Bipolar Disorder

The Science of Mental Health

Steven E. Hyman

• Publisher: Routledge
• Year: 2019
• ISBN:
  9781135712259
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

There has been a revolution in our understanding of mental illness and its effect on society. The science of mental illness has made enormous strides based on the just-completed decade of the brain and is poised to make quantum progress again based on the completion of the Human Genome Project. These and other developments are covered in this new multi-volume set, which brings together in one in-depth collection the most significant recent scholarship on mental and addictive disorders.
The volumes are organized to provide cutting-edge views of the epidemiology, genetics, evolutionary perspectives, and brain and behavioral science of mental illness, as well as selected papers on treatment. The papers are selected from leading journals in the US and worldwide based on their significance and on the need to provide a balanced perspective. The collection offers a comprehensive and up-to-date overview, and includes introductions that make the technical aspects of the papers accessible.

NATURAL HISTORY

Historical Perspectives and Natural History of Bipolar Disorder

Jules Angst and Robert Sellaro

A review of two centuries ’ literature on the natural history of bipolar disorder, including modern naturalistic studies and new data from a lifelong follow-up study of 220 bipolar patients, reaches the following conclusions: the findings of modern follow-up studies are closely compatible with those of studies conducted before the introduction of modern antidepressant and mood-stabilizing treat-ments. Bipolar disorder has always been highly recurrent and considered to have a poor prognosis.

Bipolar patients who have been hospitalized spend about 20% of their lifetime from the onset of their disorder in episodes. Fifty percent of bipolar episodes last between 2 and 7 months (median 3 months). The intervals between the first few episodes tend to shorten; later the episodes return at an irregular rhythm of about 0.4 episodes per year with high interindividual variability. Switches from mania into mild depression and from depression into hypomania were frequently reported in the 19th century and the first half of the 20th.

Antidepressant and antimanic drugs have to be given as long as the natural episode lasts. Given the poor outcome of bipolar disorders found in naturalistic follow-up studies and our lifelong investigation, intensive antidepressant, antimanic, and mood-stabilizing treatments are required in most cases. Despite modern treatments the outcome into old age is still poor, full recovery without further episodes rare, recurrence of episodes with incomplete remission the rule, and the development of chronicity and suicide still frequent. Biol Psychiatry 2000;48:445–457 © 2000 Society of Biological Psychiatry

Keywords: Bipolar disorder, natural history, course, recurrence, outcome

Introduction

This article briefly reviews the natural history of bipolar disorder, giving special weight to historical studies before the era of antidepressants; integrates the results of modem naturalistic follow-up studies; and from our own findings 1) reanalyzes data from an early multicenter study (Angst et al 1968b, 1973) and 2) includes some new data from our lifelong Zurich follow-up study (Angst and Preisig 1995a, 1995b). The article focuses mainly on episodes and recurrence and, to a lesser extent, outcome; it does not deal with rapid cycling and seasonal depression. Recent reviews of the course of bipolar disorder have been published by Lavori et al (1984), Keller (1987), Goodwin and Jamison (1990), Coryell and Winokur (1992), Verdoux and Bourgeois (1995), Kessing et al (1998), Goldberg and Harrow (1999), Marneros (1999), and Bourgeois and Marneros (in press).

The Concept of Bipolar Disorder

We owe the categorization of bipolar disorder as an illness to Falret, who in 1851 and 1854 on the basis of longitudinal observations developed the entity of “folie circulaire” (circular madness), defined by manic and melancholic episodes separated by symptom-free intervals. In 1854 Baillarger used the term folie à double forme to describe cyclic (manic–melancholic) episodes (Pichot 1995; Ritti 1879). Kraepelin called such cyclic episodes “double attacks.” In both French diagnoses the prognosis was considered to be “desperate, terrible and incurable” (Bourgeois and Mameros, in press). Circular illness was described by most authors as a recurrent condition; it became the prototype of the larger group of periodic psychoses embracing periodic mania, periodic melancholia, and periodic cyclic disorders (Ballet 1903; Mendel 1881; Pilez 1901; Ziehen 1902, 1907).

The Concept of Mixed States

The history of the concept of mixed states has been extensively studied by Mameros (in press): what we today call “mixed states” were probably already known at the beginning of the 19th century and named “mixtures” (Mischungen) by Heinroth in 1818 and “middle forms” (Mittelformen) by Griesinger (1845). Guislain (1852) gave clear descriptions of different syndromes of mixed states. The history of bipolar disorder by Haustgen (1995) traces the term mixed states to J.P. Falret’s son Jules Falret (1861).

Very influential in this field was Weygandt (1899), who worked with Kraepelin and whose monograph distinguished three forms of mixed states: manic stupor, agitated melancholia (depression with flight of ideas and agitation), and unproductive mania (elated mood, increased motor activity, and inhibition of thinking). Kraepelin’s (1899) textbook descriptions of mixed states were founded on Weygandt’s monograph. Further progress was made by Rehm’s monograph (1919, 113), which classified mixed states systematically on the basis of the permutations of the three elements that had been defined by Kraepelin: thought disorder, mood, and psychomotor activity (identified as a, b, and c for mania and as A, B, and C for depression).

