Disorders of Mood: The Experience of Those Who Have Them

The reader will excuse my frequent references to the poets for facts to illustrate the history of madness. They view the human mind in all its operations, whether natural or morbid, with a microscopic eye; and hence many things arrest their attention, which would escape the notice of physicians.

—Benjamin Rush, Diseases of the Mind (1812)1

Disorders of mood, depression, and bipolar illness are common, painful, and destructive. But they are also tied to much that makes us human: our thinking, behavior, and vitality; our hopes and imagination; our ambitions. Depression and mania disproportionately first occur during adolescence or young adulthood and carry with them a high risk of suicide, interpersonal chaos, and alcohol and drug use.2 They are treatable, but many go without care due to a lack of information, concerns about the reactions of others, professional and personal repercussions, or no access to treatment. Medication and psychotherapy, effective in treating most forms of depression and mania, are limited in their availability by cost and by the relatively small number of clinicians, clinics, and hospitals that provide reasonably priced and competent care.

The physicians of antiquity knew depression, mania, and psychosis well. Thousands of years ago, they described these conditions in their patients and instructed their students in how best to diagnose and treat them.3 One medical historian states that manic and depressive psychoses are the “scarlet threads” most clearly discernable throughout the “twisted strands of history.”4 Long before the time of Hippocrates, five hundred years before Christ, physicians and priests in Egypt, China, India, and Persia described patients with melancholy, who slept poorly, ruminated ceaselessly on death, obsessed about their unworthiness, lacked will and the energy to act, were irritable, confused, and wished only to die. Their manic patients, on the other hand, needed little sleep and were grandiose and psychotic; in their exaltation, they believed themselves to be gods, kings, or prophets, and thought themselves to be invincible, at one with the universe. They were irrational and uninhibited; they talked, ran, approached others indiscriminately, and danced without restraint. They were indefatigable, quick to rage, impulsive, suspicious, and at times violent; their thoughts and words sped in all directions.

These early doctors observed that depression and mania kept close company: symptoms of mania often existed together with symptoms of depression.5 Patients could be at once agitated and melancholic, despondent and excited, overflowing with ideas yet bleak and suicidal. Their moods were in flux more often than stable: depression switched into mania, and the exalted moods of mania switched often and precipitously into furor or violence. Mania and depression were conditions not unlike malaria and porphyria: they cycled, flared, and faded. More often than not, their cycles were beholden to the seasons.

Over the years, it became clear that understanding mania and depression—to diagnose them accurately and to treat them effectively—required clinicians to draw upon a variety of perspectives: those of physicians, both modern and ancient; psychologists, psychopathologists, and basic and clinical scientists; and, critically, the experiences of those who had been manic or depressed. These perspectives have proven productive in their own ways. Clinical and basic science research is progressing well, if haltingly. Many hundreds of studies have added immeasurably to our deep base of scientific knowledge about mood disorders.6 We have acquired a more precise diagnostic language for depression and bipolar illness, necessary for good science and good clinical care. Few would argue, however, that scientific description alone conveys the full experience of mood disorders.

What we have gained from science allows us to treat patients more effectively and compassionately, but we need accounts from patients themselves. Otherwise, in our rush to precision, we risk losing an essential measure of human understanding. We need to understand how depression and mania feel to those who experience them; how it feels to live with the unpredictability and pain of mood disorders; and how it feels to be on the receiving end of cruel remarks and discrimination. We are a storytelling species; we learn from hearing about individual lives. If we hear the stories of those who have been depressed or manic, we get a more visceral sense of what psychological suffering means.7

Personal accounts of mental illness change not only personal understanding, but public attitudes: they influence medical practice, government policy, and research priorities, and affect philanthropy. Two narratives of mental illness, one written in the nineteenth century, the other in the twentieth, have had a lasting impact on public policy and mental health reform. In 1838, after his release from an insane asylum, John Perceval, a British army officer and son of a British prime minister, published A Narrative of the Treatment Experienced by a Gentleman During a State of Mental Derangement.8 He campaigned to reform the English lunacy laws and sought to improve treatment and gain greater rights for those in asylums. His impact on the rights and the treatment of the mentally ill remains a significant landmark in the reform movement. Nearly a century later, Clifford Beers, who had had a manic breakdown after he graduated from Yale and had subsequently been confined to a series of private and public asylums, wrote a brutal account of the treatment he received. A Mind That Found Itself, published in 1908 with the support of William James, was critical in establishing the Henry Phipps Psychiatric Clinic at Johns Hopkins, helped reform the treatment of the mentally ill in America, and became the basis for the first major mental health advocacy movement in the United States.9

