by David Healy. Baltimore, Johns Hopkins University Press, 2008, 320 pp., $24.95.
Books have two aspects: as meant by authors and as received by readers. The aspects never fully match, which is perhaps why, as George Orwell wrote, “every book is a failure.” A writer cannot be blamed for his or her readers’ prejudices, but the writer must own the logical consequences of his or her ideas.
In Mania: A Short History of Bipolar Disorder, David Healy, known for his contrarian historical critiques of antidepressants/depression and neuroleptics/schizophrenia, examines bipolar disorder and mood stabilizers. I commend the book’s analysis of the pharmacological history of mood stabilizers, the historical background on key psychiatric figures, how the pharmaceutical industry manipulated patent laws to overmarket medications, and the historical overreliance on theory in medicine (an approach established by Galen, contrasting with an observation-based and disease-oriented Hippocratic approach ).
Other aspects of the book deserve critique. The history of lithium focuses on how it propelled the modern bipolar diagnosis. Biased or uninformed readers, unaware of its major prophylactic and antisuicide benefits, might conclude that there is nothing more to the drug. Similarly, the author’s analysis of the mood stabilization concept focuses on pharmaceutical marketing but does not engage the scientific debate about empirically founded definitions based on prophylaxis (2, 3), again leaving readers open to false conclusions.
Historically, the author attacks those who wish to trace bipolar concepts to ancient times, an issue of debate between us previously (4). He points out that the Greco-Roman view of mania involved a broadly defined mental excitation/agitation and a theory of four humours, not the current bipolar definition. However, the claim is not that present views of mania are the same as or better than past Greco-Roman notions, only that they have some similarities (a claim not lightly made but based on original translations from the Latin by current bipolar experts ). Indeed, if forced to choose between Hippocratic versus DSM-III definitions of mania, I might pick the former (6).
The book also chides current proponents of the bipolar spectrum model for misappropriating Kraepelin’s “brand.” Yet it fails to capture Kraepelin’s unique view of manic-depressive illness, which is that recurrence, not mania, is the essential feature (2). Kraepelin diagnosed this condition broadly, as demonstrated by the actual medical records in his Munich clinic (7). If the author’s claim is that the current bipolar disorder concept would not have been acceptable to Kraepelin, that is exactly what today’s bipolar spectrum proponents claim. (By the way, which pharmaceutical companies instigated, marketed, or benefited from Kraepelin’s broad manic depressive illness concept?)
Thus, the book has the wrong target: it seeks to deconstruct mania, thereby to dethrone bipolar disorder. However, manic depressive illness (the Kraepelinian variety, not the 19th century French/DSM-III concept) is based on recurrence, not mania.
Conceptually, this book enacts a social science dogma (8), i.e., that the story of medicine is not a progressive, simple discovery of real biological disease-entities but rather a complex cultural construction. The dogma is false, however, if interpreted to mean that disease is therefore purely socially constructed, without any biological basis that transcends its cultural classifications. (Not that the author states this notion, but much of the book implies it.) I agree that pure psychiatry, free from social and political influences, cannot exist. However, today’s postmodernist dogma sees all claims to truth solely as expressions of power used by society to repress. (A full chapter in this book analogizes the social construction of bipolar disorder to Stalinism.) When even the most biological conditions, such as manic depressive illness, are deconstructed almost into nothingness, then social construction becomes dogma, a radical denial as dangerous as compliant acceptance of pharmaceutical marketing. Indeed, Orwell, who lived it, saw this kind of postmodernist thinking as the root of all totalitarianism (9). Professors of postmodern literary theory can afford to hold these dangerous and false ideas. They, unlike doctors, never get sued (10). But in medical practice, identifiable standards exist for what is acceptable, and some views or actions are absolutely wrong by any standard (11).
There is no history without interpretation, but this does not mean that history is all interpretation and no text. Thus, when, without qualification, the book concludes that bipolar disorder is another increasingly “meaningless” entity, with an “advertising rubric” for treatment (p. 242), the author loses control, and readers take over, with logical consequences that will gladden antipsychiatry types and fellow travelers.
This review too can be misconstrued. I do not imply that everything is just fine in contemporary psychiatry; I extensively critique the status quo (11). But the opposite of falsehood is not truth. To get at the passion apparently behind the author’s antibipolar sentiment, let me explicitly agree that bipolar disorder should not be diagnosed in utero and that preschoolers generally should not receive antipsychotics. However, this short history avoids another history, the epidemic avoidance of adult manic depressive illness diagnosis for most of the 20th century (12–14). Many—likely more—adults have died from undiagnosed and untreated manic depressive illness than children have died from misdiagnosed and overtreated bipolar disorder. Both outcomes are intolerable.
Postmodernist ideology notwithstanding, Orwell got it right: “However much you deny the truth, the truth goes on existing, as it were, behind your back” (9). Whatever we call it, this recurrent mental condition will still—and not infrequently—make its deadly presence known.
1.Ghaemi SN: Toward a hippocratic psychopharmacology. Can J Psychiatry 2008; 53:189–196
2.Goodwin F, Jamison K: Manic Depressive Illness, 2nd ed. New York, Oxford University Press, 2007
3.Bauer MS, Mitchner L: What is a “mood stabilizer”? an evidence-based response. Am J Psychiatry 2004; 161:3–18
4.Healy D: The latest mania: selling bipolar disorder. PLoS Med 2006; 3:e185
5.Angst J, Marneros A: Bipolarity from ancient to modern times: conception, birth and rebirth. J Affect Disord 2001; 67:3–19
6.Koukopoulos A, Ghaemi SN: The primacy of mania: a reconsideration of mood disorders. Eur Psychiatry 2008 (in press)
7.Jablensky A, Hugler H, Von Cranach M, Kalinov K: Kraepelin revisited: a reassessment and statistical analysis of dementia praecox and manic-depressive insanity in 1908. Pychol Med 1993; 23:843–858
8.Kushner HI: Beyond social construction: toward new histories of psychiatry (review essay). J Hist Neurosci 1998; 7:141–149
9.Orwell G: Looking back on the Spanish War, in A Collection of Essays. San Diego, Hartcourt, Brace, and Company, 1981 (1946), p 199
10.Dennett D: Postmodernism and truth. http://ase.tufts.edu/cogstud/papers/postmod.tru.htm
11.Ghaemi SN: The Concepts of Psychiatry. Baltimore, Johns Hopkins University Press, 2003
12.Pope HG Jr, Lipinski JF: Diagnosis in schizophrenia and manic-depressive illness. Arch Gen Psychiatry 1978; 35:811–828
13.Copeland JR, Cooper JE, Kendell RE, Gourlay AJ: Differences in usage of diagnostic labels amongst psychiatrists in the British Isles. Br J Psychiatry 1971; 118:629–640
14.Ghaemi SN, Ko JY, Goodwin FK: “Cade’s disease” and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry 2002; 47:125–134
Dr. Ghaemi has received a research grant from Pfizer and honoraria from GlaxoSmithKline, AstraZeneca, Pfizer and Bristol-Myers Squibb.
Book review accepted for publication October 2008 (doi: 10.1176/appi.ajp.2008.08101531).