A Little MadnessManic-Depressive Illness and Poetry

Fear of an as yet imperfectly understood disease, the tuberculosis which took John Keats’ life in 1821, led to the burning of all the furnishings in the small room overlooking Rome’s Spanish Steps in which he died. Literary shrines like the Keats-Shelley Museum are rare in the Antipodes, and this visitor wandered with interest and care through the rooms where portraits, busts, framed letters and glass-encased manuscripts celebrate the lives of Keats, Percy Bysshe Shelley, Mary Shelley and George Gordon, Lord Byron. The room in which the death mask of Keats sits remains more sparely furnished than the rest, though it contains along with the sketches of the dying poet, the certificate of his qualification as an apothecary. Pausing in this room, I found myself thinking of another as yet imperfectly understood disease which affected all four of the literary figures honoured in the Keats-Shelley house. At the milder edge of the spectrum of manic-depressive illness is a condition termed cyclothymia, and the poet Keats who described himself as possessing a ‘horrid Morbidity of Temperament’ was a cyclothymic young man who may have experienced, if he had lived for a few years longer, the progression of his temperamental condition into the more pronounced ‘bipolar II disorder’ or the ‘classic’ manic depressive illness, ‘bipolar I disorder’, the illness which affected Lord Byron, Percy Bysshe Shelley and Mary Shelley. In her Touched With Fire: Manic-Depressive Illness and the Artistic Temperament, Kay Redfield Jamison (who is both a John Hopkins Professor of Psychiatry and a St. Andrews Professor of English) gives reasonably detailed evidence to support the diagnosis of each of these literary figures, along with many other well-known poets, writers, painters and composers.

Depression as an illness seems to have been much more widely understood in recent years, and the subject of educational campaigns for greater community understanding in various countries. The apathy, lethargy, hopelessness and loss of pleasure associated with major depressive, or unipolar, illness are gaining wide currency as symptoms of illness to which less and less stigma is attached. Mania and hypomania (mild mania) are less well understood. One result of this is that, as Jamison’s most recent book Night Falls Fast: Understanding Suicide notes, patients with bipolar II disorder ‘are frequently misdiagnosed as suffering from depression only’. This misdiagnosis may occur with as many as one third of sufferers of manic depressive illness according to Jamison, and as ‘anti-depressants, if prescribed alone…can precipitate mania and, occasionally, highly agitated and potentially suicidal mixed states,’ it is a misdiagnosis of grave concern. Were manic states and particularly the milder hypomanic states of manic-depressive illness as well understood and recognised by both doctors and the community, one might hope that fewer individuals with manic depressive illness would be misdiagnosed, and that less fear and stigma would be associated with manic depression. An irritability and agitation lying underneath an extended period of depression may be easily missed, and the brief mild manic states of bipolar II disorder can easily appear both to the sufferer and to others as ebullience in recovery.

In Touched With Fire, Jamison describes these manic states:

Unlike individuals with unipolar depression, those suffering from manic-depressive illness also experience episodes of mania or hypomania (mild mania). These episodes are characterised by symptoms that are, in many ways, the opposite of those seen in depression. Thus, during hypomania and mania, mood is generally elevated and expansive (or not infrequently, paranoid and irritable); activity and energy levels are greatly increased; the need for sleep is decreased; speech is often rapid, excitable, and intrusive, and thinking is fast, moving quickly from topic to topic. Hypomanic or manic individuals usually have an inflated self-esteem, as well as a certainty of conviction about the correctness and importance of their ideas. This grandiosity can contribute to poor judgement, which, in turn, often results in chaotic patterns of personal and professional relationships. Other common features of hypomania and mania include spending excessive amounts of money, impulsive involvements in questionable endeavours, reckless driving, extreme impatience, intense and impulsive romantic or sexual liaisons, and volatility. In its extreme forms, mania is characterised by violent agitation, bizarre behaviour, delusional thinking, and visual and auditory hallucinations. In its milder variants the increased energy, expansiveness, risk-taking, and fluency of thought associated with hypomania can result in highly productive periods.

