For many people who have bipolar I, lithium is that most elusive of pharmacological treatments, the “magic bullet”—a single intervention that completely eliminates the symptoms of a disease. Since the 1970s, lithium has been the gold standard for the treatment of bipolar I disorder, the intervention against which all others are judged.
What was it like to live with bipolar I disorder before lithium? Many excellent clinical studies about the course of bipolar disorder appeared in the years before effective treatments were available; these studies document and illustrate the pattern of bipolar disorder symptoms that occurs if the illness is not treated—what physicians call the natural history of the illness.
Modern studies have confirmed what earlier studies showed, that bipolar I disorder usually starts in late adolescence or early adulthood, with the peak onset during the third decade of life (ages 20 to 29).
How many episodes of illness did patients have in the days before treatment was available? How long did their episodes last? What was the length of time between episodes?
In a 1942 study, the records of 66 patients with “manic-depressive psychosis” were studied; some of these individuals had been followed for up to 26 years. Although a few patients seemed to have had only one episode of illness in the study period, about one-third had two to three episodes, about one-third had four to six episodes, and about one-third had more than seven. A few had 20 or more episodes.
How long did episodes of mania or major depression last before effective treatments were available? In the 1942 study, the average duration was about six and a half months. But we also know that depressions and manias were sometimes shorter and sometimes lasted much longer.
Dr. Emil Kraepelin, the German psychiatrist who coined the term “manic-depression” in the 19th century, wrote his landmark textbook of psychiatry at a time when there were essentially no effective treatments:
“The duration of individual attacks is extremely varied. Some last only eight to fourteen days, indeed we sometimes see that states of moodiness or excitement . . . do not continue in these patients longer than one or two days or even only a few hours. For the most part, however, a simple attack usually lasts six to eight months. On the other hand, the cases are not at all rare, in which an attack continues for two, three, or four years, and a double attack [can] double that time.”
Modern psychiatrists no longer see patients who are manic for years at a time—largely because lithium is so effective for these patients. Modern psychiatrists do, however, see patients who develop periods of mania again and again, month after month, year after year—often every time they stop taking medication. Do these patients have many episodes, or do they have many relapses of a single episode of several years’ duration? I tend to think it’s the latter, but the rhythm of the illness makes research very difficult.
How about the time between attacks? Kraepelin also noted that the time between episodes could be years, even decades—he described one case in which 44 years elapsed between one episode of illness and the next.
Subsequent studies have shown that, if untreated, episodes of bipolar disorder often occur more and more frequently in individual patients. The illness seems to accelerate if untreated, and in the days before treatment was available, mood episodes appeared to be triggered more easily as patients aged and tended to recur more and more frequently.
Another finding in these studies is that many patients “switch” from a depression to a manic episode with no interval of normal mood in between. Many individuals have a period of depression lasting several weeks or months and then switch into a manic episode, again of several months’ duration. Often, there is another switch and a third phase of the episode sets in: a long period of depression.
In a 1969 study, the course of one hundred manic episodes was described that also noted the relationship of manic to depressed periods. In this study, about half of the patients’ manic episodes showed at least one switch—a depression either before or after a manic episode. Several studies suggest that patients who “switch” from depression to mania have a more difficult-to-treat form of illness than those who switch from mania to depression.
Bipolar I is the classic manic-depressive illness, with fully developed manic episodes and episodes of severe depression. The number of episodes varies enormously, but patients who have only one or two episodes seem to be the exception rather than the rule. Before effective treatment—such as lithium—became available, the average length of each episode if untreated was about six months—but episodes that lasted years were not at all uncommon.
About one-third of patients with bipolar I disorder have nearly complete remission of their symptoms between episodes. In fact, this illness pattern has been found to predict that an individual will have an excellent response to treatment with lithium.
The course of the life of the great American poet Robert Lowell was derailed many times by his episodes of severe mania and depression. He was hospitalized 14 times for mood episodes, sometimes for many months, before starting lithium. In a letter to his editor, he described how much lithium had helped him, expressing amazement that “[a]ll I’ve suffered, and all the suffering I’ve caused, might have arisen from the lack of a little salt in my brain.”