Catherine commented:

‘I disagree with the comment about bipolar and schizophrenia being chronic, remitting etc. There are a minority who are so badly affected that they never live independently, but the majority go on to either recover, or manage their illness very well, working, hobbies etc and have a good quality of life.’

The point I was making about the chronicity of schizophrenia/bipolar disorders is that in the film ‘Ruth’ is presented to us has having recovered from her mental health crisis with no mention of follow up.  For anyone who doesn’t know, it’s often common practice in healthcare for a patient to be seen by a doctor on at least a short term basis after a problem has resolved as there may be a chance of it coming back, and psychiatry is no exception to this. We know from the film that she already has a diagnosis of BPAD and so she must have had trouble before.  The episode presented to us is quite severe, so I would say that her chance of having another relapse is high, especially with bipolar disease

Schizophrenia is considered to have a wide variety in outcomes, that said, there are not millions of long term studies; here are the ones mentioned in the Shorter Oxford Textbook of Psychiatry:

Kraeplin Dementia praecox and paraphrenia 1919
Concluded that only 17% of his patients were socially well adjusted many years later

Mayer-Gross Die Schizophrenie in Bumke’s Handbuch der Geisteskrankheiten Vol 9 Springer Berlin 1932
Reported social recovery in 30% patients at 16 years all from the same clinic

Brown et al (1966) reported social recovery in 56% in Schizophrenia and social care Maudsley Monography 17 Oxford University Press  London

Manfred Bleuler (1972,1974) followed up 208 patients who had been admitted into hospital in Switzerland between 1942 and 1943.  Twenty years after admission 20% had complete remission of symptoms and 24% were severely disturbed. 

Ciompi did a larger study looking at 1642 records diagnosed as having schizophrenia between 1900 and 1962, with an average follow up of 37 years.  A third of patient were found to have good or fair social outcome.  Symptoms were often less severe in later life. 

Johnstone E.C. (1991) Disabilities and Circumstances in Schizophrenic patients: A follow up study British Journal of Psychiatry  159 supplement 13 5-46, did a 3-13 year follow up of patients with schizophrenia discharged from 1975 - 1985 and found that almost half had a good social outcome. 

Tsoi and Wong (1991) A fifteen year follow up of Chinese Schizophrenic patients Acta Psychiatrica Scandinavica 84 217-220  did a 15 year follow up of 330 patients with first admission Schizophrenia and in this found that almost one third recovered but 17% remained unable to function outside the hospital. 

Finally in the USA Carone et al (1991 - a busy year) found that only 15% of patients meeting DSM-III criteria for schizophrenia recovered after 5 years. 

Full admission: I haven’t read any of these papers/books, and for these papers to be comparable then they should all use similar definitions for schizophrenia and select similar patients - there would be no utility is comparing patients after their first admission and patients who have been admitted countless times.  With these caveats, it appears that prognosis has improved since schizophrenia was first studied.  In the earlier studies the patients would have had no access to modern pharmaceutical treatments 

Schizophrenia outcome is further discussed in  Schizophrenia Research Volume 1, Issue 6, November-December 1988, Pages 373-384

The factors associated with good prognosis in Schizophrenia:

Sudden onset; Short episode;No previous psychiatric history; Prominent affective symptoms; Paranoid type of illness; Older age of onset; Married; No personality disorder; Employed; Good social support; Good compliance with treatment

Poor prognosis is associated with:

Insidious onset; Long episode;Previous psychiatric history; Negative symptoms; Enlarged lateral ventricles; Male gender; Younger age of onset; Single/separated/widowed/divorced; Personality disorder; Poor work record; Social isolation; Poor complicance with treatment

If you’ve still got the strength, read on for outcome of bipolar affective disorder.  Again this is from the Shorter Oxford Textbook of Psychiatry:

The average length of a manic episode (treated or untreated) is six months

At least 90% of patients with mania experience further episodes of mood disturbance

Over a 25 year follow up on average bipolar patients experience 10 further episodes of mood disturbance

The interval between episodes becomes progressively shorter with both age and the number of episodes

Nearly all bipolar patients recover from acute episodes, but less than 20% of patients with this disorder achieve a period of 5 years of clinical stability with good social and occupational peformance

It is estimated that 10% of patient with unipolar depression will eventually turn out to have a bipolar illness.   