These hypomanias and manias are episodic, as are the depressions associated with manic depressive illness, lasting days, weeks or months. Importantly, in terms of medical and community misapprehension of the illness, they are separated by periods where no symptoms are evident, periods of good health, and these periods may last days, weeks, months, or years. It is possible to speak of sufferers who cycle quickly (there are individuals who have the misfortune of all four seasons in one day) and slow-cycle manic-depression, yet these are generalisations which can mislead as the illness rarely works like clockwork; a sufferer on a slow cycle might be free of hypomania and mania and depression for five or six years, then experience bouts of each within a twelve-month period. Alcoholism and drug abuse are exceedingly high among individuals with manic-depressive illness: one reason for this is the impulsivity of hypomania and mania, but another is the possibility of a sufferer hiding the condition behind another more obvious problem (it is still the case that in many circles less stigma attaches to alcoholism or even drug use than to mental illness). Alcoholism and drug use tend to worsen the progress of illness, and greatly increase the risk of suicide of the sufferer. Often disturbed sleeping patterns and, in particular, periods of insomnia, are the trigger for hypomania and manias; for this reason cocaine, ecstasy, and most particularly amphetamine use are fraught with danger; moderate use of marijuana on the other hand may slow alchohol intake and also have a soporific effect, and I would suggest (though I know of no studies) that many sufferers of manic-depressive illness find it helpful.

The average age of onset of manic-depressive illness is eighteen years and this is markedly earlier than that for unipolar depression, which is twenty-seven years; manic-depressive illness sufferers are also usually from the upper or professional classes; though there are exceptions both in terms of age and social status. Men and women are equally likely to suffer bipolar disorder, where unipolar depression affects twice as many women as it does men. Classic manic-depressive illness is found in about one per cent of adults where a further two or three per cent will suffer bipolar II disorder or cyclothymia. These rates are less than those for major depression of the unipolar variety (five per cent) but they may be increasing. An interesting passage in Kay Jamison’s memoir of life as a psychiatrist with manic-depressive illness An Unquiet Mind (a feature film adaptation of this is in the wind with Hollywood) is suggestive of the prevalence of manic depression in senior ranks of the military. Romantically involved with the late Colonel David Laurie, a psychiatrist in the British Army Medical Corps, she tells the story of how (after he’d been told of her illness), her lover set out to reassure her ‘in his rather systematic way’, partly through dinners with serving senior officers of the British Army (and their wives) who also had manic-depressive illness. An Unquiet Mind, and also Jamison’s study of suicide Night Falls Fast, suggest that she is not alone among medicos, or psychiatrists, whose healing careers co-exist with managing the healer’s own manic-depressive illness. Scientists, lawyers, politicians and all the other professions have higher rates of manic depression than the general population figure of one per cent; to my mind the reason why the rate among poets is exceptionally high (even compared with other artists), is in part that poets are by and large the black sheep of professional families. Controversy does attach to linking poets and manic-depressive illness, not least to the statistic quoted in Jamison’s Touched With Fire, that sixty-one per cent of poets suffer manic-depressive illness, yet maybe this would die a little if we had accurate statistics for the rates of manic-depressive illness among say surgeons and admirals.

Touched With Fire deals largely with historical poets and fascinates both in its reading of literary history and in the different shades of understanding it lends to the works and lives of prominent artists, particularly poets. A feature of the book, unusual among literary studies, which relates to the hereditary nature of manic-depressive illnesses, is the plethora of genealogical charts showing the family trees of poets and artists. A blacked-in square or circle indicates respectively a male or a female family member with clear manic-depression, a dotted square or circle indicates cyclothymia, a crossed figure denotes a relative whose death was through suicide. Among the Byrons, Tennysons and the family of Virginia Woolf, manic-depression, cyclothymia, depression and suicide are quite widespread. Of Alfred Lord Tennyson’s six brothers who lived to be adults, only young Horatio 1819–1899 is left blank, though this seems cautious given his ‘strange personality was legendary’ and he had the distinction of being described as ‘rather unused to this planet’. These charts with their various choice details of contemporary description speak volumes for just how common it is for a manic-depressive individual to marry another, or to marry someone cyclothymic or depressive. This ‘assortative mating’ results often in volatile, pressure-cooker relationships. Furthermore, where the child of one manic-depressive parent has a twenty-eight per cent chance of inheriting an affective disorder, where both parents have affective disorders and a least one has manic-depression, three children out of four will inherit an affective disorder.