This essay focuses on accounts of mania and depression written by those who have suffered from them. These accounts describe what mania and depression feel like, the pain and shame that mental illness brings, and the distress that mania and depression bring into the lives of family, friends, and colleagues. This essay presents as well the observations of a few particularly astute clinicians. Personal accounts of mental illness have limitations. They are necessarily selective in what has been remembered and what has been forgotten. They tend to emphasize out-of-the-ordinary events, at times to the detriment of describing more typical experiences. The paucity of language available to describe extreme experiences, such as severe mood states, cognitive and perceptual distortions, and delusions and hallucinations, limits description. Those who are most able to articulate their experiences—writers, for example—may not represent the experiences of most patients. Further, variation in the clinical presentation of mood disorders is the rule rather than the exception. This is inevitable in illnesses that are genetically based, psychologically expressed, and environmentally influenced. Nevertheless, writers, who are particularly prone to mood disorders, have been exceptionally good at describing their experiences, and several of their accounts of depression and mania are given here.10

Benjamin Rush, the “father of American psychiatry,” wrote in his 1812 textbook on mental disease that he went to the poets in order to understand madness. Poets, he believed, brought to attention things that “would escape the notice of physicians.”11 This remains true, and writers are called upon in this essay for their portrayals of depression and bipolar illness. I have included descriptions from other individuals as well, and a few examples from my own experience of mania and depression.

Depression is more common than mania and tends to be more broadly understood and described. In the second century AD, Greek physician Aretaeus wrote about his melancholic patients whose moods, thinking, activity, sleep, and behavior were so profoundly disturbed:

The patients are dull or stern, dejected or unreasonably torpid, without any manifest cause: such is the commencement of melancholy. And they also become peevish, dispirited, sleepless. . . . Unreasonable fear also seizes them [as well as] hatred, avoidance of the haunts of men, vain lamentations; they complain of life, and desire to die.12

Emil Kraepelin, the preeminent psychopathologist of the nineteenth century, wrote extensively about the often debilitating changes in thinking during depression—confusion and the inability to pay attention or comprehend—changes that tend to be underemphasized:

Thinking is difficult to the patient. . . . He cannot collect his thoughts or pull himself together; his thoughts are as if paralyzed, they are immobile. . . . He is no longer able to perceive, or to follow the train of thought of a book or a conversation, he feels weary, enervated, inattentive, inwardly empty; he has no memory, he has no longer command of knowledge formerly familiar to him, he must consider a long time about simple things . . . [he] does not find words.13

John Custance, who served as an officer in the Royal Navy in the First World War and as an intelligence officer in the Second, was hospitalized many times for mania and depression. He wrote about the mental stultification he experienced when he was depressed:

I seem to be in perpetual fog and darkness. I cannot get my mind to work; instead of associations “clicking into place” everything is inextricable jumble. . . . I could not feel more ignorant, undecided, or inefficient. It is appallingly difficult to concentrate, and writing is pain and grief to me.14

The “perpetual fog and darkness” of depression, deeply disturbing to those who experience it, is compounded by the hopelessness at the core of depression. Lord Byron described his fear, a not uncommon one, that his inability to think coherently when he was depressed was a sign of impending madness:

I am growing nervous. . . . I can neither read, write, or amuse myself, or any one else. My days are listless, and my nights restless. . . . I don’t know that I sha’n’t end with insanity, for I find a want of method in arranging my thoughts that perplexes me strangely.15

Andrew Solomon, in The Noonday Demon, describes the gradual breakdown of all those things that he felt defined him: his thinking, his will and passion, his engagement in life, and his relationships with others. All were taken over by exhaustion, fear, and a terrifying hollowing out, a paralyzing anxiety:

When I got home that night, I began to feel frightened. I lay in bed, not sleeping, hugging my pillow for comfort. Over the next two and a half weeks things got worse and worse. Shortly before my thirty-first birthday, I went to pieces. My whole system seemed to be caving in. . . . I lay very still and thought about speaking, trying to figure out how to do it. I moved my tongue but there were no sounds. I had forgotten how to talk. Then I began to cry, but there were no tears, only a heaving incoherence. I was on my back. I wanted to turn over, but I couldn’t remember how to do that either. I tried to think about it, but the task seemed colossal.16

Sleep disturbances are pervasive in depression, and often a cause of severe distress. In her autobiographical novel The Bell Jar, Sylvia Plath described the desolation that accompanied her sleeplessness:

I hadn’t slept for seven nights.

