Brit.J.

Psychiat.

(1979),

135,97103

Artistic Productivity and Lithium Prophylaxis in

Manic-Depressive Illness
By MOGENS

SCHOU

SUMMARY
Twenty-four
manic-depressive
artists, in whom prophy
lactic lithium treatment had attenuated or prevented recurrences
to a
significant
degree, were questioned
about their creative power during
the treatment.
Twelve artists reported increased artistic productivity,
six unaltered productivity,
and six lowered productivity.
The effect of
lithium treatment on artistic productivity
may depend on the severity
and type of the illness, on individual
sensitivity,
and on habits of
utilizing manic episodes productively.
emotional
and intellectual
experiences
which
contribute
to the ability to create.
The present study was undertaken
to provide
data bearing on these questions
and to guide
psychiatrists
and creative
patients
who are
faced with the decision: lithium treatment
or no
lithium treatment?

When
prophylactic
lithium
treatment
is
contemplated,
patients sometimes
express con
cern along the following lines: My
work is to a
large extent creative.
Is there any risk that
lithium
treatment
may
interfere
with
my
creative
power?
Nerve pills are reported
to
blunt intellectual
and emotional
functions, and
I understand
that lithium
treatment
is often
given for years.
What
will happen
to my
productivity?'
This question cannot be answered in advance
for the individual
patient,
but observations
of
what happened
to other creative persons given
lithium treatment
may reveal response patterns
and trends. When such data are interpreted,
it
should be kept in mind that two factors may be
involved:
(i) the effect of the treatment
on
productivity,
and (ii) the effect of the treatment
effect on productivity.
(i) Long-term
lithium
administration
is in most cases remarkably
free
of mental side effects, but occasionally
patients
complain
of impaired
memory or restriction
of
their emotional
range.
Creative
productivity
may be particularly
sensitive to subtle psycho
logical changes induced by lithium. (ii) Prophy
lactic
lithium
treatment
often
effectively
counteracts
further
episodes
of mania
or
depression
or both. This may be beneficial for
artistic
productivity
because
interruptions
of
work are avoided. It is, however, also possible
that eradication
of the periods of elation and
melancholy
may deprive the creative person of

Method
Creativeness
may be expressed
in many
professions,
by scientists,
inventors,
business
men, administrators,
politicians,
etc. In the
present study I have limited myself to examining
artists, and chiefly those artists whose activity
was primary,
for example
composers,
rather
than secondary,
for example
instrumentalists.
The study includes only artists suffering from
manic-depressive
illness, bipolar
or unipolar,
and only those in whom prophylactic
lithium
treatment
had been successful, i.e. had attenu
ated or prevented
manic and depressive recur
rences to a significant
degree.
Patients
who
stopped
lithium
after a short time because
lithium-induced
tremor
interfered
with their
work have not been included.
Information
was collected from a variety of
sources. I have used my own clinical experience
as well as reports from psychiatrists
in many
countries. Such reports were solicited in personal
conversations
or as a response to requests
in
lectures and articles. I corresponded
with one
artist
(Case No. 21) and interviewed
four
97

