sponsored by the Johns Hopkins Affective Disorders Clinic and The Depression and Related Affective Disorders Association
by David W. Goodman, M.D.
[Summer 1997; Vol. 24 No. 2]
Over the years, this symposium has become tremendously popular. Its 750 seats were sold 6 weeks before the scheduled event and hundreds of potential registrants were turned away. The audience was composed of mental health providers, patients, and family members. The goal of the symposium was to present up-to-date research about mood disorders, and patient and family member perspectives concerning them.
In the first talk Laura A. Pratt, B.A. (Ph.D. candidate in Epidemiology at Johns Hopkins School of Public Health) presented her research involving depression and increased heart attack risk that was published in "Circulation" in 1996. Starting with the Baltimore ECA study data, she and her colleagues re-interviewed over 1,300 patients 13 years later, looking at patients who had had Major Depressive Disorder and had subsequent heart attacks. The odds of having a heart attack were 4.5 times greater if the patient had a previous diagnosis of Major Depression and two times greater with a diagnosis of dysphoria, compared to the those with no history of mood disorder. These findings were consistent across each age category. Ms. Pratt admits that there are two methodological weaknesses to this study - "heart attack" was based on patient report (not confirmed by medical documentation) and the study only looked at the survivors. The researchers are currently trying to confirm the heart attack history.
Then Alan J. Romanoski, M.D., M.P.H., Associate Professor of Psychiatry at Johns Hopkins, presented "The Complex Relationship Between Depression and Alcoholism." He categorized alcoholism into "dependence" and "abuse" sub-types. The "dependent" is characterized by increased tolerance to alcohol, repeated withdrawal symptoms, drinking to relieve or avoid withdrawal symptoms, and reinstatement of the syndrome after abstinence. In contrast, "abuse" is characterized by a "pattern of repeatedly drinking despite resulting social, medical or psychological harm." "Dependence" predisposes to a greater severity of disability and psychopathological experiences. Dr. Romanoski pointed out that in generalized anxiety disorder the odds ratio is equal for male and female; however, it is four times greater in females with panic disorder. Depression occurs in 43% of women who drink, compared to 24% of men; dysphoria occurs in 21% of women who drink, compared to 11% of men. In general, males are 5 times more likely to abuse alcohol than females and they are also far more likely to quit drinking. His conclusion is that women who drink are more likely to have long-standing alcohol abuse problems and are more refractory to treatment.
Interest in psychiatric genetics has also grown. Christopher Ross, M.D., Ph.D., Associate Professor of Psychiatry, Johns Hopkins explained some of the complex genetic considerations in psychiatric research. One genetic model is based on Huntington's disease, which has been described as having classic Mendelian genetics: autosomal dominance, complete penetrance, no new mutations and a single locus. The Huntington's abnormality is found to be an expansion of trinucleotide repeats, he explained; this is a form of mutation also applicable to "fragile X syndrome." The concept of Mendelian genetics for Huntington's disease is then modified to include triplet repeat expansion, incomplete penetrance, new mutations, and genetic heterogeneity. With this new model, he and his colleagues looked at chromosomal markers for bipolar illness and they found trinucleotide repeat seems to be an applicable model, with a location on chromosome 18q.
Francis McMahon, M.D., Assistant Professor of Psychiatry, Johns Hopkins, then presented "Genetic Advances: Addition by Division". He reviewed recent studies that attempt to identify chromosomal loci linked to Bipolar Disorder on chromosomes 4, 18, 21 and X. Dr. McMahon and his group have focused on chromosome 18. Sibling pairs affected by mood disorder are 100% concordant with a chromosome 18q marker, if they have Bipolar Disorder, Type II, he said. This is a remarkable finding in psychiatric genetics. He suggested that we need to divide mood disorders into genetically simpler sub-types.
Harold Sackeim, Ph.D., Professor of Clinical Psychology at Columbia University, then presented "Electro Convulsive Therapy: The Good, The Bad and the Controversy." He reviewed the benefits and myths associated with ECT. As ECT was delivered to patients it became apparent that the severe mood symptoms were the most responsive, he said. Approximately one million people now receive ECT annually. ECT has remained a useful treatment over several decades, he continued, because it is more effective than any antidepressant. Dr. Sackeim's study in the New England Journal of Medicine (1993) looked at the response rate to unilateral versus bilateral placement with both high and low electrical dosing. Both low and high dose bilateral placement show higher response rates than unilateral treatment. In fact, there is only a 17% response rate to low dose right unilateral ECG, he mentioned.