My mother told me I must have slept, it was impossible not to sleep in all that time, but if I slept, it was with my eyes wide open, for I had followed the green, luminous course of the second hand and the minute hand and the hour hand of the bedside clock through their circles and semicircles, every night for seven nights, without missing a second, or a minute, or an hour. . . .

I saw the days of the year stretching ahead like a series of bright, white boxes, and separating one box from another was sleep, like a black shade. Only for me, the long perspective of shades that set off one box from the next had suddenly snapped up, and I could see day after day after day glaring ahead of me like a white, broad infinitely desolate avenue.17

Virginia Woolf also described the horror of sleepless, fitful nights: “Those interminable nights which do not end at twelve, but go on into the double figures—thirteen, fourteen, and so on until they reach the twenties, and then the thirties, and then the forties . . . there is nothing to prevent nights from doing this if they choose.”18

There is a sharp contrast between the life manifest in the outer world and that experienced in the inner world of those who are severely depressed. The contrast can be devastating. Composer Hugo Wolf described how he felt when depressed, existing in the midst of the vitality in the world around him. It was an insurmountable divide:

What I suffer from this continuous idleness I am quite unable to describe. I would like most to hang myself on the nearest branch of the cherry trees standing now in full bloom. This wonderful spring with its secret life and movement troubles me unspeakably. These eternal blue skies, lasting for weeks, this continuous sprouting and budding in nature, these coaxing breezes impregnated with spring sunlight and fragrance of flowers . . . make me frantic. Everywhere this bewildering urge for life, fruitfulness, creation—and only I, although like the humblest grass of the fields one of God’s creatures, may not take part in this festival of resurrection, at any rate not except as a spectator with grief and envy.19

Suicide comes to feel like the only tenable option for many people who are severely depressed; indeed, depression and bipolar illness have the highest rates of suicide of any condition. Agitation, when combined with depressed mood, is a particularly dangerous form of a mixed state, the simultaneous presence of depressive and manic symptoms. Composer Hector Berlioz described “two types of spleen; one mocking, active, passionate, malignant; the other morose and wholly passive, when one’s only wish is for silence and solitude and the oblivion of sleep.” The “malignant” type, he said, was unbearably painful: “The fit fell upon me with appalling force. I suffered agonies and lay groaning on the ground, stretching out abandoned arms, convulsively tearing up handfuls of grass and wide-eyed innocent daisies. . . . Yet such an attack is not to be compared with the tortures I have known since then in ever-increasing measure.”20

Poet Anne Sexton, who suffered from bipolar disorder and died by suicide, described a similar convulsive state as “this almost terrible energy in me and nothing seems to help. . . . Then I walk up and down the room—back and forth—and I feel like a caged tiger.”21 Caged energy was an image called to mind by poet Robert Burns as well:

Here I sit, altogether Novemberish, a damn’d mélange of Fretfulness & melancholy; not enough of the one to rouse me to passion; nor of the other to repose me in torpor; my soul flouncing & fluttering round her tenement, like a wild Finch caught amid the horrors of winter newly thrust into a cage.22

These agitated, mixed states can result in violent impulses or actual violence. Poet Sylvia Plath, who, like Anne Sexton, died by suicide, wrote about the rage set off as she watched a girl pick a flower in the park:

I have a violence in me that is hot as death-blood. I can kill myself or—I know it now—even kill another: I could kill a woman, or wound a man. I think I could. I gritted to control my hands, but had a flash of bloody stars in my head as I stared that sassy girl down, and a blood-longing to [rush] at her and tear her to bloody beating bits.23

When pain and agitation become unbearable and the future unthinkable, suicide can become the only perceived option. Certainly this was true for me. I had stopped taking my medication and was in the middle of a prolonged suicidal depression:

I reaped a bitter harvest from my refusal to take lithium on a consistent basis. A floridly psychotic mania was followed, inevitably, by a long and lacerating, black suicidal depression; it lasted more than a year and a half. From the time I woke up in the morning until the time I went to bed at night, I was unbearably miserable and seemingly incapable of any kind of joy or enthusiasm. Everything—every thought, word, movement—was an effort. Everything that once was sparkling now was flat. I seemed to myself to be dull, boring, inadequate, thick brained, unlit, unresponsive, chill skinned, bloodless, and sparrow drab. I doubted, completely, my ability to do anything well. It seemed as though my mind had slowed down and burned out to the point of being useless. The wretched, convoluted, and confused mass of gray worked only well enough to torment me with a dreary litany of my inadequacies and shortcomings in character, and to taunt me with the total, the desperate, hopelessness of it all. What is the point in going on like this? I would ask myself. Others would say to me, “It is only temporary, it will pass, you will get over it,” but of course they had no idea how I felt, although they were certain that they did. Over and over and over I would say to myself, if I can’t feel, if I can’t move, if I can’t think, and I can’t care, then what conceivable point is there in living?

The morbidity of my mind was astonishing: Death and its kin were constant companions. I saw Death everywhere, and I saw winding sheets and toe tags and body bags in my mind’s eye. Everything was a reminder that everything ended at the charnel house. My memory always took the black line of the mind’s underground system; thoughts would go from one tormented moment of my past to the next. Each stop along the way was worse than the preceding one. And, always, everything was an effort. Washing my hair took hours to do, and it drained me for hours afterward; filling the ice-cube tray was beyond my capacity, and I occasionally slept in the same clothes I had worn during the day because I was too exhausted to undress.

I simply wanted to die and be done with it. I resolved to kill myself, and nearly did.24

There is, as Kraepelin said, a terrible desperation in people who want to kill themselves. His patients, he said, “often try to starve themselves, to hang themselves, to cut their arteries; they beg that they may be burned, buried alive, driven out into the woods and there allowed to die. . . . One of my patients struck his neck so often on the edge of a chisel fixed on the ground that all the soft parts were cut through to the vertebrae.”25

Mania, in most ways, is opposite to depression in mood, thinking, and behavior. Mood is elated, but irritable and unstable. Speech is pressured and rapid; behavior is uninhibited. Patients seem to have limitless energy and need little to no sleep. Mania is a high-voltage state: patients are restless, agitated, and “wired.” Judgment is poor. Thinking shatters and the senses quicken. Grandiose thoughts and delusions are frequent, as is a sense of oneness with the universe. In severe mania, religious delusions and hallucinations are common and patients often describe themselves as being on special journeys or adventures.

John Custance told his doctors about his sense of “intense well being” when he was manic, but the well-being was accompanied by extreme irritation and “paroxysm of anger.” His thinking and speech became impossible to follow; ideas branched out in all directions. He spoke of his “intimate personal relationship with God,” and the sense of communion “that extend[ed] to all fellow creatures.” In time, he moved beyond communicating with God to becoming God: “I see the future, plan the Universe, save mankind . . . create light, darkness, worlds, universes.” All things were possible, he said; all things came together, bound by ecstasy and the love of God. “All nature and life,” he said, “are co-operating and connected with me.”26

Ecstatic mania has an addictive power, one that many patients attempt to recapture once they have recovered from their psychosis. I tried to describe some of the glory and power of an early manic episode:

People go mad in idiosyncratic ways. Perhaps it was not surprising that, as an Air Force pilot’s daughter, I found myself, in that glorious illusion of high summer days, gliding, flying, now and again lurching through cloud banks and ethers, past stars, and across fields of ice crystals. Even now, I can see in my mind’s rather peculiar eye an extraordinary shattering and shifting of light; inconstant but ravishing colors laid out across miles of circling rings; and the almost imperceptible, somehow surprisingly pallid, moons of this Catherine wheel of a planet. I saw and experienced that which had been only dreams, or fitful fragments of aspiration.

