Burns Woodward, MD

Storms, floods, and fires caused by human-generated global warming correlate with elevated rates of anxiety, depression, and suicide.

 In the longer term, stress- and loss-related psychiatric disorders result from climate-related physical illness, economic disruption, migration, and violence. Limited coping skills and reduced socioeconomic resources make psychiatric patients especially vulnerable to these effects. In day-to-day practice, however, it can be difficult to connect these large-scale events with the treatment of individual patients. Identifying patients at risk for the psychiatric effects of climate disruption provides guidance to clinicians as they address these issues in treatment.

The impact of climate disruption on a patient’s treatment is determined by the individual’s exposure to climate-related problems, psychiatric symptoms, resources, coping skills, and readiness to address the risks he or she faces.

Patients who experience distressing or disabling anxiety, depressive rumination, or delusions about climate disruption have diagnosable psychiatric disorders. Such patients need treatment with psychotherapy and/or medication. But some patients with such symptoms also face actual dangers, and treatment is likely to be more effective when the risks they face are considered. Cognitive therapy can distinguish realistic dangers from the catastrophic thinking associated with pathological anxiety and depression. Behavioral interventions to curb internet searches, calls to public officials, and hounding of family members about energy usage can limit symptom aggravation.

Symptom management alone, however, can be maladaptive when there is actual danger. A patient with obsessive-compulsive disorder may need to limit exposure to climate- related news and manage his anxiety about CO

 emissions enough to keep his home warm. But acknowledging his children’s vulnerability to wildfire-associated respiratory illness might motivate him to participate in an advocacy group where social feedback could channel his anxieties toward meaningful steps to reduce his family’s risk.

Patients who have experienced heat waves, wildfires, floods, or other climate-related emergencies may, as the first priority, need guidance about dangers they continue to face. The US Centers for Disease Control and Prevention (CDC) provides information about reducing harm from heat, smoke, and water pollution.

 Patients with severe and persistent psychiatric illness are especially vulnerable to these risks because of poor self-care, medical conditions, and medication.

After such disasters, psychiatrists are also likely to see patients suffering from trauma-related disorders and depression as well as exacerbations of pre-existing mental and addictive disorders. After the acute trauma is addressed, clarifying the connection between the patient’s symptoms and weather-related events can lay the groundwork for anticipating and preparing for the next emergency. Moving from viewing the disaster as an unpredictable act of God, for example, to an expected consequence of global warming may free the patient to plan for future disruptions of access to food, water, medication, and treatment, as well as the possible need to evacuate. This can be a step on the path from helpless vulnerability to self-efficacy.

Those living or working in areas at risk for climate-related disasters also benefit from emergency planning, but clinicians may first need to address their patients’ apathy. This appears in many forms-outright denial of risk, belief one is invulnerable, projection of responsibility onto government officials or corporations, exaggerating the efficacy of ameliorative measures, “traditionalist” refusal to change, focusing on immediate problems, or fatalistic passivity.

 When these resistances are addressed, patients will be more able to face the tragedy of their situations.

No region is free from risk-residents of non-coastal New England, for example, may feel complacent in their low vulnerability to wildfires and storm surges but ignore dangers from heat waves, inland flooding, and vector-borne diseases.

 Patients may be open to discussing these risks during periods of severe local weather or news of climate-related events elsewhere.

Warning about danger, however, can be counterproductive when it elicits defensiveness, guilt, or anger.

 In the words of the climate scientist Susanne Moser:

People need a minimum amount of information, a realistic assessment of the threat or diagnosis, a sense of personal control over their circumstances, a clear goal, a clear understanding of the strategies to reach that goal (including the possible setbacks along the way), a sense of support, and frequent feedback that allows them to see that they are moving in the right direction.

This is clearly more than can be accomplished in a single interview; clinicians may need to view their work as a series of steps to help patients change. Motivational interviewing techniques-open-ended questions, reflective listening, summarizing statements, and supportive comments-facilitate collaborative evaluation of risk and planning for safety.

Some patients experience deeper anxieties related to loss of an expected future for themselves, their progeny, or the human species. Others grieve for familiar natural environments or for nature in its sense of an ultimate home.

 Especially vulnerable are those who have devoted personal or career resources to fighting climate change. Such “climate activists” may become despondent with news of further climate degradation or political events that threaten the environment. While some such patients are depressed, others are better characterized as suffering from a form of existential despair. A related issue is psychic numbing. This differs from the apathy associated with failure to understand climate disruption. Numbing occurs when the individual perceives the threat but feels powerless and gives up.

While symptoms of climate-related despair overlap with those of depression, the distinction is worth making, since treatment may differ. DSM-5 provides some guidance in a footnote about the differences between grief and depression.

