November 1, 2002

A Hole in His Head

In the Bay area, the Barret Robbins affair continues to simmer. We are told that the Oakland Raider all-pro center missed the Super Bowl because he was suffering from bipolar disorder and had stopped taking his medication before the big game. Apparently this triggered a major depressive response which led to an alcoholic binge and the rest, as they say, is history -- a lopsided blow-out defeat for the Raider football team.

We are also told that Robbins' bipolar disorder is a medical condition "caused by a chemical imbalance in the brain" affecting the person's "ability to comprehend and reason." We are told we should understand and show the same compassion and tolerance for those with this mental condition as with any other chronic medical problem, like diabetes or arthritis. Finally we are told that we too, are responsible for making sure these people stay on their medication, otherwise disastrous results (much more than losing a Super Bowl game) could ensue.

It appears all pretty straightforward -- scientific, authoritative and compassionate. To challenge or disagree with this position is to risk sounding Neanderthal and very politically incorrect. But there's something too simplistic about all this that bothers me. And the implications in blindly accepting this interpretation of the Robbins tragedy go far beyond the sporting world.

First about bipolar disorder. Manic-depression, the old name for the condition, was a well-defined disorder with a clear genetic pedigree and a fairly discrete cycle of behavior that responded very well to one medical treatment, lithium. It was, in fact, the best and perhaps only example of a mental condition that corresponded fairly well to the criteria set for medical problems. Still missing for manic-depression then, and bipolar now, was a fundamental causal agent -- a germ, a missing enzyme, a clear anatomic or functional abnormality of the brain.

But beginning in the 1980s, when the bipolar label replaced manic-depression, the criteria for the condition became broader and broader. So broad that some doctors believed lithium lost its effectiveness for bipolar disorder, rather than seeing this whole new group of heterogeneous behaviors as unresponsive to lithium. Indeed, these days any person with extreme behavior who does not respond to first or second line anti-depressant medications (like Prozac) may be called bipolar by some psychiatrist and tried on more powerful, felicitous sounding "mood stabilizing" drugs, like the anti-seizure medication, Depakote or anti-psychotic drug, Risperdal.

"Chemical imbalance" -- what chemical imbalance? We all are made of chemicals and our behavior both reflects and has influence on our brains' chemical make-up. There is as yet no defined or proven chemical imbalance for any of the psychiatric disorders, including bipolar. Rather, there's been an inference that there must be a chemical imbalance that is "corrected" because problematic behavior often improves after a patient starts a medication. However, no one says when my headache improves after I take aspirin, that I have an "aspirin deficiency" that caused my headache.

"Stay on your medication!" is the advice given by doctors. Well that's fine and good but all the medications for bipolar have serious adverse effects. Universally they are sedating. I wonder if Robbins was feeling those side effects and believed it was hampering his performance on the field. In fact, perhaps as a result of his stopping his medication, he made all-pro this year with the unfortunate cataclysmic ending. But who can blame him for wanting to try without. It happens all the time.

Finally, we are asked to "understand" that his was a medical problem beyond his control. Well, I've been trained over the years to explain these disorders as "an explanation but not an excuse" for bad behavior. People, even with mental problems, are still responsible for their actions (legally, if they know the difference between right and wrong). Understanding someone's personality and history allows us to not take so personally their failures that affect us. It's not that they didn't care or care about us. But expectations and limits must still be set.

The Robbins fiasco to me is about a man who pushed himself too hard in an ultimate high performance, pressure cooker environment. His failure also represents the failure of an entire system. Sure there was a biological contribution to his problems (as there is for all of us) but it's just too simplistic to reduce a man's life and fate to his biochemistry.

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