One of my patients once said the terrible thing about depression is that you know someone is going to kill you – and that someone is you.
Anthony Bourdain’s recent suicide, along with that of designer Kate Spade, has touched off a nationwide discussion about why people die from suicide. Suicide is complex, of course, but it's clear that severe depression is a major aspect. It may not be sufficient, but it's typically necessary. And when suicide happens, that depression usually reflects a severe variety, typically a disease like manic-depressive illness (also called unipolar depression plus bipolar illness).
So the importance of depression is clear. But there is another link that has been little discussed:
Those in the creative professions – like artists and writers and designers and chefs – have much higher rates of manic-depressive illness than then general population. This fact has been shown in a number of studies. Why? Partly because manic symptoms are associated with creativity and productivity: you are high energy, think fast, have racing thoughts that go in novel directions, don’t need to sleep much. All these manic traits make for success in life, especially in lines of work that value novelty. Many people have these manic symptoms all the time, as part of their personality, to a mild degree – called hyperthymia. There can be some downsides: The high energy can be accompanied by some constant anxiety (“nervous energy”) or distractibility, leading to extra diagnoses like “generalized anxiety” or misdiagnoses like ADD. Often though, no diagnoses are given or received, and the person with hyperthymic temperament leads a fast-paced, active, colorful life, with the requisite residue of mild emotional instability, such as one or more divorces and less-than-cared-for children. In all, though, the trade-off can be more positive than negative, at least for the person himself/herself, and for society.
Few have hyperthymic temperament all life, though, without any other shift in mood. And if you’re up all the time, the only other place to go is down. It seems that people with hyperthymic temperament are more likely to have depressive episodes than those who have normal (euthymic) temperament. It may not be frequent or early in life, but at some point, often in middle age or a little later, those depressive episodes start to happen. And when they come, the fall is steep from the hyperthymic baseline; and the depressive state typically lasts months or longer. In the midst of those months, it may seem that there is no way out. They contrast with decades of high-energy happiness can be too stark.
A friend of mine, a great historian, killed himself at age 69, after those many years of hyperthymia, during his second depressive episode, the first having happened in his thirties. A few months was too much.
I certainly enjoyed watching Anthony Bourdain as he traveled the world. My teenage son was a big fan, and we used to schedule evenings to watch new episodes. We recently appreciated his show on West Virginia, my wife’s home state, in particular. He was, in a way, a part of our lives. So too, I’m sure, was Kate Spade to those many who took her purses with them all day long in the cotidian pursuits of their lives.
But the colorful purses, and the constant traveling, and the creative dishes, and the risk-taking businesses wouldn’t have happened without the mania. The price for those gains was the depression, which apparently had happened in the past for Kate Spade, who was medicated presumably with antidepressants, and for Bourdain, who reportedly self-medicated with heroin. They may not have been treated at the time of their deaths; or maybe they were, I don’t know.
It is likely though that neither got diagnosed with manic-depressive illness, or the variant today called bipolar illness, especially if their manic symptoms were on the mild and constant side, as happens with hyperthymia. Even if their depressive episodes were diagnosed and then treated with the standard approach of so-called antidepressants, it is possible they would not have improved, and they might have worsened even, since antidepressants are ineffective in bipolar depression at best, and can cause or worsen manic states, which can lead to increased suicidality (during mixed states, when manic and depressive symptoms combine).
It likely was no accident that both suicides happened in June, in the springtime, the classic peak period of suicide, which many think has to do with increased light leading to mixed states in persons who have manic-depressive illness (they get depressed in the winter, manic in the summer, and the transition period in the spring is when they are mixed).
I don’t know their personal medical histories of course, and their families have every right to keep such facts private. But as a social and medical matter, it shouldn’t surprise us that such creative leaders in our world should have manic-depression, nor that they should be at risk of suicide. We value what they gave us as members of society, but we would have liked to keep them around if only to give us more of their creativity.
There is a way out: Correct diagnosis of manic-depressive illness, including concepts like hyperthymia which are outside the bounds of mainstream DSM ideology, and correct treatment, including drugs which are unpopular and underused like lithium, which is the only drug proven to prevent suicide and which indeed does so very robustly (90 percent reduction of completed suicide in placebo-controlled trials).
Stigma is half of the problem. We need to admit diseases like manic-depression exist, and that they should be accepted and treated. Ignorance is the other half of the problem. We need to call them what they are, like hyperthymia with recurrent depressive episodes, without false labels (like “major depressive disorder”); and we need to use the best effective treatments, like lithium not antidepressants.
That way we can have our creative leaders, and enjoy them longer, and let them also lead less tortured lives.