 Extrapolating from this to climate-related dysphoria generates several distinguishing features, which are summarized in the 

Affect in climate-related despair comprises feelings of emptiness, loss, and meaninglessness, while clinically depressed patients are depressed and anhedonic. Climate- related despair may be limited in scope: patients may still experience humor and joy about other subjects. Depression, on the other hand, tends to be persistent and pervasive. Individuals suffering from climate-related despair are preoccupied with climate issues and ideas of a diminished future, while in depression thoughts tend toward guilt and hopelessness about one’s own life. Self-critical thoughts in climate-related despair usually involve failure to achieve climate-related goals (eg, passing a carbon tax bill). Self-esteem is generally preserved in climate-related despair, while depressed patients experience self-loathing and worthlessness.

There is no research to support pharmacological treatment of climate-related despair. When clinical depression is present, antidepressants are likely to be useful, since they can be effective for depression in other situations of danger and loss, such as palliative care.

We have no treatment manuals or clinical trials to guide psychotherapy of climate-related despair, but a growing body of evidence supports meaning-based psychotherapy in other tragic situations.

 Such therapies typically combine various techniques, including mindfulness and cognitive-behavioral therapy, to help patients accept difficult situations and unpleasant emotions and to engage in activities that promote their personal values. One such approach, Transformational Resilience, addresses the psychosocial effects of climate disruption at both individual and community levels.

The challenges for therapists include hearing, containing, and working through patients’ despondency while monitoring for depression, which might require additional treatment. The goal is to convert such despair to what has been called tragic, or active, hope-a positive orientation toward the future despite ongoing recognition of danger and loss.

A key element in such psychotherapy may be the clinician’s role in containing the patient’s dysphoria, anxiety, and trauma symptoms during the search for a path toward meaning and hope. Moving beyond grief to behavior that furthers personal values is likely to promote healing. Some patients may progress from acknowledging danger and loss directly to action without explicit grieving, but therapists are wise to keep in mind their possible need to express unacknowledged dysphoria. Some patients may benefit further when they go beyond individual energy conservation and personal risk reduction to engage with others-by discussing climate issues, participating in community groups, advocating for governmental action, and supporting businesses and organizations that take constructive measures.

Psychiatrists may doubt the connection between climate disruption and psychiatric disorders. The evidence is increasingly strong, and Hayes and colleagues

 have recently published an excellent critical review that is free on PubMed.

Others may view climate-related mental health issues as beyond the scope of psychiatric practice. Making climate disruption the focus of every patient’s treatment would be highly inappropriate, but for many patients, addressing these issues is likely to save lives and improve treatment responses.

Climate disruption is now so politicized that clinicians may fear they will be viewed as advocates or offend patients. While political campaigning in the psychiatric office is inappropriate, effective treatment includes addressing public issues that impact patients’ treatment in clinical terms that emerge from patients’ needs and goals. We address controversial topics such as gun ownership as they relate to patients’ mental health, and we can do the same for climate-related issues.

Psychiatrists may need to address their own fears and despair about climate disruption. Such emotions can lead to avoiding discussion of climate-related issues or approaching the subject in ways that elicit fear or guilt. Recognizing that climate disruption is already occurring, future problems are inevitable, and the problem is global, psychiatrists may believe their own and their patients’ efforts are insignificant. In the end, however, climate problems will be addressed by individual human beings becoming educated and making decisions to act within their areas of influence-at the individual, community, corporate, governmental, and global levels. Addressing climate issues as they affect psychiatric patients advances global change, one patient at a time.

Like other citizens, psychiatrists can educate themselves about climate problems and reduce their carbon footprints. They can prepare their practices for climate-related events by arranging secure and accessible storage of records and making plans for communication with patients during emergencies. They can advocate for similar actions by hospitals, mental health agencies, and professional organizations. They can participate in APA District Branch disaster preparedness committees, the APA Caucus on Mental Health and Climate Change, and the Climate Psychiatry Alliance.

Discussing relevant aspects of climate disruption with individual patients can reduce their exposure to harm. In some cases, it will improve treatment responses. Addressing the paralysis associated with climate- related despair can increase both clinicians’ and patients’ sense of agency in dealing with problems they perceive as out of their control. I have a mental checklist I review annually with each of my patients, which includes screening for tardive dyskinesia, laboratory monitoring for medication adverse effects, smoking status, firearm safety, and contraception. Climate disruption is now on that list.

Dr Woodward is a psychiatrist in private practice in Waban, MA

Dr Woodward reports no conflicts of interest concerning the subject matter of this article.

 Hayes K, Blashki G, Wiseman J, et al. Climate change and mental health: risks, impacts and priority actions. 

 Centers for Disease Control and Prevention. Tips for preventing heat-related illness: 

https://www.cdc.gov/disasters/extremeheat/heattips.html

 Centers for Disease Control and Prevention. Protect yourself from wildfire smoke: 

https://www.cdc.gov/features/wildfires/index.html

 Centers for Disease Control and Prevention. Flood safety tips. 

https://www.cdc.gov/features/flood-safety/index.html

 Moser SC. More bad news: the risk of neglecting emotional responses to climate change information. Moser SC, Dilling L, Eds. 

