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Photograph by Ric Evans



Reality is under constant attack for millions of people who have bipolar disease. Fortunately, there may be real hope for returning normalcy to their lives. The potential breakthrough is a result of a new approach by University of Pittsburgh researchers in treating the condition.

Two-Faced


Kris B. Mamula



David Kupfer and Ellen Frank
Hymns suddenly blared from the clock radio, jarring Rick Taylor awake from a night of uneasy dreams. He awoke feeling giddy. How did the radio come to be tuned to church music? He lived alone, couldn’t remember switching the station. Then it occurred to him: Maybe the hymns hadn’t come from the radio at all. "I knew something incredible was happening," he says.

Taylor got out of bed, showered, shaved, and dressed in white shirt and business-casual slacks. He would drive eight miles to have breakfast with a friend in Pittsburgh. He would order his usual, eggs sunny-side up. He would then walk the few blocks to his law office. Nothing out of the ordinary.

On this day, though, he found that his hearing had suddenly become more acute, his awareness keener. Concentrating was easier. Time seemed to pass faster than normal—flip, flip, flip—as though he were in a speeded-up movie.

From the moment he got out of bed, Taylor knew the world had been altered in some powerful ways. Not only had it changed, but also he believed that he’d been given great insight into the workings of this thrilling new place. Feelings of excitement, of being in control, grew inside him during the 20-minute drive to his breakfast appointment.

Everything was on course.

Rolling southbound along Route 28 around 60 miles per hour, his yellow Cadillac had the feel of an antique car ride at an amusement park. If he let go of the steering wheel, he was sure the car would continue being guided by an invisible track. But he felt no need to try it.

As he eased his car into a parking garage downtown, Taylor began noticing other signs that his life was on a new track. Suddenly, on the wall of the garage, appeared a rectangular box with bright, pulsating lights—red, orange, blue. Clocks without faces took shape inside the box. He says he knew intuitively the box was some kind of cosmic timing device. The device was governing his new life as an angel. It was all so enchanting but somehow exactly what was expected. He only studied the box for a second. Bigger things awaited. He wanted to get going.

After breakfast, walking along Grant Street to his office, angels passed by. Taylor wasn’t alarmed. He was an angel, too. His job now, his very purpose on Earth, was to spread love. "All we had to do was blow love through the walls to keep ahead of evil in the world," he says.

Dick Thornton, Taylor’s friend, remembers him acting strangely at breakfast that day. Taylor kept asking Thornton about 1936 Olympic star Jesse Owens—a "topic that came out of the blue," Thornton says.

At the office, Taylor asked his boss if it’s true that every time a bell rings an angel gets its wings. The question was lifted from the classic motion picture It’s a Wonderful Life, a Taylor favorite. The boss replied, yes, it’s true, Taylor says. He remembers feeling reassured. Meanwhile, the boss called Taylor’s girlfriend to warn her that it seemed like Taylor was on drugs. By afternoon, Taylor, looking for a friend, tried stepping through a full-length mirror at a store.

Charles Richter Taylor Jr. was crashing.

Two years and a 10-day psychiatric hospitalization would pass before Taylor would fully understand what was happening that January day in 2000. He was bipolar.

"Why this illness happens, no one really knows," says Susan Bergeson, vice president of Depression and Bipolar Support Alliance, a patient advocacy group based in Chicago. There is no cure for the disease and, left untreated, it usually gets worse. Even people who have been stabilized with drugs and talk therapy often remain feeling emotionally fragile.

Bipolar disorder, also known as manic depression, is among the oldest-known illnesses. Ancient Greeks described melancholia, or depression, as a sign of a brain disorder, an idea backed by modern science. But it wasn’t until the 19th century that scientists suggested mania and depression were faces of the same disease.

The condition has been described as being stuck in rush-hour traffic in a race car. People with the illness experience wild mood swings, from darkest despair to wild euphoria, much like Taylor experienced that January day in 2000. In any given year, more than 2 million Americans have bipolar disease, according to the National Institute of Mental Health. But a 2002 University of Texas study indicates that number doesn’t accurately reflect how many people may be living with the condition—some 10 million Americans in all. Bipolar disorder is "misdiagnosed to a frightening degree," Bergeson says.

