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Bipolar disorder (BD) is serious mental health condition that is relatively uncommon in adolescents. Because of its varied presentations, BD can sometimes be difficult to distinguish from typical adolescent development or attention-deficit/hyperactivity disorder (ADHD). Understanding these varied presentations can be helpful in determining when concerns for bipolar disorder are warranted. Key points in differentiating BD from typical development or ADHD lie in its episodic nature and the severity of symptoms. Effective treatments for BD exist, and teens should be evaluated promptly when concerns are identified so that treatment can be started early.

This interview follows my autobiographical chapter in this volume, “Adventures in Psychobiography and the Study of Lives: A Personal Journey”. In earlier work, I had explored “Alternatives to Psychobiography” and “Reconceptualizing the Relationships Between History and Psychology” (Runyan, 1988a, b). Interview responses draw on recent reading on interesting developments in psychobiography. Examples include Irvin Yalom, psychiatrist at Stanford, publishing on psychotherapy, historical novels about eminent philosophers, and most recently a memoir. A second fascinating life is that of Kay Redfield Jamison, researcher on manic depression, and autobiographer of her own struggles with manic depression. A third example is Eric R. Kandel, trained in both psychoanalysis and neuroscience, striving to integrate the two throughout his Nobel Prize-winning career.

The article focuses on how deep brain stimulation using implanted electrodes may be a viable treatment for major depression, as well as mood disorders such as manic depression, bipolar disorder, and obsessive-compulsive disorder. Information is provided on brain mapping of neural circuitry linked to depression, electrotherapeutic treatment for major depressive disorders, and the side effects of electroconvulsive therapy.

Medicine has been the deadliest profession in the United States for decades as physicians continuing dying by suicide at rates twice the general population. The problem is difficult to study and much attention has been paid to individual risk and resilience factors. However, occupational risk factors, obsolete definitions of health, and inconsistent regulation provide powerful disincentives to physician health and wellness that must be addressed if this tragic statistic is to change. Employers, licensing authorities, credentialing bodies, and physician advocacy organizations all have a role to play in improving the health of physicians and the practice of medicine. Standardization of regulatory practice in a manner consistent with the gains made by the Americans with Disability Act would be an important step in the process of improving physician health without sacrificing public safety. Physician advocacy organizations also have a role to play in providing or facilitating best practices in physician peer support, consistent and fair regulatory practices, and facilitation change in occupational factors related to impaired physician health and physician death by suicide.

In this short chapter, I discuss coercive practice by calling on personal experiences of over 20 years being treated for manic depression to give a patients’ perspective. This is of course a biased and somewhat anecdotal view of coercion that focuses on negative aspects, but reflects a patient’s experience of these techniques. In the context of this book, it is hoped that this account of coercion provides an alternate view to what readers may have already gained from previous chapters. I utilise treatment experiences over my time as a patient to emphasise my arguments. The chapter aims to question the rational of using coercive methods and questions the benefit to a patient over time. After defining what I think coercion is, I conclude by questioning why it is used and if it is at all an effective way of treating people with a mental health condition.

By 1909 the French actor, playwright, and director Max Linder was probably the most popular male film star of his time, and his success as an innovative writer-actor of variety and revue continued until the outbreak of the First World War. But this followed five years of frustration in stage-ornament roles on the professional, ‘legitimate’ stage, and only after success in the cinema did his playlets, integrating filmed and live action, further enhance his fame in variety venues across Europe. After the war, and Linder's stints in Hollywood, his long descent into bouts of manic depression tragically began. But his theatrical spirit survives in the cine-stage works of the Prague theatre, Laterna Magika, and Frank Bren also discusses here his possible influence on the work of Erwin Piscator, and more surely on the spectacular Paris music-hall production, Jour de fête à l'Olympia, created by and starring Jacques Tati in 1961. This was plainly modelled on Linder's cinema-theatre creations of 1910–1914, with Tati and Pierre Etaix the outstanding successors to Max in French film comedy. Australian actor-author Frank Bren is currently writing a biography of Pierre Etaix, whose classic film comedies of the sixties are now being restored for international re-release – two of them paying discreet homage to Max Linder. Bren has written or co-written histories of Polish and Chinese cinema and theatre as well as articles for diverse international periodicals.