Creating a Climate for Change: Communicating Climate Change and Facilitating Social Change

. New York: Cambridge University Press; 2007: 64-80.

 United States Environmental Protection Agency. Climate Impacts in the Northeast. 

https://19january2017snapshot.epa.gov/climate-impacts/climate-impacts-northeast_.html

 Pihkala P. Eco-anxiety, tragedy and hope: psychological and spiritual dimensions of climate change. 

Diagnostic and Statistical Manual of Mental Disorders

, 5th ed. Arlington, VA: American Psychiatric Association; 2013.

 Vos J, Vitali D. The effects of psychological meaning-centered therapies on quality of life and psychological stress: a metaanalysis. 

Transformational Resilience: How Building Human Resilience to Climate Disruption Can Safeguard Society and Increase Wellbeing

Articles

While some psychiatrists may doubt the connection between climate disruption and psychiatric disorders, the evidence is growing stronger every day.

Climate Disruption and the Psychiatric Patient

By Gerda Saunders
Reviewed by Burns Woodward, MD

is the highly original account of a courageous and generous woman’s progressive cognitive impairment, and an exploration of its meaning in relationships and life. It will be good reading for psychiatrists and neurologists, other health professionals, patients, family members, and readers who enjoy fine writing.

Gerda Saunders, an emerita professor of gender studies, was diagnosed with vascular dementia at age 60. Her MRI showed multiple frontal lobe lesions. She describes her blunders-mismatched clothing, exiting stores without paying, damaging her car in a parking lot, rescue calls to her husband-with good-natured empathy. The story is carried by memories of her childhood in apartheid South Africa, university education in science, courtship and marriage, the family’s emigration to Salt Lake City, and her careers as mother, professor, and grandmother. With this she interweaves medical, psychological, and legal information about dementia. Most compelling are her fearless explorations of dementia in intimate relationships, and of suicide and assisted death for people with end-stage dementia.

The discrepancy between “the indignities accumulating in my daily activities” and her preserved writing skills led Saunders to wonder if she was “faking” dementia. Studying cognitive science, she learned of patients with more severe functional impairments who retained high-level skills they learned long ago. Her conclusion: “persons having spent a lifetime mastering particular knowledge structures and intellectual skills may retain access to this expertise even after becoming utterly dependent in daily activities . . . But in truth, writing is getting slower and harder.”

Slower and harder, but compelling. Her account of cortical functions is more cogent than most neuroscience writing:

The parietal lobe is the site where visual auditory, and haptic, or touch-based, information combine to make sense of the world. The left parietal lobe is the area where letters come together to form words and where words are put together in thoughts. The right lobe enables understanding of the spatial nature of the world, including the ability to recognize faces and shapes, be aware of body states and deficiencies, and know directions.

Two central chapters explore the implications of dementia for intimate relationships. She draws on her own marriage; John Bayley’s memoir of the dementia that killed his wife, the writer Iris Murdoch; a neighbor couple who had to be separated when the husband’s aggression became unmanageable; and a legislator who was tried and acquitted for sexual abuse of his wife, the claim being that she was too impaired to consent.

Dementia is an arduous subject, but Saunders’s understated style and creative juxtapositions hold and engage the reader. A feminist analysis of her relationship to fashion quickly morphs into struggles to remember what outfits go together, remedied by a photo album of successful combinations, followed by a trip to Nordstrom to resolve a funky mood but getting trapped in a locked stairwell. This ends, “I’m afraid my projects of writing down and/or photographing my outfits have, for the moment, come to an end. It takes me so long to write and just take care of myself that I have not been able to keep up my mnemonic system.”

No American state allows assisted suicide for people with dementia (or any other mental disorder). In a final chapter which rivals those on relationships for its unflinching courage, Saunders explores end-of-life issues around dementia. She does not want a painful and burdensome existence when her mind is gone, but more important is protecting her family from legal risk for hastening her death. She settles on voluntary stopping eating and drinking as a possible method. Here are a few of the “flags” she has provided to her relatives and health care agent about whether her quality of life is “dwindling below the level of acceptability”:

• Do I appear and act happy for more hours per day than I appear and act unhappy?

• Do I enjoy being in my garden (or that of the care center) watching the plants, birds, and insects? Can I physically get there without needing a team of people?

• Am I physically approachable without getting myself into a state of fear or anger; that is, is it still a pleasure for me to cuddle with a friend or child or grandchild?

Saunders includes more childhood memories than needed to understand her dementia-one senses an impulse to “get it all down.” But reviewing a life while one is still able can be psychologically important for the individual and family. I would have been grateful for an index, but this is no reference tome. It is a book to be read and experienced.

Dr Woodward is a psychiatrist in private practice in Waban, MA.

Gerda Saunders, an emerita professor who was diagnosed with vascular dementia at age 60, explores the meaning of progressive cognitive impairment in relationships and life.

