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Bipolar, Barbiturates, and Punk Rock

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Brian Wilson, Lou Reed, and Ian Curtis all created new music genres, and each of them is reputed to have had bipolar disorder. We look at the evidence behind that, and learn a few things about psychiatry and creativity along the way. But it all starts with Lou Reed’s first Velvet Underground concert, performed – of all places – at a psychiatric convention. Here’s the footage [link].

Published On: 5/31/2021

Duration: 21 minutes, 15 seconds

Transcript:

Kellie Newsome: Brian Wilson, Lou Reed, and Ian Curtis all created new music genres, and but did they also suffer from bipolar disorder?

Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003.

Dr. Aiken: I’m Chris Aiken, the editor in chief of the Carlat Report.

Kellie Newsome: And I’m Kellie Newsome, a psychiatric NP and a dedicated reader of every issue.

Punk Rock Debuts at a Psychiatric Convention

The Hotel Delmonico sits at the base of central park in New York City. Or at least it used to sit there. The towering structure is now called Trump Park Avenue, but in its earlier days it was a meeting ground for the celebrated and influential. The Beatles introduced Bob Dylan to marijuana there in their 6th floor suite. And on January 14 1966, the hotel was about to play host to one of the most unlikely musical debuts. 

It was a Friday night, and dozens of psychiatrists were gathering inside the Delmonico ballroom to kick off the 43rd annual meeting of the New York Society for Clinical Psychiatry. The program chair, Robert Campbell, invited Andy Warhol to stage a “happening” while the psychiatrists dined on roast beef and potatoes. These “happenings” were all the rage in the 1960’s art world – they were multimedia, live performance pieces where artists interacted with the audience. The idea seemed to fit with the interactive directions that psychoanalysis was taking – focusing more on the therapeutic relationship – but, in the spirit of good performance art, the evening did not play out as expected.

Warhol and his troupe descended upon the crowd with Super 8 cameras, posing vulgar questions to the doctors in front of their spouses – questions like – I don’t think we can repeat this here but – like whether the doctor’s anatomy was big enough to please his wife – you get the idea. As the doctors blushed, Warhol moved into the anxiety, asking “Why are you getting embarrassed? You’re a psychiatrist; you’re not supposed to get embarrassed.”

Soon the circus was drowned out by an even more dissonant sound, as a rock band blasted their amps from the hotel stage. The name of the band was probably familiar to some in the audience – it was borrowed from a recent textbook on sexual deviance: The Velvet Underground.

It was the group’s first live performance, and its lead singer, Lou Reed, had crafted a raw, jarring sound that would soon give birth to an entire new genre: Punk rock. But the audience was less sure. “It seemed like the whole prison ward had escaped” said one, “A short-lived torture,” said another. Others adopted more analytic neutrality: “I suppose you could call this gathering a spontaneous eruption of the id,” said Dr. Alfred Lilienthal.

Kellie Newsome: Paul McCartney credits Brian Wilson of the Beach Boys with starting psychedelic rock. Lou Reed and the Velvet Underground invented punk rock.  And Ian Curtis of Joy Division turned punk rock into the expressive tones of alternative rock. All 3 of these trailblazers are reputed to have suffered from bipolar disorder. But bipolar disorder is not an easy diagnosis to make, even when you are interviewing the patient in person. And each of these musicians took drugs or medications that might have influenced their moods. We can’t confirm these diagnoses, but we will offer up some biographical details and learn a little about psychiatry and creativity along the way.

Brian Wilson, Bipolar, and Psychedelic Rock

Dr. Aiken: In 1966, the Beach Boys released Pet Sounds. Its melancholy introspection was miles away from the band’s usual merriment. Their chief songwriter, Brian Wilson, was no longer able to manage the stress of touring, so he locked himself in the studio and began experimenting with multitrack recording, creating elaborate layers of vocal harmonies, bicycle bells, French horn, flutes, beverage cans, and the Electro-Theremin. Like the Velvet Undergrounds work, the music is pretty raw and can be hard to listen to. It was a commercial failure, but one fan who bought the record tried to imitate the sounds, and in doing so started a trend of psychedelic rock. That fan was Paul McCartney cites, whose Sargent Pepper Beatles album took more than a few cues from Pet Sounds.

