Living Crazy

Find attached a book review that was accepted for the American Journal of Psychiatry residents’ edition.  Most of it will be familiar from the mini-talk you invited me to do last November.  Sorry I couldn’t do more justice to your wonderful book, but I figure one of my roles is to get psychiatrists to read things they need to but wouldn’t ordinarily.  

See you soon,

Helena

Book Review

Bipolar Disorder as Culture Bound Syndrome: 

A Review of Anthropologist Emily Martin’s

Bipolar Expeditions: Mania and Depression

in American Culture

By Helena Hansen, MD, PhD, PGY4

NYU Medical Center Department of Psychiatry

Contact Information:

Helena Hansen MD, PhD, PGY4

Phone: (212) 562-2240

Email: helena [dot] hansen [at] nyumc [dot] org

If Kay Jamison,who argued that bipolar disorder fosters creativity by retrospectivelydiagnosing famous artists and authors in history, helped to usher an era inwhich mania is valorized, Emily Martin might be the anti-Kay Jamison.  Both Martin and Jamison write from thevantage point of their own diagnoses, but that is where the parallel ends.  Rather than asking how bipolar disorderfosters creation, as Jamison does, Martin issues a sharp critique by asking howbipolar disorder itself is works as a concept in popular culture, and what usesthe increasingly widespread concept has in contemporary American society.

Emily Martin is anaward winning medical anthropologist of renown among social science andhumanities scholars.  With thepublication of Bipolar Expeditions: Maniaand Depression in American Culture (Princeton University Press, 2007), sheturns from her previous subjects of inquiry (women’s physiology, immunology) tothe problem of bipolar disorder, applying her formidable skill to unearth howthe details of clinical practice reflect popular culture. 

An ethnographythat interweaves her self-reflection with interviews and observations ofbipolar support group members, clinicians treating bipolar disorder, andpharmaceutical marketing professionals, Martin’s book does not recognizeboundaries.  Like a psychoticperson, it breaks down the distinction of self and other; it does not respectprivate property.  And privateproperty is precisely what the book takes on.

In BipolarExpeditions, Emily Martin uses herself to challenge the idea that living withthe diagnosis of manic depression is an intimate, personal affair.  She cannot keep her own diagnosiswithin the confines of her psychiatrist’s office; at every turn she shows howher experience affects her students, her colleagues, her written and spokenwords.  She wrestles out loud withstanding “in a doubled position” as a person who uses psychopharmacology andtherapy, but also questions their historical and cultural significance.  As a member of the support groups aboutwhich she writes, she offers her story in order to replace “secrecy and fear”around the stigma of mental illness with “collective responsibility.”  At the same time she avoids glamorizingthe diagnosis as a famous anthropologist coming out as bipolar.  She points out that the bipolarcreativity portrayed in the media is one that furthers the status quo ratherthan challenging it.  Moreover, shedocuments how the creative potential of the people in her study is hinderedrather than helped by bipolarity. 

Emily Martinshatters common sense distinctions of public and private, individual andcommunal.  In the process, shemakes sense of what may seem counter-intuitive on the surface: the consciousself-presentation and sociality of people living with the diagnosis of manicdepression.  As Emily Martin putsit, even a “mad” manic can be social.

Manic people, shepoints out, are conformist: they engage; they gravitate to others; as producersthey are “tightly bound to social conventions” and “innovative…in terms themarket can value” (Martin 2007: 259). They are disruptive because they are social to excess: in their pursuitsand seduction they invade, they irritate. Depressed people withdraw, but as they descend it is impossible to do sowithout others noticing.  As theyget so depressed that they are not able to carry on everyday life, it becomesobvious to all, and all are moved in some way.  In both mania and depression, disrupted social rhythms callattention to the sufferer; they bring about a lack of privacy.  Mania and depression are enactedthrough social relations, like those in the support groups that Martindescribes.

It is an ironythat something as private as mania and depression have such a social impact andare experienced through social connections.  The “privacy” of the psychotherapeutic cultural model thatAmericans have for dealing with relational problems is unique: traveling greatdistances to consult in a sound-proofed room with someone we choose because heor she does not know anyone we know, and can guarantee confidentiality.  Consider how different the model isfrom the majority of non-European societies, where relational problems aremediated collectively in the community. Perhaps psychiatrists help to sustain a myth of privacy (of industry,property, individual psyches).  Yeteach of us brings our personal history to the present, and this history iscreated by our experience of other peoples’ emotions and realities. In thatsense, no act of consumer choice, foreclosure, plant construction, orpharmaceutical advertisement can be private.

Martin exposes asecond irony of manic depression. American media have propagated the idea that the mood of the economy, inparticular the stock market, reflects the mood of individual consumers andinvestors as it cycles between extreme optimism and risk taking on the onehand, pessimism and withdrawal on the other.  But the media have not shed light on the ways that theeconomy itself creates individuals with mood disorders.  Using examples ranging from magazineads that portray Ted Turner’s bipolarity in order to boost his image withstockholders, to stockbroker training programs that teach new traders to “behypomanic,” Martin argues that bipolarity is symbolically cultivated as aheroic property.  In the newmillennium, bipolarity has become a way of seeing the world, a way of makingsense of individuals, making sense of markets, and a way of demonstrating one’svalue. 