There is something both extraordinary and perhaps profoundly luckless about the lived reality of ‘assortive mating’; partners of those with manic-depressive illness need the patience of saints often at those times when wife, husband or lover is blowing up into manic behaviours, and also must face the bewilderment of the person who shares their bed breaking down into depression and staying there. In sexual terms, intensified heightened sexuality one month and famine the next is something that can take a little getting used to in a lover. The assortative attraction between sufferers of affective disorders being strong, the person from whom saintly levels of understanding are required is very often battling their own mood disorder simultaneously. ‘She/he would have to be mad to go out with him/her’ is a statement of considerable banality when attached to relationships in which love and manic-depression are both present. Into such explosive unions are born children who must learn to live with interesting parents, and who themselves carry the genes which make mood disorders of their own highly likely. If you are yourself affected by manic-depression, you are also almost certain to know difficult life situations where someone close is suicidal, where someone close must be coaxed into a temporary holiday in a mental health facility, where someone you love is falteringly making small steps back into (irrationally terrifying) everyday life. Before you are thirty, you will have an ethic for interventions in the mental health-care arrangements of others, and also an ethic for the intervention of others in your own.

Over-compensation for profound feelings of inadequacy, guilt or shame, are often what lies underneath, what underpins, hypomania or mania. Both the hereditary nature of affective disorders, and the pronounced assortative attraction in relationships, tend to provide many a difficulty of the bewildering variety; manic overcompensation (for all that it may, as grandiose, seem arrogant or self-obsessed) is normally rooted in impotence before the suffering of others. As Jamison notes in Night Falls Fast, the depression which usually follows an episode of mania (which is a period of pronounced suicide risk) lasts around four months in most circumstances, however, where a death or serious illness in the family preceded the climb into the manic, the recovery time triples to eleven months. Those who suffer from depressive illness or manic-depressive illness are fifteen to twenty times more likely than the general population to commit suicide. In manic-depressive illness, the times of recovery from profound depression or from manic periods constitute one kind of high risk, while the possibility as the disease progresses of experiencing ‘mixed states’ where manic and depressive elements of mood coexist simultaneously provide the other. These mixed states are often at the watershed between the two poles of the disease and are periods of high energy and fast dramatic swings of mood. To be both profoundly depressed and jumping out of your skin is an extremely difficult experience and in terms of self-slaughter an extremely dangerous one.

Whether a prolonged, bleak, crushing period of depression is associated with unipolar or manic depression, it is a truism (rather than a tragic freakish circumstance) that the sufferer emerging once more into the light may commit suicide. Utter depression permits thoughts of suicide but rarely the will to go through with the act. Night Falls Fast is very acute on this point – the return of the will, a feeling that the depression through which one has just lived could not be borne again, a feeling of being a burden to others: these plus the availability of means can be quickly fatal. That it is true of the different forms of mood disorders points, as Jamison suggests here and there, to the binarism between unipolar and bipolar being flawed beyond the level of useful generalisation. Which is to say, that ‘mixed states’ may be implicated in the vast majority of suicides, even when unipolar depression is to all other intents and purposes a correct diagnosis. To put it another way, when the great pleasureless grey world suddenly releases the sufferer from a life without any form of joy, whose mood would not swing up perhaps too quickly somedays, perhaps with elements of depressed thought, depressed feeling still embedded? Jamison is a strong advocate of the mood-stabiliser lithium for its anti-suicidal properties (and these properties seem to apply even where it does not lend stability of mood). Though I’m about to point to lithium’s shortcomings in another context, in the context of the depressed individual entering a phase of recovery I’m totally in favour of it as a brake on suicide. Life is precious, and even those creative individuals who find lithium hampers creativity should, with an awareness of its efficacy as a break on suicide, put their objections to one side when it is administered because the patient is believed to be in a transitional phase to which suicide risk adheres.