Was it real? Well, of course not, not in any meaningful sense of the word “real.” But did it stay with me? Absolutely. Long after my psychosis cleared, and the medications took hold, it became part of what one remembers forever, surrounded by an almost Proustian melancholy. Long since that extended voyage of my mind and soul, Saturn and its icy rings took on a painful beauty, and I don’t see Saturn’s image now without feeling an acute sadness at its being so far away from me, so unobtainable in so many ways. The intensity, glory, and absolute assuredness of my mind’s flight made it very difficult for me to believe, once I was better, that the illness was one I should willingly give up.27

Moods are mutable and so are the thoughts and words that accompany them. The flight of ideas and the delusions so common in mania move quickly from exhilarating to terrifying. One patient wrote about this:

The condition of my mind for many months is beyond all description. My thoughts ran with lightning-like rapidity from one subject to another. I had an exaggerated feeling of self importance. All the problems of the universe came crowding into my mind, demanding instant discussion and solution—mental telepathy, hypnotism, wireless telegraphy, Christian science, women’s rights, and all the problems of medical science, religion and politics. I even devised means of discovering the weight of a human soul, and had an apparatus constructed in my room for the purpose of weighing my own soul the minute it departed from my body. . . .

Thoughts chased one another through my mind with lightning rapidity. I felt like a person driving a wild horse with a weak rein, who dares not use force, but lets him run his course, following the line of least resistance. Mad impulses would rush through my brain, carrying me first in one direction then in another. To destroy myself or to escape often occurred to me, but my mind could not hold on to one subject long enough to formulate any definite plans.28

Leonard Woolf, Virginia Woolf’s husband, described the deterioration in her speech as her mania progressed: “She talked almost without stopping for two or three days, paying no attention to anyone in the room or anything said to her. For about a day what she said was coherent; the sentences meant something, though it was nearly all wildly insane. Then gradually it became completely incoherent, a mere jumble of dissociated words.”29

Patients with mania not only speak and think rapidly, they become involved in a frenzy of activities. British novelist Morag Coate, for example, wrote about her far-flung ideas and plans, and the intense significance they took on for her:

I must record everything and later I would write a book on mental hospitals. I would write books on psychiatric theory too, and on theology. I would write novels. I had the libretto of an opera in mind. Nothing was beyond me. My creative impulse had found full outlet and I had enough now to write to last me for the rest of my life.

I made notes of everything that happened, day and night. I made symbolic scrap-books whose meaning only I could decipher. I wrote a fairy tale; I wrote the diary of a white witch; and again I noted down cryptically all that was said or done around me at the time, with special reference to relevant news bulletins and to jokes which were broadcast in radio programmes. The time, correct to the nearest minute, was recorded in the margin. It was all vitally important. . . . of profound significance.30

Elation and grandiosity prevent many manic patients from recognizing or caring about the consequences of their impulsive behavior. Rash spending, or ­“engaging in unrestrained buying sprees,” as one of the diagnostic criteria for mania puts it, is a classic symptom of mania.31 This, as I found out to considerable expense, can lead to fleeting delight, absurd purchases, and paralyzing debt:

Unfortunately, for manics anyway, mania is a natural extension of the economy. What with credit cards and bank accounts there is little beyond reach. So I bought twelve snakebite kits, with a sense of urgency and importance. I bought precious stones, elegant and unnecessary furniture, three watches within an hour of one another (in the Rolex rather than Timex class: champagne tastes bubble to the surface, are the surface, in mania), and totally inappropriate sirenlike clothes. During one spree in London I spent several hundred pounds on books having titles or covers that somehow caught my fancy: books on the natural history of the mole, twenty sundry Penguin books because I thought it could be nice if the penguins could form a colony. . . .

But then back on lithium and rotating on the planet at the same pace as everyone else, you find your credit is decimated, your mortification complete: mania is not a luxury one can easily afford. It is devastating to have the illness and aggravating to have to pay for medications, blood tests, and psychotherapy. They, at least, are partially deductible. But money spent while manic doesn’t fit into the Internal Revenue Service concept of medical expense or business loss. So after mania, when most depressed, you’re given excellent reason to be even more so.32

The flight of ideas so characteristic of mania, the thoughts leaping from subject to subject, can lead to imaginative, if not altogether viable work. Russian poet Velimir Khlebnikov, while hospitalized for his psychotic behavior and volatile mood swings, wrote down the connections he made when he was manic and his mind psychotically expansive:

Working with number as his charcoal, he unites all previous human knowledge in his art. A single one of his lines provides an immediate lightninglike connection between a red corpuscle and Earth, a second precipitates into helium, a third shatters upon the unbending heavens and discovers the satellites of Jupiter. Velocity is infused with a new speed, the speed of thought, while the boundaries that separate different areas of knowledge will disappear before the procession of liberated numbers cast like orders into print throughout the whole of Planet Earth. . . .