As the Beatles few to new heights with Sargent Pepper, Brian Wilson sank somewhere darker. While working on his follow up album, Smile, he started hearing derogatory voices telling him that he was going to die. His mind could no longer organize the dozens of layers in his multi-track sound, and after 3 years of struggle his album was left unfinished. He spent most of the next 15 years in a depression, unable to leave his bedroom, until in the early 1980’s he was diagnosed with schizoaffective disorder, bipolar type.

Daydream Believers

Patients with mania often say they have multiple trains of thought at the same time. Some compare it to multiple tapes playing. In the 1990’s, Fred Goodwin and colleagues at the NIMH called this “trait daydreaming” – and they found that it was one of the top 3 signs that a unipolar depression would turn into a bipolar one. The others were more obvious – high energy and mood lability. I once asked Fred Goodwin what “trait daydreaming” means. He said, “It’s like those Walter Mitty types who can get lost in a fantasy while carrying on routine things. They are shopping at the grocery store while writing the great American novel in their head.

It sounds like a useful trait for an artist, but that kind of creative energy can only bring fruit if the frontal lobes are intact. Artists need executive functioning to filter and edit their work and bring it to completion. Keep that fact in mind the next time a bipolar patient tells you they are more productive off their medication. That maybe why we see a trend here – an artist with supposed bipolar starts a fire that quickly turns to ash, but someone else picks the embers, organizes the flame, and turns it into something more popular. 

Lou Reed: A Family’s View

Kellie Newsome: In the same month that Brian Wilson started recording Pet Sounds in California, Lou Reed took to the stage at the Hotel Delmonico to perform before an audience of psychiatrists. Lou was no stranger to psychiatry. In 1959 his parents found him in his college dorm in a catatonic state, depressed, vacant-eyed, and seeing things crawling on the walls. He was brought to Creedmoor Psychiatric Hospital and treated with ECT. 

Rumors spread that the ECT was used to treat Lou’s bisexuality, and while it’s true that bisexuality was viewed as a mental disorder back then it was not treated with ECT – rather, with psychotherapy. Lou’s sister Merrill Reed Weiner disagrees with those rumors, and wrote in recent article that it was manic-depressive behaviors that brought him to treatment. Merrill is a psychiatric social worker. Here’s what she saw:

 “During Lou’s teenage years, it became obvious that he was becoming increasingly anxious, avoidant and resistant to most socializing, unless it was on his terms. In social situations he withdrew, locking himself in his room, refusing to meet people….

His violent outbursts frightened the family. If people came into our home, he hid in his room. He might sit with us, but he looked dead eyed, non-communicative. I remember one evening when all of us were sitting in our den, watching television together. Out of nowhere Lou began laughing maniacally. 

His episodes took him in and out of college, and at the nadir of his functioning his parents took him to a psychiatrist who recommended ECT, which Lou received and later wrote about bitterly in his song “Kill Your Sons.” Throughout his career, he returned to live at home when severe episodes returned.”

Dr. Aiken: Lou’s sister stops short of making a diagnosis, and we don’t know the cause of those symptoms which may have been influenced by drugs. Lou Reed’s spent half of his 40-year career addicted to amphetamines and alcohol, but he sobered up in the 1980’s with a combination of tai chi, meditation, and hard work. He died in 2013 from complications of liver failure.

Lou was a notoriously difficult artist to work with, and he largely kept aloof of the punk rock scene he inspired. As other artists were reworking his ideas in the 1970’s, Lou was holed up in his apartment creating a double sided album of random electric guitar feedback called Metal Machine Music. His record company tried to bury it, but even this unlistenable work would later resurface as the inspiration for yet another new genre: Industrial rock.

Ian Curtis, Joy Division, and Bipolar?

