- Mania: A Short History of Bipolar Disorder
- The Johns Hopkins University Press, 320 pp.
This latest in the Johns Hopkins Biographies of Disease series is much more than a history of the medical condition du jour. It is also an impassioned call for reassessment in psychiatry, which, as its author says, ‘is in a muddle.’ David Healy, a professor of psychiatry and director of the North Wales Department of Psychological Medicine at Cardiff University, is a notorious critic of the commandeering of his profession by drug companies. So outspoken has he been that in 2001 it cost him a post at Toronto University. In The Antidepressant Era (1998) and Let Them Eat Prozac (2004) David Healy criticised the whole business of psychopharmacology and raised very serious concerns about a possible increase in the risk of suicide with regard to certain drugs. The disturbing questions about the relationship between science and commerce which he has done so much to bring to public attention, and which he once more raises in this book, will not go away.
David Healy disputes claims that bipolar disorder can be traced all the way back to antiquity. Hippocrates may have been the first to put mania and melancholia on the medical map but ‘for the Greeks visible signs made it reasonable to locate the problem in the body of the sick person … for us, diagnoses depend on what people say.’ Our time of ‘negotiated’ illness bears little relation to the age of Hippocrates and later Galen. What mattered to them was what they could see: ‘the swelling, heat, and redness of tumor, the smell of urine, the mute rigidity of stupor, the frenzy of delirium.’ The story of the woman from Thasos, often cited by psychiatrists today, is one of nausea, insomnia, fever and spasms. This is distinct from modern accounts of bipolar mania, common symptoms of which include grandiosity, recklessness, racing thoughts, rapid speech, high or irritable mood and, in severe cases, hallucination. For Hippocrates mania is, in essence, delirium. A case of ‘maniacs rather than manics.’ And melancholia, far from bringing to mind our well-established criteria for depression – diminished interest, inability to concentrate, emptiness and feelings of worthlessness – seems to be something more like ‘stupor’ or ‘lethargy.’
The revolution of science in the Renaissance began to focus attention on ‘internal mental states.’ In seventeenth century England, Thomas Willis’s work on the anatomy of the brain, and Thomas Sydenham’s description of hysteria helped the mind replace the body as the locus of investigation of troubled mood. In the nineteenth century the building of the asylums gave physicians unprecedented access to the multifarious forms of human madness and in the 1850s two French psychiatrists, Jean Falret and Jules Baillarger, working independently and later to dispute priority, described a single disease, distinct from full-blown mania or depression. However, at the end of the nineteenth century the German psychiatrist Emil Kraepelin did not even cite folie circulaire or foile a double forme when he formulated his new concept of manic-depressive illness. Kraepelin did not believe that what he was describing had the regular and predictable cycles that had been posited. In fact, it ‘might not involve any cycling at all.’ Clinical uptake of Kraepelin’s condition was slow. ‘Sifting through 3,872 admissions from North West Wales between 1875 to 1924,’ Healy writes, ‘it becomes clear that bipolar disorder patients are hard to find. Only 127 patients were admitted for the first time during this period.’ This was to change dramatically. In 1966 two academics, Carlo Perris and the appropriately named Jules Angst, published separate studies which supported the idea of a bipolar disorder. The focus was now on the circularity and regular recurrence of this curious condition. (In some way, this was a return to the ideas first discussed in Paris more than a hundred years earlier by Falret and Baillarger.) Within thirty years there were reports that 5% of the US population had bipolar disorder of one type or another. This illness had gone from being a rare condition to one that seemed ready to swallow up the whole of humanity. What is to explain the sudden ‘epidemics of behavioural disorders?’ Is the explosion of interest in bipolar disorder in recent years down to little more than the successful marketing of pharmaceutical companies?
This is a fascinating, timely and urgent piece of work. At its high points it pulsates with a controlled anger. When David Healy turns his attention to the ‘industrialization of medicine,’ the ‘global therapeutic mania’ born of a ‘marketing that conjures diseases out of vicissitudes,’ the book comes powerfully alive. The author writes of ‘our desperate need for cures.’ He refuses to accept the dominance of money over medicine and the alarming diagnoses of bipolar disorder in infants. ‘We now have a system that inhibits our abilities to find cures while encouraging companies to seek short-term profits by co-opting bipolar disorder for the purposes of increasing the sales of major tranquilizers to infants. Giving major tranquilizers to children is little different from giving children cancer chemotherapy when they have a cold.’ He is also critical of the way that the marketing departments of drug companies have used Kay Redfield’s sensitive (if absurdly romantic) analysis of the mental state of various artistic figures in Touched By Fire to compile lists of the brilliantly afflicted to include in leaflets advertising mood stabilizers. When an illness becomes fashionable, something is very wrong. Bipolar disorder is now so well known that were it a celebrity it would have its own chat show.
Mania: A Short History of Bipolar Disorder is an extraordinary tale of ferocious contention, confusion, conflicting accounts and competing interests. David Healy’s story of changing perceptions, terminological shifts, dispute over treatment, the use of mood stabilizers and the way in which responsiveness to these drugs now seems to define bipolarity is stimulating and provocative. However, if you have no grounding in medicine you may want to read it with a medical dictionary at hand. But, putting to one side the occasional difficulties this book presents for the reader unversed in the relevant terminology, this is vital stuff. In our psychotic age of multiple ‘issues’, in which any non-standard aspect of behaviour has to be tested against a possible disorder, in which each one of us must be in possession of a significant emotional problem that requires immediate (and possibly pharmaceutical) intervention – as if the very essence of existence is to be lost and in need of being pinned down by chemicals – the horrible, distressing reality of genuine illness can be forgotten. David Healy reminds us that we need to ask ourselves what it means to be ill and what it means to be well.