Book Review: “Mania: a Short History of Bipolar Disorder”

How does modern society per­ceive Bipolar Disorder? Some would describe this disorder as a mind oscillating between a manic state of agitation, creativity, and elation – and a depressive state of dark despair. Some of us have watched acquaintances, friends, or loved ones begin the arduous process of finding an effective “mood stabilizer” after being diagnosed as bipolar. Mired in the societal present, it is easy to believe our current vision of Bipolar Disorder has been the same throughout the ages, but this is not the case.

In a definitional whirlwind, David Healy in Mania upsets any notions of the conti­nuity of our time’s mental disorders. He begins the journey on the isle of Thasos in Greece, where a woman lying in a bed is diagnosed with Bipolar Disorder. Healey argues that she is misdiagnosed. Although she is described as having states of melan­cholia alternating with mania, those who cite this as an early case of bipolar disorder disregard the accompanying black urine and bleeding, which are signs of an infection.

Those who may have had mental disor­ders, as defined modernly, at the time of the Greeks would have been lost in a sea of patients whose madness, like the woman of Thasos, was the result of bacterial infection. Melancholia and mania in ancient Greece, moreover, were not the depression and mania of today. The humors, or fluids, that govern the body’s disposition could thicken to result in the lethargy of melancholia or become hot to drive a person into a sort of frenzy. For the next few thousand years, the humoral theory of madness would remain strong, even as perceptions of mental disorder overturned with the generations.

With asylums and increased sanitation, hygiene doctors were able to monitor those with mental disturbances en masse for the first time. Doctors became increasingly better at diagnosing the mentally ill. The French cities of the 1800s became the site of the first diagnoses of la folie circulaire, or circular madness. Although la folie cir­culaire posited alternating states of elation and depression, these alternations were thought to occur at regular intervals, unlike our currently defined bipolar disorder.

Meanwhile, in Germany at the end of the century, Kahlbaum and Kraepelin championed the new concept of manic depression. However, this manic depres­sion included all psychiatric conditions that exhibited a remitting course. All conditions that continued to worsen were lumped into a category called dementia praecox. Manic depression caught on, but would come to mean something very different than the grouping by disease course.

In 1966 Jules Angst and Carlo Perris published the first empirical studies that attempted to differentiate between depres­sions that had only one phase (unipolar) and two opposite phases (bipolar). Only in 1980 was bipolar disorder accepted as a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSMIII). Estimates of the prevalence of bipolar disorder were 1 percent of the population in 1995. By the time lithium, the first “mood stabilizer,” was introduced in the United States in 1998, estimates increased to 5%.

During the interim, diagnosis criteria drastically changed: manic episodes could be self diagnosed or diagnosed by a non-medical third party and Bipolar II, III, and IV disorders emerged with even more lax criteria. Of interest is that, as Healy com­ments, “clinicians and the public seem unaware that the picture was so different just a few years earlier and that the term bipolar disorder would have been mean­ingless to most people until very recently. In part, this amnesia must stem from the assiduous promulgation of a message that bipolar disorder was nothing new – that everything had been well recognized as far back as the Greeks.”

As the population diagnosed with Bipolar Disorder ballooned, so did the pharmaceu­tical industry. A diagnosis in our society demands treatment, and in the case of Bipolar Disorder, the required pharmaco­logical mood stabilization is life-long. These life-time patients form a stable market for pharmaceutical companies that have come to be major supporters of scientific confer­ences and of the dissemination of mental illness information. Healy spends the rest of this engaging history examining how these industries – with direct to consumer advertising – have hijacked the system where a diagnosis depends largely on words, not biological markers. Are pharmaceutical companies helping identify undiagnosed individuals? Or are they marketing diseases?

David Healy’s Mania unleashes an intel­lectual adventure that will forever change the way you think of mental illness in his­tory, free markets, and society.