What's in the cards for manic-depression?

What's in the Cards for Manic Depression?

In the midst of recent preparations tomove the Phipps Psychiatric Clinic at Johns Hopkins University School of Medicine in Baltimore to a new building, Joseph H. Stephens opened an unused locked closet and, much to his surprise, stepped into the lives of thousands of former psychiatric patients.

Stephens, a Hopkins psychiatrist, discoveredmore than 10,000 5-by-8-inch cards neatly filed in the closet. The cards were the remnants of a project conducted from 1936 to 1950, in which detailed clinical descriptions and follow-ups were prepared for all patients admitted to the Phipps Clinic between 1913 and 1940. A rare opportunity was at hand -- individuals unexposed to the modern arsenal of psychoactive drugs could be tracked over decades for clues to the natural ebb and flow of psychiatric symptoms.

Stephens and his colleagues sorted the8,172 patients portrayed on the cards into eight groups based on current psychiatric diagnoses. The long-term outlook for those who were manic depressive was examined first, reported Stephens at the recent American Psychiatric Association meeting in Chicago. And the results were not encouraging.

As many as 2 million people in theUnited States are estimated to suffer from manic depression, a condition marked by periods of severe depression interspersed with episodes of uncontrollable elation, restlessness, racing thoughts and delusions of grandeur. There are indications that specific genes may predispose some people to manic depression (SN: 2/28/87, p. 132). For more than 30 years, the basic treatment for this disorder has been lithium carbonate, a drug that often dampens manic and depressive mood swings. In the past decade, research has suggested that, even with lithium, manic depression is usually more persistent and severe than depression alone.

Among 234 pre-lithium manic depressivesfollowed for an average of 15 years after discharge from the Phipps Clinic, the Hopkins researchers found that one-third continued to suffer from severe symptoms and ended up back in the hospital for long stretches. Another 39 percent were moderately disturbed and reentered the hospital once or twice. The remaining 28 percent were not rehospitalized, but only half of them suffered no further episodes of mania or depression.

These findings are somewhat bleakerthan current figures that have emerged from a National Institute of Mental Health (NIMH) study involving 1,000 manic depressives at several medical centers, says NIMH psychiattrist Robert M.A. Hirschfeld. Over the past 10 years, about one-third of these patients have not improved despite lithium treatment. Refering to psychiatrists' attempts to treat manic depression, which is also called bipolar disorder, Hirschfeld maintains that "we're doing better, but we're sure not doing fabulously."

Although a small percentage of personsare thought to experience only manic episodes, says Stephens, a surprisingly high 12 percent of the Phipps cases fit that description at discharge. Their outlook was brighter, with about half never having another period of mania or hospitalization.

The outcome data are muddied byhaving to rely on second-hand, written descriptions that were not based on modern diagnostic criteria, acknowledges Stephens. He adds, however, that episodes of mania and depression were probably underestimated at the time, since many people were kept at home until their mental disorders overwhelmed family resources.

The Hopkins investigators now plan tocompare the outcomes for manic depressives with those for patients discharged with severe types of depression, but no mania.

The findings so far are underscoredby another study presented at the same meeting. Even in the age of lithium, says project director Joseph F. Goldberg of Michael Reese Hospital in Chicago, "a surprising number of manic patients have a more severe, recurrent and pernicious disorder than many clinicians and investigators previously believed."

Goldberg and his co-workers followedup on 40 patients originally hospitalized due to bouts of mania and 40 patients hospitalized or severe depression. Four years after discharge, the lithium-treated manic patients--most of whom were later found to be manic depressives -- were doing significantly worse than the depressed subjects, who took other medications. About one-third of the manic patients displayed a number of problems, including poor functioning in work and social situations, psychotic symptoms (mainly delusions and hallucinations) and multiple rehospitalizations. Approximately two-thirds showed severe difficulty in at least one area of functioning outside the hospital.

During the four-year follow-up, saysGoldberg, over half of them were rehospitalized at least once.

Nearly half of all patients on lithiumtake it improperly or stop using it against medical advice, factors that may account for the poor outcomes of some manic depressives, says NIMH scientific director Frederick K. Goodwin.

Perhaps the best hope for successfultreatment, says Goodwin, lies in a combination of lithium, which can take the edge of perilous mood swings, with psychotherapy, which can help make sense of a troubled life and rein in terrifying thoughts and feelings.