Bipolar Expeditions (35 page)

As mania becomes valuable intellectual and emotional property, it may also, as we have seen for John and Marcy, elicit fear. Are two kinds of mania emerging, as it were, a “good” kind, harnessed by Robin Williams and Ted Turner, and a “bad” kind to which most sufferers of manic depression are relegated? In the troubles that followed his “barbaric yawp,” did Howard Dean stumble into a place where he exemplified both kinds? In this case, even if the value given to the irrational experience of mania increases, validity would yet again be denied to the “mentally ill,” and in fact their stigmatization might increase. After all, if those living under the description of manic depression have, by definition, the ability to be manic or hyperactive, and if that ability comes to be seen as an important key to success, then why are they so often social and economic failures? Or, will the presence of a
manic style
in popular culture reduce the stigmatization of manic depression? Now that he is widely thought of as manic depressive, could Robin Williams's performances as a stand-up comedian contribute to moving the category mania altogether away from the stigmatized, because his performances give pleasure, bring rewards, and, in their inventiveness, produce forms of value? Do his funny, madcap antics enhance the growing perception that mania is valuable intellectual property? He may be creative
at a cost to himself,
but in a manner his society values.

A Mental State as a “Thing”

In my fieldwork, I was often struck by how pharmaceutical development, marketing, and advertising strive to move mania and depression away from being thought of as context-dependent experiences and toward being thought of as stable and thing-like. Movement toward thinglike status makes mania and depression seem possible to identify, manipulate, and optimize through the technology of psychotropic drugs and through taxonomic apparatuses. At the 2000 APA, I met a young doctor who practiced in a well-known hospital near Hollywood. We were at a dinner sponsored by Solvay Pharmaceuticals, maker of Luvox, a drug prescribed for depression and anxiety. When he heard about my research, he became quite interested and offered me this experience.

Where I work, we get a lot of Hollywood comedians coming in. They are manic depressives. There are two important things about this: first, they do not want their condition publicized, and second, their managers always get involved in the details of their treatment. The managers want the mania treated just so. They do not want it floridly out of control, but they also absolutely do not want it damped down too much.

He felt he was being called upon to
optimize
the patients' moods (for particular professions and for the particular kinds of creativity each requires) through proper management of their drugs. His comment made me realize that drugs I was taking were being optimized for my profession, too: not so much lithium that my hands shook when I wrote on the blackboard; not so much Lexapro that my mind slowed down and stopped generating ideas during a class; not so little Focalin that my attention wandered constantly and I couldn't write articles and books; not so little Lamictal that I got depressed and became unproductive altogether. A little like the Hollywood comedians, I was in the fortunate position of being able to afford expensive, expert advice about all this and working in a profession I valued. I began to feel uneasy about the prospect of extending the optimization of psychotropic drugs to suit other kinds of employment. What would happen if optimizing states of mind were extended, through health insurance, say, or perhaps as a condition of employment, to people who work in physically demanding jobs, for long hours, low pay, and little hope of advancement? To people who work in retail jobs demanding continuous emotional work (make the customer smile!), for long hours, low pay, and little hope of advancement? Or to soldiers on combat duty?
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Mulling over these questions, I wandered into the Wyeth Ayerst product display area for the drug Effexor, named “Wellness Park” on an enormous banner. I struck up a conversation with a sales representative from Florida, who had taken some anthropology courses in college. We chatted about the displays, many of which showed the same smiling woman in three photographs, the first faded out, the second normally exposed, and the third vividly colored. “We are trying to achieve a higher standard in care for depression,” she offered, to explain the vivid coloring in the third photograph. Effexor will help patients be
better than they were even when they were not depressed.
Doctors need to have higher expectations for their patients and this is what the three photos of the smiling woman show, that none of them is depressed anymore,
but there are higher degrees of life satisfaction, performance, and functioning.
She then referred me “upstairs” to a pharmacist who could answer more questions and give me technical literature. I found a spiral staircase, which wound about a life-sized artificial tree trunk along the way. The many, luxuriantly leaved boughs of this tree shaded the whole display area and gave concrete meaning to the “Wellness Park” theme. There was a heart carved into the bark of the tree enclosing chemical symbols for serotonin and for another neurotransmitter, norepinephrine, which represent the two pathways Effexor works on in the brain.

Upstairs in the tree house, I was offered a seat on the other side of a desk from a pharmacist. In response to my question about the significance of the three photographs, he said,

The FDA grants efficacy for depression when studies find people are 50 percent less depressed on the HAMD scale [a standard measurement of depression] than before treatment. This is defined as a “response.” But Effexor gives even
more
response than that, and we have termed this “remission.” Remission means return to a virtually asymptomatic state.

He showed me a brochure in which Effexor is said to lead to “more complete and sustained improvement” and then a reprint from the
Journal of Clinical Psychology
called, “Why Settle for Silver When You Can Go for Gold?” The reprint stated that remission, not “response only,” will yield “energy, zest, and social drive.” In the pharmacist's words,

The science of depression is to reach a higher standard. The higher standard can be attained through Effexor because it has a dual mech anism, like the old antidepressants, the tricyclics, which had both a serotonin reuptake inhibitor and a norepinephrine reuptake inhibitor. Those drugs worked very, very well, except for their severe side effects. With the dual mechanism and without the side effects, Effexor works better than the other antidepressants which are only SSRIs.

This has implications for the patient—can he go back to work? And it has an economic impact—will people be more productive?

