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Skip to 0 minutes and 10 seconds So Andrew, we talk about depression, sometimes we talk about bipolar disorder, sometimes we’ve talked about manic depression. So what are these terms and are you comfortable with these definitions? Well the term we use nowadays, largely, is bipolar disorder. Historically, that was commonly known as manic depressive disorder or manic depression. But it’s an incredibly difficult condition to manage. Essentially it’s… the term bipolar is a reference to the two poles of mood that the patient experiences. So the highs, the so called hypomanias or indeed the manias. Hypomania refers to the milder form of mania, whereas mania is the completely uncontrolled form of elevated mood. And that can switch in time to a very low mood and depression. It’s uncontrollable. It’s unpredictable.

Skip to 1 minute and 4 seconds And it’s long term. It’s incredibly destructive. So on the one hand we know about the creative aspect of mood disorder and manic depression, bipolar. Historically, that’s fed, we believe, countless works of art, poetry, literature, painting. But on the other hand, it’s an incredibly destructive condition to have. There are countless consequences from a social, occupational, financial point of view. We know nowadays, statistically, for example the suicide rate is more than 6% over 20 years following diagnosis. The self-harming rate is about 30-40%, that’s massive. So that’s something I as a general practitioner deal with an awful lot, this long term sequelae, the long term fallout of this condition. The condition bipolar, we divide into two at the moment.

Skip to 2 minutes and 2 seconds So bipolar one, which is categorised by one or more episodes of overt mania. So overt mania when there’s this utterly uncontrolled, severe form of unpredicted mania that ends up almost requiring treatment to stabilise. And the longer term we talk about mood stabilisers, psychotherapy, all sorts of things that can give balance. But one can’t aim to flatten things, nor should one, as we said, want to do that because we want to preserve the person’s personality, and energy, and drive, and creativity. So it’s really with each patient it’s… and partly driven by what the patient wants as well, how much they do or do not want to take drugs. How much circumstances dictate whether they want to be treated or not.

Skip to 2 minutes and 56 seconds So bipolar two has to come to describe patients who have less severe episodes of mania, so hypomania. These often are more copeable with. They’re less likely to end up in someone being admitted to hospital, undergoing emergency treatment, at worst sometimes even ECT, which can help people when they’re at their severest end and nothing else works, nothing else helps in terms of drug medication. But we categorise in terms of numbers of episodes that someone experiences, and severity of episodes. Do we know what causes bipolar? Well, the answer is we don’t. But we know an awful lot about, for example, the genetics of inheritance. So there’s, there’s certainly genetic components. There’s inevitably an interplay with the environment, as with depression.

Skip to 3 minutes and 51 seconds We know, it’s through countless studies that it’s something to do with brain chemicals, neurotransmitters. At a very simplistic level, we know that low levels of one neurotransmitter called serotonin are associated with lower mood. And indeed, we have drugs called serotonin reuptake inhibitors. So these are drugs that boost the amount of serotonin. But it’s not as simple as that. It’s much more complicated. And I think, and I think increasingly, it’s thought the effect of these drugs on different people has a different effect on different people, which probably explains why they’re more effective in some, rather than others. So although one can think about it… and some say it’s better to describe it to patients as a boosting of chemicals.

Skip to 4 minutes and 35 seconds It’s a sort of natural process of restoring mental health and stability. The truth is it’s much more complicated, idiosyncratic, and unpredictable. So Andrew, I get a bit concerned about the link between creativity and mental illness. And I wonder whether sometimes it’s a cliché. On the other hand, we know from people who’ve suffered from what we would now cool bipolar, people I suppose like Sylvia Plath and Van Gogh, that there is a link between mental health and creativity. What do you think as a GP? I think there undoubtedly is. What I see more of is the destructive element of it where certain people need treatment, benefit from treatment.

Skip to 5 minutes and 22 seconds But I’m also aware that people, particularly experiencing the milder forms of mania, so what we call hypomania, where there is… someone described it once as seductively effortless energy, ambition, and creative ability that can be harnessed. Whereas if one becomes overtly manic, which is a far severer form, then one can’t control these feelings, these thoughts, these so-called racing thoughts, flight of ideas, the sucking in of all sorts of information and creation that is impossible to put down on paper, put down as music, put down as the sculpture. You can’t do that. And the destructive side takes over. But that also is the case with depression.