Quoting from a 1970 and 1979 study on the effects of lithium on the productivity of writers and artists, Jamison in Touched With Fire reports that, ‘The overwhelming majority indicated that their productivity while on lithium had either increased (fifty-seven per cent) or remained the same (twenty per cent)’, which (though it says nothing of quality) vindicates the idea that lithium can indeed be liberating for writers and artists with manic-depressive illness. Anecdotal suggestions make me think a study of poets alone might give figures of a less promising nature, however, as Jamison further reports, ‘Approximately one-fourth (twenty-three per cent) reported a decrease in productivity, and a significant minority (seventeen per cent) stated they had stopped taking lithium due to its adverse effects.’ It’s not stated, but I take this to mean ‘adverse effects’ on the quantity or quality of artistic production, and thus see the reporting indicating that one in four writers and artists who suffer manic-depressive illness find lithium throws out their creativity with the bathwater, and most of these won’t take it. Author of the 1979 study, M. Schou, is reported by Jamison as having ‘noted that lithium might affect inspiration, the ability to execute ideas or both’, and as stressing that, ‘artists and writers clearly vary in a number of important ways, including severity and type of their illnesses, their degree of dependence on manic periods for artistic inspiration, and individual sensitivities to the pharmacological action of lithium’.

Schou speaks of ‘their degree of dependence on manic periods for artistic inspiration’ and I think ‘degree’ is well chosen, for most artists living with the illness do tend to link creativity with the up-periods. Hypomanias and even the less extreme manic states fuel creative fires; a decreased need for sleep is combined with pronounced combinatory thinking, an increase in intellectual functioning and an elevation in mood; these can be times of artistic breakthroughs because the realm of the possible seems larger in a hypomanic state. Of course, the artist must resist the likely simultaneous rise of a desire to go out and blow the rent on alcohol or drugs, but hypomanias, as mild mania, are full of the possibility of finally getting some work done. Across pretty well all the forms of artistic expression, boldness and expansiveness are seen as positives, and the intensity of works essayed in hypomania or even the beginnings of mania are permitted boldness and expansiveness. Even mixed states can in their radical ambiguity and their fraughtness spark flashes of artistic brilliance. The radical productivity of these times can see six months work produced in a weekend; it’s not the side of manic-depressive illness that artists want to give up. For some, and I’d venture that with poets it is more than ‘one-fourth’, lithium does involve losing these times of heightened artistic facility and productivity. Of course many poets have no affective illness, and many who do find lithium works for them, but if Shelley had lived under a medical absolutism that insisted all manic-depressives should be on lithium, he may never have said that ‘poets are the unacknowledged legislators of the world’. I’ve heard that very absolutism uttered by a psychiatrist at a fellow artist’s Mental Health Review Board hearing as an argument against the restoration of her liberty, and I do not like it.

Lithium is still much in use as a lifetime medication for manic-depressive illness, yet a significant minority of artists with the condition do find it has for them such adverse effects on creativity that they won’t take it ‘for life’. I don’t think that there is anything ‘non-compliant’ about an artist refusing the medication on these grounds, and it is not a rare problem with lithium; if it is true that six out of ten poets suffer manic-depressive illness and that one in six writers and artists refuse lithium because of its adverse effects, then we are talking about one in ten poets finding lithium unsuitable. Lithium saves a lot of lives, and Kay Jamison is right to praise it and point to its anti-suicidal properties. Nobel Laureate James D. Watson is quoted in the blurb of Touched With Fire – ‘an emphatic analysis of the creativity that emerges from a little madness and the horror from too much’ – and I think where Jamison writes of lithium, that ‘emphatic’ can be seen as cutting both ways. Valproate and other anti-convulsants are becoming more common in the treatment of manic-depressive illness, and beyond Touched With Fire, in her more recent Night Falls Fast, Jamison again points to the anti-suicidal properties of lithium, yet qualifies her emphasis:

The clinical problem is complex, however. Not everyone who has depression or manic-depressive illness is suicidal. If a patient refuses to take lithium or does not respond to it, anti-convulsants provide an important and often more agreeable treatment alternative. Lithium is effective in preventing suicide only if patients are willing to take it and if they respond to it. Not everyone will take it. Not everyone will respond to it.