Memory’s Last Breath: Field Notes on My Dementia

Many people with psychiatric disorders engage in creative activities, from informal hobbies to highly accomplished careers. While some distinguish their symptoms from their creative talents, others avoid treatment, fearing it will impair mental and emotional processes they value. After a brief summary of the complex relationship between creativity and psychiatric illness, this article focuses on the treatment of such patients. Two cases-the mathematician John Nash and the author David Foster Wallace-are presented to illustrate a nuanced approach that integrates medical knowledge with patients’ perspectives.

A few years after the groundbreaking work that earned him a Nobel Prize, John Nash began to experience signs of schizophrenia. About his delusions, he explained, “the ideas I had about supernatural beings came to me the same way my mathematical ideas did. So I took them seriously.”

 Nash avoided psychiatric treatment, and the only productive mathematical work he accomplished after his first psychotic episode occurred during several months when he took trifluoperazine.

David Foster Wallace, a MacArthur Fellow whose fiction and essays caught the experience of a generation, suffered from recurrent depression. In 2007 he discontinued longstanding treatment with phenelzine in part because he thought it was interfering with his ability to finish a novel. Tragically, his depression relapsed, and he committed suicide without completing the book.

 While it is impossible to determine the validity of Nash’s and Wallace’s ideas about their illnesses, medication, and creative abilities, their beliefs that they were linked contributed to decisions that ended their productive careers and, in Wallace’s case, his life.

A century of biographical research has documented mental illness in the lives of individuals like Nash and Wallace; a recent example is a study of the poet Robert Lowell by Kay Redfield Jamison, PhD. Lowell’s racing thoughts, flight of ideas, and divergent thinking during times of rising mania generated highly original language, which required extensive revision during euthymic periods.

Older case reports have explored these issues as well. Mogens Schou, MD,

 described varying effects of lithium on artistic productivity in 24 lithium responders. Half reported benefit, but several discontinued the medication, believing it interfered with their creativity. Schou attributed the variations to type and severity of illness, individual sensitivity, and whether the artist tended to use manic symptoms productively.

Modern research using psychological tests, population surveys, and genetics has looked both at psychiatric illness in creative individuals and at creativity in people with diagnosed psychiatric disorders. The results indicate modestly higher rates of bipolar disorders in creative individuals, as well as elevated psychological traits associated with creativity in people who have bipolar illness.

These associations are found in the visual arts, literature, music, performing arts, business, politics, religion, and science. The connection is strongest for milder conditions like cyclothymic and bipolar II disorders, since the functional impairment associated with florid mania can interfere with creative work.

Because it is difficult to study symptomatic individuals, most research looks at creative traits during euthymic periods: the limited evidence documenting creative work during symptomatic periods, usually hypomania, comes from patient accounts and case reports. Divergent thinking, high verbal productivity, and intense or contrasting mood states can generate original work, and grandiosity, high energy, and reduced sleep can increase productivity. Manic ambition and sociability can enhance public recognition.

 The relationship of creativity to depression is less clear.

Creativity shares genetic roots with both bipolar disorder and schizophrenia, and symptoms associated with schizophrenia can contribute to creativity.

 Flattened affect, apathy, and a sense of strangeness may manifest themselves in creative irony, rule-breaking, self-reference, and temporal and spatial dislocations. Psychotic symptoms can also impede creative work, which may account for higher rates of avocational creative activities like poetry and photography in people with schizophrenia.

Creativity carries mental health risks. And artistic exploration can intensify mood states. The uncertainties of a creative career can worsen psychiatric symptoms. Creative peers may promote one another’s substance abuse. Irregular sleep and activity schedules can be destabilizing. And mood disorders are associated with heightened reactivity-success can trigger manic symptoms, and people with bipolar disorder experience more frustration than others when goals are not met.

Psychiatric disorders, then, have a complex relationship with creativity. Some mild to moderate traits and symptoms can enhance original thinking, problem solving, productivity, and recognition, but confusion, depression, mania, bizarre behavior, and social isolation get in the way. Many psychiatric patients value their creativity, and some, like Nash and Wallace, believe it is connected to their symptoms and treatment.

One of psychiatry’s creative skills is the ability to think in more than one way at the same time-to maintain one’s medical perspective while exploring a patient’s experiences and beliefs. This is not always easy: a narrow focus on symptoms can jeopardize the treatment alliance by ignoring a patient’s concerns that treatment will interfere with creativity, but blind acceptance of a patient’s views can overestimate creative abilities, their importance in the patient’s life, or their connection to the patient’s symptoms.

Many patients, particularly those with depression, recognize that their symptoms interfere with creative activities and welcome relief, although some, as appears to have been the case for Wallace, complain that medication limits their emotional responsiveness. Others value symptoms like rapid thinking and unusual mental associations. And a few, like Nash, believe their symptoms and creativity arise from the same source. When patients identify such connections, it is helpful to look at when and under what circumstances psychiatric symptoms and creative thinking occur and at what factors, including medication, heighten or diminish them. The goal is a clearer understanding of any possible connection.

