In this issue of The Journal the subject of affective or mood disorders is presented from an array of perspectives-those of patient, family member, clinician and researcher. The most severe of affective disorders, Major Depressive Disorder and Bipolar Disorder, are discussed.

Of critical importance to our readers is the knowledge that these disorders are frequently severe and often incapacitating. Although they generally occur in cycles, those afflicted may not feel or be “well” between cycles. Also, these disorders may at times be as chronic and long term in the suffering and burden they impose on families and the disablement they cause for those afflicted, as is the case with schizophrenia.

For example among the Los Angeles Skid Row population of homeless persons reported on by Paul Koegel and his colleagues in 1988, Bipolar Disorder was reported as having occurred among 10.6% of those interviewed, compared to a lifetime prevalence rate for schizophrenia of 13.7% among the same homeless population.

A further indicator of the severity of the affective disorders is the recent report by Dr. Ken Wells and colleagues from the very large Medical Outcomes Study carried out by the RAND Corporation. The level of impairment of functioning among persons ill with depression was compared with that produced by such major chronic medical conditions as arthritis, diabetes, hypertension, gastrointestinal and pulmonary disorders. Only chronic heart disease among the eight conditions measured, produced a level of impairment comparable to that which resulted from depressive illness.

Affective disorders are extremely common as well as often severe and disabling. The NIMH-sponsored Epidemiologic Catchment Area (ECA) study, which carried out face-to-face interviews with over 18,500 persons in five U.S. communities, found that the lifetime prevalence rate for Major Depressive Disorder (five-site mean) was 4.4%, for Bipolar Disorder 1.2%, and for Dysthymia, a somewhat less severe but chronic form (at least 2 years duration) of depressive illness, was 3.1%.

The four anonymous first-person reports in this issue powerfully describe the all-inclusive pervasiveness of the altered mood states of mania and depression-that “madness carves its own reality.” The essentiality of both a trusted psychotherapeutic relationship and appropriate medication is also convincingly presented. An anonymous wife discloses the limits of human endurance in life with a bipolar spouse-the social and economic as well as emotional ruination which the disease so frequently visits upon the burdened family.

Janis Medley reminds us that even the person who to outward appearances has coped successfully with affective illness and holds a responsible position, may have to pay a high price in anguish and pain.

Dr. Callaway, with candor rare among mental health professionals, shares with us the painful dilemma of stigma in self-disclosure regarding depressive illness, and Judy Cooperberg shares a poignant event in her life which conveys the power of such stigma to shatter even the most loving of human bonds.

Dr. Kay Jamison, one of our leading clinician-scholars of bipolar disorder, documents her own research findings of an extraordinarily high level of affective illness among highly gifted artists and raises the complex issue of the benefits as well as the potential costs to such persons of utilizing medication to regulate their disorders.

Betty McDermott gives us a very personal and convincing account of how creative activity has literally been her “salvation.”

Dr. Asarnow provides a succinct review of the ways in which affective illness expresses itself in children with compelling evidence that it is not rare among the very young.

Dr. Cole informs the reader of the tragic fact that depressive illness is frequently misdiagnosed as dementia in the elderly and tends to be of longer duration than among younger persons. However, his good news is that treatment is usually quite effective in restoring the quality of life to the elderly depressed.

From the scientific perspective, Dr. David Segarnick introduces readers to the actual mechanisms at the chemical and cellular level which may underlie the mood stabilizing effect of lithium. Mel Glaustein, M.D. provides a brief clinical overview of mania and major depression and their treatment, and Michael Gitlin M.D. gives us a more extensive review medications used in the treatment of mood disorders, while William Boyer, M.D. explores the pros and cons of the new medication, Prozac.

The remarkable and even life-saving benefits which can be provided by electroconvulsive therapy (ECT) are described not by a clinician partial to such treatment, but by a father, whose son suffered a sustained and catastrophic psychotic illness which had failed to respond to conventional treatment efforts, but has had a many years long complete remission induced by ECT.

In all, this issue provides a rich introductory menu of information concerning one of the most prevalent and damaging of all human afflictions. The rate of growth of our knowledge in the past 30 years concerning affective illness has been exhilarating, and the promise for the future is even brighter.
Dr. Karno is a member of the Editorial Advisory Board of The Journal, and Professor of Psychiatry and Behavioral Sciences at UCLA Medical School.

This Is How It Feels…

Anonymous

There is a particular kind of pain, elation, loneliness, and terror involved in this kind of madness. When you’re high it’s tremendous. The ideas and feelings are fast and frequent like shooting stars and you follow them until you find better brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others becomes a predictable certainty. There are interests found in uninteresting people. Sensuality is pervasive and the desire to seduce or be seduced is irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence, and euphoria now pervade one’s marrow.

But, somewhere, this changes. The fast ideas are far too fast and there are far too many; overwhelming confusion replaces clarity. Memory goes. Humor and absorption on friends’ faces are replaced by fear and concern. Everything previously moving with the grain is now against-you are irritable, angry, frightened, uncontrollable, and enmeshed totally in the blackest caves of the mind.

Madness carves its own reality. It goes on and on and finally there are only others’ recollections of your behavior-your bizarre, frenetic, aimless behaviors-for mania has at least some grace in partially obliterating memories.

What did I do? Why? When will it happen again? Where? Credit cards revoked, bounced checks to cover, explanations due at work, apologies to make, friendships gone or drained, a ruined marriage. And always, which of my feelings are real? Which me is me? The wild, impulsive, chaotic, energetic, crazy one? Or the shy, withdrawn, desperate, suicidal, doomed, tired one? Probably a bit of both. Hopefully much of that is neither.

Virginia Woolf, in her dives and climbs, said it all: “... how far do our feelings take their colour from the dive underground? I mean, what is the reality of any feeling?”

This Is What It’s Like…

Anonymous

At this point in my life, I cannot imagine leading a normal life without both taking lithium and being in psychotherapy. It is more than clear to me, from my startings and stoppings of lithium, that it is an essential part of maintaining my sanity and avoiding a totally tumultuous existence. Lithium prevents my seductive and disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. But, ineffably, sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality; they only bring one back headlong, careening, and faster than can be endured at times. Psychotherapy is a sanctuary, it is a battleground, it is a place where I have been psychotic, neurotic, elated, confused, and despairing beyond belief. But, always, it is where I have believed or have learned to believe-that I might someday be able to control all of this.

No pill can help me deal with the problem of not wanting to take pills; likewise, no amount of analysis alone can prevent my manias and depressions. I need both. It is an odd thing owing one’s life to pills, one’s own quirks and tenacities, and to this unique, strange and ultimately profound relationship called psychotherapy.

Anne Sexton (1928-1974) - Poet

“... Is life something you play?
And all the time wanting to get rid of it?
And further, everyone yelling at you to shut up.
And no wonder!
People don’t like to be told
that you’re sick
and then be forced
to watch
you…”

After many episodes of depression, at the age of 46, in the midst of a highly successful career, Anne Sexton took her own life.

“... Well, death’s been here for a long time” A.S.

Gustav Mahler (1860-1911) - Composer

“I have become a different person. The fires of a supreme zest for living and the most gnawing desire for death alternate in my heart, sometimes in the course of a single hour. I know only one thing: I cannot go on like this!”

Composer of nine innovative symphonies that radiated intense joy and bleak sorrow, and more than 40 orchestral songs that were equally masterful in conveying human feelings, Mahler was, by his own admission, prisoner of his mood swings. Like Handel, Mahler’s frantic energies and imagination were at their peak in the summer, sometimes almost unbearably so.