Monday, April 23, 2012

Magic Buttons, Silver Linings, and Two-Edged Swords

The Subjective Ups and Downs of Mood Disorders

The last post, Suffering for art is still suffering, took a critical look at studies claiming that individuals with bipolar disorder are more creative.1 And instead of romanticizing the tortured bipolar artist, it considered the toll the disorder can take on those who live with it (and the people around them).

Some readers might have objected to the overly pessimistic tone of that post, prompting them to say things like, "It was a very negative post and clearly you are down on bipolar disorder, if not people who have it." That was not my intent.

So why don't we take a look at the sunnier side of serious mental illness!

The 'Magic Button Question'

“If you could live your life again, would you press the ‘magic button’ to experience life without a mood disorder?”

That's the question Parker et al. (2012) asked 885 patients attending an affective disorders clinic.2 Of that number, 335 patients (38%) returned the questionnaires: 111 with bipolar disorder and 224 with unipolar depression. The authors wanted to assess whether the respondents perceived any advantages to their disorders.
Such positives are rarely volunteered, more commonly emerging only when the individual contemplates whether, if they were to live their life again, they would choose to have their mood disorder. A variant of this question was evident in Stephen Fry's BBC documentary (Wilson, 2006) where he explored his and others' experiences of a bipolar disorder. He asked several people to imagine there was “a button” that, if pressed, “…would take away every aspect of your bipolarity and cyclothymia”, and questioned whether they would press that button.
The results of Parker et al.'s study are based on a biased sample of patients who returned the survey: 83% of the bipolar population was diagnosed with Bipolar II (n=92), compared to only 17% with Bipolar I (n=19). In New Zealand,3 the lifetime prevalence of Bipolar I is 1.0%, compared to 0.7% for Bipolar II (Merikangas et al., 2011; see their Table 2). In the US, the figures are 1.0% and 1.1%, respectively. So we know right away the sample is highly self-selected.

Individuals with Bipolar II were three times more likely to endorse advantages to their disorder than those with Bipolar I.4 Because of the small number of individuals with Bipolar I, the authors collapsed across subtypes [which doesn't make sense] and found that 62% of bipolar people claimed some positive elements to their illness, compared to only 22% of the unipolar depressed group. "Thematic analyses" suggested that the four most common benefits named by bipolar individuals were:
  • increased empathy (18%) 5
  • increased creativity (14%)
  • increased self-awareness (12%)
  • increased productivity (8%)
Not to belabor the obvious, but this means that 86% did not identify creativity as a benefit, and 92% did not see productivity as an advantage of being bipolar. Hmm. Hardly a ringing endorsement for the bipolar advantage.

In the unipolar depressed group, 14% listed increased empathy as a positive aspect of depression; 9% mentioned self-awareness, 1% creativity and 0% productivity.

Wait, what about the 'magic button' question? The questionnaires didn't ask directly. Despite the title of the paper and four other references to buttons, Parker et al. never did get their answer.

Clouds and Silver Linings

An older paper by Dr. Kay Redfield Jamison and colleagues didn't ask the 'magic button' question either, but it left a sunnier impression of bipolar's positive side. In 1980, Jamison et al. wrote:
Although the psychiatric literature is replete with case reports, symptom checklists, and rating forms designed to assess changes during different mood states, to our knowledge there has been no systematic study of short-term, or state-dependent, positive experiences of affective, behavioral, and perceptual changes perceived by the patients themselves. Nor have patients been asked what long-term benefits they feel they derive from their mood disorders. For these reasons we did a preliminary, admittedly subjective investigation of such experiences in patients with primary affective disorders. We were interested in which changes during hypomania were evaluated as the most important and enjoyable. ... Although the usual caveats about retrospective and self-report data apply, the purpose of our study necessarily makes them less applicable than for other types of research.
Their sample consisted of 61 patients attending an outpatient clinic: 35 were diagnosed as bipolar and 26 as unipolar. The format of the questionnaire was more constrained than that of Parker et al. (2012). While euthymic (asymptomatic) or only mildly depressed, the patients were asked:
“Do you feel that your mood swings have resulted in overall personality characteristics that make you different from most people in the following ways?” for each of the several attributes: overall psychological sensitivity, sexual enjoyment, productivity, creativity, and social outgoingness and ease. Response choices were 1) yes, definitely, 2) probably, 3) probably not, and 4) definitely not.
The bipolar individuals were queried further about specific changes they perceived during episodes of mania or hypomania. Of particular interest was whether the phenomenology of hypomania differed between men and women. The authors readily admit that the phrasing of their questions might have elicited a positive response bias, and that the participants' answers were based on perceptions (and not necessarily reality). Perhaps this can account for the much higher percentage of very positive or somewhat positive ratings for productivity and creativity (relative to the study of Parker et al., 2012), as shown below.