Driving home the theme that people once suffering from depression can be better than normal, the display area contained many posters and brochures of laughing people with the claim, “I got my playfulness back.” There were also numerous video projectors shining words on screens: “smile,” “giggle,” “love,” and “fun.” You could even get your own picture taken under the artificial boughs of the tree, which would be framed and sent to you through the mail. A couple of months later, my own picture arrived in a handsome frame, showing my image digitally inserted into a scene of a phone booth crammed with people, alongside a sign reading, “I got my playfulness back, at this year's APA.” The ads promote the idea that depression can be replaced with something like ebullience through the action of a drug. The state of, say, playfulness, is good for the person's and the economy's productivity, and it is so much the same thing for everyone that the same visual scenario can be used to frame any individual's image. The call for people to shift from depression toward the manic end of the scale takes a one-size-fits-all form. So, people on Effexor will be
better
than “normal.”

Far more than advertising is involved in the increasing thing-like quality of mania. Mania is technically part of the condition of bipolar disorder, and bipolar disorder is also becoming easier to see, and to desire, in broader groups of people. For example, the diagnosis is increasing in prevalence among people who would have been seen as psychologically unremarkable not long ago.
New York Magazine's
cover story, “Are You Bipolar?” wonders if “mild bipolar disorder may be to this decade what depression was to the nineties,” thanks to new drugs and an expanding definition.
⁴⁹

8.3. Framed photograph obtained as a gift at the 2000 American Psychiatry Association meeting. After the author's photo was taken at the meeting, it was digitally inserted into the scene of an overcrowded phone booth and labeled with the advertising slogan for Effexor, an antidepressant. Courtesy of Emily Martin, 2000.

But when do ordinary peaks and valleys become “pathological”?
⁵⁰
The author of the article, Vanessa Grigoriadis, herself diagnosed with mild bipolar disorder, contrasts her condition with classic mania, where you “book a first-class ticket to Paris and spend $30,000 in one weekend at the Plaza Athénée. Or look on amazed, or terrified, as the sunlight metamorphoses into a band of descending seraphim. Or systematically begin to date all 525,003 men in your Friendster personal network.” In her own case, she simply felt “smarter, funnier, cooler, prettier,
better
than I had before. I had fabulous concentration, was undistracted by any edge of competition or envy, and found that I could function easily on five or six hours of sleep. I went out to parties often, dressed in tight fuchsia tops and barely there miniskirts. No one was saying no to me; ‘no' was not an acceptable answer.” Grigoriadis interviewed a psychiatrist, Frank Miller, on the Upper East Side in New York City who described a hypothetical patient: she “comes in a little more dressed up, a woman maybe in a dress that's too short, a lipstick too widely applied, a kind of spontaneity, a spunkiness that you've just never seen before. It only lasts for a week, and then all of a sudden, they're depressed.” Miller describes the diagnosis this way: “That person could easily be reconceptualized as a bipolar individual, although that is the totality of the hypomania that you'd see: four or five days, quite subtle, and not recognized by family, friends, or colleagues as evidence of anything extreme. But there it is: a third mood, so to speak.” What is noteworthy about this article is not Miller's diagnosis—a similar form of bipolar disorder is in the DSM under the heading “Bipolar II”: depression alternating with hypomania. What is noteworthy is the news coverage of the topic and what Grigoriadis says next.
⁵¹
For her, this “third mood” is

“heightened experience—a drug you want more of…. This can seem to be your best self, the state of self-actualization that one prays to get to with self-exploration, therapy, and medication, but for many remains just out of reach.”
⁵²
Both Grigoriadis and Miller suggest bipolarity might be a distinctively New York City phenomenon, the frenetic urban pace attracting bipolar people there in the first place (much as Tom Wolfe described Atlanta in
A Man in Full),
while provoking other people to manifest bipolarity for the first time.

8.4. A 2004 cover of
New York Magazine
illustrates an article about the wide dissemination of mild bipolar disorder with a woman who is smiling and crying at the same time. © 2004
New York Magazine.
All rights reserved. Reprinted by permission. Photo by Andrew
Eccles/JBGPhoto.com
.

The category bipolar is also being increasingly extended to young people. Another cover story appeared in
Time Magazine
under the title “Young and Bipolar.”
⁵³
The increasing tendency to identify bipolar disorder in young people, and to medicate them for it, is the subject of controversy, to be sure.
⁵⁴
But the age of onset of bipolar disorder is sliding downward, and young bipolars are, like adults, being charged with the creative burden.
⁵⁵
Time
prints a sidebar of photographs titled “Manic Genius,” including the usual suspects, Edgar Allan Poe, Vincent van Gogh, Ernest Hemingway, and so on. But
Time
adds a new, young manic: Kurt Cobain, who “took his band Nirvana to the pinnacle … but then took his life at the age of 27.”
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Other major mass media publications have picked up the theme: the
Saturday Evening Post
ran an article called “The Challenge of Being Young, Creative, and Bipolar,” featuring the author, Lizzy Simon, whose book,
Detour,
describes her life with bipolar disorder after being diagnosed at the age of seventeen. Simon's MTV special, Web site, and public appearances are also part of the increasing salience of bipolar disorder in the self-understanding and perhaps even self-fashioning of young people.
⁵⁷
The major patient advocacy organization for adult mood disorders, the DBSA, has joined with a new foundation, the Child and Adolescent Bipolar Foundation, to mount a Web art exhibition of pictures painted by children with mood disorders, some as young as six.
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