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OVER the last few weeks, “Homeland,” Showtime’s new psychological thriller, has had quite a rush. Claire Danes, the show’s incandescent star, was nominated for, and then won, the Golden Globe for best actress in a TV drama series; the show also won for best TV drama. Why do I care? Because I know her character all too well.

Not in every sense, of course. I’m not a blond C.I.A. agent, and I’ve never hunted down or fallen in love with suspected terrorists. But as fans of the show — including, it’s said, President Obama — know, that’s not the only important part of Carrie Mathison, the character played by Ms. Danes. Like me, Carrie has bipolar disorder.

My sister Meredith Stiehm is a writer and consulting producer for the show, and she drew on my experience with the disorder to portray Carrie’s character. Not long ago, I retold the tale of my single manic episode to her, sharpening memories of that day in all its colors.

It was a painful testament to my sister’s skill that scenes that might have been of just passing interest to other viewers pushed me to tears, because in a real way they carried an uncanny emotional resonance.

And yet for all that, I feel the show’s creators, writers and producers, and Ms. Danes, have done us all a public service: perhaps, with the show’s glowing reception, Americans can finally talk openly about bipolar disorder.

Meredith’s interest in my condition is not, of course, limited to her work as a writer. After the manic episode landed me in the Johns Hopkins hospital years ago, Meredith stayed with me at home for a week to help me get back to the regular simplicity of sleeping and waking. One of the first things they tell you about the condition is that sleep really is the “chief nourisher in life’s feast,” as Macbeth put it. I have a mild case, so sleep, and lithium under the care of a doctor, have helped me stay healthy ever since.

My sister knows my back pages well, and while writing the script, she asked me about that spell of several sunny October days. Dormant memories awakened: I was a reporter for The Baltimore Sun, and I was filing stories in the newsroom faster than ever before. It’s strangely fitting that I worked in journalism, which at its best also has its share of frenetic late nights, deadlines and homing in on people. As a reporter at The Sun once said to me, “This is a manic-depressive business.”

Didn’t I know it. A “hypomanic” state, which precedes an episode of mania, is in fact an enhanced, alert, productive mood where one can feel exhilarated and immune to life’s dangers. I seemed to see into people’s hearts when I smiled at them. My speech sped up so much few could understand me.

I ran around Baltimore’s Inner Harbor at high speed, exulting in all my energy. For several days, I woke up at dawn to see the sunrise and take pictures of it. I felt sure something big was going to happen soon in Baltimore and only I could foresee it.

Similarly, a haunted Carrie is convinced that a big terrorist attack is looming large. Her furious focus on her quarry under time pressure leads to sleepless nights and reckless risks, behavior that is both symptom and contributing cause of bipolar illness. Her elevated mood cycles higher and higher, and she falls rapturously in love with the married Marine who she thinks is working for Al Qaeda, played with minute precision by Damian Lewis. Viewers can’t totally dismiss her visions — but then again, she’s not rational. In the hospital ward, she demands a green pen to write everything down, her voice racing faster and faster. Meredith had bottled my mercurial emotions so exactly it hurt.

Bipolar extremes can be truly hard to watch, excruciating even in memory. To see that experience depicted so intensely by Ms. Danes was like peering at a portrait gallery of my own psyche.

As I recovered, I found comfort in company. My colleagues could not have been more gracious. But at the end of the show’s first season (spoiler alert), poor Carrie has lost her job and appears left in a lonely place, about to undergo electroconvulsive therapy.

However, contrary to widespread belief, electroconvulsive therapy is extremely effective. A family friend, Dr. Leon Rosenberg, a geneticist and former dean of Yale Medical School, has the same malady. As a patient overwhelmed by suicidal depression, he made remarkable progress after electroconvulsive therapy. As a doctor, he described his own case in a medical journal and discusses his descent and recovery with students.

Yes, the show cuts close to home at points, but it gets the lead character’s story right. How rare to see a sparkling and spirited representation of what it’s actually like to walk through life with bipolar disorder. So let a thousand conversations bloom. Secrets held up to light and air lose their power in the public square. Spies know it as keepers, and writers know it as tellers.

Jamie Stiehm, a journalist,

is writing a biography of the social reformer

Lucretia Mott.

My So-Called Bipolar Life,
NYT,
17.1.2012,
https://www.nytimes.com/2012/01/18/
opinion/my-so-called-bipolar-life.html

Bipolar Soars

as Diagnosis for the Young

September 4, 2007

The New York Times

By BENEDICT CAREY

The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers report today in the most comprehensive study of the controversial diagnosis.

Experts say the number has almost certainly risen further since 2003.

Many experts theorize that the jump reflects that doctors are more aggressively applying the diagnosis to children, and not that the incidence of the disorder has increased.

But the magnitude of the increase surprises many psychiatrists. They say it is likely to intensify the debate over the validity of the diagnosis, which has shaken child psychiatry.

Bipolar disorder is characterized by extreme mood swings. Until relatively recently, it was thought to emerge almost exclusively in adulthood. But in the 1990s, psychiatrists began looking more closely for symptoms in younger patients.

