Bipolar Articles

A History of Bipolar Disorder

 

Though it’s impossible to trace the first case of bipolar depression or mania, much is known about the evolution of its identification and subsequent classification and naming as manic depression—now known generally as bipolar—and about those specialists whose breakthroughs have contributed so much to our present-day treatment expertise.

As might be expected, the early history of bipolar and other mental disorders is not pretty, but rather a testimony to ignorance, misunderstanding, and fear. Consider that in 300 to 500 AD, some people with bipolar disorder were euthanized, according to Dr Cara Gardenswartz, of California, with specific expertise in bipolar disorder and in its history.

“In the earliest days of documentation, these people were viewed as ‘crazy,’ possessed by the devil or demons,” Dr. Gardenswartz says. Their treatment or punishment, she explains, included restraint or chaining; their blood was let out; they were given different potions, or electric eels were applied to the skull—“much in the way witches have been treated in various cultures. In fact, witchcraft was often used to try and ‘cure’ them,” Gardenswartz says. “Less is known about bipolar disorder from 1000 to 1700 AD, but in the 18th and 19th centuries, we adopted a healthier overall approach to mental disorders.”

Consider these developments in the evolution of bipolar disorder, which was observed and studied in the second century by physician Aretaeus of Cappadocia—a city in ancient Turkey. In his scholarly work, On Etiology and Symptomatology of Chronic Illnesses, Aretaeus identified mania and depression; he felt they shared a common link and were two forms of the same disease. The ancient Greeks and Romans coined the terms “mania” and “melancholia” and used waters of northern Italian spas to treat agitated or euphoric patients—and, in a forecast of things to come, believed that lithium salts were absorbed into the body as a naturally occurring mineral. In 300–400 BC, the ancient Greek philosopher Aristotle had thanked “melancholia” for the gifts of artists, poets, and writers, the creative minds of his time. Conversely, in the Middle Ages, those afflicted with mental illness were thought to be guilty of wrongdoing: their illness was surely a manifestation of bad deeds, it was thought.

In 1621, Robert Burton—English scholar, writer, and Anglican clergyman—wrote what many deem a classic of its time, a review of 2,000 years of medical and philosophical “wisdom”: The Anatomy of Melancholia, a treatise on depression that defined it as a mental illness in its own right. In 1686, Swiss physician Théophile Bonet named “manico-melancolicus” and linked mania and melancholia.

Measurable progress was made in the early 1850s when Jean-Pierre Falret, a French psychiatrist, identified folie circulaire or circular insanity—manic and depressive episodes that were separated by symptom-free intervals. He broke substantial new academic ground when he chronicled distinct differences between simple depression and heightened moods. In 1875, because of his work, the term “manic-depressive psychosis,” a psychiatric disorder, was coined. Scientists also credit Falret with recognizing a genetic link associated with this disease. “We owe the categorization of bipolar disorder as an illness to Falret,” write Jules Angst, MD, and Robert Sellaro, BSc, of Zurich University Hospital in Switzerland, in their September 2000 paper, “Historical Perspectives and the Natural History of Bipolar Disorder,” published in Biological Psychiatry.

“It is remarkable how Falret’s description of symptoms and hereditary factors are so similar to descriptions found in present-day books and journals,” writes Erika Bukkfalvi Hilliard, MSW, RSW, of Royal Columbian Hospital in New West-minster, British Columbia, in her 1992 book Bipolar Disorder, Manic-Depressive Illness. “Falret even encouraged physicians to diversify medications used in the treatment of manic-depressive illness in the hopes that one of them might one day discover an effective drug therapy.”

Dr. Angst and Sellaro note that con-currently in 1854 French neurologist and psychiatrist Jules Gabriel François Baillarger used the term folie à double forme to describe cyclic (manic–depressive) episodes. Baillarger apparently also recognized a distinct difference between what we now know as bipolar and schizophrenia.

In their treatise, the Swiss specialists detail more specifics about the face of an emerging illness, particularly as it relates to “mixed states.” They write, “The history of the concept of mixed states [symptoms of mania and depression occurring simultaneously] … were probably already known at the beginning of the 19th century and named ‘mixtures’ … and ‘middle forms.’” A 1995 paper by French psychiatrist T. Haugsten, “Historical Aspects of Bipolar Disorders in French Psychiatry,” also traces the term “mixed states’ to J. P. Falret’s son, Jules Falret.

At the end of the 19th century, in spite of the contributions of Falret, Baillarger, and [German psychiatrist Karl Ludwig] Kahlbaum (among others), most clinicians continued to consider mania and melancholia as distinct and chronic entities with a deteriorating course,” José Alberto Del Porto, Paulista School of Medicine of the Federal University of São Paulo, states in an October 2004 research paper published in Revista Brasileira de Psiquiatria. However, the acceptance of this theory would not prevail forever.

