Bipolar disorder in historical perspective

Psychiatric disorders are like children laughing and playing gaily in the park, while behind a screen other children, dimly seen, cry out to us for help. We want to come to their aid but their shapes are like shadows. Nor do we know where they are. Bipolar disorder is like one of these children. We have it before us in the pharmaceutical advertising, the woman going up and down on the merry-go-round and helped with ‘mood stabilizers’. Meanwhile, behind the screen there are other forms. Maybe a historical analysis will help us to see them more clearly. Physicians have always known the alternation of melancholia and mania. It would be as idle to ask who was the first to describe this alternation as to ask who first described mumps. Aretaeus of Cappadocia, around 150 years after the birth of Christ, wrote of the succession of the two illnesses. It is clear from the context (Jackson, 1986, pp. 39–41) that he was using the two terms to describe what we today would consider mania and melancholia. Yet Aretaeus did not consider the alternation of mania and melancholia to be a separate disease. Etienne Esquirol, director of the Charenton asylum outside of Paris and one of the founders of modern psychiatry, noted in 1819 (Esquirol, 1819, p. 169), ‘sometimes melancholia passes into mania; indeed it is the ease with which this ... transformation occurs that has led all the authors to confuse melancholia with mania.’ There is no hint in Esquirol’s writing that he considered the alternation of melancholia and mania to constitute a separate disorder. For these remote centuries I use ‘bipolar disorder’ to mean the succession of melancholia and mania. A word of clarification: in the twentieth century, after the writing of Kleist and Leonhard, ‘bipolar disorder’ implies that there is a separate unipolar depressive disease. By contrast, the term ‘manic-depression’ suggests that there is only one depression, whether linked to mania or not. But the term ‘manic-depressive insanity’ itself did not surface until 1899. To describe mania, melancholia and their alternation in previous centuries, I shall simply call it bipolar disorder and crave the reader’s indulgence. So the big question is not who first described bipolar disorder, but rather is it one disease or two? The decades and centuries of clinical experience that lie behind us constitute a mountain of evidence of some weight. And in this tremendous accumulation of practical learning, has bipolar disorder been considered one disease? Or two: the alternation of two separate diseases, mania and melancholia? A third possibility: Is bipolar disorder an alternation of several different kinds of mood disorder that includes episodes of catatonia, melancholia, psychotic depression, mania and hypomania, each an independent illness entity in its own right? Conrad Swartz has suggested 1