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THE SAN FRANCISCO CHRONICLE, January 29, 2003

[Editor's Note: When an illness strikes someone in the public eye, the
public gets to learn more about the illness. Below, Raiders fans are
taught about bipolar disorder, including from an insight supplied by Dr.
E. Fuller Torrey.]

By Carl T. Hall


Psychiatrists joined the Raider Nation on Tuesday in an effort to
understand the apparent medical meltdown of All-Pro center Barret
Robbins.

Robbins, 29, displayed signs of emotional problems and then disappeared
the day before the biggest game of his life on Sunday. Hospitalized in
San Diego, he was pulled from the Raiders' lineup before his teammates
endured a thrashing by the Tampa Bay Buccaneers.
He reportedly had stopped taking prescription medications for bipolar
disorder. Although medical experts all declined to comment on the
particulars of the Robbins case, they called it a classic scenario of
stress complicating a struggle with mental illness. "All illnesses are
exacerbated by stress, including bipolar disorder," said Dr. Robert
Hirschfeld, chair of psychiatry at the University of Texas Medical
Branch at Galveston, Texas.

Any event that pulls someone out of his "normal life rhythms" can
trigger new symptoms, Hirschfeld added, which in depressive disorders
often can include a tendency to make some very bad decisions.
"We hope people would be able to exercise some self-control," Hirschfeld
said. "Unfortunately, it's in the nature of this illness for people to
lose the ability to control themselves."

Bipolar disorder, or manic-depression, is marked by extreme mood swings.
Often mistaken for the more common condition of major depression,
bipolar afflicts an estimated 2 million people in the United States, or
about 1 percent of adults at some point in their lives.
The prevalence appears to be higher in high-achieving occupations,
including professional sports, because of the productivity, energy and
drive to excel that can be hallmarks of the condition's "up" phase.

Bipolar is considered incurable but can be managed effectively through
use of mood-stabilizing drugs such as lithium and divalproex (Depakote).
Many other drugs and treatment approaches also are being tried.
Few medical details have emerged in the Robbins case. Doctors said the
reported circumstances highlight the difficulties that arise even in
cases where a patient can afford top-notch treatment.

"The people who do very poorly are the people who don't get it, who
don't have a proper respect for the illness," said Dr. Terence Ketter,
chief of a bipolar-disorders clinic at Stanford University Medical
Center. "People who admit they have a problem and are willing to work on
it do a lot better."
One key component is a marked tendency to forget one's vulnerability
during the treatment phase. This denial may be ascribed to a personal
choice one makes, but many doctors view it as one more devilish way the
disease manifests itself.
"It can be a phase of the illness," Ketter said. "It's not just people
who are jerks, or just don't accept they have a problem. Unfortunately
some people have to have a few episodes before they realize this is
something they really have to deal with."

People with bipolar disorder often have remarkably little insight into
their illness, even if it's painfully obvious to everyone around them.
"It's part of the illness that they do not see they have an illness,"
Hirschfeld said.

Doctors described success-driven patients becoming convinced that
treatment side effects -- virtually insignificant to any outside
observer -- were robbing them of vitality when they needed it most.
To an offensive lineman, for instance, treatment could be seen as
costing the subtle edge that might make the difference between a clean
block and a fall on one's face in the Super Bowl.
Subtle side effects "that may be a nuisance to an ordinary individual
may be significant to a professional athlete," said Dr. Victor Reus, a
psychiatrist at UCSF Medical Center. "Artists, performers, highly
creative talented people of all kinds tend to very self-aware of subtle
variations in their performance."

Abrupt discontinuation of medication after a period of successful
treatment can be extremely risky, linked in studies to particularly
violent mood swings, alcohol and drug use and erratic behavior. Suicide
is not uncommon.
"A lot of people have the idea that if they get off the medicine, they
do better," said Dr. Marc Graff, a bipolar-disorder specialist at Kaiser
Permanente in Los Angeles. "These are all world-class players. I am sure
the temptation to get that extra edge is always there."

Graff cited "VIP syndrome" as another possible culprit in the rarefied
world of professional sport.
"There are special rules for special people," Graff said. "Anyone who
gets into professional athletics certainly is a person, at least in our
culture, who is catered to and may become used to having things done for
him."
Such people tend to have "a flying V of hangers-on protecting them, and
so they don't often have to deal with the consequences of their actions.
And that can make treating a person's mental illness very difficult," he
said.
Understandably, perhaps, Robbins did not seem to be inspiring much
public sympathy after the Raiders' loss. After he failed to show up for
the Raiders' last practice and a team meeting Saturday, some of his
teammates clearly were angered by his apparent irresponsibility.

Physicians said some of the anger may be justified, but they also said
that the harsh judgments might be premature if there were, in fact,
underlying medical factors.
The physical roots of mood disorders are somewhat mysterious but are
thought to be related to the genetics of brain chemistry, giving rise to
imbalances in the biochemical crosstalk that allows neurons to
communicate with one another.

"We tend to put the burden on the person and don't understand these are
brain diseases," said Dr E. Fuller Torrey, executive director of the
Stanley Medical Research Institute in Bethesda, Md., and author of the
recent book "Surviving Manic Depression."
Even Robbins, at 6-foot-3 and 320 pounds, might have been ill-equipped
to shake the monkey off his back. [SOS Psiche]