Martin’s argumentabout bipolarity builds on a literature historically linking psychiatricdiagnoses to the ethos of their time. A version of this history, reproduced by people as varied as David Healy(2006), Nikolas Rose (2007), and Jonathan Metzl (2003), is that post WWIIpsychiatry offered the metaphor of anxiety disorder and the panacea ofbenzodiazepines to a generation obsessed with insecurities about the cold war,changing gender and race relations. In the 80’s, with the introduction of Prozac, an aggressively marketedselective antidepressant free of the side effects of earlier antidepressants,the psychiatric metaphor shifted from anxiety to depression. The Prozacgeneration of baby boomers confronted the decline of American colonialism, andhit the limits of economic expansion. At the same time, physicians’ diagnosticpatterns shifted just as dramatically from anxiety to depression, with aneight-fold increase in antidepressant prescriptions written between 1990-2000(Rose 2007). 

Emily Martindescribes the third wave: the bipolar generation.  Thrust into broadband speed by the internet, and hardened bybooms and busts, from dot coms to the war on Iraq, this generation’s economy demandsimprovisation, risk taking, and perpetual motion.   Martin astute observation goes beyond metaphor.  Like the Indian theater she references,one can create the “conditions that excite a mood” rather than locating moodsin individuals.  In other words,mental illness may not necessarily come from deep within; it may beoverdetermined by the setting that directs its performance. 

The shift to thepsychiatric metaphor of bipolarity in the market has been accompanied by anexpansion of the diagnosis and treatment of bipolar disorder in actualclinics.  A standing joke in mydepartment involves attendings in whose care every patient ends up diagnosedwith bipolar disorder.  Variationson the diagnosis of bipolar disorder are proliferating, which new categoriessuch as “pseudounipolar depression” in those with no manic or hypomanicepisodes, but reporting irritability with depression, and often familyhistories of bipolar disorder, who are thus prescribed mood stabilizers.

In addition, thediagnosis of Bipolar II, which does not require patients to meet full criteriafor a manic episode, is leading young psychiatrists to rediagnose many peoplewho have long been diagnosed with depression.  Psychiatrists cite studies indicating that a number ofpatients mistakenly diagnosed with depression were actually sent into a manicepisode as a result of taking antidepressants without mood stabilizers.  It is striking that currently, patientson the inpatient service in my hospital are rarely discharged on an antidepressantalone.  These days, most leave withsome form of mood stabilizer or antipsychotic.  Among prescribers, there is a mania about the risk ofcausing mania with antidepressants. As a result, doctors prescribe bipolar medications.  Does the fact that Lamictal was onpatent until this year have anything to do with this?  What about the fact that second generation antipsychoticssuch as Seroquel and Zyprexa, whose patents both expire in 2011, are FDAapproved and promoted for use in bipolar disorder?

Products createconsumers, and new diagnoses create patients.  The market literally has turned bipolar, with Seroquel(making $2.76 billion/year), Lamictal (at 0.8 billion pounds/year) and Zyprexa(at $2 billion/year) named the top three profitmakers for pharmaceuticalcompanies by 2006. (health.dailynewscentral.com 2006, Glaxo SmithKline Annual Review2006).  Martin calls forpsychiatrists’ vigilance regarding the social effects of diagnosis, writing“The authority behind the act of naming means that the person will be treatedas if he or she had the condition; this is the sense in which the act ofdiagnosis is performative” (Martin 2007:148).

If we attempt totake Emily Martin’s social analysis to its logical conclusion, what does allthis mean?  Her book gives us someclues.  Bipolarity serves certainpurposes of the market.  Bipolardisorder is sold to Americans as a problem of self-regulation, of impulsivedecisions in an era of too much choice. The irony is that the marketing industry within popular media is soadvanced, as a technology of social manipulation, that bipolarity is ever morepredetermined.

Works Cited:

Healy, David. Let Them Eat Prozac: The Unhealthy Relationship Between thePharmaceutical Industry and Depression. NYU Press, New York 2004.

Jamison, Kay Redfield (1989):  “Mood Disorders and Patterns of Creativity in BritishWriters and Artists. ”  Psychiatry52(2):125-134.

Emily Martin. Bipolar Expeditions: Mania and Depression in American Culture PrincetonUniversity Press, Princeton 2007.

Glaxo SmithKline Annual Review March 30 2006.  Electronic document www.flixotidecopd.co.uk/investors/reps05/annual_review_2005/business_operating_review.htm). 

health.dailynewscentral Feb 3, 2006.  Electronic documentwww.health.dailynewscentral.com.

Metzl, Jonathan. Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. DukeUniversity Press, Durham 2003.

Rose, Nikolas. The Politics of Life Itself: Biomedicine, Power and Subjectivity in theTwenty-First Century.  PrincetonUniversity Press, Princeton 2007.