Le Peintre Fou - Trouble bipolaire

 

maj 3 janvier 2008

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The Skeptic's Dictionnary Robert Todd Caroll   Analyse du livre de K.Redfield JAMISON  "An Unquiet Mind A Memoir of Moods and Madness"
Traduit en français sous le titre "De l'exaltation à la dépression"

Manic depression is a disease which is biological in its origins. There is also strong evidence that there is a genetic basis for the illness. There is also evidence that lithium, the most common drug used in treatment for the disease, can cause birth defects. Think of the complications this means for a woman who wants to have children. If I go off the drug and get pregnant, what will happen if I have a manic episode during the pregnancy? If I stay on the drug while pregnant, what will happen if my fetus is adversely affected? If I have a child, will the child be manic depressive? What kind of mother can I be if I am ill? Eventually, perhaps another question will be askable: if a genetic test indicates my fetus has the gene for manic depression, should I abort? Add to these dilemmas, the comment of a psychiatrist who tells you that you should not even think about having children and you have a blueprint for a condo in Hell.

Hell is fueled not only by the fire in the brain. Jamison herself was the child of a mentally ill father, one who functioned quite well for many years before becoming hopelessly mad. Not only would Jamison not exist if her father had taken the advice of this psychiatrist, but the world would be a much duller place, less creative and diverse, certainly the worse for it if the mentally ill did not reproduce. The desire for a "pure" race of balanced brains is a vision of Lilliputian proportions, worthy of a small mind living in small, tidy, dull world. It does not take long to whip up a list of great artists, poets, writers, athletes, etc. who have suffered from neurochemical dysfunction. It is obvious that the species and human culture have benefited from the mentally ill and their progeny. To suggest that anyone with a neurochemical dysfunction should not even think of having children is an idea so preposterous as to deserve laughter rather than the rage it is likely to evoke from a mentally ill woman of Jamison's character and disposition. Who knows what great achievements would not have been conceived much less attempted but for mania? And who knows what foolish endeavors have been avoided because of the depression of world leaders? What would our libraries and museums look like if we removed everything created by a mentally ill person or the descendent of a mentally ill person? But while laughing at the suggestion that we should practice eugenics with the mentally ill, we should not get so carried away as to think that somehow having a neurochemical problem is a ticket to creativity or genius. Even if it were, the pain and suffering that accompany the diseases of the brain would not justify a policy of breeding creative geniuses.

The reason it is easy to come up with a list of great insane people is probably not because the genes which are major causal factors in neurochemical problems are also the genes which are the major causal factors in creativity or intelligence. The reason is much more mundane. There are lots of famous people and there are lots of people with neurochemical problems; that the two lists should overlap a great number of times is to be expected. The vast majority of the mentally ill are probably of ordinary intelligence and creativity. We never hear of them because they are not eloquent, do not create great works of art, etc. We only hear about mental illness from eloquent people: either the highly educated professionals who care for them or the highly articulate and creative ones among them, or, as in Dr. Jamison's case, both. Studies which claim there are a disproportionate number of poets, artists, composers, etc., who suffered from depression or manic depression may be accurate, though it is difficult to establish just what percentage of any population is "mentally ill." Also, I don't know how many poets would appreciate being told that their affinity for alliterative allusions may be due to a neurotransmitter malfunction.

Many of the "ordinary" mentally ill persons roam our streets and sleep in ditches. They scavenge the trash bins in our cities and towns. Some of them have children and it is monstrous to suggest that none of these people should have been born or given birth. The shame on humanity is not from its mentally ill, but from the rest of us because of the way we treat them...or rather because of the way we mistreat or fail to treat the less fortunate among us. But the lack of proper treatment for a large percentage of the mentally ill is a social problem and is not Jamison's area of specialization. Clinical problems, however, are her specialty.

Dr IVAN
The best way to control of bipolar disorder during pregnancy depends on a number of factors. Most important are the history of prior episodes, and the past results of discontinuing lithium. For many women, prengancy is a time of improved mental functioning, while the post-partum period is often a time when depression may be a problem.

If a woman's history includes relatively few mood episodes that have been separated by long periods of euthymia, the VERY gradual discointinuation of lithium (over a couple of months) might precede attempts to become pregnancy. If prior attempts to gradually discontinue lithium have resuled in the rapid onset of a depressive or manic episode, discontinuation prior to trying to get pregnant does not make sense.

At one time it was thought that lithium was extremely toxic to the developing fetus, and that approximately 1% of babies exposed to lithium in-utero would develop severe, possibly lethal, heart defects. More recent research has determined that the risk of such defects is actually one-tenth of a percent rather than the 1% previously estimated. As the anti- convulsant drugs used as lithium alternatives can also cause severe congenital abnormalities, they cannot be considered as alternatives to lithium duing pregnancy. Four of my patients have delivered five healthy babies after taking lithium though- out their pregnancies.

Ref: Sachs GS & Cohen LS Update on pharmacologic treatment of mood disorders: Bipoolar disorder and management through preg- nancy and postpartum. Psychiat Clin N Amer 1995, 2, 21-75.

Lithium in breast milk and nursing infants: clinical implications.

Viguera AC, Newport DJ, Ritchie J, Stowe Z, Whitfield T, Mogielnicki J, Baldessarini RJ, Zurick A, Cohen LS.Am J Psychiatry. 2007 Feb;164(2):342-5.

    Perinatal and Reproductive Psychiatry Clinical Research Program, Department of Psychiatry, Massachusetts General Hospital, Simches Research Bldg., Second Fl., Suite 2200, 185 Cambridge St., Boston, MA 02114, USA. aviguera@partners.org

 OBJECTIVE: Current practice guidelines discourage use of lithium during breast-feeding, despite limited data. This study aimed to quantify lithium exposure in nursing infants.

 METHOD: In 10 mother-infant pairs, the authors obtained assays of lithium in maternal serum, breast milk, and infant serum and indices of infant renal and thyroid function.
RESULTS: Maternal serum, breast milk, and infant serum daily trough concentrations of lithium averaged 0.76, 0.35, and 0.16 meq/liter, respectively, each lithium level lower than the preceding level by approximately one-half. No serious adverse events were observed, and elevations of thyroid-stimulating hormone, blood urea nitrogen, and creatinine were few, minor, and transient.

CONCLUSIONS: Serum lithium levels in nursing infants were low and well tolerated. No significant adverse clinical or behavioral effects in the infants were noted. These findings encourage reassessment of recommendations against lithium during breast-feeding and underscore the importance of close clinical monitoring of nursing infants.