It is the most stupid question. Or so I used to think.
I went to Caltech for my graduate studies, and the Counseling Center sends a questionnaire periodically. The results are analyzed in aggregate to assess the overall mental health of the members of the Institute, particularly students. A prevalent, memorable question is always: “Do you no longer enjoy activities that you used to enjoy?” It is simple, to the point and for me, and many others, it was the take-home question––even though my friends and I often teased each other with it. I believe now that the answer to that particular question is the most telling single indicator of a mood disorder.
I was diagnosed with bipolar II in September 2011 when I was 26 and three years into my doctoral program in materials science. The two broad categories of mood disorders are unipolar, commonly known as depression, and bipolar, in which the patients go through manic states in addition to the depressive ones. Bipolar disorders are further classified into bipolar I, known in the past as manic depression, and bipolar II, in which the depressive episodes tend to be shorter but more severe, and the elevated states of mania tend to be less serious than in bipolar I. Other characteristics can be used to be more specific. For example, I have shown psychotic and melancholic features during my illness, and I have often had mixed episodes in which I had a great deal of physical energy, difficulty controlling my thoughts, which were usually self-destructive, and unwarranted feelings of guilt.
The diagnosis finally came months after I had started therapy at the urging of my mother and partner at the time. It took a long time to realize that I was suffering from a mood disorder and not just reacting to challenging life events––my relationship was crumbling, my research was stagnant, and I was constantly putting my life in danger. While I realize now that those were effects, not the causes, of my problems, it illustrates just how difficult it can be to diagnose a depression and even a manic episode. What is wrong about feeling energized and productive, anyway? It is astonishing to me that medical science has been able to discover and treat an illness that shows no obvious physical signs, one that has been described in literature as an “illness of the soul.”
Origins of Diagnosis & Treatment
As both a scientist and a patient, I am fascinated by the evolution of the modern understanding of mood disorders and their treatment. It started with the observations of Emil Kraepelin in the late 19th century, who classified psychosis into two types: manic depression and dementia praecox, the latter one now called schizophrenia. Psychosis is a very broad term, but it implies a loss of contact with reality. A psychotic person, for example, might have hallucinations or delusions and be easily agitated. Note that oftentimes a person might act in a psychotic way without being bipolar or schizophrenic––perhaps as a result of a very stressful event, drug use or abuse, or a different medical condition. Kraepelin’s breakthrough was to notice that while the symptoms of different conditions can be very similar, the occurrence patterns are different: by paying close attention to patterns it is possible to make the correct diagnosis. This attention to behavioral changes has been a key in all subsequent breakthroughs; it is essential for an individual diagnosis, and it is the first weapon that we have against mood disorders.
The seminal evidence that mood disorders, and mental conditions more generally, can be treated with medication came from John Cade, who discovered in a rather interesting way that lithium had a calming effect on guinea pigs. It was 1948 and he had been injecting them with urine extracts from schizophrenic patients and healthy subjects trying to isolate metabolic compounds that could be responsible for the illness and he used lithium urate to increase the water solubility of uric acid. Like every good scientist, he experimented on himself to determine the right dosage in humans and then started a small trial on patients suffering from depression, bipolar, and schizophrenia. He found that lithium alleviated the manic symptoms of bipolar patients; and although it did not do too much for clinically depressed patients, it did not exacerbate their symptoms either. He also noticed that lithium had a calming effect on schizophrenic patients but did not help with the bottom-line problems such as delusions; in a way, validating Kraepelin’s classification. Subsequent studies showed that lithium not only works in acute cases of mania, but also has a prophylactic effect and in 1970, became the first medication approved by the FDA for the treatment of manic illness.
A new Frontier of Research
Based on Cade’s discovery, it is easy to naively assume that bipolar disorder is caused by a lithium deficiency. However, the path to understanding mood disorders, and the human brain in general, has been much more interesting and is far from over. There are several leads as to what actually causes mood disorders, but there is no agreement regarding its neuropathology––physical differences between healthy and sick brains. Some regard depression and bipolar disorder as being on the same spectrum. This is likely the case, but they differ on some important aspects. For example, the administration of an antidepressant to a bipolar patient in a depressive episode can cause him or her to switch to the manic state, but this does not happen with patients with unipolar depression. Physicians are careful in these situations because the rate of suicide is particularly high during these antidepressant-induced manic states; and therefore, antidepressants are usually not the first line of attack. This hints that the neurochemistry of the diseases is different. Another important difference is in the hereditability of the conditions, which seems to be significantly higher for bipolar than for depression.
The positive effects of the main classes of drugs that are currently used to treat mood disorders––antidepressants, antipsychotics and anticonvulsants––were discovered in serendipitous ways not too different from the discovery of lithium, and modern drug development is painfully based on trial and error. Most of what we know about these conditions comes from the fact that certain drugs do seem to alleviate the symptoms. For example, antidepressants inhibit an enzyme that breaks down monoamine neurotransmitters while antipsychotics block certain neurotransmitter receptors on the neuron. Bipolar and depression then might seem to arise from an imbalance of neurotransmission, but this is also naïve. The medication acts immediately on the brain but it takes days or weeks for the effects to be noticeable on the mood; so, the underlying cause is likely a problem with how this imbalance affects the brain’s neuroplasticity, which is the ability of the brain to make new neural connections.
A Cultural Neural Network
While the brain is fascinating, society and culture are almost equally so. They are natural extensions of us humans––the collective result of “neural networks” of brains, each one learning from and reacting to their particular environment and communicating with others in every human way. It is not surprising that the environment plays a preeminent role in mood disorders, since it is a fundamental element in neuroplasticity. For example, the concordance rate in monozygotic twins is only 40 percent––if a twin suffers from a mood disorder, his sibling with identical genetic code will suffer from the same disorder in only two out of five cases.
