The Unreal World: ‘Homeland’ and bipolar disorder

“Homeland,” “The Vest”

10 p.m. Dec. 11

Showtime

The premise

Sgt. Nicholas Brody (Damian Lewis) returns as a hero to the U.S. after spending eight years as a prisoner of war in Afghanistan. Carrie Mathison (Claire Danes) is a mentally unstable CIA officer who is convinced that Brody is an agent of Al Qaeda. She gets antipsychotic medication and lithium from her sister, psychiatrist Maggie Mathison (Amy Hargreaves), but she fears she’ll lose her job if she gets medical treatment through normal channels. In this episode, Carrie is hospitalized after being burned and bruised in a briefcase bomb explosion. She hasn’t taken her medication in several days and is becoming increasingly manic. Saul Berenson (Mandy Patinkin), her mentor at the CIA, is alarmed by her behavior, and Carrie admits that she is bipolar. Her sister arrives and gives her a ramped-up dosage of lithium as well as clonazepam to “level her out.” When she is discharged from the hospital, Carrie tries to run away and is nearly hit by a car.

The medical questions

What is bipolar disorder? Is it possible to hide the symptoms from one’s co-workers, especially in a high-stress job such as Carrie’s? Can the condition be exacerbated after a traumatic event, such as a bombing? Is it proper for a doctor to treat a close relative, even if the patient won’t get medical care any other way?

The reality

Bipolar disorder is a serious mental illness involving extreme mood swings, in which people go back and forth between periods of elevated or irritable mood (mania) and depression, explains Carrie E. Bearden, associate professor of psychiatry, biobehavioral sciences and psychology at UCLA. Other characteristics, all exhibited by Carrie Mathison, include grandiosity, decreased need for sleep, pressured speech, racing thoughts, distractibility and obsessive goal-directed behavior. In addition, 60% of people with bipolar disorder experience psychotic symptoms.

“People with bipolar disorder can function extremely well and continue in their jobs when their symptoms are effectively treated,” Bearden says. Lithium, a mood stabilizer, is one of the first-line treatments. Stopping it precipitously can provoke a manic episode (50% of patients will develop such an episode within three months after coming off the medicine). Clonazepam, an anti-anxiety medication, is often used for short-term relief of anxiety or agitation.

Bipolar disorder can be difficult to treat, and a high-stress job such as Carrie’s makes it harder. The situation is even more challenging when a second condition is present, such as psychological trauma. An acute stress such as a bombing could definitely trigger a relapse or the onset of a manic or psychotic episode, Bearden says.

Should a doctor treat a relative? This is at best controversial and probably the answer is close to never, especially in psychiatry, says Dr. Stephen M. Stahl, adjunct professor of psychiatry at UC San Diego and author of the book “Depression and Bipolar Disorder.” One cannot be objective, records are often not kept and the person inadvertently receives substandard care.

Bearden agrees that it would not be appropriate or advisable for a patient’s relative or close friend to prescribe medications and/or provide ongoing psychiatric treatment.

Siegel is an associate professor of medicine at New York University Langone Medical Center. His latest book is “The Inner Pulse: Unlocking the Secret Code of Sickness and Health.”

marc@doctorsiegel.com