Abstract
Bipolar disorder 40 years ago: a critical period of transition
It is always difficult to fully grasp the Weltanschauung of another society, another culture, another era. Even when we attempt to understand the minds and views of predecessors in our own discipline of psychiatry, this is no less difficult a task. We can only hope to glean some meaningful insights into their thoughts from a considered perusal of their writings.
In this article, we will focus on bipolar disorder and try to comprehend the contemporary knowledge and understanding of this condition and its treatment 40 years ago. For this purpose, we will examine the decade from 1960 to 1970.
In the early twenty-first century, we currently consider bipolar disorder to be a not uncommon condition, with studies of life-time risk suggesting rates of DSMIV- defined illness of at least 1–2% and even up to 4% [1]. Furthermore, there are strong proponents (such as Akiskal and Angst) for an even broader concept of this condition, with claims that up to 10% of the population may suffer from the “bipolar spectrum disorder” [2], and that many with this condition are erroneously diagnosed with unipolar depression or personality disorder.
In our era, there is, moreover, enormous academic and pharmaceutical industry interest in this condition. Many companies have active bipolar disorder research development programs for existing or novel compounds. Industry educational and marketing strategies are directed not only at psychiatrists, but now target general practitioners who are advised of the common nature of this illness.
The contrast with the period 1960 to 1970 could not be more marked.
First, some issues of nomenclature must be addressed. Forty years ago, the term “manic-depressive psychosis” (or illness) was still in common usage. Originally coined by Kraepelin at the turn of the nineteenth into the twentieth century, this rubric encompassed a broad range of disorders including those with manic or hypomanic episodes, and also those with only severe recurrent depressive episodes. The diagnostic systems employed in the 1960s (both the American DSM-II and the World Health Organisation ICD-8) still incorporated the term ‘manic-depressive psychosis’. Although the EastGerman psychiatrist Karl Leonhard had already proposed the concept of “bipolar disorder” in 1957 [3], and Carlo Perris [4] and other European researchers had validated this distinct diagnostic entity in the 1960s, it was not until 1980 that the term “bipolar disorder” entered the DSM pantheon (with the advent of DSM-III). This new diagnostic term was not incorporated into the ICD system until the tenth edition. For the sake of simplicity, and at risk of being considered anachronistic, this article will use the term bipolar disorder when reviewing writings from the 1960s.
That decade was not only a time of dramatic transition for Western society in general; it was time of marked transition for both the treatment and diagnosis of bipolar disorder. At the beginning of the 1960s, the condition was considered to be rare or uncommon. Most textbooks of the era give it scant mention [5], usually subsuming it under a broader discussion of affective disorders. Certainly in the USA, the condition was frequently misdiagnosed as schizophrenia, with distinctive diagnostic practices in the USA and UK being exposed in the Cross-National Study of the Diagnosis of the Mental Disorders, which was commenced in the late 1960s [6]. In Australia— ‘the home of lithium’—a reading of the Bulletins of the Australasian Association of Psychiatrists (the fore-runner of the RANZCP) reveals not one presentation on bipolar disorder or its treatment at the regular scientific meetings of that organization in the first half of the decade [7].
One of the major driving forces determining the likelihood of particular diagnoses in medicine has been the availability of effective remedies. Psychiatry has not been exempt from this phenomenon, with the introduction of lithium into clinical practice in the late 1960s and early 1970s leading to substantial increases in the diagnosis of bipolar disorder over that time. For example, in Australia, Parker et al [8] demonstrated that in NewSouth Wales, the diagnosis of bipolar disorder increased dramatically (with a concomitant decrease in the diagnosis of schizophrenia) from the mid-1960s to the mid-1970s, despite there being no overall change in the total number of those with ‘functional psychoses’.
As with diagnosis, and not unrelated, this decade was also a major period of transition for the treatment of bipolar disorder. This dramatic shift was captured evocatively in an article by the prominent US researcher Nathan Kline [9] in a special issue of the American Journal of Psychiatry, which he entitled ‘Lithium comes into its own’.
The dramatic story of John Cade's discovery of lithium's effect in mania has been covered elsewhere [10–12], so will not be dealt with here. Our interest is in the 1960s, when lithium changed from being a novel compound of esoteric interest, to the major mainstream treatment for bipolar disorder. For more details, the reader is encouraged to turn to the writings of Mogens Schou [13]— sadly recently deceased—and Gordon Johnson and Sam Gershon [14] in the 1999 supplement to this Journal produced to commemorate the fiftieth anniversary of Cade's report.
In essence, at the beginning of the 1960s, lithiumwas of minimal academic interest internationally and not commonly prescribed, even in Australia where it had received approval from regulatory authorities by at least 1963 (personal communication, Philip Chipman, Australian Therapeutic Goods Administration). Although Schou had commenced research on lithium in the early 1950s, the pivotal studies by Baastrup and Schou were not published until the end of the 1960s [15, 16]. While the initialmirrorimage design of their 1967 report was compelling, it was not until the publication of the definitive 1970 doubleblind trial that the (at times vituperative) scientific scepticism from Shepherd and Blackwell from the UK was quelled.
In the USA, lithium research had been initiated by the Australian émigré Sam Gershon, who was later joined by Gordon Johnson. The work of those two, and that arising from the New York Psychiatric Institute (with the incipient interest in lithium being largely due to Schou's having earlier worked there in the late 1940s), among others, led to a seminal NIMH report on this compound being produced in 1970, with the Food and Drug Administration (FDA) soon afterwards approvingmarketing and clinical usage. According to Johnson and Gershon [14], widespread ‘research’ and off-label prescribing in the USA in the late 1960s was one of the major factors ultimately determining the FDA decision. Clearly, clinicians were impressed by lithium's effectiveness!
So, by the end of that decade, bipolar disorder and lithium had finally come of age. This achievement was acknowledged in the prescient concluding comment of Kline's article [9]: Lithium is a new and different key for dealing with affective and possibly other psychiatric disorders. How many locks it will fit – clinical and research – remains to be seen, but even the few doors thus far opened have given us glimpses into vast new potentials.