The surface of Planet Earth is 510,051,300 square kilometers; the surface of a red corpuscle—that citizen and star of man’s Milky Way—0.000,128 square millimeters. These citizens of the sky and the body have concluded a treaty, whose provision is this: the surface of the star Earth divided by the surface of the tiny corpuscular star equals 365 times 10 to the tenth power (365 x 10¹⁰). A beautiful concordance of two worlds, one that establishes man’s right to first place on Earth. This is the first article of the treaty between the government of blood cells and the government of heavenly bodies. A living walking Milky Way and his tiny star have concluded a 365-point agreement with the Milky Way in the sky and its great Earth Star. The dead Milky Way and the living one have affixed their signatures to it as two equal and legal entities.33

Recovery from mania and depression is usually difficult, slow, and erratic. “I have been out in the garden for 2 hours; and feel quite normal,” Virginia Woolf wrote from a mental hospital. “I feel my brains, like a pear, to see if its ripe; it will be exquisite by September.”34 The blood, she added, “has really been getting into my brain at last. It is the oddest feeling, as though a dead part of me were coming to life.”35 All the voices were gone, she said, the ones that had driven her mad. The poet Robert Lowell also described this gradual, precarious reentry into sanity: “Today I feel certain that I am not going off the deep end,” he wrote to his friend and fellow poet Elizabeth Bishop. “Gracelessly, like a standing child trying to sit down, like a cat or [rac]coon coming down a tree, I’m getting down my ladder to the moon.”36 Recovery for Lowell, like for most recovering from mania or depression, was marked not only by the slide in mood, but by becoming aware of the humiliating things done and left undone while ill, and by having to confront the toll that mental illness takes on others.

“Nothing! No oil / for the eye, nothing to pour / on those waters or flames,” wrote Robert Lowell. “I am tired. Everyone’s tired of my turmoil.”37 In a letter to T. S. Eliot, written as Lowell was recovering from a manic attack, he confided, “The whole business has been very bruising, and it is fierce facing the pain I have caused, and humiliating [to] think that it has all happened before and that control and self-knowledge­ come slowly, if at all.”37 Another patient wrote simply: “No one who has not had the experience can realize the mortification of having been insane.”38

In addition to the psychological suffering, there are repercussions from illness: loss of jobs, medical costs, ruined marriages and friendships, debts incurred during mania, and the psychological aftermath of damage done to others through physical or verbal abuse. For most patients, the toll is cumulative. “I was only forty-­five years old,” wrote Joshua Logan, director and cowriter of South Pacific, Mister Roberts, and Picnic, after one of his bouts of mania. “But I felt exhausted by this last experience, hollowed out, as though I were a live fish disemboweled.”39 His wife, also at the end of her tether, expressed the fear of many spouses, that a hereditable psychosis will be passed on to their children:

I asked her if she wanted to have children with me.

She said no.

I asked why, but she refused to answer. . . .

I looked at her blankly, and she added:

“I have no wish to bring insane children into this world.”40

Depression is often recurrent, bipolar illness always. Fear of recurrence of mania or depression, like fear of a recurrence of cancer or a second heart attack, is a source of anxiety in those who have mood disorders. A physician writing anonymously in The Lancet expressed his fears that his mania would come back:

The most daunting problem is the prospect of further episodes of mania. The depression if it occurs is a more private feature of the syndrome. Mania is very public and is accompanied by a multitude of embarrassing excesses and, not infrequently, scandals. . . . Will there be future episodes; how frequently; and will they be as debilitating? What about my capacity to work, earn a living, to occupy myself, and fulfill my responsibilities? The qualities for a doctor are vastly different from those of a poet. A hospital consultant is nothing if not reliable. My unreliability is already manifest.41

In his last book of poetry, Robert Lowell, who had been hospitalized twenty times for mania, wrote lines that could stand in for his frequently expressed terror of going mad again: “If we see a light at the end of the tunnel,” he wrote, “it’s the light of an oncoming train.”42

Treatment is much better now; public attitudes and education about mood disorders have improved. But the words of the writers and doctors presented here give insight into the experiences of those who suffered, or who died before effective treatment existed. They speak still for those whose treatment fails, and those for whom treatment is neither available nor affordable. The lack of basic health care for those with mental illness is not only unfair, it kills. Few patients, family members, or doctors would disagree.