So, with both bipolar affective disorder and schizophrenia, I do think that if a patient has one episode they are likely to be troubled by the illness at a later date and this is what I meant by a chronic condition.       

I’ve written a previous post about celebrity lives and why they predispose people towards problems with their mental health.  In it I mention Britney Spears, who has been regularly described in the press as ‘troubled’ for some time now.  Things took an altogether more serious turn when on Thursday she was taken to a psychiatric hospital under a 72-hour detention.  This was the second time she has been taken to hospital in recent weeks, the first was after she refused to relinquish her children  who were to be taken into the care of her ex-husband.  On this occasion, in a pantomime show some 30 cars trailed her ambulance, twelve of them belonging to the police.  By way of contrast, here in London it can take a week to get one police car to attend a section.

Recent news is that Ms Spears period of involuntary stay in hospital has been extended to 14 days.  Not that I have given it a great deal of thought, but I’d always considered that Spears’ problems were likely to be personality based, that is to say as the result of learned behaviour, rather than because of a serious mental illness.  Even if I am right, it appears that her problems have become much more severe than just throwing her toys around when someone refuses to pick out the blue M&Ms. 

Her behaviour certainly has been bizarre, Associated press report that

Since her breakup with Federline, Spears has been seen at public events in short skirts and without underwear, has shaved her head bald, run over a photographer’s foot with her car, left the scene of a fender bender, flogged another car with an umbrella and abandoned a car in traffic when it had a flat tire. Recently, she was seen sitting on a sidewalk, holding her pet dog and crying

elsewhere it is said that before she was admitted she had not slept for five days.

It’s impossible from this vantage point to know what’s wrong with Spears.  The diagnosis of mental illness requires a period of assessment and often is only settled with response to treatment.  Emma Forrest writing in the Guardian seems to have decided that she’s got bipolar disorder and writes an article sympathetic to Spears detailing her own experiences.  Biopolar has become quite a fashionable diagnosis these days - I’ve been toying with the idea of doing a survey where I ask people whether they think it’s okay to be bipolar now that Stephen Fry says that he has it. 

Let me finish on a confession: I’m more than a bit disgusted with myself for writing a post about Britney Spears when the best medicine for her is for us all to leave her alone.  But that won’t happen. 

Britney’s perfume still selling well - Britney and the Sweet Smell of Distress Laura Barton Guardian 25 February 2008

Lisa Appignanesi’s Out of Control Guardian 10 March 2008 - an excellent article discussing her mental health problems in the context of how differently she would have been treated were she a man.

Despite being very famous, Heath Ledger had somehow passed me by until a few weeks ago when I watched ‘Monster’s Ball’ and ‘Brokeback Mountain’ within a few weeks of each other.  It seems likely that his death was caused by an overdose of sleeping pills, either mistakenly or intentionally.  As a psychiatrist I was struck by something Ledger said in his last interview with Sarah Lyall, published in the Observer.

‘Last week, I probably slept an average of two hours a night,’ he said. ‘I couldn’t stop thinking. My body was exhausted and my mind was still going.’ One night, he took an Ambien sleeping pill, which didn’t work. He took a second one and fell into a stupor, only to wake up an hour later, his mind still racing

Obviously there’s not much to go on here, but I wonder if Ledger is suffering from hypomania, although I note that there is no mention of elevated mood in the article.  It is also worthy of note that Ledger had been flying between Manhattan and the UK, as he had been filming ‘The Imaginarium of Doctor Parnassus’ in London.  According to NICE guidelines, if a person has a predisposition towards bipolar disorder, relapses can be triggered by ‘night flying and flying across time zones, and routinely working excessively long hours, particularly for patients with a history of relapse related to poor sleep hygiene or irregular lifestyle’

There’s also been press speculation about Hedger’s history of drug use.  In 2006 he was the victim of a paparazzi sting operation during which time he was filmed admitting to smoking ‘five joints a day for twenty years’; in the background of the film were unidentified persons snorting what is presumably cocaine.  At the time the tape was not shown due to legal threats, but now Ledger is dead no such restriction aside, of course, from decency.