Jane Pauley in August of 2004 went public with the fact that she has bipolar disorder and takes a mood stabilizer (Lithium). She details the development of her illness in a new book, Skywriting. How did the "all American girl" become "mentally ill?" I don’t like the term mental illness. It has too many pejorative connotations, including insanity and craziness. Even in patients with schizophrenia the label "mental illness" implies a hopelessness and pessimism about treatment.

So l will rephrase. How did Jane Pauley develop a serious mood disorder that for a time resulted in impaired reality testing and caused her to go many months before she could return to work? While hospitalized for a manic episode she said she cried for the loss of Jane, the "most normal girl on TV." WHY?

Probably most important is genetics. Her father was a closet alcoholic. She had evidence of biorhythmic sensitivity, suffering from severe hives on a 7 year cycle at ages 7, 14, 21, and 49. She reports having thyroid problems, which increase mood swings. And she was perimenopausal. Then, while doing a feature article about her father she was forced to deal with the reality that in some ways her "whole life had been a lie" since she had spent most of it in denial about her father’s alcoholism. The stress of this and her seven year cycle caused a severe outbreak of hives which required 2 courses of steroid treatment.

Bipolar episodes are more likely precipitated by hormone changes or certain medications, especially steroids and antidepressants. Jane Pauley’s second round of steroids caused symptoms of depression, and she was prescribed an antidepressant. The beginnings of hypomania induced by steroids and antidepressants cause problems with sleep, and lack of sleep is one of the most powerful mood destabilizers in susceptible individuals.

The fact that she had genetics for bipolar disorder is not the reason that she decompensated. Were it not for the steroids and antidepressant, she may never have developed overt bipolar disorder. The brain has remarkable plasticity (adaptability), and a lot of our genes never get turned on or are modified by experience. In the future we will know who is vulnerable to certain kinds of treatments, and hopefully be able to protect the Jane Pauleys of the world from bipolar and other dreaded diseases.See Bipolar Newsletter

"Study Discovers Help for Hypochondriacs" headlined an article in the Dallas Morning News. "Advancement in Hypochondriac Therapy" announced a shorter article in USA Today. Both articles make the point that this condition is "mental not physical."

A quarter of the patients in the study dropped out after being told the problem is in their heads. Of the patients who were willing to attend 6 therapy sessions: 57% showed significant improvement and felt their quality of life was better (This is not to say normal.). 32% of patients assigned to the usual medical treatments had a similar outcome. These news reports were based on an article appearing week in the March 2004 Journal of the American Medical Association. The interpretation given for the patients who didn’t complete all their sessions or didn’t attend any was that "the treatment didn’t fit with their belief that their illnesses were real."

The problem I have with these reports is that it represents one of the most important issues in medicine. The idea that the mind and body are two different things is the old paradigm. This mind/body dualism goes back 3 1/2 centuries to Descartes. The new paradigm is that there is no mind without brain, and brain is part of the body.

Recently a patient of mine went through a life threatening illness and eventually heart surgery. He had a past history of serious depression, well controlled for years with maintenance medication, an antidepressant. He was so sick that he forgot to continue his meds, and his doctors did not see fit to prescribe for him or contact me. I explained to him that depression – which developed during his medical illness to the point that he said, "all I thought about was death" for several weeks – increases the risk of dying from serious illness 2 to 3 fold.

His response was, "I guess they took good care of me physically but not mentally." My response was "What’s the difference?"

So what difference does all this make? Why didn’t his doctors make sure he stayed on his antidepressant? His doctors increased his risk of dying. Why? Because many if not most physicians are still stuck in the old paradigm.

"For every twisted thought, there’s a twisted molecule; straighten the molecule and you’ll straighten the thought." But, responded the cognitive therapy oriented people – "If you straighten the thought, you straighten the molecule."

So, which is right? Both. There are numerous studies now for obsessive compulsive disorder and depression that adequate cognitive behavior therapy (CBT) can change the chemistry and functioning of the brain. Scans of brain functioning can be seen to return to normal for some patients. The right medication(s) at the right dose frequently return the brain to normal. Some patients do better on one approach and not the other. Some patients would do equally well on either, and some need both.

Why would anyone choose medication if cognitive therapy would work? The problem is that CBT therapy takes longer, costs more, takes a lot more time, it’s hard to find people who know how to do it, and it may not work. Medication is simple, quicker, cost less money and less time.