John Gartner on Treating Hypomania

On his latest blog piece on Psychology Today - Malpractice Is the Standard of Care When Medicating Hypomanics - John Gartner (pictured here)  cited me twice. Actually, Dr Gartner was my prime influence in my rethinking of hypomania, as this extract from a much longer mcmanweb article - Treating Hypomania, dating from 2005 - attests. I substantially rewrote the article earlier this year, but this extract has stayed intact ...

Said John Gartner PhD, an associate professor of clinical psychiatry at Johns Hopkins and author of "The Hypomanic Edge: The Link Between a Little Craziness and a Lot of Success in America," in a 2005 interview with this writer, "the most common form of this disorder is being treated as if it were a rare weird variation."

In his book Dr Gartner views hypomania as a genetically transmitted temperament whose adaptive advantages far outweighs the disadvantages. Thanks to the people brave enough (and crazy enough) to leave their settled existences to strike out for an uncertain life on a strange shore, argues Dr Gartner, America has been blessed with a generous supply of wild wacky creative geniuses and go-getters, plus an abundance of those egging them on. This is often a source of dismay to the Europeans, who are alarmed by our excesses, even as they embrace the many positive aspects of our culture. (See Hypomanic Nation.)

One of Dr Gartner’s case studies is the brilliant Founding Father Alexander Hamilton, who had a spot reserved on Mt Rushmore until he stupidly offered up his body for target practice. Which raises some interesting questions. Suppose lithium and other meds had been available to Hamilton. Would the treatment have dulled his brain to the point where he would have opted to become a Founding Bystander rather than a Founding Father? Or would he have prudently skipped his appointment with Aaron Burr and gone on to become America’s greatest President?

$64,000 question for psychiatrists: If Alexander Hamilton were your patient, how would you treat him? Is this the same standard you apply to your other patients?

Certainly, many of us feel hypomania is our true identity, not just a mood aberration to be medicated out of existence. "That’s very important," Dr Gartner told me. "When you think about it, how many people have died just to preserve their sense of identity? Think of all the Jews who died because they wouldn't renounce their religion. All they had to say was, yes I’m a Christian. It’s hard for people who are not hypomanic to appreciate how integral this is to someone’s identity and how important it is to preserve that."

This led to the crux of our interview: "First of all, most psychiatrists don’t know when their patients are hypomanic because they haven’t been trained to look for it. Also, no one ever came to their offices saying, I’ve got hypomania, please cure me. When they do become aware that the patient has hypomanic symptoms, then I think their tendency is to over-react, react as if it is the same as mania, which it is not in terms of the risk and the danger."

Some people can obviously benefit from meds, but Dr Gartner makes it clear we are talking of the equivalent to microsurgery involving careful microadjustments "to take the edge off of the edge."

"I liken it to the pitcher in Bull Durham," he related, "the guy who has the 100 mile per hour fastball but keeps beaning the mascot. He needs a little bit more control. He’s got speed. You wouldn’t want to give him so much medicine that he threw a fifty mile per hour fastball. We want to slow it down just enough so that he can deliver the ball where it’s supposed to be."

Think of Hamilton, brilliant as ever, lightening up a tad on Aaron Burr.

This may involve clinicians rethinking their concept of therapeutic doses. Current dosing levels are based on trials involving bipolar I patients in the acute (initial) stage of mania. Even lithium, the most studied mood stabilizer, has not been tested for hypomania. Clinical treatment guidelines are silent on the topic. In this so-called era of evidence-based medicine, we simply have no evidence.

Check out John Gartner's website