German psychiatrist Emil Kraepelin (1856–1926) is one of the most recognizable names in the history of bipolar. He is sometimes referred to as the founder of modern scientific psychiatry and psycho-pharmacology. He believed mental illness had a biological origin and he grouped diseases based on classification of common patterns of symptoms, rather than by simple similarity of major symptoms, as those who preceded him had done. This forward-thinking specialist postulated that a specific brain or other biological pathology was at the root of each of the major psychiatric disorders. Kraepelin felt that the classification system needed revising, and so he did just that.

In the early 1900s, after extremely detailed research, he formulated the separate terms “manic-depression” and “dementia praecox,” the latter later named schizophrenia” by Eugène Bleuler (1857–1940). Widespread use of the term “manic depression” prevailed until the early 1930s—it was even used until the 1980s and 1990s. Also during the early 1900s, Sigmund Freud broke new ground when he used psychoanalysis with his manic-depressive patients: biology then took a back seat. He implicated childhood trauma and unresolved developmental conflicts in bipolar disorder.

In the early 1950s, German psychiatrist Karl Leonhard and colleagues initiated the classification system that led to the term “bipolar,” differentiating between unipolar and bipolar depression. Dr. Gardenswartz notes that “once there was a difference between bipolar and other disorders, individuals suffering from mental illnesses were better understood, and in turn—along with the progress in psychopharmacology—were able to receive better treatment.”

The term “bipolar” logically emphasizes “the two poles” of mood episodes, according to the prominent psychiatrist Robert L. Spitzer, MD, who was a major force in developing the modern approach to classifying and diagnosing psychiatric illnesses. People with unipolar depression experience low mood episodes only, while people with bipolar depression experience both depressed and elevated moods in a cyclical manner. (In some cases of bipolar I disorder, people have manic episodes only.)

Dr. Spitzer led the task force that wrote the third version—an undeniably major revision—of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). After DSM-III was published in 1980, the reference work became so influential it is often referred to as the “bibIe” of American psychiatry. (Specialists in many other countries use the International Classification of Mental and Behavioural Disorders, or ICD.)

Among the monumental changes in the DSM-III, the term “manic-depression” was dropped and “bipolar disorder” introduced—eliminating references to patients as “maniacs.” Further revisions of the DSM over the years have clarified inconsistencies in diagnostic criteria and incorporated updated information based on research findings, according to the American Psychiatric Association (APA). The APA issued the latest edition, DSM-5, in 2013.

Noted American neuroscientist and psychiatrist Thomas Insel, MD, former director of the National Institute of Mental Health, has said that whatever the changes in the DSM over the years, the reference work ensures that clinicians use the same terms in the same way.

Each edition has also reflected changes in philosophy in psychiatric practice. For example, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) noted that the DSM-5 takes a “lifespan” perspective that recognizes the importance of age and development on the onset, manifestation, and treatment of psychiatric disorders.

When the DSM-5 came out, an editorial in the International Journal of Bipolar Disorders predicted that some of the changes should address an “under-recognition” of bipolar disorders. The chapter traditionally covering “mood disorders” was broken into separate chapters for unipolar depressive disorders and bipolar disorders. In addition to bipolar I (“classic” manic-depression), bipolar II (depression plus hypomania), and cyclothymic disorder (mood episodes that don’t meet the full diagnostic criteria for either bipolar I or II), the new chapter includes a more flexible category for “bipolar-like phenomena.”

Furthermore, the criteria for diagnosing elevated mood states now includes an emphasis on shifts in energy level and goal-directed activity. The editorial writers felt this would make it easier to distinguish bipolar depressions from unipolar depressions in the absence of a current hypo/manic episode, since notable upticks in energy and activity would be easier for individuals to identify and recall in self-reports.

As the labels for psychiatric disorders evolved and changed, so, too, did the range of treatments for those with bipolar disorder, says Dr. Gardenswartz. She points to the use of sedatives and barbiturates prior to the 1950s; patients were also institutionalized to separate them from others. Prefrontal lobotomies and early forms of electroconvulsive shock therapy emerged as two more radical treatment options.

“Starting in the mid-1900s, with the advent of psychiatric and antipsychotic mood-stabilizing medications, patients were able to be viewed more as human beings suffering from illness that could be treated,” Dr. Gardenswartz affirms. Additionally, doctors and the public began to view various illnesses “as the separate entities that they were: schizophrenia, ongoing without breaks or relief from symptoms when untreated; or bipolar, in which people could typically function normally during periods between this cyclical illness.”