Michael E ThaseDepartments of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA; the Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA; and the University of Pittsburgh Medical Center, Pittsburgh, PA, USAAbstract: Bipolar depression is more common, disabling, and difficult-to-treat than the manic and hypomanic phases that define bipolar disorder. Unlike the treatment of so-called “unipolar” depressions, antidepressants generally are not indicated as monotherapies for bipolar depressions and recent studies suggest that - even when used in combination with traditional mood stabilizers – antidepressants may have questionable value for bipolar depression. The current practice is that mood stabilizers are initiated first as monotherapies; however, the antidepressant efficacy of lithium and valproate is modest at best. Within this context the role of atypical antipsychotics is being evaluated. The combination of olanzapine and the antidepressant fluoxetine was the first treatment to receive regulatory approval in the US specifically for bipolar I depression. Quetiapine was the second medication to be approved for this indication, largely as the result of two pivotal trials known by the acronyms of BOLDER (BipOLar DEpRession) I and II. Both studies demonstrated that two doses of quetiapine (300 mg and 600 mg given once daily at bedtime) were significantly more effective than placebo, with no increased risk of patients switching into mania. Pooling the two studies, quetiapine was effective for both bipolar I and bipolar II depressions and for patients with (and without) a history of rapid cycling. The two doses were comparably effective in both studies. Although the efficacy of quetiapine monotherapy has been established, much additional research is necessary. Further studies are needed to more fully investigate dose-response relationships and comparing quetiapine monotherapy to other mood stabilizers (lithium, valproate, and lamotrigine) in bipolar depression, both singly and in combination. Head-to-head studies are needed comparing quetiapine to the olanzapine-fluoxetine combination. Longer-term studies are needed to confirm the persistence of response and to better gauge effects on metabolic profiles across months of therapy. A prospective study of patients specifically seeking treatment for rapid cycling and those with a history of treatment-emergent affective shifts also is needed. Despite the caveats, as treatment guidelines are revised to incorporate new data, the efficacy and tolerability of quetiapine monotherapy must be given serious consideration.Keywords: bipolar disorder, manic depression, depression, quetiapine, mood stabilizer

Neil Hunt explains how to recognize bipolar disorder, the symptoms of which may remain masked for years or mistaken for other illnesses

Aripiprazole is an antipsychotic medication, works by changing the actions of chemicals in the brain. It is used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar disorder (manic depression). In order to formulate a newer aripiprazole immediate release tablet of strength 30mg we evaluated the physical characteristics and the dissolution profile of the lab scale batch. The dissolution profile of the reference product and in house product was compared. The tablets from the lab scale batch were also subjected to accelerated stability studies. The results obtained were satisfactory and within the specified limits. In-vitro release profiles of the in-house product and reference product were similar. The lab scale batch tablets were found to be stable.

Aims and MethodObjective and subjective lithium compliance was investigated in 30 out-patients attending at an affective disorders clinic. Possible precursors of compliance levels were investigated; namely lithium knowledge and attitudes, patient satisfaction and dosage of lithium administered.ResultsAll patients were defined as currently compliant. Patients with a previous history of non-compliance were exclusively diagnosed with manic depression. Patient satisfaction, lithium knowledge and attitudes were not good predictors of lithium compliance.Clinical ImplicationsCompliance with lithium can remain excellent in the presence of moderate lithium knowledge and poor attitudes. Poor attitude towards lithium worsens with years on medication, despite high levels of compliance. Clinicians should be aware that larger prescribed dosages of lithium may be associated with poorer compliance.

On the basis of printouts of the Danish Central Death Register compiled by the National Board of Health, the frequencies of the three types of death diagnoses stated on the death certificate (the underlying, the secondary, and the tertiary cause of death) have been calculated for all deaths registered as suicide during a period of 22 years. In addition, samples of death certificates have been scrutinized. Analyses showed that the number of suicides registered under a psychiatric diagnosis decreased during the period from 76% to 59% for males and from 79% to 66% for females. For both males and females, the most frequent psychiatric diagnosis was non-classifiable psychoses; for males the second most frequent diagnosis was alcoholism, and for females manic depression, closely followed by alcoholism. The suitability of using death certificates and cause-of-death statistics only as basis for studying death diagnoses among suicides is critically discussed.

Lithium has been used to treat manic depression for decades, and may help combat other brain disorders. So how come no one knows for sure why it works? Helen R. Pilcher reports.

