her called The Unquiet Mind .Released in 1995,it became a bestseller and contains a very lucid elaboration of how she was able to merge from the stigma unscathed.She recounts her own self-denial in the book. Somehow, Jamison thought she was an exception to the research that shows that the illness not only comes back—but that it comes back more severely and more frequently if left untreated. Like other manic-depressives, Jamison was loath to give up the intense highs. Life seemed less intoxicating, less interesting when she was “normal,” she recalls in her book. Despite the fact she knew the risks, she went on and off lithium for years.At the age of 28, she tried to commit suicide ( a very common consequence) by taking a massive overdose of lithium. She was saved when she picked up the ringing phone.Fearing that disclosure would damage her academic and hard-won professional career, Jamison kept her illness secret from even her closest associates.“To suffer is to have learned,” she once told the rapt crowd, pointing out that creative geniuses like Anne Sexton, Robert Lowell, Virginia Woolf, and Edgar Allan Poe (“never really chipper even on a good day”) used their suffering for their work.Mental illness is a club that nobody wants to belong to.When you find attractive, compelling, amazing people who are in the club—who are successful and likeable and brilliant—it makes it easier to contemplate joining.My own belief is that the real measure of a civilized society is the treatment it metes out to those who do not have a voice. We have ignored the mentally ill for centuries not because we did not have the tools to comprehend their distress but because we did not have the will and the inclination to do so. It is about time that we effect a redressal that would enable so many of these individuals to realize their potential and make a stellar contribution to the society that they are surely capable of. This is The News Minute section which reports on health and related issues.