This

One

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98

ARTISTIC PRODUCTIVITY AND LITHIUM PROPHYLAXIS IN MANIC-DEPRESSIVE ILLNESS

(Cases No. 1, 11, 23 and 24). Information

about
the others I obtained,
with their permission,
from their psychiatrists.
Information
is abundant
about some of the artists, scanty about others.
Statements
about
changes
in quantity
and
quality
of artistic work are based on reports
from the artists themselves,
sometimes
supple
mented
with
assessments
by spouses
and
psychiatrists.
The artists
were from Belgium,
Canada,
Czechoslovakia,
Denmark,
England,
Italy,
Sweden, Switzerland,
West Germany,
and the
United
States. In the case reports presented
below some of the information
has been changed
in order to preserve
the artists'
anonymity,
though
not in such a way as to distort any
inferences which may be drawn concerning
the
effects of lithium treatment.
Twenty-four
case reports weigh heavily on an
article,
and some readers
may choose to go
directly to the discussion. I have made attempts
to present the information
in table form, with
and without
illustrating
case reports,
but the
results were unsatisfactory.
Firstly because this
form of presentation
might give the readers the
impression
that the paper provides quantitative
information,
and that would be misleading.
Secondly
because tabulation
results in loss of
nuances and individuality.
I wanted to give the
readers
a feeling
of having
met,
however
briefly, each one of these twenty-four
artists, and
hence, in spite of its heaviness,
I chose pre
sentation in the form of case reports.
Case Reports
Cases with increasedproductivity
Case 1. A 40-year-old male painter suffered from manic
and depressive recurrences from the age of 20. Lithium
treatment was for a long time intermittent
due to trouble
some side effects, but use of sustained-release
tablets
during the past year has permitted continuous treatment.
This has attenuated,
but not completely prevented,
recurrences of the patient's mood swings.
During depressions the patient's paintings were char
acterized by dark colours and rather sad subjects; his
productivity
decreased, and at times he could not paint
at all due to too much self-criticism and lack of initiative.
During manias he might paint several pictures a day,
using light colours and choosing happy subjects. The
patient explains that treatment
with sustained-release
lithium tablets has been good for him, both personally
and artistically.
It prevents or ameliorates
depressions,
thereby increasing productivity.
It also prevents manias

from getting
out of control'. The patient feels that he has
been more productive,
has painted better pictures, and
has matured
artistically
during the year of consistent
lithium intake.
Case 2. In a 42-year-old male physician and author,
severe bipolar manic-depressive
illness started when the
patient was 20. During prophylactic
lithium treatment
over the last six years the cyclic course has continued, but
episodes have become shorter and much milder.
While on lithium, the patient has never had to interrupt
work as a physician.
His writings have increased
in
volume and also, according to his own opinion and that of
his critics, improved in quality.
Case 3. A 62-year-old male author suffered from the age
of 19 from frequent recurrences of manic-depressive
illness
with moderate depressions and severe manias, the latter
combined with alcohol abuse.
During lithium treatment for 14 years the episodes have
been markedly attenuated,
and the alcohol consumption
has come under control. He has been more stable and
reliable in his work and has been able to adhere to a tight
working schedule, so that his productivity has increased.
Case 4. A 42-year-old
male publisher and amateur
painter
suffered from recurrent
depressions
with in
capacitating
anxiety
and phobias
since adolescence.
Starting to draw and paint gave some relief from anxiety
and was experienced as a joyful means of self-expression.
He became very productive and had a successful exhibition
in spite of being self-taught.
Lithium treatment,
begun two years ago, has been
adhered to punctiliously.
It has led to fewer and less
severe depressions but not to complete stabilization.
The
patient feels that lithium treatment has helped his artistic
productivity by reducing dysphoria and anxiety.
Case 5. A 35-year-old female author suffered since the
age of 16 from severe depressions
and mild manias.
Lithium treatment during the last three years has led to
mood stabilization. There are occasional slight dysphorias.
She started writing at an early age, but the apathy,
bleakness and painfully slow mentation during depressions
interfered seriously with her work. Not till after two years
of lithium treatment did she resume writing. She now feels
full of creative power; she is steady in mood and not
tossed
about' by her affects. Whereas previously her work
tended to be misty
and indistinct', it is now defined
and
informative'.
Only occasionally
does she miss the
manias. Productivity
is regular, and ideas come to her
readily.
Case 6. A 49-year-old
male journalist
and author
developed manic-depressive
illness in his late twenties with
violent manias and prolonged depressions. This interfered
so much with his work as a journalist that he obtained an
invalid pension. Prophylactic
lithium treatment
given
from the age of 36 gave excellent response during the first
five years. Thereafter minor mood swings occurred.
The patient has been active as a journalist and author,
writing both books and film scenarios. Although during
lithium treatment he missed the manic periods of excessive
joy and initiative, he was in no doubt that the treatment
raised his productivity.
Not only did it prevent the
unproductive depressions, but it also saved him from manic