A discussion of medications to treat bipolar cannot be complete without acknowledging the work of John Cade, an Australian physician who introduced lithium to the practice of psychiatry in 1949 quite by accident when he observed that lithium urate appeared to calm guinea pigs. Lithium has since remained one of the most effective medications for those with bipolar disorders, providing a springboard for further research and discovery of biomedical treatments. As the ancient Greeks and Romans suspected, natural lithium can indeed be found in hot springs and there is scientific justification for their historical use as a treatment for bipolar disorder.

Inspired by Dr. Cade, Mogens Schou, MD (1918–2005), Prof. Med. Sci., continued groundbreaking research into lithium. Dr. Schou was emeritus professor of the Psychiatric Hospital in Risskov, Denmark, and was named honorary president of the International Society for Bipolar Disorders. Dr. Schou labeled manic-depression “the national illness” of his country and in the 1960s, Dr. Schou used lithium on an experimental basis with a group of his patients who experienced mania. Schou’s work proved that when used properly with monitoring, lithium could be very effective in treating bipolar mood episodes. In no small part because of Dr. Schou’s efforts, the U.S. Food and Drug Administration (FDA) finally approved lithium as a treatment for mania in 1970, and in 1974, as a preventive treatment for manic-depressive illness.

TREATMENT TRIAD

It’s 2020, and treatment for bipolar disorder has evolved to recognize the importance of “three pillars” for wellness: medication supported by psychotherapy and self-care. Current pharmacotherapy for bipolar disorder has expanded to include mood stabilizers (a category to which lithium belongs), antipsychotics (especially the newer “atypical” formulations), anti-anxiety medications, sleep medications, and antidepressants under certain circumstances.

Which specific formulations and dosages to use vary according to individual responses. It often requires multiple trials of different medications to finally deter-mine the right combination. This broad-stroke approach, while frustrating at times, comes about because there are no reliable lab tests that can determine what medication will be effective in a particular case—although researchers are working on that.

Meanwhile, research has validated two types of brain stimulation as effective for treatment-resistant bipolar depression. One is electroconvulsive therapy, which has been greatly refined since its notorious “shock therapy” days in the 1940s. In this technology, controlled electrical currents are passed through the brain while the individual is under sedation. An alternate therapy, transcranial magnetic stimulation (TMS), delivers electro-magnetic pulses through the scalp.

Still at the experimental stage: vagus nerve stimulation (VNS), in which a device implanted in the chest sends electric pulses to the vagus nerve, and deep brain stimulation (DBS), which involves two electrodes placed in the brain plus a pulse generator in the chest.

Talk therapy also has evolved greatly since the 1970s, when more action-oriented, humanistic approaches became firmly established alongside traditional Freudian analysis.

Plenty of scientific evidence suggests that psychotherapy specific to bipolar challenges, when used with medication, works better than medication alone. Much of that evidence relates to cognitive behavioral therapy, or CBT, since that is the most commonly researched form of psychotherapy. CBT helps individuals pin-point unhelpful attitudes and behaviors and substitute more positive patterns. A 2017 review of 19 randomized, controlled trials, published in the journal PLOS ONE, found CBT effective in decreasing relapse rates and improving symptoms, mania severity, and psychosocial functioning. Best results for depression or mania occurred with at least 90 minutes of treatment per session, and people with bipolar I had a lower relapse rate.

The range of therapeutic approaches continues to diversify. A variant called CBTm adds a mindfulness component to the traditional approach. Dialectical behavior therapy, or DBT, incorporates cognitive-behavioral principles, mindfulness, and interpersonal skills to help people tolerate painful emotions and become more assertive in relationships. Interpersonal and social rhythm therapy (IPSRT), developed specifically as an intervention for bipolar, emphasizes establishing daily routines, managing stress, and tracking connections between mood and life events.

Other options include narrative therapy (reframing your past to emphasize personal strengths), family-focused therapy (promoting communication and problem-solving between the individual with the disorder and other family members), and group psychoeducation (information and coping strategies offered by a trained facilitator). Peer support, a mutual exchange of lived experience without professional involvement, has also proven to be a powerful tool—giving rise to certified peer specialists who typically work in tandem with behavioral health practitioners at care facilities.

Perhaps the biggest transformation in managing bipolar disorder since the advent of lithium has been the shift to “patient-centered” or “person-centered” care—reflecting a larger shift in medicine and psychiatry over the last two decades. Rather than passively following the dictates of health care professionals, the person being treated is considered a partner in setting goals, deciding on interventions, and pursuing independent strategies that contribute to wellness.