Kraepelin’s Manic–Depressive Insanity

At the turn of the 19th century Kraepelin’s unifying approach to the classification of mood disorders (1899) resulted in bipolar disorders being subsumed within manic-depressive insanity (MDI), a broad group that included single-episode and recurrent depression. Kraepelin (1913, 1183) was later himself to raise the possibility of the heterogeneity of MDI. Unlike the French concepts, Kraepelin’s MDI had a good prognosis and did not develop into severe dementia, although Kraepelin conceded the existence of mild residual states after recovery from the episodes themselves (Schwächezustände; Kraepelin 1913, 1349) and of mild fluctuations between episodes. Kraepelin considered periodicity to be unimportant for the diagnosis (Pilez 1901). As a consequence of Kraepelin’s unification of affective disorders, research on their course frequently failed to distinguish between depression, mania, and bipolar disorder (Bratfos and Haug 1968; Fuller 1935; Paskind 1930; Pollock 1931a, 1931b, 1931c; Poort 1945; Rennie 1942; Tomasson 1947).

Notable contemporary authors nevertheless disagreed with Kraepelin’s Unitarian approach, and their studies of the natural history of affective disorders maintained the distinction between mania, depression, and bipolar disorder (Ballet 1903; Pilez 1901; Ziehen 1902, 1907). This data on the course of bipolar disorder collected in the 19th century and the first half of the 20th, before the introduction of modem antidepressants and mood stabilizers, is of special value in that it represents the disorder’s untreated natural history.

Onset of Bipolar Disorder

The dating of the age of onset is to a certain extent unreliable because it is usually retrospective and dependent on insecure recall. Bipolar disorder begins about 10 years earlier than recurrent depression, as shown by a review of the literature (Angst 1988). Earlier studies indicated a mean age of 28 to 33 years; epidemiologic and newer clinical studies show that bipolar symptoms start frequently in adolescence (Weissman et al 1988) and that manic episodes manifest usually in the early 20s (Fogarty et al 1994).

Periodic Mania and Switches of Polarity

There is considerable interest today in data on the course of single and multiple episodes, which can answer questions about the psychopathology, duration, and frequency of episodes; the syndromal stability over lifetime; and the frequency with which initial major depression develops into bipolar disorder. Today the switch of an episode from depression to hypomania is often assumed to be drug induced, but the phenomenon was already very common as “reactive hyperthymia” before the introduction of antidepressants.

A century ago the concept of periodic mania was well known and the diagnosis much more frequent, quite simply because it was applied to cases that today would be considered bipolar disorders. For instance, an initial depressive syndrome cycling into a manic episode, although frequently observed, was not considered an indication of bipolarity (Mendel 1881; Ziehen 1902), Similarly, “post-melancholic reactive hyperthymia” with clear hypomanie symptoms was compatible with the diagnosis of pure periodic melancholia (Ziehen 1907, 26).

Mania switching into depression was likewise very commonly reported as “reactive depression” (Ziehen 1902, 546, 554; Wernicke 1906, 355). Postmanic depression lasted a few days or a few weeks according to Wernicke (1906, 355). Mild depression was observed preceding or terminating manic attacks in most of the 128 manic patients studied by MacDonald (1918).

Modem naturalistic and treatment studies have also found that mania frequently cycles into depression: the rates of cycling observed in follow-up studies over 8 weeks vary from 17% (Tohen et al 1990) to 30% (Keller et al 1986a). Our earlier retrospective record study of 300 manic patients (admitted between 1920 and 1970) found that 21% of manic episodes cycled into depression, a rate that did not change significantly during the intervening decades (Angst 1987).

In a retrospective record study, depression switching into hypomania was found in 29% of bipolar patients hospitalised between 1920 and 1959 (Angst 1987).

Diagnostic Change from Depression to Bipolar Illness

The syndromal course over lifetime has been little investigated. It was frequently assumed that mania was predominant in earlier years and depression in the second half of life. Kinkelin (1954) followed-up 146 hospital first admissions suffering from MDI (1929–1947) until 1948 in a study covering an average of 21.8 years of the total course of the disorder. Of the 146 cases, 125 began with depression and 21 with mania. During the follow-up period 36 (28.8%) of the 125 depressive patients developed manic episodes, a figure that would correspond to a diagnostic change from depression to bipolar illness of 1.3% per year of observation. Mameros et al (1991b) reported that the initial diagnosis of depression remained stable in 79% of cases over 27 years. In our preponderantly prospective study we found a rate of diagnostic change from depression to hypomania/mania of about 1% per year (Angst and Preisig 1995a). Coryell and colleagues’ (1995a) intensive prospective follow-up study of 381 depressive subjects over 10 years found that 10.2% devel...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Introduction
• Overview
• Diagnosis and Epidemiology
• Genetics
• Natural History
• Childhood Onset
• Evolution
• Neurobiology of Disease
• Treatment
• Acknowledgments