MOGENS SCHOU
valueless overproduction,
which later had to be sifted
carefully in order to retrieve the few pieces of some merit.
During lithium treatment
he was able to return to his
activities as a journalist
because now, in contrast to the
period before lithium, he could keep assignments.
He
died at the age of 49 from a heart attack.
Case 7. In a 37-year-old male teacher and amateur
painter bipolar manic-depressive
illness started four years
ago with moderate depressions and severe manias requir
ing hospitalization.
Lithium treatment for the last three
years has prevented depressions and attenuated
manias
so that they no longer incapacitate the patient socially and
professionally.
During the first year of his mood disorder the patient's
productivity
decreased. Under lithium treatment he has
again become more productive and has changed his style
from realism to more abstract painting. He ascribes his
rise in productivity to stabilization of mood and possibly to
more frequent hypomanic episodes.
Case 8. A 38-year-old
female journalist
and author
suffered from the age of 18 from bipolar manic-depressive
illness with schizo-affective
features;
she had many
hospitalizations
and a number of treatments.
Since the
start of lithium treatment eight years ago the patient has
had one brief mania and one mild depression.
During
lithium
treatment
artistic productivity
has
increased quantitatively,
and she also finds it of better
quality than before her lithium treatment
was started.
Her latest book is considered by the critics to be her best.
Case 9. A 44-year-old male painter had mild manias and
anxious and somewhat agitated depressions from the age
of 21. During lithium treatment over the last two years
there have been no episodes.
Before lithium treatment the depressions interfered with
his artistic work. During the treatment
he has become
more motivated
to undertake
creative activity, and he
works quicker and more freely.
Case 10. A 55-year-old male commercial illustrator and
painter suffered from recurrent depressions since the age
of 30. Lithium administration
for fiveyears led to marked
improvement
with complete
absence
of recurrences
during the last three years of treatment. The patient then
stopped lithium, and depressions reappeared.
After three
years without lithium, treatment was resumed.
The patient's artistic productivity rose markedly during
lithium treatment,
both subjectively and objectively. His
work was much more stable, and he changed from being
a commercial
illustrator
into becoming
a successful
painter.
Case 11. A 44-year-old male theatre producer and author
began suffering from bipolar manic-depressive
illness
twelve years ago. Lithium treatment, started seven years
ago, has completely abolished the manic episodes; brief
periods of slight mood lowering may occur.
Before lithium treatment manic episodes were associated
with restlessness, irritability and an uncontrolled
flow of
not very useful ideas. Depressions were grey, unpleasant
and tiring, and they did not provide material that could
be used artistically.
Lithium treatment
has led to emo
tional stability with more efficient utilization of artistic
abilities. Productivity
has gone up; within the last five

99

years the patient has published four novels and had two
plays performed.
Case 12. A 22-year-old male painter and artist-craftsman
became depressed at the age of 14 and later had a number
of depressions but no manias. Lithium treatment
was
started when he was 16; at first there was poor com
pliance, but gradually the patient became co-operative,
and depressions disappeared.
The patient is an art student, who also paints and works
with ceramics
and collages.
During
depressions
his
productivity
decreased, and colours and shapes changed
in his productions.
Lithium treatment
may have been
helpful to his artistic work by preventing depressions, but
it is difficult to distinguish this effect from that of con
comitant rapid maturation.
He stopped lithium a year ago
and has since then been less creative, possibly because he
now pays more attention to his formal training.
Cases with wzaffectedproductivz@y
Case 13. A 46-year-old male composer suffered from the

age of 25 from depressionswith lack of initiative and many

somatic symptoms. There were occasional manic episodes.
Lithium
treatment
during the last five years has not
prevented episodes, but these have become shorter and
less frequent. Ideas of suicide have disappeared.