A patient’s concern that treatment will interfere with creativity may point toward treatment options to which he or she is more likely to be adherent. Patients with bipolar disorder, for example, may be more comfortable with anticonvulsant mood stabilizers such as valproate or lamotrigine than with lithium or ECT, which may have adverse cognitive effects (although, with lithium, these can usually be managed by careful dosing). As treatment unfolds, it is worthwhile to ask about changes in creativity along with symptom levels and functioning. Clinicians who use rating scales may find a self-report questionnaire such as the Inventory of Creative Activities and Achievements useful.

After his third hospitalization, John Nash agreed to take trifluoperazine. He worried that the drug would prevent him from thinking clearly enough to resume mathematical work. His psychiatrist was sympathetic and kept the dose low. Months later he relapsed to florid psychosis. It is unclear whether he had discontinued the medication or whether the dose was simply too low. In his discussion of Nash’s treatment, Peter Weiden, MD,

 recommends taking a patient’s concerns seriously, trying to persuade the patient that his intellect is strongest when his preoccupations are at a low level, and developing a treatment goal for avoiding hospitalizations. Then, reviewing evidence that medication maintenance reduces the risk of relapse might persuade the patient to accept ongoing treatment.

 A patient like Nash might also agree to monitor his symptoms and creativity with rating scales so dose adjustments can be based on data rather than on the patient’s fears or the clinician’s assumptions.

The nature of David Foster Wallace’s treatment alliance when he discontinued phenelzine is unknown, nor is it clear whether he was receiving psychotherapy. In retrospect, it would have been best to see him regularly; include input from his wife; discuss the risks and possible benefits of treatment discontinuation as well as early signs of relapse; taper the medication with monitoring by the patient, family, and psychiatrist; and intervene early if depression returned. A few months after he stopped taking phenelzine, Wallace was hospitalized for severe depression. Other antidepressants were prescribed, but his anxiety about adverse effects led to early discontinuation. After an unsuccessful course of ECT, he asked to restart phenelzine. Despite some signs of early response, he hanged himself. Wallace’s story illustrates both the benefits of treatment-on medication, he had 22 productive years-and the complexities of treating a highly creative individual.

Patients’ experiences with their creativity, symptoms, and treatment follow many paths. Some are grateful to have their symptoms controlled so they can live and create more fully. Others are ambivalent, associating their illnesses with creativity out of a romantic fantasy or, as with Nash, from personal observation. Even when creativity is closely related to psychiatric symptoms, treatment may facilitate creative work. An inquiring attitude toward patients’ creative aspirations and activities-grounded in medical evidence but encompassing the complexities of their experiences and beliefs-can be rewarding for the clinician and facilitate patients’ creative work.

Dr. Woodward is Assistant Clinical Professor of Psychiatry, Boston University School of Medicine. He is in private practice in Newton, MA.

 Weiden P. Why did John Nash stop his medication? 

 Max DT. Every Love Story Is a Ghost Story: A Life of David Foster Wallace. New York: Penguin; 2012.

 Jamison KR. Robert Lowell: Setting the River on Fire. A Study of Genius, Mania, and Character. New York: Knopf; 2017.

 Schou M. Artistic productivity and lithium prophylaxis in manic-depressive illness. 

 Taylor CL. Creativity and mood disorder: a systematic review and meta-analysis. 

 Johnson SL, Murray G, Fredrickson B, et al. Creativity and bipolar disorder: touched with fire or burning with questions? 

 Power RA, Steinberg S, Bjornsdottir G, et al. Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. 

 Carson SH. Creativity and psychopathology: a shared vulnerability model. 

 Sass LA. Schizophrenia, modernism, and the “creative imagination”: on creativity and psychopathology. 

 Murray G, Johnson SL. The clinical significance of creativity in bipolar disorder. 

 Diedrich J, Jauk E, Sylvia PJ, et al. Assessment of Real-Life Creativity: The Inventory of Creative Activities and Achievements (ICAA); 2017. 

Many people with psychiatric disorders engage in creative activities, from informal hobbies to highly accomplished careers, but some avoid treatment entirely. Two cases illustrate a nuanced approach that integrates medical knowledge with patients’ perspectives.

Creativity and Psychiatric Illness: Finding the Sweet Spot

Robert Lowell, Setting the River on Fire: A Study of Genius, Mania, and Character

by Kay Redfield Jamison; New York: Alfred A. Knopf, 2017

 is an investigation of one of the most famous and well-documented cases of manic-depressive illness (the former term for bipolar disorder), as well as a fresh look at the relationship between mood disorders and artistic creativity. Kay Redfield Jamison’s previous books have taught us a great deal: 

, the textbook she co-wrote with Frederick Goodwin, is an essential reference.

, her bestselling memoir of her own bipolar illness, showed us what it means to experience extreme mood swings.

 was a fearless consideration of suicide.