Kellie Newsome: One of those punk rockers was Ian Curtis, who formed his band Joy Division in 1976 with musicians he met at a Sex Pistols concert. Ian’s group took punk rock in a different direction, turning the raw anger into a more melodic, emotionally expressive sound that would inspire alternative rock artists like The Cure, U2, Interpol and Radiohead.

But Ian Curtis never lived to see that commercial success. He died 41 years ago this month of a preventable illness – one that peaks in the spring months and happens with alarming frequency in people with psychiatric disorders: Suicide. His first commercial success came later, with the posthumously released single Love Will Tear Us Apart.

Last year Drs. Hirakawa and Ishii from Oita University in Japan published an article in the journal Bipolar Disorders speculating that Ian Curtis had bipolar disorder. The evidence here is a little thinner than for our other two musicians. 

Ian’s widow, Deborah Curtis, revealed in a biography that Ian suffered from depression and epilepsy. Others who knew him well attest to his mood swings and explosive, unpredictable rages. 

Ian’s epilepsy was also severe though, and epilepsy can cause symptoms of mania and depression. The epilepsy was difficult to control – he frequently had seizures on the stage that were misinterpreted by his fans as inspired dancing. After his first album he started taking the anticonvulsants phenytoin and phenobarbital for the epilepsy, but his mood worsened on those medications. How could that be when anticonvulsants are supposed to help mood swings and epilepsy? 

Barbiturates, Phenytoin, and Bipolar

Dr. Aiken: Phenobarbital is a barbiturate that’s been used for epilepsy since 1912. Its sedative properties were quickly appreciated, and the first recorded use of phenobarbital in bipolar disorder was 1913. Back then the drug went by the enticing name Luminal, and bipolar disorder was called manic depression. Before 1960, the barbiturates and opioids were the most widely prescribed drugs for mood and anxiety disorders. We didn’t have rigorous studies back then so we can’t be sure they helped, but they probably worked on some level.

Ian’s other anticonvulsant – phenytoin – is usually not thought of as a mood-stabilizing anticonvulsant but it actually has decent evidence in bipolar mania. Phenytoin was developed in the 1930’s to treat epilepsy, and has a similar chemical structure to phenobarbital but is not a barbiturate. Phenytoin has never been widely used in psychiatry, but in the early 2000’s a group of Israeli psychiatrists published two small but controlled studies showing phenytoin could successfully treat and prevent mania,Mishory, Mishory and another small study that showed possible antidepressant effects of phenytoin where they compared it to fluoxetine (Note: this last study did not include a placebo group so may have been a statistical mishap).Nemets

But let’s not think that all anticonvulsants treat bipolar disorder. Gabapentin, topiramate, levetiracetam, and oxcarbazepine have all tried and failed – in large, industry sponsored trials.

And while phenytoin has suggestive evidence in bipolar, there’s no evidence from Ian’s life that it was helping. His moods got worse with time. It’s also possible that the anticonvulsants were causing side effects that made his mood worse. Like the benzodiazepines, phenobarbital has been known to make people depressed, irritable, or disinhibited. But those effects are pretty rare and they aren’t the reason that psychiatrists stopped using barbiturates. The barbiturate era came to an end because of a much more serious and common adverse effect: Death.

Kellie Newsome: Even slight overdoses of barbiturates could be fatal, and they were a common cause of death for the famous and unfamous alike. Judy Garland, Jimi Hendrix, Marilyn Monroe, all died of barbiturate overdose, and Ian Curtis attempted suicide by phenobarbital overdose in April 1980. His life was saved by emergency intervention, but sadly he died by completed suicide a month later. 

Creativity and Bipolar: The Research

Kellie Newsome: Brian Wilson is open about his diagnosis, but we don’t really know about Ian Curtis and Lou Reed. I mean, on the one hand there are these reports of bipolar behaviors, and on the other hand rock stars are notorious for acting that way anyway.