Lithium carbonate is a drug for manic depression. We experienced an operated patient with hyperparathyroidism which might be induced by lithium.A 54-year-old woman had been received lithium carbonate 600-1200 mg daily for manic-depressive psychosis since 1980. In 1989, the patient was pointed out hypercalcemia, and she was referred to the hospital because of suspected hyperparathyroidism caused by lithium carbonate in January 1990. Serum calcium and iPTH levels were as high as 13.1 ml/dl and 12.4% pg/ml, respectively. Parathyroidectomy of the right lower gland was carried out under the diagnosis of hyperparathyroidism. The tumor was 419 mg in weight and was adenoma histologically. There has been no recurrence for one year and 11 months after the operation. It can be thought that two actions of lithium, namely, parathyroid hormone-releasing action from the parathyroid tissues and growth promoting action, might cause hyperparathyroidism. If lithium induces hyperparathyroidism in the normal gland, one could make a possible candidate for subtotal thyroidectomuy (hyperplasia). If lithium promotes hyperparathyroidism, the appropriate treatment would be excision of the adenoma. For rational selection of operative procedure, the improtance of clarification of etiology for the disease is emphansized.

In the expanding vocabulary of manic depression, bipolar 1 disorder denotes episodes of depression alternating with mania (which may be psychotic); bipolar 2 describes depression alternating with hypomania (essentially a milder form of mania); bipolar 3 describes a first episode of mania precipitated by antidepressant medication; and bipolar 4 describes depression in someone who has been previously hyperthymic (expansive or “larger than life”). Readers of Andy Behrman's memoir may ask themselves which of these syndromes are being described. The press reviews cited on the book's cover suggest that psychiatrists will question Behrman's account. “Don't listen to them,” warns the Times …

Answers on p 379. A 72 year old man with manic depression, who had recently started lithium treatment, presented to casualty with a two day history of severe nausea and vomiting. His serum urea and electrolytes were normal (sodium 139 mmol/l, potassium 4.1 mmol/l, creatinine 94 mmol/l, and urea 5 …

Publisher Summary This chapter focuses on the biological aspects of depression. Depression is a state of low spirits or vitality. Psychiatrists divide depression into two types: endogenous, which is no apparent external cause, and reactive, which is an identifiable external cause, and while such a division may be of some value regarding ancillary treatment, there is currently no evidence to suggest that the biochemical changes that may be causally linked to the illness differ or any evidence that the ways in which the patient should be assisted by drugs differ substantially. Other international classifications of depression are based on the mono- and bipolar dichotomies that separate those patients with depressive symptoms only from those that fluctuate between depression and mania (i.e., manic depression) or have only manic symptoms. There are four major approaches to understanding the biochemical etiology of depression—namely, the analysis of postmortem brain of depressed suicide victims for neurotransmitters and their metabolites, the analysis of cerebrospinal fluid from depressed patients, the investigation of peripheral markers of neurotransmitter receptors by studying blood cells, for example, platelets and lymphocytes, and endocrine disturbances, which appear to be linked to the onset and duration of depression.

How the health service deals with severe mental illness which might pose a danger to others is always a matter of concern to the public. But it is often overlooked that it is the sufferer who is at the greatest risk. My daughter, who suffered from manic depression, received no treatment and committed suicide, aged 26, in September 1995. I have been trying to ascertain what went wrong, how she could have been helped, and who is interested in preventing such tragedies in the future. So far I have had little success. It seems as if general practitioners are not as well informed about mental illness as they might be. My daughter had registered with a general practitioner in the south of England on starting a job there towards the end of 1994. She presented with severe weight loss and gastric disturbance; in January 1995 I …

▪ Abstract How lithium works in manic-depressive illness is unknown. Recently, however, a powerful hypothesis has been gaining momentum. Distinguished by its testability and clinical implications, the inositol depletion hypothesis of lithium action is relevant to treatment of lithium side effects, to the development of new compounds with the clinical profile of lithium, and to new experimental treatment of depression.

In Chapter 1 the major studies of offspring of parents with affective disorders were discussed and their general findings were noted. Across the various projects a generally dismal picture emerged: children of mothers and fathers with depression or manic depression were significantly more likely to have diagnoses and impairment than were children of normal parents. In this chapter the findings are reviewed in greater detail, with primary interest in the studies that employed direct interview methods and DSM III criteria. Such studies permit us to compare rates of disorder across studies, by different parental diagnoses.