Some experts say greater awareness, reflected in the increasing diagnoses, is letting youngsters with the disorder obtain the treatment they need.

Other experts say bipolar disorder is overdiagnosed. The term, the critics say, has become a catchall applied to almost any explosive, aggressive child.

After children are classified, the experts add, they are treated with powerful psychiatric drugs that have few proven benefits in children and potentially serious side effects like rapid weight gain.

In the study, researchers from New York, Maryland and Madrid analyzed a National Center for Health Statistics survey of office visits that focused on doctors in private or group practices. The researchers calculated the number of visits in which doctors recorded diagnoses of bipolar disorder and found that they increased, from 20,000 in 1994 to 800,000 in 2003, about 1 percent of the population under age 20.

The spread of the diagnosis is a boon to drug makers, some psychiatrists point out, because treatments typically include medications that can be three to five times more expensive than those for other disorders like depression or anxiety.

“I think the increase shows that the field is maturing when it comes to recognizing pediatric bipolar disorder, but the tremendous controversy reflects the fact that we haven’t matured enough,” said Dr. John March, chief of child and adolescent psychiatry at the Duke University School of Medicine, who was not involved in the research.

“From a developmental point of view,” Dr. March said, “we simply don’t know how accurately we can diagnose bipolar disorder or whether those diagnosed at age 5 or 6 or 7 will grow up to be adults with the illness. The label may or may not reflect reality.”

Most children who qualify for the diagnosis do not proceed to develop the classic features of adult bipolar disorder like mania, researchers have found. They are far more likely to become depressed.

Dr. Mani Pavuluri, director of the pediatric mood disorders program at the University of Illinois, Chicago, said the label was often better than any of the other diagnoses often given to difficult children.

“These are kids that have rage, anger, bubbling emotions that are just intolerable for them,” Dr. Pavuluri said, “and it is good that this is finally being recognized as part of a single disorder.”

The senior author of the study, Dr. Mark Olfson of the New York State Psychiatric Institute at the Columbia University Medical Center, said, “I have been studying trends in mental health services for some time, and this finding really stands out as one of the most striking increases in this short a time.”

The increase makes bipolar disorder more common among children than clinical depression, the authors said. Psychiatrists made almost 90 percent of the diagnoses, and two-thirds of the young patients were boys, said the study, published in the September issue of The Archives of General Psychiatry.

About half the patients were identified as having other mental difficulties, mostly attention deficit disorder.

The children’s treatments almost always included medication. About half received antipsychotic drugs like Risperdal from Janssen or Seroquel from Astrazeneca, both developed to treat schizophrenia.

A third were prescribed so-called mood stabilizers, most often the epilepsy drug Depakote. Antidepressants and stimulants were also common.

Most children took a combination of two or more drugs, and 4 in 10 received psychotherapy.

The regimens were similar to those of a group of adults with bipolar diagnoses, the study found.

“You get the sense looking at the data that doctors are generalizing from the adult literature and applying the same principles to children,” Dr. Olfson said.

The increased children’s diagnoses reflect several factors, experts say. Symptoms appear earlier in life than previously thought, in teenagers and young children who later develop the full-scale disorder, recent studies suggest.

The label also gives doctors and desperate parents a quick way to try to manage children’s rages and outbursts in an era when long-term psychotherapy and hospital care are less accessible, they say.

In addition, drug makers and company-sponsored psychiatrists have been encouraging doctors to look for the disorder since several drugs were approved to treat it in adults.

Last month, the Food and Drug Administration approved one of the medications, Risperdal, to treat bipolar in children. Experts say they expect that move will increase the use of Risperdal and similar drugs for young people.

“We are just inundated with stuff from drug companies, publications, throwaways, that tell us six ways from Sunday that, Oh my God, we’re missing bipolar,” said Dr. Gabrielle Carlson, a professor of psychiatry and pediatrics at the Stony Brook University School of Medicine on Long Island. “And if you’re a parent with a difficult child, you go online, and there’s a Web site for bipolar, and you think: ‘Thank God, I’ve found a diagnosis. I’ve found a home.’ ”

Some parents whose children have received the diagnosis say that, with time, the label led to effective treatment.

“It’s been a godsend for us,” said Kelly Simons of Montrose, Colo., whose son Brit, 15, was prone to angry outbursts until given a combination of lithium, a mood stabilizer, and Risperdal, which was often given to children “off label,” several years ago. He now takes just lithium and is an honor roll student.

Other parents say their children have suffered side effects of drugs for bipolar disorder.

Ashley Ocampo, 40, of Tallahassee, Fla., whose 8-year-old son is being treated for bipolar, said that he had tried several antipsychotic drugs and mood stabilizers and that he had improved.

“He has gained weight,” Ms. Ocampo said, “to the point where we were struggling find clothes for him. He’s had tremors and still has some fine motor problems that he’s getting therapy for. But he’s a fabulous kid. And I think, I hope, that we’re close to finding the right combination of medications to help him.”