Now she returns to questions about mood and creativity raised by her groundbreaking 1993 book, 

 goes much further, drawing on the words of Lowell and his highly articulate family members, friends, and doctors to give us one of the richest portraits ever written of bipolar illness and its effects on patients and those who care about them.

Lowell (1917-1977) was one of the most original and influential poets of the mid-20th century. His work drew extensively on his life experience, family history, and public events. From adolescence he experienced 

 of psychotic mania, followed by depressive remorse about his hurtful behavior. “I remember all the mean things I said and did while I was sick,” Lowell wrote. “One by one . . . I just shrivel with shame.” Yet he not only produced elegantly crafted poetry but maintained rich and lasting relationships with friends and family, especially his second wife, Elizabeth Hardwick, who is in some ways the heroine of the book. He addressed his experiences of mental illness explicitly in poems like “Waking in the Blue,” “Home After Three Months Away,” “Man and Wife,” and “Skunk Hour.”

Jamison obtained consent from Lowell’s daughter to review the medical and psychotherapy records of his 20 hospitalizations. She juxtaposes Lowell’s distinctive observations of his mental status with the medical language of his doctors. Lowell’s mania responded well to the treatments of the times-ECT and later 

. In the late 1960s, lithium gave him a few years of relatively stable moods. Jamison also discusses the role of Lowell’s psychotherapy in the generation of his poetry.

 that “Jamison’s study tells us a lot about bipolar disorder, but it can’t quite connect the dots to Lowell’s work.”

 Arguing that while rates of mood disorders are elevated in creative individuals, and features of manic speech (such as clang associations) are similar to poetic devices (like rhyming), most poets do not have bipolar disorder, and most people with bipolar disorder are not especially creative. Furthermore, he says, for most poets-especially Lowell-rhyme indicates the “calculation and aesthetic design” that emerge from disciplined revision.

Jamison proposes that the intense emotional states of mania enable the artist with bipolar disorder to focus on single ideas, similar to the way stimulants focus the minds of people with ADHD.

Although Jamison does not fully resolve the conundrum of creativity and madness, she advances our understanding. After describing the knight’s-move thinking in manic flight of ideas, she proposes that the intense emotional states of mania enable the artist with bipolar disorder to focus on single ideas, similar to the way stimulants focus the minds of people with ADHD.

Although Lowell’s poetry emerged from his mood states, his artistry was far more than the ramblings of a manic patient. In Jamison’s words, “When mania swept through Robert Lowell’s brain it . . . came into dense territory, thick with learning, metaphor, and history. . . . The words of Dante, Shakespeare, Pasternak, Hardy, and Milton were not just in his mind but were his mind, kept alongside the place he kept for Dutch paintings and Beethoven’s late quartets. . . . Mania, when it came, shook his memory as a child shakes a snow globe.” And, as Chaisson notes, discipline was crucial.

 “My trouble,” Lowell wrote, “is to bring together in me the Puritanical iron hand of constraint and the gushes of pure wildness. One can’t survive or write without both but they need to come to terms. Rather narrow walking-”

The subject of the book is more literary than biological, but Jamison mentions a fascinating genome-wide association study of the inheritance of creativity and bipolar disorder,

 another finding that the tendencies to elated versus irritable mania can be distinguished genetically,

 and interesting experimental work on induced positive moods.

 An appendix on Lowell’s medical history by Jamison’s husband, cardiologist Thomas Traill, briefly discusses the reduced life expectancies of persons with bipolar disorder, to which the strongest contributor is the cardiovascular disease that killed Lowell at the age of 60.

Jamison emphasizes another element in Lowell’s success, which she calls character-a combination of 

, the ability to maintain loving relationships, and courage: “Lowell ran the race set before him aware of the precariousness of his mind, uncertain after each break whether he would write again, love again, teach again. Or whether he could regain the edge to write poetry that would ‘change the game.’”

Jamison’s paragraphs vibrate with quotations from Lowell, his wives, family, friends, literary colleagues, and physicians, as well as her own original language. She offers fascinating new readings of a number of Lowell’s poems. At the end of the book she discusses what many consider his greatest poem, “For the Union Dead.” The author meditates on its subject-the first all-black regiment to fight in the Civil War, Saint-Gaudens’s great memorial sculpture on Boston Common, the courage of Colonel Shaw and his soldiers in their mortal fight, and Lowell’s courage in fighting his way back from repeated episodes of insanity.

Psychiatrists and the lay public will find in 

 a uniquely rich case study of bipolar disorder by a great psychiatric writer, illuminated by a courageous, perceptive, and articulate patient; his doctors; family; and friends. Those interested in 

 will find a new exploration of this complex area, and literary readers will appreciate Jamison’s perspectives on Lowell’s poems. People with mood disorders and those who care about them are likely to experience a healing reconsideration of their own experiences as they read this wonderful book.

This article was originally published on 5/8/17 and has since been updated.

Dr. Woodward is Clinical Assistant Professor of Psychiatry at Boston University School of Medicine.

Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression

. 2nd ed. New York: Oxford University Press; 2007.

An Unquiet Mind: A Memoir of Moods and Madness

Touched With Fire: Manic-Depressive Illness and the Artistic Temperament

 Chaisson D. The mania and the muse. Did Robert Lowell’s illness shape his work? 

http://www.newyorker.com/magazine/2017/03/20/the-illness-and-insight-of-robert-lowell

 Power RA, Steinberg S, Bjornsdottir G. Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. 

 Greenwood TA, the Bipolar Genome Study (BiGS) Consortium. Genome-wide association study of irritable vs. elated mania suggests genetic differences between clinical subtypes of bipolar disorder. 

People with mood disorders (and those who care about them) are likely to experience a healing reconsideration of their own experiences as they read this book.

Creativity and Bipolar Disorder: A Fresh Look

, Nora Volkow and her colleagues at the National Institute on Drug Abuse highlighted the evidence that connects marijuana use with psychosis, anxiety, depression, and addiction.

 examined its harmful effects on cognition, psychosis, and motivation.

 The American Psychiatric Association’s position statement begins, “There is no current scientific evidence that marijuana is in any way beneficial for the treatment of any psychiatric disorder.”

Despite near-unanimous medical warnings, marijuana use is widespread among 

 for anxiety, depression, and bipolar disorder

; and medical marijuana regulations in 9 states include PTSD as a qualifying condition. Psychiatry’s apprehension plainly disagrees with more favorable attitudes in patients and the public. How can psychiatrists best address their patients’ marijuana use in this contentious environment?

is Assistant Clinical Professor of Psychiatry at Boston University School of Medicine. He is in private practice in Newton, MA.

What follows is a critical summary of the evidence now available that connects marijuana with cognitive problems, psychosis, anxiety, PTSD, depression, and addiction. I have relied on published reviews, supplemented by PubMed searches for more recent data. Be forewarned-this is an evolving picture, since credible research about the psychiatric effects of cannabis is only now emerging after decades of legal constraint. I argue that patients benefit when psychiatrists attend to their marijuana use-a hands-off approach is likely to miss an important influence on their symptoms-and that a collaborative approach can steer between the Scylla of harsh admonition and the Charybdis of naive acceptance.

The psychopharmacology of marijuana is complex. Delta-9 tetrahydrocannabinol (THC), the most psychoactive of its many cannabinoid constituents, acts on endogenous cannabinoid receptors, which, like those for monoamines and endogenous opioids, are found in brain areas subserving memory, cognition, emotions, and motivation. Cannabidiol (CBD), another cannabinoid found in marijuana, appears to counteract the psychedelic effects of THC; it is being investigated as a treatment for a number of medical and psychiatric conditions.

 Samples of illegal marijuana these days have very low 

, which maximizes psychedelic effects, while medical marijuana is advertised with CBD:THC ratios as high as 20:1.

 Thus, it may be important to understand the source and purported characteristics of the marijuana a patient is using.

Extensive laboratory, clinical, and epidemiological evidence connects marijuana use to cognitive impairment, and both clinical and epidemiological data link it to psychosis. The correlations with addiction, anxiety, and depression, however, are based mainly on interviews of national population samples, which are likely to differ from patients who present for treatment. The evidence that marijuana benefits PTSD comes mostly from animal data. 

 summarizes this evidence, along with treatment recommendations.

Non-intoxicated regular cannabis users perform worse on global neuropsychological tests by a third of a standard deviation or less. Some evidence suggests this cognitive impairment may be short-term, with recovery occurring over days to months after cessation of use. Its extent and persistence are worse with early age of onset, high frequency, and long duration of use.

 Marijuana-induced cognitive dysfunction may account for its association with motor vehicle accidents at a level approaching that of alcohol, as well as with reduced life achievement.1 Discussing patients’ marijuana use in high-risk situations, including driving and sexual activity, may be lifesaving, and exploring its effects on academic and work performance may improve outcomes.

Marijuana-related problems fall well within the scope of psychiatric practice: many patients use marijuana, which is likely to affect their psychiatric symptoms and response to treatment.

For decades, marijuana has been associated with the emergence of schizophrenia and other psychotic disorders. Recent data show that in genetically vulnerable individuals, psychotic disorders are more likely to emerge and to emerge earlier if marijuana is used.

 Ongoing marijuana use by patients with schizophrenia is associated with worse outcomes.

 Thus, patients with individual or family histories of psychosis can be counseled that marijuana use puts them at greater risk for the development or exacerbation of a psychotic illness.

The widely quoted statistic about marijuana’s addictive propensity-that a cannabis use disorder will develop in 9% of people who try marijuana-comes from a national epidemiological sample of 34,653 individuals interviewed in 2001 to 2002 and again in 2004 to 2005. The researchers found marijuana less addictive than nicotine (the corresponding figure is 68%), alcohol (23%), and cocaine (21%). For psychiatric patients, however, the picture is far bleaker. In the study, individuals with psychotic or conduct disorders who used marijuana had double the risk of addiction; triple the risk of mood, anxiety, and attention deficit disorders; quadruple the risk of personality disorders and alcohol dependence; and cocaine dependence increased the risk by a factor of 6.