Endnotes

• 1Benjamin Rush, Medical Inquiries and Observations Upon the Diseases of the Mind (Philadelphia: Kimber & Richardson, 1812), 160.
• 2Frederick K. Goodwin and Kay Redfield Jamison, Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression (New York: Oxford University Press, 2007); and Iria Grande, Michael Berk, Boris Bimather, and Eduard Vieta, “Bipolar Disorder,” The Lancet 387 (10027) (2016): 1561–1572.
• 3J. R. Whitwell, Historical Notes on Psychiatry (London: H. K. Lewis and Co., 1936); Stanley W. Jackson, Melancholia and Depression: From Hippocratic Times to Modern Times (New Haven, Conn.: Yale University Press, 1986); and Giuseppe Roccatagliata, A History of Ancient Psychiatry (New York: Greenwood Press, 1986).
• 4S. E. Jelliffe, Series of Research Publications II, Manic-Depressive Psychosis, Research in Nervous and Mental Diseases Proceedings (Baltimore: Williams & Wilkins, 1931).
• 5For early discussions of the mixed clinical presentation and cyclicity of mood disorders, see Aretaeus, The Extant Works of Aretaeus, the Cappadocian, ed. Francis Adams (London: Sydenham Society, 1856); Thomas Willis, Two Discourses on the Soul of Brutes, trans. S. Pordage (London: Thomas Dring, 1683); Jules Baillarger, “De la Folie a Double Forme,” Annales Medico-Psychologiques 6 (1854): 369–391; Jean Pierre Falret, “Memoire Sur la Folie Circulaire,” Bulletin l’Academie de Medecine 19 (1854): 382–415; and O. Diethelm, “Mania: A Clinical Study of Dissertations Before 1750,” Confinia Psychiatrica 13 (1970): 26–49.
• 6Goodwin and Jamison, Manic-Depressive Illness; Katherine E. Burdick, Manuela Russo, Sophia Frangou, et al., “Empirical Evidence for Discrete Neurocognitive Subgroups in Bipolar Disorder: Clinical Implications,” Psychological Medicine 44 (14) (2014): 3083–3096; Christoph Abé, Christopher R. K. Ching, Benny Liberg, et al., “Neuroimaging Study of 1232 Individuals by the Enigma Bipolar Disorder Working Group,” Biological Psychiatry 91 (6) (2022); Jenny Guidi and Giovanni Fava, “Sequential Combination of Pharmacotherapy and Psychotherapy in Major Depressive Disorder: A Systematic Review,” JAMA Psychiatry 78 (3) (2021): 261–269; David Miklowitz, Orestis Efthimiou, Toshi Furukawa, et al., “Adjunctive Psychotherapy for Bipolar Disorder: A Systematic Review and Component Network Meta-Analysis,” JAMA Psychiatry 78 (2) (2021): 141–150; and Kevin S. O’Connell and Brandon J. Coombes, “Genetic Contributions to Bipolar Disorder: Current Status and Future Directions,” Psychological Medicine 51 (13) (2021): 2156–2167.
• 7Kay Redfield Jamison, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament (New York: Free Press, 1993); Kay Redfield Jamison, Night Falls Fast: Understanding Suicide (New York: Alfred A. Knopf, 1999); and Kay Redfield Jamison, “Clinical Description” and “Psychotherapy” in Goodwin and Jamison, Manic-Depressive Illness, 29–87, 869–905.
• 8John Thomas Perceval, A Narrative of the Treatment Experienced by a Gentleman During a State of Mental Derangement (1838). Republished and edited by Gregory Bateson as Perceval’s Narrative: A Patient’s Account of His Psychosis, 1830–1832 (London: The Hogarth Press, 1962).
• 9Clifford Beers, A Mind That Found Itself (Pittsburgh and London: University of Pittsburgh Press, 1981).
• 10Jamison, Touched with Fire. For a recent updating and summary of research, including large population studies, see Kay Redfield Jamison, Robert Lowell, Setting the River on Fire (New York: Alfred A. Knopf, 2017), 253–318.