Women in general endorsed "very much increased" positive attributes more often than men, but when collapsed across "very much" and "somewhat" increased, only productivity reached statistical significance. The authors noted that... is interesting that manic-depressive illness -- which ostensibly carries with it more negative social, financial, and interpersonal sequelae and results in more frequent episodes of dysfunction and mood swings (which might also account for its perceived greater influence) than unipolar illness -- is assessed by most patients as making positive contributions to their lives in one or more important ways.
One issue of note for clinicians is the possibility of medication non-compliance. If manic or hypomanic episodes are very enjoyable, a bipolar individual may be inclined to go off medication so as not to blunt or eliminate such experiences.

Two-Edged Swords

Finally, a recent paper in the Journal of Affective Disorders (Lobban et al., 2012) appeared to be the most positive of all, but also the most biased [at least to me] and therefore limited in its generalizability. It presented the opinions of 10 bipolar people in the UK using qualitative methodology:
Interpretative Phenomenological Analysis (IPA) was used to understand the data. This approach is grounded in interpretive epistemology and emphasises the perceptions and experiences of individual participants from their point of view. It attempts to understand how participants make sense of their world and, in this instance, the positive aspects of their bipolar experiences. IPA recognises the active role of the interviewer and analysts and, therefore, prior to the interviews the authors documented their expectations about what the study would find and made explicit
their underlying assumptions where possible. The interviewer also informed all participants of her own diagnosis of BD at the outset of the interview.
While the experiences of these 10 people are certainly valid, it was odd for me to see them represented in a peer-reviewed medical journal. In brief:
Positive aspects were numerous, highly valued and participants welcomed the opportunity to discuss them. Three important themes emerged: 1) Direct positive impact of bipolar experiences on everyday life including amplification of internal states, enhanced abilities and more intense human connectedness; 2) Lucky to be bipolar – the sense of having been given a special gift; 3) Relationship between the self and bipolar experiences.
The participants were all recruited from outside a formal mental health setting and were (perhaps) more likely to see the bright side of their diagnoses. In the words of one participant:
Alan: “It's almost as if it opens up something in the brain that isn't otherwise there, and er I see colour much more vividly than I used to. .....So I think that my access to music and art are something for which I'm grateful to bipolar for enhancing. It's almost as it's a magnifying glass that sits between that and myself.”


1 Based on Rothenberg's 2001 critique of the work of Andreasen and Jamison.

2 The Black Dog Institute Depression Clinic, based in Sydney, Australia.
Patients are requested to complete a detailed series of questionnaires prior to attending the clinic, with salient questions asking them to describe the “best” and “worst” aspects of having a mood disorder, to agree or disagree with the statement that “having a mood disorder can have advantages” and, if the latter is affirmed, to describe any such advantages they had experienced. Questionnaire data were collected from patients referred to the clinic over the 2008–2011 period.
3 Sorry, Australia, you weren't included in that study.

4 The numbers given in the paper to support this statement make absolutely no sense, so I won't reproduce them here.

5 However, some studies have reported a decrease in cognitive empathy.


Jamison KR, Gerner RH, Hammen C, & Padesky C (1980). Clouds and silver linings: positive experiences associated with primary affective disorders. The American journal of psychiatry, 137 (2), 198-202 PMID: 7352574

Lobban, F., Taylor, K., Murray, C., & Jones, S. (2012). Bipolar Disorder is a two-edged sword: a qualitative study to understand the positive edge. Journal of Affective Disorders DOI: 10.1016/j.jad.2012.03.001

Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, Viana MC, Andrade LH, Hu C, Karam EG, Ladea M, Medina-Mora ME, Ono Y, Posada-Villa J, Sagar R, Wells JE, Zarkov Z. (2011). Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry 68:241-51.