Kevin Austin, executive director of Health and Counseling Services at Caltech, and designer of the aforementioned questionnaire, says that many students with potential mood disorders initially reject the possibility that they might suffer from one, and even feel somewhat offended when caregivers ask them about family history. “When we start asking questions such as: does anyone in your family sometimes have days or weeks in which it is impossible for that person to go to work? Or does someone in your family often drink too much? They start to see the big picture.”
I could not agree more. Now that I have developed that attention to detail that was so helpful to Kraepelin and Cade, I can detect certain patterns not only in my own life, but also in those of close relatives. After investigating some more, I even extracted some reluctant “confessions” from some of them who actually have a bipolar disorder diagnosis but kept it secret. This secrecy is still part of the culture of every ethnic group in the United States; but perhaps due to less awareness among our communities, it is more marked in ethnic minorities. It’s paramount to recognize and understand that mental illness is real and the symptoms are not character flaws that should be kept as shameful secrets.
The title of one of Andrew Solomon’s TED Talks is “Depression, the secret we share.” It is one of the best and most concise descriptions of depression that I have come across, and the title is indicative of his main finding: depression is pervasive, but people don’t talk about it. About 10 percent of the population will suffer from depression at some point, so it is almost impossible that we don’t know someone who suffers from it. The incidence rate for bipolar is about 2 percent. Information is the second weapon we have against mental illness. While I was lucky that I was diagnosed and have been treated, much suffering for me and for others would have been spared if I had been diagnosed during my first unequivocal depression my sophomore year of college––and being aware of my relatives’ diagnoses would have given me a head start against my illness.
Changing Attitudes, Emerging Resources
Depression and mania were considered “functional” diseases at the beginning of the 20th century, to distinguish them from “organic” diseases in which a clear physical origin exists, such as a heart disease. They were associated with personal weakness or character faults and many in the medical community did not consider them “real” illnesses. Unfortunately, more than 100 years later, this mentality is still extant in the general population. Attitudes are changing rapidly, says Austin. “In my parents’ generation, nobody talked about cancer––people were more superstitious and it was a death sentence. Many believed that getting cancer was somehow a punishment and that it was deserved. Those ideas disappeared when medicine elucidated the causes of cancer and made a cancer diagnosis not a death sentence.” Dr. Austin believes that as medicine continues to make strides into the cause of mood disorders and better treatments appear, more people will realize that a mood disorder is like any other illness––one that should be diagnosed and treated––and the stigma that it carries will continue to dissipate.
I have to concede that early on I was part of the problem. Like many other Hispanic men and women, I was raised to be strong, to work hard, and to defeat the odds. I disregarded depression as an excuse for laziness and mania as the stuff of myths or movies. During my elevated states I thought that I was really being myself. When for months at a time I experienced a loss of interest in activities that I used to enjoy, including fostering my relationships, I thought that my brain and body were taking a break. Like many, I had the idea that depression was sadness, but it is unfortunate that these words are used interchangeably. A medical depression is the loss of vigor and the ability to feel either sadness or happiness. Perhaps that still would be my opinion, but if left untreated, both depressive and manic episodes tend to become more severe and more frequent as the patient ages. I am aware that being open about my condition might be detrimental to my career or other areas of my life, but knowing that this might help others brings me joy. It is also not inconsistent with who I am or with my culture. I realized that to be strong I had to understand my weaknesses, and that being humble and wise enough to ask for help only made me stronger. I have been defeating the odds for a long time; as a Hispanic scientist with a PhD, I already am an iconoclast of sorts.
Austin related that at Caltech it is relatively easy to provide appropriate services to undergraduates because of the small student population (typically less than 1,000) and because most live on campus. The resident assistants are trained for emergencies, there is always a psychologist or social worker on call, and students notice changes in behavior quickly. There is also high penetration of information about mental health and services provided by the school, so stigmatization is almost nonexistent.
Austin noted that the challenges Caltech faces with graduate students are more representative of the challenges faced by bigger schools. The students live off campus, so it is more difficult to reach them to inform them about available services. They move often between apartments or dorms, and students tend to have more social groups but interact for less time with each one, making it more difficult for others to notice behavioral changes. In the case of graduate students, their research group often is their main social group so in principle, it should be easy to reach them through advisors––but some advisors are not as responsive as they could be.
Educational institutions have built a good infrastructure for mental health care, but it’s challenging to raise awareness among students. Most universities offer counseling services and have 24-hour crisis hotlines. There are national student organizations with local chapters such as Active Minds that work on raising awareness and providing support––and local SACNAS chapters are a great place to start talking about the science and illnesses of the brain. Scientific research and advances in medicine have resulted in more effective medication and less serious side effects, and this is the trend. Medical treatment and therapy are not cheap, but the Affordable Care Act requires that health insurance plans cover mental health disorders and that screening services for depression are provided for free.
Living with bipolar is challenging, but the provisions to keep my symptoms under control––such as being mindful of my behavior, maintaining open communication with my loved ones, and being disciplined with my schedule––are not too different from what I should be doing anyway. The medication has side effects such as severe drowsiness, so events like going out at night require some more planning. Other side effects like weight gain and increased blood sugar require some gym time and a safer selection of food. Therapy was very helpful to me at the beginning. It is also important to learn how to deal with stressful situations, and certain approaches such as dialectical behavioral therapy have proven to be very effective for this. Taking these provisions, the medication, and with the help and patience of my advisor, I started doing productive research again and graduated with my doctorate in June 2013. Some parts of my life suffered irreparable damage, but I have managed to accept who I am and forgive myself, and this is part of the healing process.
This article originally appeared in SACNAS News Magazine, the newsletter of the Society for Advancement of Chicanos and Native Americans in Science. Read the original here.