Mood Disorders and Creativity: Getting the Diagnosis and Treatment Right

To honor the past chair of our Department of Psychiatry and Behavioral Sciences, Dr. T. Byram Karasu, we created a named lectureship in his honor at Montefiore and the Albert Einstein College of Medicine. Dr. Peter J. Buckley, a frequent contributor of essays on great artists to the American Journal of Psychiatry, presented a lecture on the association of madness and creativity. The artists he discussed were Caravaggio, the 16th-17th century Italian master of Baroque painting; William Blake, the 18th-19th century English Romantic poet, painter, and printmaker; and Vincent van Gogh, the 19th century Dutch Post-Impressionist painter.

That these artists were troubled is a settled matter. As to their diagnoses, that is more debatable, but there is a fair consensus that they suffered from severe mood disorders and had psychotic symptoms during their lives. Retrospective diagnosis of great artists should be thought of as speculative, and fortunately it does not violate APA’s Goldwater rule.

The presence of bipolar disorder in writers and artists was first studied by Dr. Nancy Andreasen at the University of Iowa—she found that 80% of the writers she studied had mood disorders. Dr. Kay Redfield Jamison found that the rate of bipolar disorder was 30 times greater in British poets than in the general population. Writers such as Virginia Woolf, Samuel Taylor Coleridge, Earnest Hemingway, Robert Lowell, Sylvia Plath, and Leo Tolstoy may well have had bipolar disorder. This is not to suggest that mood disorders are a requirement for creativity, but they are common in many creative people. Many of these individuals experienced psychotic symptoms, including auditory and visual hallucinations and delusions.

For many years I have been concerned that the presence and prominence of psychotic symptoms in patients seeking treatment often lead clinicians to diagnose schizophrenia or schizoaffective disorder, even though DSM-5 notes that mood congruent and incongruent symptoms are specifiers and not inconsistent with the diagnosis of bipolar disorder. In a seminal U.S.-U.K. study, Dr. J. E. Cooper and colleagues (1972) found that U.S. psychiatrists were eight times more likely to diagnose schizophrenia in manic-depressive patients. Drs. Pope and Lipinski (1978) reported that psychotic symptoms had little demonstrated validity in predicting patients’ diagnosis, prognosis, or treatment response and were associated with an overdiagnosis of schizophrenia in affective illness, particularly mania.

Why this is of such consequence is that lithium is a markedly better maintenance treatment for patients with bipolar disorder than either second-generation neuroleptics or valproate. Numerous studies support lithium as the preferred maintenance therapy, but the ease of use of neuroleptics and the belief that the patient has schizoaffective disorder lead to the continued use of these medications from the acute phase of treatment into the maintenance phase. Between worsened prognosis and adverse side effects, we are not returning our patients to maximum functionality or preventing future episodes of their mood disorder as effectively as we could.

In an opinion piece titled “Even When I’m Psychotic, I’m Still Me” in the February 21 New York Times, writer and editor Susanne Antonetta talked about her recurrent psychotic bipolar episodes. These episodes began when she was 29; she was treated with quetiapine and olanzapine and experienced metabolic, neurologic, and cognitive side effects. I couldn’t help but associate this talented writer with bipolar disorder with Dr. Buckley’s lecture on madness and creativity and whether her prognosis would have been better if she had been prescribed lithium. One concern that came up in the discussion after the lecture was whether lithium affects creativity, but it was the consensus of the clinicians who have treated artists and writers that lithium does not affect creativity.

The takeaway from this column is not that great artists or writers with mental illness should be exclusively maintained on lithium, but that psychotic symptoms need to be considered as a common presentation of bipolar disorder and that lithium is both the “gold” standard and the treatment of choice for maintenance therapy. ■