 In clinical practice, patients with cannabis use disorder may have great difficulty limiting or abstaining from marijuana use, which exacerbates psychiatric problems, and treatment may need to target marijuana use as well as other issues.

Earlier data associated marijuana with anxiety disorders, and it is clear that marijuana intoxication elicits panic-like symptoms and even paranoid thinking in some individuals. Recent analyses of population-based data have disagreed about how much excess risk for anxiety disorders can be attributed to marijuana use and how the risk varies among subgroups.

Marijuana use is common among patients with PTSD. Animal studies have found that cannabinoids can prevent stress-induced emotional and memory effects, and preliminary studies have found reduction in some PTSD symptoms in humans. There have, however, been no large-scale, controlled studies.

 Clinicians who treat marijuana-using patients with anxiety or trauma-related disorders will need to explore the relationship of their symptoms to marijuana use on a case-by-case basis.

 found elevated rates of depression in marijuana users as well as evidence of depression increasing with ongoing use,

 in more recent analyses the correlation has dropped out when potential 

 found antidepressant medication ineffective in depressed patients with cannabis use disorder, but the trials cited had very high placebo response rates, probably because of the intensive psychosocial treatments they also provided.

 As with anxiety disorders, it is important to explore with patients the relationship between their marijuana use and depression. Severely depressed patients may have difficulty participating in such explorations, and a trial of abstinence may be the best strategy, which may require psychotherapy or family intervention to implement.

Evidence-based treatments for cannabis use disorder include motivational enhancement therapy, cognitive-behavioral therapy for addiction, and contingency management, which are 

 Pharmacological options are quite limited: dronabinol (THC) is effective for cannabis withdrawal, but using it for that purpose would require a legal waiver. There is limited evidence that gabapentin may relieve cannabis withdrawal symptoms, and that gabapentin and 

-acetyl cysteine may be useful for cannabis use disorder.

A collaborative approach to evaluation and treatment

Marijuana-related problems fall well within the scope of psychiatric practice: many patients use marijuana, which is likely to affect their psychiatric symptoms and response to treatment. 

 lists some general principles for working with such patients. Addressing marijuana use is often an ongoing process, and it is helpful to inquire about the patient’s experience and readiness to change during each interview. The disease model of addiction can help clinicians avoid moral criticism and shaming, which tend to elicit defensiveness. Patients sometimes need education about the adverse consequences of marijuana use, but many know about the risks, and the clinical task is to help them use what they already know. Family members can provide important information for evaluation and monitoring.

While the evidence-based treatments-motivational enhancement, cognitive-behavioral therapy for addiction, and contingency management-are not part of every psychiatrist’s repertoire, basic skills in these areas are easy to learn and can be incorporated into both medically oriented and psychotherapeutic treatment. Psychiatrists who are not comfortable working in these areas can refer patients to addiction specialists, but referral is often facilitated by a motivational approach.

Our growing knowledge of the psychiatric effects of marijuana is being rapidly outstripped by increased public acceptance and legal availability. For now, psychiatrists will find it most rewarding to approach their patient’s marijuana use in a spirit of inquiry and collaboration to guide them toward effective self-care in this important area of their mental health.

This article was originally posted on 2/14/2017 and has since been updated.

Dr. Woodward is Assistant Clinical Professor of Psychiatry at Boston University School of Medicine. He is in private practice in Newton, MA.

Dr. Woodward reports no conflicts of interest concerning the subject matter of this article.

 Volkow ND, Baler RD, Compton WM, Weiss SRB. Adverse health effects of marijuana use. 

 Volkow ND, Swanson JM, Evins AE, et al. Effects of cannabis use on human behavior, including cognition, motivation, and psychosis: a review. 

 American Psychiatric Association. Position Statement on Marijuana as Medicine. December 2013. 

https://www.psychiatry.org/File%20Library/Learn/Archives/Position-2013-Marijuana-As-Medicine

 Lopez-Quintero C, Perez de los Cobos J, Hasin DS, et al. Probability and predictors of transition from first use to dependence on nicotine, alcohol, cannabis, and cocaine: results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). 

 Foti DJ, Kotov R, Guey LT, Bromet EJ. Cannabis use and the course of schizophrenia: 10-year follow-up after first hospitalization. 

 Smoker J. Top 5 Mental Conditions Treated With Marijuana. The Weed Blog. August 12, 2011. 

https://www.theweedblog.com/top-5-mental-conditions-treated-with-marijuana

 Welty TE, Luebke A, Gidal BE. Cannabidiol: promise and pitfalls. 

 How to interpret the CBD & THC ratio results? Alpha-Cat. 

Burns Woodward, MD

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