Historical Overview

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Throughout history scholars have described the symptoms and effects of manic-depressive illness. Ancient Greek, Persian, and biblical writers recorded and attempted to explain the complexities of bipolar illness. In the second century ad Areteus wrote about patients who, in a state of euphoria, danced throughout the night, talked publicly, and acted overly self-confident then, for no apparent reason, shifted into a state of sorrow and despair. The fourth century bc Greek physicians lead by Hippocrates were perhaps the first to hypothesize that symptoms we now call bipolar disorder represented a neurological illness highlighted by major uncontrollable shifts in a person's mood. These early Greek scholars further taught that mental illness is caused by natural rather than spiritual forces, identified the brain as the major organ responsible for sanity and intellectual processes, attempted to classify major mental disorders, and developed crude medical treatments for mental disorders. Unfortunately, however, records from the ancient Egyptians, Greeks, Romans, Middle Ages, European Renaissance, and early American history indicate that this hypothesis gave way to assumptions of demoniacal possession, witchcraft, sinfulness, and other dehumanizing concepts. Nonetheless, traces of scientific and medical inquiries into bipolar disorders periodically appear throughout history.

The first person to identify the link between mania and melancholia or depression was Theophile Bonet. In 1686 Bonet described patients who cycled between high and low moods as having ''manico-melancoli-cus.'' During the mid-1800s, French researchers Falret and Baillarger each independently observed that patients having manic and depressive episodes were not experiencing two different disorders, but rather two different presentations of the same illness. Falret described the disorder as ''circular insanity'' and listed the symptoms much as they appear in today's medical books and journals. He also (remarkably) hypothesized that the illness was hereditary and believed that through research a medication would be found for effectively treating the symptoms. The German psychiatrist Emil Kraepelin, building on Falret and Baillarger's work in the late 1800s and early 1900s, developed the definitive description and classification for manic-depressive illness that largely stands to this day. Kraepelin is credited with sensitizing past mood studies, clearly documenting that mania and depression are different symptoms of the same disorder, and with being the first researcher to assert that all mood disorders are neurologically related.

Kraepelin's basic concepts were challenged and widened by Eugen Bleuler in 1924. For Bleuler, mental disorders could not be classified into two major categories as Kraepelin claimed. Kraepelin believed that all mental illnesses fall into two basic, but separate groups. An illness was classified either as causing periodic recurring symptoms, such as manic-depression, or as a disorder characterized by ongoing neurological deterioration, such as schizophrenia. In his later work, Kraepelin did, however, clarify that it was impossible to neatly place everyone with mental illness into these two categories and that one cannot always discriminate among major disorders. Bleuler argued that manic-depressive illness and dementia praecox (schizophrenia) were not separate classifications, but rather a continuum. How a person was diagnosed and placed on the spectrum depended on the number of symptoms of schizophrenia that were found. More importantly, Bleuler broadened the manic-depression classification by identifying a number of subcategories and introducing the term affective illness. Between the early 1920s and mid-1980s, criteria independently developed by Kraepelin and Bleuler shaped most of the world's psychiatric diagnostic systems.

Between 1930 and 1940, mental health treatment providers largely abandoned the assumption that manic-depression and most other disorders, including schizophrenia and autism, developed from neurobio-logical abnormalities. Following World War II and until the early 1980s, mental health theory and treatment were mostly guided by psychoanalytic concepts proposed by Freud and his followers. Whereas psychoanalytic theory agreed that biological components played a role in affective disorders, practitioners insisted that early childhood parental or other environmental conflicts usually explained the onset and recurrence of manic-depressive episodes. As a result, it was thought that manic-depressive symptoms would resolve if individuals gained insight into their unconscious anger or other hidden emotional conflicts. Even though psychoanalysis and other forms of psychotherapy offered little help for most patients with severe manic-depressive problems, talk therapies nonetheless became the treatment of choice for decades. This preference continued for a number of years even after the introduction of lithium, the first drug found to successfully treat manic episodes.

Dr. John F. J. Cade, a doctor in the Mental Hygiene Department of Victoria, Australia, was dedicated to the belief that manic-depression was a biological, not an unconscious, psychological disorder. In the 1940s he was attempting to discover how urine toxicity levels from patients with various mental disorders differed. Cade wanted to inject guinea pigs with various concentrations of uric acid. However, uric acid is insoluble in water and difficult to inject. To resolve this problem Cade mixed uric acid with lithium. To Cade's surprise, guinea pigs injected with the lithium solution had less toxicity in their urine. The scientist next injected the animals with lithium carbonate and observed that the animals remained conscious but less active and responsive to their environment. On the basis of these findings, Cade administered a lithium salt preparation to several highly agitated manic patients. Each of the patients had a remarkable reduction in symptoms. After Dr. Cade successfully treated 10 additional patients with the solution, European doctors started to quickly accept lithium as an important advancement in treating bipolar disorders. Because of safety concerns documented by cases of hypertension and deaths resulting from a consumer salt substitute containing lithium, the drug was not approved for use in the United States until 1970.

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