New national guidance for England and Wales encourages doctors to spot and treat bipolar disorder sooner and more accurately. Bipolar disorder, formerly known as manic depression, affects around 1% of the population and takes an average of eight years to be correctly diagnosed. It is associated with the highest suicide rate of any mental illness—one in seven people who are untreated commit suicide—but it …

Peter McGuffin, Michael J Owen, Michael C O'Donovan, Anita Thapar, Irving I Gottesman Gaskell/Royal College of Psychiatrists, £10, pp 230 ISBN 0-902241-65-6 During most of its history psychiatric genetics has focused on family, twin, and adoption studies and on statistical models aimed at resolving major gene effects or other transmission patterns. These studies strongly support the role of heredity in some psychiatric disorders - notably schizophrenia and manic depression - but the mode of genetic transmission remains unknown. With the advent of molecular genetic techniques the subject has gained in vigour …

Sixty two per cent of people with mental health problems are denied a choice of drug treatment, said a new report published yesterday by the National Schizophrenia Fellowship. The report is based on a survey of 2600 people carried out by the Manic Depression Fellowship and Mind. Although 73% of doctors discussed treatment, only 38% offered a choice, and only 54% …

In a sample of 73 undergraduates, obsessional-compulsive tendencies (and especially checking) were associated with scores on measures of manic, depressive, and suicidal tendencies.

Lady Caroline Lamb's madness is a stereotype of the romantic period: she was the woman Byron drove insane. Her literary output has been seen simply as the product of a "diseased sexuality," as Malcolm Kelsall has aptly put it (4). Perhaps so, but the "disease" in her writing is different from what criticism has led us to believe. Lady Caroline almost certainly suffered from bipolar disorder (manic depression), which is often associated with creativity. Her volatility, self-recriminations and temper tantrums clearly predated her affair with Byron. Her behavior as a child, often exaggerated as completely wild and uncontrollable, nonetheless showed cyclothymic tendencies-a pattern of emotional peaks and troughs dramatic enough to attract the attention of her peers and elders. Her moods seem to have been sustained over periods as short as minutes and, at other times, over months, or even years. These changing moods captivated her companions throughout her life. Even at the end, when Lady Caroline was struggling with drug and alcohol addiction, Lady Morgan observed, "One of her great charms was the rapid transition of manner which changed to its theme" (Morgan 2: 255).

Poets suffer from higher levels of manic depression than playwrights or prose writers, says a study published in the May issue of the British Journal of Psychiatry. But the study found that playwrights and prose writers had a higher prevalence than poets of depression, alcoholism, personality deviations, and marital problems. The data were collected from postmortem biographies of a hundred British and American male writers. Each writer was then ranked for “amounts of psychopathology”—penalty points were given for such characteristics as potentially handicapping personality traits, …

Depression has been associated with altered immune function. Acute phase prnteins (alpha-1-acid-glycoprotein [AGP], AGP microheterogeneity [AGPRC], interleukin-l-beta [IL-I B], interleukin-2 [IL-2], IL-6, and soluble IL-2 receptor [slL-2R]) concentrations were measured in sera from 86 bipolar I (BPI), 22 bipolar II (BPII), 51 unipolar MDD patients, and 13 healthy controls. AGP was increased in BPI compared to unipolar patients (2.185 +_ 0.503 vs. 1.995 + 0.598, p = 0.047), although neither patient group differed from controls, slL-2R was increased in BPI vs. MDD patients (706.930 + 298.621 vs. 512.667 _+ 206.118, p < 0.0001), while IL-IB was lower in BPI vs. MDD patients (3.579 _+ 12.909 vs. 10.314 _+ 28.490, p 0.043). slL-2R values were slightly higher in BPI vs. control subjects (706.930 + 298.62 l vs. 556.846 +_ 134.237, p 0.060). No other differences were observed for IL-6 or IL-2 levels. There were no significant effects of age or gender. It is concluded that elevations in one or more acute phase immune proteins may help to differentiate BPI from unipolar patients, and suggests the presence of a possible immune-priming etiology for manic depression.

Lithium carbonate has been used to treat manic-depressive illnesses since 1949. Its use is limited by many side effects.1,2Exophthalmos has been reported with long-term lithium therapy and a proportion of these patients went on to develop clinical hypothyroidism.3However, patients generally have few or no ocular complaints due to the drug. We describe an unusual case of a patient presenting with persistent chemosis and ultrasonographic evidence of enlargement of the extraocular muscles. Possible mechanisms associating extraocular muscle enlargement with lithium therapy are discussed. Report of a Case. —A 76-year-old woman presented with a 2-month history of increasingly gritty eyes. There was no significant ophthalmic or other medical history, except that she had been treated with lithium carbonate for manic depression during the previous 22 years. On examination, visual acuity was unimpaired. Conjunctival chemosis was present, more markedly on the left. Hertel exophthalmometry measured 19-mm right and left