Before lithium treatment

the patient had his best

creative periods at the start of manic and depressive

episodes. When the episodes were fully developed,
the
creative power decreased or disappeared.
When main
tained at serum lithium levels above 0.6 millimoles per
litre, the patient suffers from side effects which interfere
with his work. At serum levels of 0.4-0.6 millimoles per
litre there are no side effects and yet the partial prophy
lactic effect of lithium is preserved. Under these circum
stances the patient feels that his net productivity
is the
same as before lithium treatment.
Case 14. A 36-year-old male actor suffered for many
years from bipolar manic-depressive
illness and alcohol
abuse. Manic episodes were prominent,
while depressive
episodes mostly appeared
as downswings following the
manias. Prophylactic
lithium treatment was started nine
years ago, but tablet compliance has been doubtful, and
the manic and depressive episodes have not disappeared
completely.
Nevertheless
their intensity and frequency
have decreased.
Before lithium treatment
the patient's acting became
exaggerated and characterized
by extremes when he was
manic. Under lithium treatment this has disappeared, and
attenuation
of the episodes has led to more disciplined
artistic work.
Case 15. A male painter (age not given) suffered for
many years from bipolar manic-depressive
illness. About
ten years ago he started lithium maintenance
treatment,
which controlled
his disease well for about six years.
Thereafter manic and depressive episodes reappeared
in
spite of lithium administration.
Before lithium
treatment
the severe manias
and
depressions interfered with creative work, even though the
initial phase of a depression often induced a creative urge.
During
the successful period of lithium
treatment
artistic productivity was unaltered.

100

ARTISTIC PRODUCTIVITY AND LITHIUM PROPHYLAXIS IN MANIC-DEPRESSIVE ILLNESS

Case 16. A 48-year-old male composer suffered from the

age of 38 from bipolar manic-depressive
illness with mild
manias and moderate
to severe depressions.
Lithium
treatment for seven years has completely prevented manic
and depressive episodes. There has been no change in
artistic productivity during the treatment.
Case 17. In a 44-year-old
female painter,
bipolar,
somewhat
atypical
manic-depressive
illness started
15
years ago. There were several hospital admissions and a
considerable
alcohol abuse. Lithium treatment has been
given for five years, the first two years with poor com
pliance but during the last three years with better co
operation and only occasional mild depressions.
When the patient's disease started, her style of painting
changed, becoming surrealistic with religious and sexual
themes. The quality remained good; she held exhibitions
and obtained art grants. While on lithium she feels, during
depressive episodes, that the treatment
lowers her pro
ductivity;
when she is not depressed,
however,
she
considers her creative power unaffected by the treatment.
She has retained the surrealistic style of her paintings.
Case 18. A 45-year-old male civil servant and author
suffered during 30 years from frequent severe manic and
depressive episodes, often necessitating
hospitalization.
Lithium maintenance
treatment during the last five years
has led to mood stabilization. Occasional very slight mood
swings have been difficult to distinguish
from normal
mood changes.
Before lithium
treatment
started,
the patient
had
recurrences of such frequency and severity that no artistic
creativeness could have manifested itself even had it been
there. The patient now executes his work with success
and many ideas, and three years ago he wrote a poetic
philosophic book of considerable quality.
Cases with lowered productivity
Case 19. A 42-year-old
female author began having
recurrent depressions followed by short manias 12 years
ago. Lithium treatment, started two years later, was given
for five years, and during this period the patient was
free of depressions.
She interrupted
treatment
because
she missed the slight elations which usually activated her
artistically.
She felt that during treatment
she lacked
inspiration and ideas, and although her mental condition
was clearly more stable during lithium administration,
she did not want to continue treatment.
Case 20. A 46-year-old female composer suffered from
bipolar manic-depressive
illness for many years. She started
lithium treatment
five years ago, and episodes became
markedly
fewer and less severe. She nevertheless
dis
continued lithium four years later, because she felt that
the treatment interfered with her creative power.
While on lithium the patient might be conscious of a new
harmony that she wished to develop, but she did not have
sufficient drive to put her ideas on paper. Reduction in
productivity was equally strong throughout the four years
of lithium treatment.
Since coming off lithium she has
remained
without manic and depressive relapses, and
she feels that her creative power has grown.
Case 21. A 42-year-old
female painter suffered from
recurrent depressions for four years. During one year of

