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,1 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.1 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.
1. Weiden P. Why did John Nash stop his medication? J Psychiat Pract. 2002;8:386-392.
2. Max DT. Every Love Story Is a Ghost Story: A Life of David Foster Wallace. New York: Penguin; 2012.
3. Jamison KR. Robert Lowell: Setting the River on Fire. A Study of Genius, Mania, and Character. New York: Knopf; 2017.
4. Schou M. Artistic productivity and lithium prophylaxis in manic-depressive illness. Br J Psychiatry. 1979;135:97-103.
5. Taylor CL. Creativity and mood disorder: a systematic review and meta-analysis. Perspect Psychol Sci. 2017;12:1040-1076.
6. Johnson SL, Murray G, Fredrickson B, et al. Creativity and bipolar disorder: touched with fire or burning with questions? Clin Psychol Rev. 2012;32: 1-12.
7. Power RA, Steinberg S, Bjornsdottir G, et al. Polygenic risk scores for schizophrenia and bipolar disorder predict creativity. Nat Neurosci. 2015;18:953-955.
8. Carson SH. Creativity and psychopathology: a shared vulnerability model. Can J Psychiatry. 2011;56:144-153.
9. Sass LA. Schizophrenia, modernism, and the “creative imagination”: on creativity and psychopathology. Creativity Res J. 2010;13:54-75.
10. Murray G, Johnson SL. The clinical significance of creativity in bipolar disorder. Clin Psychol Rev. 2010;30:721-732.
11. Diedrich J, Jauk E, Sylvia PJ, et al. Assessment of Real-Life Creativity: The Inventory of Creative Activities and Achievements (ICAA); 2017. https://osf.io/xj3g2/. Accessed May 4, 2018