Manic depression: success story dims.

Since the discovery more than 30 years ago that lithium salts can take the edge off the sharp mood swings of manic depression, psychiatrists have considered this treatment a major success story. However, a 7 1/2-year follow-up of formerly hospitalized manic depressives shows that about 40 percent of those receiving lithium, sometimes combined with other treatments, continue to experience marked emotional highs and lows, as well as serious problems at work and home.

On the positive side, the study charts consistent improvement and good overall functioning among one in three lithium-treated manic depressives.

Joseph F. Goldberg of Michael Reese Hospital in Chicago presented the new data last week at the annual meeting of the American Psychiatric Association in New Orleans. The results extend his four-year follow-up of the same group of patients, which yielded similar findings (SN:6/27/87, p.410).

Other recent studies show that within two years of starting lithium treatment, about 40 percent of manic depressives experience a new episode of mania, says William Z. Potter of the National Institute of Mental Health in Bethesda, Md.

"Our standard treatment for manic depression isn't working as we hoped it would," Potter asserts.

An estimated 2 million to 3 million people in the United States suffer from manic depression, characterized by periods of severe depression alternating with episodes of uncontrolled elation, restlessness, racing thoughts and delusions of grandeur. Periods of normal mood typically occur between manic and depressive episodes.

Goldberg's team evaluated 35 manic depressive patients and 35 depressed patients with no mania, initially treated in two psychiatric hospitals. The researchers assessed each patient 2 1/2, 4-1/2 and 7 1/2 years after discharge to outpatient treatment, which usually included lithium in combination with psychotherapy and psychoactive drugs such as antipsychotics or antidepressants.

At the final follow-up, 12 of 35 manic depressives functioned well and generally lacked the psychiatric symptoms that had led to their hospitalization. Among patients hospitalized for depression only, 19 of 35 achieved that same level of functioning.

Another 19 manic depressives and 13 depressed individuals achieved "intermediate" functioning after 7 1/2 years, with periodic returns of symptoms, difficulties in social situations, and occasional rehospitalizations. The researchers observed poor functioning and no improvement since the initial hospitalization in four of the manic depressives and in three of the depression patients.

A number of factors contributed to the poorest outcomes in the manic depressive group, they say. These include failure to take lithium or follow prescription instructions, occurrence of "mixed states" in which symptoms of mania and depression coexist, and rapid alternations between periods of mania and depression.

Further long-term lithium studies must examine a broader spectrum of manic depressives, with a special focus on those who do not get better, Potter says. Pharmaceutical firms should also direct their efforts toward identifying novel chemical compounds that can quell symptoms of manic depression, he contends.

Further research would also benefit from a redefinition of manic depression, maintains Frederick K. Goodwin, head of the Alcohol, Drug Abuse and Mental Health Administration in Rockville, Md. Goodwin argues that the current

diagnostic manual of psychiatric disorders inappropriately separates manic depression from the various forms of depression without mania. People with manic depression and people with recurring severe depression share important qualities, he points out, such as the tendency to show symptoms by young adulthood, recurrence of psychiatric episodes every one to two years, and in many cases a family history that includes manic depression.