lithium treatment
the depressions were somewhat ame
liorated. Treatment
was discontinued
at the patient's
request.
The patient asserts that depressions do not interfere
with her artistic productivity.
While she took lithium,
however, she found her creative power diminished,
and
she regards this as a direct drug effect. Later information
from the psychiatrist
reveals that the patient lost her
husband while she was on lithium and that the rise in
productivity
after discontinuation
of treatment was only
transitory.
Case 22. A 63-year-old male author suffered for many
years from recurrent
manic-depressive
illness combined
with alcohol abuse. Lithium maintenance
treatment
for
one year led to disappearance
of manic and depressive
episodes and of the excessive urge to drink.
The patient stopped lithium treatment because he felt
that it held back his creative energy. Nevertheless he wrote
a successful book while on lithium. A second book was
written partly on and partly off lithium, and the author
feels that the parts written after discontinuation
of lithium
are of higher quality than those written under the influence
of the drug.
Case 23. A 58-year-old book-keeper and poet suffered
during the last seven years from clearcut manic episodes
and slight depressions. Lithium treatment during the last
two years has almost abolished recurrences.
The patient has published small books about art history
and writes poems for a weekly magazine. During manic
episodes he wrote many poems a day, but their quality
was not very high. Depressions impaired productivity and
did not give experiences which could be used artistically.
During lithium treatment there is the urge to write, but
ideas do not come as readily as before. The creative power
is returning gradually
but is still not as flourishing as
before treatment started.
Case 24. A 62-year-old female amateur painter suffered
from recurrent manic-depressive
illness for 27 years before
starting lithium treatment
seven years ago. Since then
there have been only slight recurrences,
possibly due to
lack of compliance.
The patient makes painted collages from fish bones and
scales, sea weed, and other natural materials. After the
start of lithium treatment all creative activity stopped for
a year or two. Thereafter
it returned, and although she
may miss the spells of creative urge associated with
manias, her net productivity
is now as before lithium.
The quality has risen. She is more critical of what she
does, and instead of starting many projects simultaneously
in the way she did previously during manic episodes, she
now finishes one thing at a time.
Discussion

The sample studied

here is small, and its
degree
of representativeness
is not known.
Even when the results are combined with those
of previous
studies,
the data do not permit
quantitative
conclusions
about
how artistic
productivity
is affected by lithium prophylaxis.

MOGENS SCHOU

What the observations can and do illustrate is

that there is a diversity of response patterns.
The responses fall roughtly in three groups:
increased,
unaffected,
and lowered produc
tivity.

Marshall

ci al (1970)

reported

about

five

nationally recognized artists and businessmen,

who found that overall productivity was more
uniform

and

of sounder

quality

during

lithium

treatment that before. Polatin and Fieve (1971)

and Polatin (1972) referred to a
limited number'
of severely ill bipolar creative patients, who also
claimed an overall increase in productivity and
creativeness while on lithium. In the present
material eleven, perhaps twelve, cases belong to
this group. In Case 12, who was a young person,
increased artistic productivity may have been
due to maturation
with age rather than to
lithium treatment.
The reason for the increased productivity
during lithium treatment seems fairly obvious.
A direct stimulatory effect of lithium on creative
power is conceivable
but unlikely. Lithium
treatment does not produce highs',
and none of
the artists reported euphoriant
effects of the
drug. The rise of productivity during lithium
treatment was due to the prophylactic action
of the latter. Before lithium, depressive and
manic episodes had interfered with the artists'
life and work, leading to long and barren
periods or to periods of productivity without
value, sometimes
to hospitalization.
When
lithium treatment brought the disease under
control, the artists not only remained creative
but in fact produced more and better work than
before. They felt that the treatment had led to
stabilization of their working ability, to better
emotional control, greater maturity and stricter
artistic discipline.
The second type of response to lithium
treatment is shown by artists with unaltered
productivity but possibly a qualitative change in
their productions.
Fieve (1975) described a
theatre director and producer, who remained
creative on lithium treatment (Iseem to be as
productive as I've ever been'). He also referred
to a painter, who developed a new style during
lithium

treatment

(his lithiumperiod').