Dr. Aiken: I do have a clinical pearl about that one. Once I saw a heavy metal musician who presented with bipolar disorder. He had been hospitalized for a manic episode while on tour – I’m changing the details a little here. I asked him “I understand people thought you were manic, but how can we be sure? I mean, isn’t it kinda normal to act manic on stage – breaking things and jumping into the audience?”  “Oh no,” he said, “The things I was doing were way over the line – my bandmates were calling it quits with me.” 

Later I learned he was right, and I was a little naïve to think that the Rock and Roll lifestyle is without norms or expectations. When Guns and Roses was about to release their first album in 1987, the lead singer Axl Rose was so out of control – skipping out on shows, or causing riots if he showed up – that his bandmates made him sign a contract that required him to seek psychiatric care in order to continue in the band. By his report, he was diagnosed with bipolar disorder.

Every culture has its norms, and the nature of mania is to break norms. When Janice Egeland and Abraham Hostetter went into the Pennsylvania Dutch Amish community in the 1970’s to study the genetic transmission of bipolar disorder they had to rethink their definition of mania. Typical manic behaviors in among the Amish were: Racing one’s horse and carriage too fast, buying or using machinery or worldly items, using the public telephone excessively, and – my favorite – planning vacations at the wrong season.

Bipolar is not the only mental condition that breaks with cultural norms. Three leaders who changed the world all had suicidal episodes in their early 30’s: Abraham Lincoln, Martin Luther King, and Mahatma Ghandi. I’m not saying they had bipolar disorder. Lincoln sought treatment for depression, but I know of no evidence that he or these other leaders had bipolar disorder. 

Kellie Newsome: A few studies have looked at various groups of accomplished creatives and concluded that poets and musicians have the highest rate of bipolar disorder – with estimates that range from 30-70%. And I can see why. Reading over the mental status terminology for mania and you can almost think your reading about poets and musicians. There’s excessive rhyming – clang associations; expressive, lyrical speech; loose associations or – in the eyes of an artist – brilliant metaphors. Cognitive studies have found that people with bipolar disorder have above average verbal abilities – they know more words and use them effectively. 

Dr. Aiken: Most of those researchers relied on biographies, but one of the better ones was done by Nancy Andreasen, who is also known for finding the first brain abnormalities in schizophrenia with imaging studies. In 1987 she went out to study graduate students in the leading creative writing program, the Iowa Writers workshop. She saw connections between creativity and psychosis, and expected to find high rates of functional schizophrenia. But as she tested the students with structured diagnostic interviews, what came up time and again was bipolar disorder. Instead, she found bipolar disorder. 43% of the creative writers had bipolar spectrum disorders – which back then meant bipolar I, cyclothymia, or bipolar II, compared to only 10% in control group in a non-creative field, but with similar levels of IQ, education, gender and age.

She also interviewed the relatives of the writers, and found higher rates of bipolar in them as well. Other studies have confirmed that the unaffected family members of bipolar patients have higher levels of creativity. 

Creativity is often mistaken for mental illness, and its association with bipolar disorder perhaps doesn’t help. But creativity is a strength. It aids problem-solving, builds social connections, and brings meaning to life. One study looked at how personality traits influenced the outcome of psychotherapy for depression. The traits that predicted the best outcome were creativity and openness to experience.

Whole Exome Sequencing

Kellie Newsome: 

And now for the word of the day…. whole exome sequencing

Kellie Newsome: Whole exome sequencing – or WES – is a genetic testing technique that maps a patient’s genome… well, not the entire gene, it takes a short-cut, mapping only the genes that code for proteins. These make up 1.5% of the genome, in terms of health and disease they are among the most important. Long used in research, whole exome sequencing is now used clinically to identify rare genetic disorders. In psychiatry, it is used to screen for known genetic causes of autism and intellectual disability. 

Antidepressants in Post-Stroke Depression

Join us next week for an interview with John Nurnberger on pharmacogenetic testing.

And follow us on tweeter for fun and practical research updates. Today we’ll tweet on a new randomized controlled trial comparing sertraline, escitalopram, and the European antidepressant agomelatine in post-stroke depression.

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