Parker, G., Paterson, A., Fletcher, K., Blanch, B., & Graham, R. (2012). The ‘magic button question’ for those with a mood disorder — Would they wish to re-live their condition? Journal of Affective Disorders, 136 (3), 419-424 DOI: 10.1016/j.jad.2011.11.008

Wilson, R., (Director). 2006. Stephen Fry: The secret life of a manic depressive [Motion Picture - YouTube]. BBC: Scotland.

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At April 23, 2012 1:47 AM, Blogger Neuroskeptic said...

Good post. I was struck also that in the Parker study, of the unipolar people who did report advantages, they mostly were "increased understanding of depression" or "increased empathy to depressed people". etc.

A number of them seemed to be mental health professionals who felt being depressed had helped them diagnose & treat depression.

I'd say that's all very well but it's not specific to depression.

You could say the same about cancer. I'm sure having cancer helps you to empathize with people with cancer but that's not a 'benefit of cancer' as such, it's just life experience.

At April 23, 2012 2:53 AM, Anonymous Warren Davies said...

Reminds me of a Star Trek episode where someone has a chance to go back and remove an injury they had as a teenager, then see what their future was like. And it was boring because it taught him that life is precious, you have to make the most of it etc.

And it's just a better way of framing mental illness, if post-traumatic growth exists then treatment can focus on coming out of it better off, rather than just dealing with the issue, or learning to live with it.

At April 23, 2012 5:48 PM, Blogger The Neurocritic said...

Neuroskeptic - Thanks. And good point about the lack of specificity. Barbara Ehrenreich wrote a great book called Bright-sided in the US and Smile or Die in the UK. In the second chapter (Smile or Die: The Bright Side of Cancer) she talks about her own experiences with breast cancer and how expressions of anger and sadness were frowned upon, to the point that some patients really did talk about the "bright side" of cancer. She goes on to critically review the history of American optimism. She also paints an unflattering picture of Martin Seligman and positive psychology.

At any rate, I don't know why it's in vogue these days to extol the benefits of major depression.

Warren Davies - All that said, the authors of the papers here do mention things like building resilience and positive psychology as important elements of treatment.

At April 24, 2012 9:33 AM, Blogger andy said...

Thanks for this. I think it's true we shouldn't romanticize suffering or insist on positive attitudes when expressions of anger or loss etc. are important. Nevertheless, I wonder to what extent individuals with mental illness suffer because they are told they are not 'normal' and the way they are is labelled as sick. Not to say it would be all perfect were it not for labeling. But there is such stigma still and judgment that must contribute to the suffering. Everything has positive and negative elements, and it's always problematic to focus on only one side. I think it's worth at least acknowledging the positive sides of such conditions (as you have attempted).

At May 06, 2012 7:44 AM, Anonymous Anonymous said...

You've done a wonderful job as usual of accessing and summarizing the relevant research. I, however, after looking at said research myself, was alarmed at the way some of these studies posed the question, as the results returned by the subjects seemed to romantacize pathology, rather than truly address a 'positive.'

Note that Jamison's study asks what people like about their MOOD SWINGS--and of course they like enhanced productivty, sociability, etc. But that is part and parcel of a manic episode--and almost every BD person loves their mania. But they love it--and are often medically non-compliant to keep it--at the expense of their inevitable fall into the morass of depression.

The most reason Lubban study again addresses enhanced productivity, sexuality, and sociability. Readers: Meet Mania.
These are not positives of BD--they are symptoms of a grave illness not being properly managed, and to publish information touting such 'silver linings'romanticizes mania, part of the pathology, encourages medicine non-compliance, and does not at all answer what is positive about BD, except to say that people enjoy the 'feel good' part of an unmanaged illness.


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