Sufferers of manic-depressive illness have an extraordinary sensitivity to seasonal changes in light. Manias and hypomanias tend to occur in autumn and spring when fluctuations in light are greatest. The grim side of this is that late spring and early summer are the annual peaks of suicide, manic-depressive illness being very often the background to suicide. This isn’t to say that sufferers go up and down with every season; the episodic nature of the illness might, however, follow the flow of an autumn hypomania, a spring mania and a black summer in one year after a few years of uninterrupted good health. Various graphs in Touched With Fire show that artistic and literary production tends to peak in autumn and spring and to fall away sharply in winter and summer. These might seems surprising charts to contemporary readers, yet they probably strike a true chord with many artists and writers: the poet who like W.H. Auden always writes by electric light with the curtains drawn, is still unusual.

Jamison’s chapter on George Gordon, Lord Byron, is one of the longest in Touched With Fire and pleases with researched detail, such as the story of the night Byron’s daughter was born, with the father downstairs cutting off the tops of every soda bottle in the house with his sword. Readers can enjoy Don Juan less guiltily for the understanding of the poet who struggled long and hard against severe manic-depressive illness. It was Auden who called Don Juan, ‘for all its faults, the most original poem in the language’, and read against the life understood as being a constant battle with the illness that made him ‘mad, bad and dangerous to know’ his considerable achievements, especially the long poem, can be perhaps more fairly appreciated. Neither his mother, nor his great uncle nor Lady Caroline Lamb were what you might think of as easy to know, as heredity and assortative mating tends to make the case with many sufferers. The unkind picture of his wife in Don Juan (though he denied Donna Inez was an ‘elaborate satire on the character and manners of Lady Byron), is interesting to peruse after reading Touched With Fire. Annabella Milbanke somewhat before divorcing Byron on the grounds of his insanity is quoted: ‘The day after my marriage he said, “You were determined not to marry a man in whose family there was insanity…You have done very well indeed,” or some ironical expression to that effect, followed by the information that his maternal grandfather had committed suicide, and a cousin…had been mad, and set fire to a house.’ Now, however odd this may seem as something said the morning after marrying someone, it isn’t a story without a history. Three years earlier in 1812, the heiress Annabella Milbanke had turned down a proposal (presumably politely) from Lord Byron; she had also that year turned down Peninsular War hero General Sir Edward Pakenham on the ground that ‘All the Pahenham family have a strong tendency towards insanity’. That rather damaging rejection tended to get quoted then (as it does in biographies now) because Sir Edward was the brother of Lady Wellington and as a grandson of the first Baron Longford, Thomas Pakenham (1713–1766), he had a lot of important and powerful relations in Ireland and in England who didn’t think of themselves as having ‘a strong tendency towards insanity’. Remarks like Annabella Milbanke’s can easily cause wide offence; this writer too is descended from Thomas Pakenham, and like Sir Edward Pakenham his first cousin, my great great great grandfather had his Dublin address IN Rutland Square. I’m sure she’d have been safer on the Pakenham line, but I too can see the irony of her having married Lord Byron.

Touched With Fire gives in an appendix a list of poets ‘with probable cyclothymia, major depression, or manic-depressive illness’ and the only Australian listed is Adam Lindsay Gordon. Gordon committed suicide the day after his Bush Ballads and Galloping Rhymes was published. Yet, other leading Australian poets, including Les Murray and Bruce Beaver have written of struggles with depression or manic-depression. The rising generation of poets is not without individuals affected by such difficulties, and the next generation will doubtless include manic-depressive poets. In recent years a career in Australian poetry has become more difficult through major publishers ceasing to publish contemporary poetry; it’s a literary culture where poets are seen as difficult individuals at home though among English language poetries Australian poetry is seen as quite vital internationally. It can be something of a dog’s life, the life of poetry, and for many the early onset of manic-depressive illness arrives simultaneously with first recognition as a poet. I can’t help thinking that the stigma associated with affective disorders is implicit within the marginalisation of poetry within Australian literary culture. When I encounter young poets of talent attempting to start careers, with no equivalent prize like the Australian/Vogel Award for Fiction to aim for, and with few interested publishers to aim for, well, I tend to wish them better pay and better conditions.

Works by Kay Redfield Jamison: Night Falls Fast: Understanding Suicide (Picador 2000), An Unquiet Mind, A Memoir of Moods and Madness (Picador 1996), Touched With Fire: Manic-Depressive Illness and the Artistic Temperament (Free Books, 1993).