On the Road in Edinburgh, Part III

John McManamy Health Guide
  • It’s 10 in the evening here in Edinburgh. The International Society of Bipolar Disorder's Second Conference wrapped up earlier in the afternoon, and I had time to sample the city. Visitors are pouring in from all over for the Edinburgh Festival, Fringe Festival, and the Royal Tattoo, swelling the population to twice its normal size. Since the Scots and Brits drive on the left hand side of the road and the rest of the world (almost) on the right, this means chaos on the mobbed sidewalks. Pedestrians gravitate toward their “home” orientation, with Scots and Brits colliding with Yanks and Euros in one massive gridlocked urban scrum.
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    But what a scrum. Festival time brings out the street performers – acrobats, musicians, bagpipers, jugglers. I watch closely at the drummer accompanying a piper. His sticks move faster than a fly’s wings and the sound of his roll is reminiscent of a card against the spokes of a kid’s bicycle. Tomorrow I will witness about a thousand massed pipers and drummers marching out of the ancient Edinburgh Castle. I managed to procure an impossible-to-get ticket to the Tattoo, and I am savoring the moment over my favorite new beverage – ginger beer – in a café in an ancient stone building looking out into a cobblestoned intersection framed by fabulous turreted structures.

    The conference. Oh yes, the conference. Yesterday Eduard Vieta MD, PhD of the University of Barcelona delivered an interesting talk about thinking ahead. It works like this: A patient comes in the clinic with manic symptoms. You give him an anti-mania med to bring the mania down, right? Then what? We know bipolar is a cyclic illness, and that depression is far more common than mania. So even when the patient is in mania, says Dr Vieta, we should be thinking ahead to how to prevent any future depressions.

    This is easier said than done, of course. Antidepressants are problematic for bipolar depression. Lithium has some clinically-proven depression-prevention properties and so does Lamictal. The problem with Lamictal, however, is it does not work for mania, so this means at least two drugs. Zyprexa also has clinical trial evidence for preventing bipolar depression. Seroquel may be the next flavor-of –the-month med, with two strong trials for treating acute (initial phase) bipolar depression, but there are no long-term studies showing the drug works at preventing depressive relapses, Dr Vieta cautioned. Talking therapy is also useful, he added.

    My favorite conference sound bite: “In many ways, temperament is the link between genotype and phenotype.” This came from a session that featured Gulio Perugi MD of the University of Pisa as one of the speakers. Dr Perugi is a frequent collaborator of Hagop Akiskal MD of the University of California at San Diego (the leading proponent of a “spectrum” approach to mood and personality disorders).

    Genotype refers to a person’s genetic makeup. Phenotype refers to an individual’s symptoms, such as being depressed and irritable and unable to sleep. Between genotype and phenotype is a vast Terra Incognita that the brain scientists are beginning to explore and chart. What Dr Perugi is driving at is somewhere in between the mechanics of genes coding various proteins and the phenomenon of a person in an episode (or even stable) lies a biological predisposition to certain behaviors. Hyperthymic (energetic) types are predisposed to behave one way, depressive types, another, and so on. Temperament, then, may drive, or at the very least, interact with our illness.

  • Oddest sight at the conference: A prominent brain scientist taking a smoke break outside. What next? Jessica Simpson reading James Joyce?
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    No conference is complete without paying homage to Emil Kraepelin, the pioneering diagnostician who coined the term, manic-depression, and distinguished it from schizophrenia. More than one speaker at the conference was for revisiting that distinction. Nick Craddock MD, a geneticist at the University of Cardiff, pointed out that there are now a number of candidate genes that are implicated in both bipolar disorder and schizophrenia. Moreover, his task in teasing out suspect genes was made a lot easier when he threw out the diagnostic rulebook.

    In this context, we are talking about a “psychosis spectrum,” where mania meets psychosis. Ironically, at the other side of the spectrum, where mania meets depression, leading authorities (such as Dr Akiskal) talk about a return to Kraepelin. This is because the DSM put up a wall between depression and mania (which Kraepelin did not), which may be in need of considerable modification.

    Rifle shots. Artillery fire. It’s coming from the castle. Tonight’s Tattoo has just wound up. Tomorrow night I will be there, seated in makeshift bleachers beneath torch-lit battlements that have survived countless sieges. I love this place.

    This if John McManamy, reporting “live” from Edinburgh.
Published On: August 09, 2006