A hefty body of evidence shows that regular exercise, a healthy diet, methods to relieve stress, and good sleep all contribute to stability in people with bipolar disorder. Some practitioners prescribe exercise as part of treatment, and multiple studies indicate that both yoga and mindfulness practices are helpful in maintaining wellness. Mood tracking—a self-recorded diary of daily emotional fluctuations and activity patterns—helps with self-awareness, identifying mood triggers, and better symptom management.

Bipolar disorder is a condition for which it’s “blatantly apparent” that lifestyle modifications, self-care, and self-management strategies make a real difference, says Erin E. Michalak, PhD, a psychiatry professor at the University of British Columbia. “It is now known that many people with bipolar disorder use lifestyle interventions to manage not just depression, but also escalation into hypomania and mania,” she adds.

Michalak founded and leads the Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD). The research network, based in Vancouver, focuses on self-management strategies and seeks to involve people with bipolar in shaping its investigations.

In many ways, the rise of the Internet, social media and smartphones has made self-management easier for people with bipolar. Information on bipolar symptoms and treatments is easier to find. So is a community of peers, either through forums, blogs, or self-help portals. A proliferation of apps can help with everything from mood-tracking to mindfulness exercises.

Those kind of apps fall under the umbrella of mobile health technology, or mHealth, which broadly covers wellness-related information and services accessed via computer, phone, or wearable devices. For example, teletherapy has been gaining traction. Getting regular psychotherapy appointments can be tough for people who live where there aren’t enough providers or the providers aren’t easy to get to—or the community is so small everyone knows your business. For teletherapy users, the convenience, access, and privacy provided by this kind of “remote” counseling outweighs the loss of nonverbal cues that are more obvious when meeting in person.

Dr. Michalak was first author of a two-phase study, published in April 2019 in JMIR (Journal of Medical Internet Research) Mental Health, that found digital health technologies provide one effective route to support healthy lifestyle behaviors for people with bipolar disorder. She’s a fan of digital technologies, also known as e-interventions. In her view, however, such resources should supplement, not replace, connecting socially face-to-face.

Evan H. Goulding, MD, PhD, an assistant professor of psychiatry and behavioral sciences at Northwestern Medicine’s Feinberg School of Medicine, says digital interventions that provide real-time feed-back to users can improve patient self-management.

Goulding was awarded a grant from the National Institutes of Health to study the usefulness of a phone-based program developed at Northwestern called LiveWell: A Mobile Intervention for Bipolar Disorder. The intervention was tested by a group of people with bipolar I who were currently in the care of a psychiatrist. Participants were sent educational modules, checked in regularly with health coaches, and had their daily activity tracked with digital devices.

“People want tools to help themselves. This is a catalyst, outside of visits [with practitioners], to integrate into the person’s daily life,” Goulding says, adding that research teams are working on psychosocial apps similar to LiveWell in North America and abroad.

As a researcher, Goulding welcomes technologies that can send important feedback the other way: from patient to clinician. Behavioral and physiological data gleaned directly from real life could improve understanding of bipolar disorder and treatment, he says.

Meanwhile, medical science continues to move forward in the search for tools to better manage bipolar. In addition to studying e-interventions, researchers are looking into new medications, neuroscience, genetics, complementary options such as hormone therapy and nutraceuticals (foods that provide health benefits), and personalized medicine. Advances in neuroscience and genetics are expanding knowledge about brain-based disorders, though as yet very little has translated to clinical practice.

“We have a lot to be grateful for,” says Dr. Gardenswartz, “and there’s much more to come. In the next several decades, we’ll see increased differentiation of symptoms and of treatment, and possibly, the ability to prevent and detect the onset of the disorder.”

The third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, dropped the term “manic depression” and substituted “bipolar disorder.” There are some people—prominent bipolar researcher and memoirist Kay Redfield Jamison among them—who would like to go back to the old name.

In her book Robert Lowell: Setting the River on Fire, Jamison explains that the renaming was “a result of attempts by clinicians and scientists to distinguish between those patients who have a history of both mania and depression from those with a history of depression only.” She presents several reasons not to “abandon” the term manic-depressive illness, partly so we don’t lose the historical and social dimensions of the phrase.

While many find the term “bipolar disorder” less stigmatizing, she acknowledges, she finds it “misleading, rather trivializing.” Rather, she argues, we should appreciate mania and depression’s association with accomplishments “in the arts, sciences, and other fields of human endeavor” and “understand moods and their aberrations in the context of individual lives and imaginations; the role they have in shaping societies; and the meaning they assume in the human condition.”

Stephanie Stephens