Skip to 6 minutes and 17 seconds So certain levels of depression produce an ability to write, produce the impetus and energy to write. Whereas if one becomes too depressed everything turns inward and the patient cannot produce, cannot create, cannot sometimes survive or exist and needs help. One question I wanted to ask you is whether there’s a sort of danger in prescribing certain kind of drugs that can impede the creative process. So for instance, this may be a cliché, but lithium. I’ve spoken to some people that say they didn’t want to… famously Stephen Fry said I don’t want to take lithium. Because the mania’s part of him, the creative energy is part of what fires him.

Skip to 7 minutes and 2 seconds And the worry is that if he dampens that down, then he loses a vital part of himself. Can that happen? Well, I think it does happen. And I think when it’s necessary, then it’s necessary. When someone is so dangerous to themself or others, then you have to treat. But other times, I think it can - and this is the paradox - that it can deaden, someone called it a deadening of the sensibilities. So you end up less, some people describe it as feeling less alive, less energetic, less free with these racing thoughts. But then at what price? There’s this paradox of stability, safety, and someone feeling calmer, and less liable to these massive shifts towards the mania or depression.

Skip to 7 minutes and 51 seconds And Stephen Fry says I’d want to be… I’d rather live with the angels as well as the devils. Do remember what he… I brought this along. This is his first autobiography Moab Is My Washpot and he’s… so he’s talked about, as you say, not wanting to be necessarily treated or treated long term. And again, harnessing the energy that this provides him. And he describes, this is him in his own words ‘It’s not all bad. Heightened self-consciousness, apartness, an inability to join in, physical shame, and self-loathing, they are not all bad. Those devil’s have also been my angels. Without them, I would never have disappeared into language, literature, the mind, laughter, and all that mad intensities that made and unmade me’.

Skip to 8 minutes and 45 seconds Andrew, we’ve come a long way from John Clare and his struggles with mental health. And just hearing you talk about the positive side of this, is I think really important. I think it is. And I think we’ve talked about the pharmacology and these massive advances we’ve made. But I think the biggest advance of the last 50 years or more is the de-stigmatising of mental illness in general, and a bipolar disorder in particular. That people can now talk about it. People can now talk without feeling guilty, because there’s no reason to feel guilty. Can talk without shame, there’s no reason for feeling shame. And can seek treatment, can seek help. And can seek support and understanding.

Skip to 9 minutes and 30 seconds And that, I think, makes the biggest difference long term.

Physiology of bipolar: Discussion with Andrew Schuman GP

Earlier in the week, we spoke to Dr Andrew Schuman about the symptoms, diagnosis and treatment of depression. In this video, we ask Andrew to talk about the physiology of bipolar disorder in particular.

Andrew explains that bipolar disorder, which used to be known as ‘manic depression’, is characterised by the extreme poles of mood that a person with the condition experiences. At times, they will experience symptoms typically associated with depression, while at other times, they will have episodes of mania or ‘hypomania’ (a slightly less extreme form of mania). There are currently two recognised forms of bipolar; in bipolar 1, the manic episodes are more severe, while in bipolar 2, a person typically experiences hypomania rather than overt mania.

Andrew talks about the links between bipolar disorder and creativity, and about the difficult of finding a balance when treating patients with bipolar, between curbing mania and dampening creative energy. Andrew emphasises that although we often focus on the creative output that can result from bipolar disorder, it can be a very debilitating and distressing condition to live with; moreover, the episodes of mania can be just as difficult to endure as the episodes of depression.

At the moment, we don’t fully understand what causes bipolar disorder, although Andrew explains some of the brain chemistry that scientists think may be behind the condition. The more we understand about bipolar, the easier it becomes not only to treat the condition, but also to reduce the stigma attached to it, by encouraging people to realise that the symptoms they suffer are in no way their fault. Writers who have shared their own experience of the condition are also helping to reduce this stigma, by making people feel more able to speak out and seek help.

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