• 11Rush, Medical Inquiries and Observations Upon the Diseases of the Mind, 160.
• 12Aretaeus, The Extant Works of Aretaeus, 299–300.
• 13Emil Kraepelin, Manic-Depressive Insanity and Paranoia (Edinburgh: E. & S. Livingston, 1921), 75.
• 14John Custance, Wisdom, Madness, and Folly: The Philosophy of a Lunatic (New York: Farrar, Straus & Cudahy, 1952), 62.
• 15George Gordon Byron, letter to Francis Hodgson, October 13, 1811, in Byron’s Letters and Journals, Volume 2: Famous in My Time, 1810–1812, ed. Leslie A. Marchand (London: John Murray, 1973), 111–112.
• 16Andrew Solomon, The Noonday Demon: An Atlas of Depression (New York: Scribner, 2001), 49–50.
• 17Sylvia Plath, The Bell Jar (New York: Harper & Row, 1971), 143–144.
• 18Virginia Woolf, The Voyage Out (New York: Modern Library, 2001; 1915), 342–343.
• 19Hugo Wolf, quoted in F. Walker, Hugo Wolf: A Biography (London: J. M. Dent & Sons, 1968), 322.
• 20Hector Berlioz, Memoirs, trans. David Cairns (London: Granada, 1969), 226–228.
• 21Anne Sexton, quoted from a psychotherapy session with Dr. Martin Orne, cited in Diane Middlebrook, Anne Sexton: A Biography (New York: Vintage, 1992), 36.
• 22Robert Burns, letter to Mrs. W. Riddell, December 1793, in The Letters of Robert Burns, Volume II, 1790–1796, ed. G. Ross Roy (Oxford: Oxford University Press, 1985), 145.
• 23Sylvia Plath, journal entry June 11, 1958, The Journals of Sylvia Plath, ed. Ted Hughes and Frances McCullough (New York: Anchor Books, 1998), 237.
• 24Jamison, An Unquiet Mind, 110–111.
• 25Emil Kraepelin, Manic-Depressive Insanity and Paranoia, trans. R. M. Barclay, ed. G. M. Robertson (New York: Arno Press, 1976; 1921), 25.
• 26John Custance, Wisdom, Madness, and Folly: The Philosophy of a Lunatic (New York: Farrar, Straus & Cudahy, 1952), 37, 51.
• 27Jamison, An Unquiet Mind, 90–91.
• 28Patient quoted in Eduard Reiss, Konstitutionalle Verstimmung und Manisch-Depressive Irresein (Berlin: J. Springer, 1910).
• 29Leonard Woolf, Beginning Again: An Autobiography of the Years 1911–1918 (New York: Harcourt, 1964), 172–173.
• 30Morag Coate, Beyond All Reason (London: Constable, 1964), 84–85.
• 31American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Arlington, Va.: American Psychiatric Association, 2013), 124.
• 32Jamison, An Unquiet Mind, 74–75.
• 33Velimir Khlebnikov quoted in Vladimir Markov, ed., The Longer Poems of Velimir Khlebnikov (Westport, Conn.: Greenwood Press, 1975), 362–363.
• 34Virginia Woolf, letter to Vanessa Bell, July 28, 1910, written from the Twickenham Mental Home, in The Letters of Virginia Woolf, Volume One, 1888–1912, ed. Nigel Nicolson and Joanne Trautman (New York: Harcourt Brace Jovanovich, 1975), 431.
• 35Virginia Woolf, letter to Violet Dickinson, September 1904, in ibid., 142.
• 36Robert Lowell, letter to Elizabeth Bishop, August 9, 1957, in The Letters of Robert Lowell, ed. Saskia Hamilton (New York: Farrar, Straus and Giroux, 2005), 282.
• 37Robert Lowell, letter to T. S. Eliot, June 30, 1961, in ibid., 384.
• 38Patient quoted in Reiss, Konstitutionelle Verstimmung und Manisch-Depressive Irresein.
• 39Joshua Logan, My Up and Down, In and Out Life (New York: Delacorte Press, 1976), 338, 153.
• 40Ibid., 153.
• 41Anonymous, “Manic-Depressive Illness,” The Lancet 324 (8414) (1984): 1268.
• 42Robert Lowell, “Since 1939,” in Robert Lowell: Collected Poems, ed. Frank Bidart and David Gewanter (New York: Farrar, Straus and Giroux, 2003), 741.