In bipolar, one affects the other.

by John McManamy


THE FOLLOWING is drawn from my book, NOT JUST UP AND DOWN ...

Let’s keep it simple, for now. Think of mania, hypomania, and depression in terms of “up” and “down.” Two thousand years ago, Aretaeus of Cappadocia described both melancholia and mania and linked them to the same condition. Here is his partial description of “up”:


Some patients with mania are cheerful, they laugh, play, dance day and night, they stroll in the market, sometimes with a garland on the head, as if they had been winner in a game: these patients do not bring worries to their relatives.

But “others fly into a rage.”

As for melancholia:

The patients are dull or stern, dejected or unreasonably torpid, without any manifest cause …

Aretaeus described fear and sleeplessness, and as the condition intensifies, patients “complain of life and desire to die.”

Aretaeus also regarded mania as emerging from melancholia. Never mind for now whether this is actually the case. Let’s simply acknowledge that by connecting the two—by pairing “up” to “down”—he became the first person we know of to identify what we would later call bipolar disorder. But to accomplish that, first he had to ask himself how two apparently opposite conditions could possibly be related.



This is completely contrary to the DSM polarity mindset, which would have us believe that depression and mania exist independently of one another, that neither is influenced by the other. Cyclicity, on the other hand, asks us to think in terms of each state exerting a sort of gravitational pull on the other.

One simple way of approaching this, according to the late Greek psychiatrist, Athanasios Koukopoulos, is by viewing depression as the spent remains of mania or hypomania. In essence, our manic or hypomanic engine has run out. No gas in the tank, no power in the batteries. Or, as the Renaissance philosopher Marsilio Ficino put it: “The melancholic humor lights and burns, producing that excitement which the Greeks call mania and we furor. But when it dies out, only a black soot is left …”

If you think this applies to you, then your best depression-prevention strategy may be an effective mania-prevention strategy. Mania and depression are connected. This is Dr Koukopoulos’ point.




Dr Koukopoulos also points to studies that show when patients are prematurely taken off lithium, they relapse initially into mania rather than depression, as if mania is the default pathology. In addition, we can make a very strong evolutionary biology case that depression is our body’s way of telling us to slow down from our over-exertions—to rest, heal, reset all our biological systems.

But who has time for rest?

We can go a step further by pointing to winter depressions—most likely an artifact of a much earlier age—when our very survival depended on our ability to go into partial hibernation at certain times of the year. Unlike us, the ancients were very much aware of the most subtle changes in the seasons. As well as noticing the association between winter and melancholia, our ancestors couldn’t help but observe that mania tends to break out in the summer.

Seasonal cycles. Cycles. Always cycles.

According to Dr Koukopoulos, moderns think of time as a linear progression rather than circular. One event follows the other, or may even have a timeless dimension, such as Freud’s unconscious. With the ancients, by contrast, all of creation was in flux, but everything inevitably came back to the same place.

Dr Koukopoulos goes farther by tying in cyclicity to homeostasis. Homeostasis has to do with the zillion and one biological processes that maintain our equilibrium. The principle explains, for instance, why our blood pressure and body temperature and so on remain fairly constant. In a similar vein, our nervous system tends to push depression back toward normal and level off manic tendencies.



In our enthusiasm to treat episodes in isolation, however, we lose track of the fact that our meds interfere with homeostasis. We can view bipolar as a breakdown in homeostasis—the thermostat isn’t working. At the same time, an ill-considered meds strategy may make a bad situation worse. Anti-manic meds may push us into a depressive stupor. Antidepressants may induce mania and speed up cycling.

As Oregon psychiatrist Jim Phelps stresses over and over again in his 2006 book, Why Am I Still Depressed, we need to treat the cycle rather than the symptom du jour.

Companion articles:


Mixed States

June 23, 2016


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Bipolar Stuff in the Shack with John and Maggie