Bipolar Soars as Diagnosis for the Young,
NYT,
4.9.2007,
https://www.nytimes.com/2007/09/04/
health/04psych.html

When Bipolar Masquerades

as a Happy Face

Feb. 17, 2004

The New York Times

Reporter's File

By RICHARD A. FRIEDMAN, M.D.

At 45, my patient Bruce was at the pinnacle of his career, with a lucrative law practice. Then his life was cruelly turned upside down by two medical events, a crushing first episode of major depression and a series of strokes from untreated hypertension.

For many years, Bruce struggled with severe depression and high blood pressure without much headway. Then something strange happened.

He suddenly pulled out of the depression and dove into his work. Not only that, but he felt the surge of energy and self-confidence that he used to have. No hurdle seemed too high or problem unsolvable, he recently recalled.

No one questioned his renewed energy and vigor, because he had always been vivacious. Nor did his combative behavior and ever increasing volume of provocative e-mail messages to friends and colleagues raise a suspicion that something might be seriously amiss.

Betting that his future earnings would more than cover large expenses, he put off filing his state tax returns. No one seemed to recognize just how impaired his judgment had become. Even the judge who placed him on probation for failure to file tax returns missed the real story.

When I met Bruce in a consultation, he spoke loudly and rapidly, and I had difficulty interrupting him. It wasn't hard to figure out that he had been living with an unrecognized and untreated psychiatric illness that had driven him to the edge of ruin — bipolar disorder, also known as manic depression.

Like most diseases, bipolar disorder comes in different shapes and sizes and can be difficult to diagnose. Few people or physicians would miss classic bipolar disorder, with its cyclic episodes of severe depression and full-blown mania. After all, there is nothing subtle about mania, grandiose and often psychotic thinking, elated mood, superhuman energy and libido and reckless judgment.

But a milder form of mania, called hypomania, is not obvious at all, especially in someone like Bruce who happens to be temperamentally dramatic and lively. That is because hypomanic people feel very happy, have lots of energy, need little sleep and are generally fun to be with. And they certainly do not run to doctors complaining of happiness.

So it is easy to see how hypomania could masquerade as cheerful character. In the same way, dysthymia, hypomania's dark twin, has often been confused with gloomy temperament, when in fact it is a treatable form of low-grade depression.

Unlike depression, though, hypomania is intrinsically pleasurable. It is a better-than-well state that often confers a heightened sense of creativity and power.

So what is the down side to hypomania? Well, it can subtly and sometimes powerfully impair a person's judgment. After all, exuberance and supreme confidence can blind someone to the potential consequences of decisions.

Despite obvious financial constraints, Bruce went through long periods of extravagant spending with an inflated sense of his own power and ability. The results proved catastrophic. Not only that, but hypomania is very often an unstable state that cycles into periods of depression, which are sometimes very severe. When that happens, as in Bruce's case, it is called bipolar type 2 disorder.

Bipolar disorder is a potentially fatal illness, because 10 to 20 percent of patients commit suicide, the National Institute of Mental Health says.

According to a survey sponsored by the institute, the prevalence of bipolar disorder is 1.1 percent. That estimate covers just people with the classic form of the disorder.

A more recent survey by Dr. Robert M. Hirschfeld, published in The Journal of Clinical Psychiatry in 2003, found significant bipolar symptoms in 3.7 percent of the United States population. About 20 percent of people identified as bipolar in the survey had been given correct diagnoses, and most had not received effective treatment. The study also found a much higher rate of bipolar disorder, 9.3 percent, among patients 18 to 24 years of age.

The very different rates reported in these two surveys reflect different questions, definitions and methods to diagnose bipolar disorder. If a survey includes the milder types, as the above study did, the prevalence will be much higher.

In fact, the whole spectrum of bipolar disorder is very broad. Some people learn for the first time that they have bipolar disorder when they are treated for depression. That's because antidepressants can precipitate mania in 5 to 10 percent of people with no histories of mania.

Depression is associated with decreased activity of important neurotransmitters like serotonin and norepinephrine. The converse is hypothesized for mania. Because antidepressants significantly increase the availability of those neurotransmitters, they can spark mania in some biologically vulnerable people.

So can "recreational" drugs like cocaine and methamphetamine, which instantly flood the brain with another neurotransmitter that regulates mood, dopamine.

The problem is that the milder types of bipolar disorder are often hard to recognize as an illness because the symptoms are chronic and less severe. In contrast, a person who develops a florid acute disease, whether appendicitis or full-scale mania, is obviously ill to any casual observer, because the contrast between the normal base line and the illness is stark.

Bruce, his family and friends, as well as his physicians were all taken in by his hypomania masquerading as mere happiness. In effect, they mistook his bipolar illness for his personality.

In the end, Bruce has responded very well to lamotrigine, an anticonvulsant mood stabilizer. Some time after, he was calm and rational and had an even mood. It was only then that he was able to see clearly the illness that nearly destroyed him. Now he is beginning to put the pieces of his life back together.

When Bipolar Masquerades as a Happy Face,
NYT,
https://www.nytimes.com/2004/02/17/
health/cases-when-bipolar-masquerades-as-a-happy-face.html

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