The average bipolar patient sees five doctors and waits 10 years before being correctly diagnosed. It’s the sixth leading cause of disability in the world, according to the World Health Organization, and up to half of those with it attempt suicide at least once, according to scientific studies.

Theories about the origins of the disease range from genetics to disturbances in metabolism, hormones, and even one’s internal clock, says Andrea M. Fagiolini, assistant professor of psychiatry at the University of Pittsburgh. "It’s as though mania is the fire, and depression is the ashes," says Fagiolini, who is also medical director of the new Bipolar Disorder Center for Pennsylvanians located at Western Psychiatric Institute and Clinic (WPIC). "We’re very far from being able to treat this disorder and say it’s cured."

Antidepressants like Prozac can be prescribed for people who have been diagnosed with the disease. But research shows that the depression associated with it is much harder to break than depression alone. "Bipolar depression is much less receptive to treatment than unipolar depression," says Ellen Frank, professor of psychiatry in the School of Medicine (with a secondary appointment in the Department of Psychology) and director of the Depression and Manic Depression Prevention Program at WPIC.

A naturally occurring mineral, lithium, has long been used to ease the excitability of mania by regulating impulses in nerve cells. In fact, the use of lithium to treat mania is believed to have begun during the days of the Roman Empire, when doctors prescribed drinking spring water that was especially alkaline. Experts say the water probably contained lithium. The first scientific paper on lithium’s therapeutic uses was published in 1949. Twenty-one years later, the U.S. Food and Drug Administration approved it as a prescription drug.

Many people, including Frank, thought lithium virtually cured the disease. She learned otherwise in the late 1980s at a medical conference. She says she was "stunned" to hear families describe the impact of bipolar disease.

Lithium continues to be a mainstay in the treatment of bipolar disorder, but, Frank says, "Lithium is no longer the miracle drug it once was. We’re seeing much, much more complicated cases now." Complications can include patient drug and alcohol abuse or what doctors sometimes refer to as "self-medication."

The goal in bipolar treatment is to balance mood with counseling and medications, including lithium and antidepressants. Just last year, the FDA approved the first drug specifically designed for bipolar depression treatment. It’s not a new drug, though: Symbyax contains two drugs—olanzapine and fluoxetine HCl—that have been prescribed separately for years to treat mania and depression.

Despite these options, there is still no magic formula for leveling the emotional valleys and mountain peaks patients experience. "Keeping these people stable is no easy task," says Taylor’s doctor, Pitt Associate Professor of Psychiatry Mark D. Miller.

For many years, Rick Taylor’s life seemed stable. He married in 1963 and, though he dreamed of being a writer, he enrolled in Pitt’s law school at the urging of his family, graduating in 1966. He worked hard, and it paid off. By the early 1980s, he was practicing corporate law at a big-name firm in Pittsburgh. He made a six-figure salary that was more than he or anyone in his family had ever made. And he had the toys to prove it: a home in an exclusive suburb, fancy country club membership, Steelers tickets to entertain clients, big cars.

Life was good. Or so it seemed.

By the late 1980s, his productivity at work was off, his office politics terrible. Then came the screaming matches. "I was a mess," he says. He was fired in 1989. He went to work at a smaller firm soon after, but was fired in 1993. A couple of smaller law firms employed him after that, minus the perks of a big law practice. His finances were spiraling out of control. He found himself having to pay office and other overhead costs—amenities once provided by his employer. The fees ran as high as $7,000 a month, he says.

Taylor was treated for bouts of deep depression as early as 1994. Around that time, he remembers looking at a chair in the 32nd-floor law office where he was working. He was thinking that he would smash the window with the chair, then jump to his death. It turns out that wasn’t the first time he contemplated suicide. As an undergraduate student back in the mid-1960s, he considered jumping to his death from a fraternity house balcony.

