by Bruce A. Hershfield, M.D. and David Goodman, M.D.
[Spring/Summer 1998; Vol. 25 No. 1]
On April 30, 1998, an audience of more than 750 DRADA members and others interested in affective disorder listened to a series of lectures and interviews presented at Johns Hopkins Medical School.
Dean MacKinnon, M.D., of Johns Hopkins began with a description of "The Manic Panic Connection." He explained that anxiety symptoms may point to a genetically distinct form of bipolar disorder. He noted that this was consistent with the finding (in thousands of patients) reported shortly afterwards in the epidemiological catchment area study. Researchers have identified a subset of families where more than 50 percent of the family members of bipolar patients who themselves have bipolar disorder also have panic disorder, said Dr. MacKinnon. The subset of families appears to have linkage on chromosome 18, he pointed out. At the conclusion of the talk, he asked 1) What is the course of treatment when two illnesses occur together? 2) Would this subset of families respond better to one mood-stabilizer than to another? At present, we do not know the answer to these two questions.
Glenn J. Treisman, M.D., Ph.D., Psychiatric Residency Training Director at Hopkins, then enchanted the audience with "The Impact on Patients with HIV and Mood Disorders" as he examined some of the interactions between psychiatric illness, particularly depression and HIV. Charging the audience to avoid "therapeutic nihilism"-the "discard file" for therapeutically hopeless patients-he pointed out that triple and quadruple (combined) therapy appears to stop viral replication. However, compliance can be problematic in a population where 18 percent are so cognitively impaired that they operate at the level of mental retardation. Dr. Treisman defines a period of neurovulnerablity to depression caused by HIV. This period, twenty-four months before AIDS and six months after AIDS develops, is when major depression typically occurs. Because the depression rate goes up as HIV damages the brain, 60 percent of HIV patients eventually get depressed, he said. The good news, he added, is that about 85 percent respond to treatment for depression that includes the use of antidepressants. Depression, he concluded, is a powerful factor in blocking compliance; "If you are depressed, all of the levers of life are turned off."
Godfrey Pearlson, M.D., Professor of Psychiatry, then talked about "Brain Imaging in Mood Disorder and other Related Conditions." He mentioned that Darwin believed in the genetically based expressions of emotions as evidenced by his studies of animals. Facial expressions of emotions are recognized in all cultures and are clearly established in the first year of life. He reviewed data for 1) cerebral blood flow studies in subjects experiencing happiness, sadness, and disgust, 2) subjects who watched film clips designed to induce emotions, 3) subjects who viewed faces portraying various emotions, and 4) brain-damaged subjects, indicating that the amygdala and frontal lobes seem to be the most important sites for depression, as well as other emotional states. On PET scan, sadness seems to cause an increase in orbito-frontal activity, in contrast to depression, that reduces orbito-frontal activity. This evidence would suggest that sadness and depression are distinctly different neurologic events, not the same emotion on different parts of a spectrum. Fear seems to light up the left amygdala while disgust lights up the right insula and not the amygdala. New technology may now allow us to neurologically define common emotions. He concluded that mood-mediating circuits are disturbed or dysfunctional in mood disorders.
Gabrielle Carlson, M.D., of the State University of New York at Stoneybrook, talked about "Bipolar Illness: What is Different about Young People." After mentioning that about 40 percent of bipolar patients have their first episode before they are 25; she examined the reasons why the diagnosis is so often missed. She proposed five reasons to explain the misdiagnoses of bipolar adolescents: 1) the patient is often having a first episode so there is no history, 2) bias against the diagnosis, 3) the explanation of "adolescent raging hormones," 4) comorbid conditions clouding the diagnosis, and 5) psychotic symptoms presumed to be schizophrenia. Twenty percent of depressed adolescents will develop bipolar disorder. Thirty percent of the psychotic depressions in this population will develop into a bipolar disorder. She talked about differentiating between mania and ADD/oppositional defiant disorder. She also discussed the high rate of childhood psychopathology among patients who later develop comorbid bipolar disorder/substance abuse. Those who have early onset of bipolar disorder have much higher rates of recurrence. She concluded with remarks about the synergistic uses of lithium and Ritalin in adolescents who have comorbid bipolar disorder and ADD.
In a special treat for the audience, Katherine Graham of "The Washington Post," winner of the Pulitzer Prize for Personal History, spoke about the bipolar disorder that afflicted her late husband. She movingly described his mood swings from 1957 to 1963-a period in which he played an important role in politics and in publishing. She highlighted his impressive productivity while manic. It may have been during one manic episode that her husband strongly influenced John Kennedy to take Lyndon Johnson as the vice-presidential candidate. When he was depressed, Phillip Graham believed he had little power or influence; this may have contributed to his tragic suicide in 1963.
Kay Jamison, Ph.D., professor of psychiatry at Johns Hopkins, lectured about "Scientists and Mood Disorders," continuing her series about famous and creative people who have suffered from affective disorders. She talked about scientists from Newton (who was subject to "rage and melancholia") to Buzz Aldrin (the second man on the moon, who has spoken openly about his recurrent depressions). For example, Charles Darwin suffered from panic symptoms and depression. His father was known to have had dark moods. A sister experienced depression and a paternal uncle committed suicide at age forty. As on so many occasions in the previous eleven DRADA symposia, Dr. Jamison spoke eloquently about the tragic influences of these disorders on the lives of societyµs most creative and productive individuals.
Benjamin Greenberg, M.D., Ph.D., lectured about exciting new research findings concerning "Transcranial Magnetic Stimulation." Dr. Greenberg, Chief of the NIMH Adult OCD Research Unit, said that compulsions and mood improve after transcranial magnetic stimulation of the right pre-frontal cortex. The treatment lasts 20-30 minutes and can cause local discomfort and headache, he said. There have been twelve studies of its use in depression; the effects have been "modest to moderate" and may only be temporary, said Dr. Greenberg.
Finally, J. Raymond DePaulo, Jr., M.D., interviewed "Charles," a New York attorney who had his first episode of bipolar disorder at nineteen, who went through a series of fall-winter depressions, and who now has been free of significant episodes since March 1992. Charles said, "Life is really a lot better with the treatment."