Dr. Sackeim then addressed the issue of brain damage resulting from ECT; thus far, no studies suggest any significant findings. "The conditions necessary to produce neuronal death do not apply in ECT...changes in memory do not mean changes in brain structure." He acknowledges that there are cognitive effects: they are time-dependent, although some degree of retrograde amnesia will be permanent. Forgetting is far more likely to occur with bilateral than non-dominant unilateral placement, he stated. It is clear that patients who do respond to ECT need to be re-started on psychotropic medication to diminish relapse potential, he noted; there was an 87% relapse rate when patients were re-started on placebo. The relapse rate dropped to 38% when patients were re-started on lithium and nortriptyline, if a patient remains in remission 4 weeks following ECT, the likelihood of relapse decreases further. As a procedure, ECT appears bizarre and barbaric to the general public he said, however, it remains the most effective psychiatric treatment available for specific disorders.
Kay Jamison, Ph.D., Professor of Psychiatry at Johns Hopkins University annually presents an eloquent description of a noted writer or composer who suffered with depression. This year she talked about Virginia Woolf, who committed suicide by drowning in 1941. Details of her presumed bipolar disorder are highlighted in the Flight of the Mind by Dr. Tom Caramagno. Dr. Jamison mentioned that Virginia Woolf's family history was riddled with mood disorders. Her father suffered three major depressive episodes and was subject to fits of rage, his brother died of manic exhaustion while institutionalized and her two brothers and her sister also suffered from major depressive episodes. Her mother is described as having been chronically depressed. Virginia Woolf's first suicide attempt occurred in 1895 and a second in 1915. She also suffered from episodes of mania with delusions and auditory hallucinations. She wrote about "hearing birds talking in Greek." The writer describes the torment of moods: "I wish you could live in my brain...it is awash with violent moods..."
This year, George McGovern and Art Buchwald talked about how mood disorders have impacted their lives. McGovern, a presidential candidate in 1972, spoke about the painful and tragic death of his daughter, Terry, who was found frozen to death in 1994. That evening, she had been drinking heavily in a bar, shortly after discharge from an alcohol treatment center, he said. Mr. McGovern reviewed the events of his daughter's life, speaking proudly and happily of his daughter's younger years. He mentioned that at 19 she suffered her first clear major depressive episode, drug and alcohol use started in her mid-teens and became quite heavy at age 25. In 1972 she assisted her father in the presidential campaign. He was quite pleased with the way she handled the pressure, frequent traveling and public presentations, but her alcoholism and drug use necessitated 68 detox program admissions. She was treated for recurring depression with multiple antidepressants and she was on Prozac at the time of her death. Extensive treatment had little impact on her alcohol problems, said Mr. McGovern, who spoke of the anger he experienced during all the years of her treatment. He had to come to "separate the loathing for the disease from the love for this person."
Art Buchwald, a humorist whose writings are carried by over 400 newspapers, was the last speaker of the symposium. Ray DePaulo, M.D. set upon the task of interviewing Mr. Buchwald. Friends with William Styron and Mike Wallace, both of whom have spoken at the DRADA symposium, Mr. Buchwald noted that some people can make a career out of writing about their depression. He referred to his book, Leaving Home, in which he detailed his upbringing. The most tragic event was the institutionalization of his mother for over 35 years. When he was admitted for depression he was admitted to the same psychiatric unit where his mother had been. He has been hospitalized twice; once for depression, and once for mania. His first depressive episode occurred in 1963, and although he had episodes of depression for the next 20 years, there was no suggestion that he was bipolar, until he had his first manic episode in 1985. This episode lasted 4-5 months and he described it as "wonderful...grandiose and powerful."
He spent considerable time speaking about his appearance on the Larry King show along with Kay Jamison, Ph.D., Mike Wallace, and Naomi Judd. Apparently, Mr. King got more requests for video tapes of that show than for any previous shows and as a result of overwhelming demand, the show was replayed 2 weeks later.
Mr. Buchwald told the story of a woman who had overdosed at home. As she rolled over on the bed, she accidently hit the remote control, which turned on the TV. There on the TV, responding to Mr. King's question about suicide, Mr. Buchwald was saying "You just can't do that, suicide's out of the question, just don't do it." The woman believed it be a sign, so she got out of bed and induced vomiting. Referring to the stigma of mental illness, he says that the public admission of his mood disorder has "freed" him both socially and in his writing. Although he has not experienced the detrimental effects of stigma, he remarked that Rod Steiger, diagnosed with depression, couldn't get insurance to work on a movie for 8 years, which brought his acting career to a halt. He said that he noticed no effect of lithium on his creativity. He spoke about how his wife managed his suicidality. When he was suicidal in the hospital, his wife placed a picture of his children on the shelf in his hospital room, where he discovered it some time later. He said having that picture in his room fueled his resistence to suicide.
Art Buchwald is a man of words and humor. One can only begin to imagine the pain and sadness that have been factors contributing to his creativity and wit.
At the end of the day, casual remarks by audience members were clearly positive. Each year the symposium satisfies the audience's need for information and guidance. As a psychiatrist, I find it deeply rewarding to see patients and family members with these disorders converge to give each other support and understanding and I learn from (and teach) the professionals who work with them.