By 1995, Taylor was living paycheck-to-paycheck, tapping his retirement plan to pay bills and extending himself on credit. Five years later, when he awoke to "church music," it was his debt, not salary, that was astronomical.

Taylor’s crash landed him in WPIC under the care of Miller. Taylor’s sister, Judy Williams, remembers Miller asking her if she thought her brother was manic. "I told him I didn’t know what that was."

Miller would eventually refer Taylor to the new Bipolar Disorder Center for Pennsylvanians, an innovative program offered through Pitt academic partner WPIC, where advanced treatment is provided free of charge. The idea for the center at Pitt was born in August 2002, two months after Taylor was released from WPIC. The Pennsylvania Department of Health had requested proposals for projects that would improve mental health while addressing disparities in the treatment of the young, elderly, people who live in rural areas, and African Americans. Grant money for such projects was available from a $23.1 million settlement, Pennsylvania’s share of a national lawsuit filed against big tobacco companies.

Coincidentally, that same year, David J. Kupfer, Thomas Detre Professor and chair of the Department of Psychiatry, headed a study that found the suicide-attempt rate for people with bipolar disease exceeded 50 percent for 3,000 Western Pennsylvanians, including 64 percent for African Americans. What’s more, Kupfer, Frank, and other Pitt researchers had come to believe that bipolar disorder had to be redefined, approached in an entirely new way. Change the way the disease is thought of, and new treatments will follow, the thinking went.

Kupfer sketches out a new view of the condition by comparing it to diabetes: Bipolar disorder, like diabetes, is a serious, chronic, recurring medical problem. Like diabetes, symptoms may be significantly alleviated with medication and lifestyle changes, including exercise, diet, and stress management.

"Medication is not all that is needed," emphasizes Kupfer, who is also medical director and director of research at WPIC. He considers the disease a medical problem with psychological symptoms. "Very few people think about it that way, but that’s what it is."

A proposal for the most comprehensive approach ever undertaken for treating bipolar disorder became part of Pitt’s application for funding. Kupfer wants, in part, to confirm that intensive counseling of bipolar patients regarding lifestyle choices will markedly improve their quality of life. Pitt received $5 million from the state to open the bipolar center. Kupfer directs the center and Frank is the codirector.

Some 600 patients will be accepted into the program from around the state, then carefully followed during the next four years. Patients will also have the opportunity to participate in clinical trials. To recruit patients from across the state, cooperative agreements were reached with researchers and staff at the University’s Graduate School of Public Health’s Center for Minority Health, Thomas Jefferson University in Philadelphia, Clearfield Community Mental Health Center of Dubois, Pa., and Lincoln University outside Philadelphia.

The center is unique in several ways, among them its being the first to conduct a controlled study of bipolar depression in late life, and the first to admit patients from all ages, races, and socioeconomic backgrounds. The center will address the disease in the young, elderly, and African American populations, which historically have not received adequate mental healthcare.

Kupfer says the center, with its emphasis on the lifestyle choices of patients, may validate the effectiveness of treating bipolar disorder with intensive counseling in addition to medication. The study should also improve awareness of the disease, both within the medical community and among the public. The study will also bring greater understanding to the medical community of the manifestation of the disease, the signs and symptoms. All this could lead to faster diagnosis and more effective treatments that will ultimately reduce healthcare costs and help patients live fuller, happier lives.

Taylor, who is in the center’s program, may be one of the patients benefiting from this new approach. At age 62, he says he finally has his life back. He’s living comfortably, keeps up with his bills, faithfully takes lithium and Paxil, which is from the Prozac family of drugs, and keeps his doctor’s appointments.

Gone are the country club membership and other trappings of affluence he once enjoyed. Those things have been replaced by tightly packed bookshelves in the modest, one-bedroom apartment where he now lives. More books are piled on the floor around a wooden desk, where he spends most of his days pecking away at a personal computer.

Taylor is a barrel-chested man with salt-and-pepper hair and a deep voice. He very much looks the part of a trial attorney. But he no longer practices law. Instead, he is pursuing his first love—writing—which only seems appropriate. Some of his experiences really are the stuff of fiction.

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