It is not

clear whether this was associated with a net

change of productivity. A painter described by
Villeneuve
(1973) remained creative during

101

lithium treatment, but his style became modi

fied, more figurative and with colours of softer
tone. The present material contains six cases of
this kind. In one of the patients (Case 18)
comparison before and during lithium treat
ment is difficult, because he only started serious
artistic work after his bipolar manic-depressive
illness had been controlled by lithium treatment.
Lithium treatment
did not prevent creative
work in the six cases of this group; some of them
might arguably have been placed in the group
with increased productivity.
There is finally the group of artists who feel
that their productivity decreases during lithium
treatment.
Baszormnyi (1970) described
a
painter, Marshall ci al (1970) a creative patient
(artist?), Bertagna ci a! (1971) some
artists and
other creative persons',
Polatin and Fieve
(1971) two writers, Polatin (1972) a sculptress
and a writer, Arnold (1974) an author and a
dramaturge,
and Benson (1975) four creative
patients (artists ?), who missed the manic and
hypomanic periods of inspiration and impetus.
Some of the patients discontinued
lithium
treatment
for this reason. Six of the artists
described here showed a response of lowered
creative activity during lithium treatment. Five
were bipolar and one unipolar. Four of the
patients stopped lithium, two thereafter feeling a
return of creative power. Lowering of pro
ductivity could be due to lack of inspiration
(Ihave the urge, but ideas do not come as
readily as before') or lack of ability to execute
(Ihave the idea but not the drive to put it on
paper').
Reduction of artistic productivity
may be
temporary. This is illustrated by Cases 7 and 23
but most clearly by Case 24. This patient lost
almost all creative power during the first 12
years of lithium
treatment
but thereafter
became as productive, qualitatively and quan
titatively, as before lithium.
It is not in all cases clear why productivity
was lowered during lithium treatment.
The
reduction may have had coincidental causes:
increase of age, somatic illness, altered family
situation, etc. Lithium-induced
malaise may
have played a role.
It is also possible that exposure of the organism
to lithium may affect the cerebral processes

102

ARTISTIC PRODUCTIVITY AND LITHIUM PROPHYLAXIS IN MANIC-DEPRESSIVE ILLNESS

which

form

the

basis

of creativeness.

One

of

the patients in this study who rejected lithium

treatment
was unipolar (Case 21) and therefore
had experienced
no manias which she could
miss. She felt that lithium inhibited her creative
power

directly,

but

additional

factors

been at work.
Studies on healthy

volunteers

value
lithium

possible
direct
It is difficult,

in

elucidating
on creativeness.

may

have

are of limited
effects
of
perhaps

impossible,
to measure
creative
ability
with
objective psychometric
tests. Related cognitive
functions were studied by Judd et al (1977), who
compared
the effects of lithium
and placebo
given for two weeks each to 24 normal subjects.
Neither
the Meyer Art Test, which measures
aesthetic
perception
and art judgement,
nor
the Guilford-Christensen
Fluency Tests, which
assess semantic fluency as a possible measure of
creative
ability, showed significant
differences
between the two treatments.
Analysis of the cases reported in the literature
and in the present study indicates that a number
of

artists

lost

productivity

because

energy

and

ideas.

When

lithium

treat

ment deprived
them of these periods, they felt
their creative power fall to, or even below, the
level they usually experienced
during intervals.
In some

cases

this

was

so intolerable

stopped
ductivity

lithium,
preferring
to health without

that

they

illness with pro

or with lowered

productivity.

It seems conceivable
that also periods
of
melancholy,
dwelling in the land of the shadow
of death,
might
provide
experiences
which
could be used creatively,
if not during
then
perhaps after the depressions.
However, none of
the observations
collected
until now supports
this notion;
on the contrary,
the artists de
scribed
the depressions
as grey, barren,
and
unproductive
of intellectual
and emotional
material

of artistic

The present

Acknowledgements
It is my pleasant duty to thank the psychiatrists who
provided the information and the artists who gave it and
permitted its use in this study.

before

treatment
they had been in the habit of basing
their production
on the manic
episodes
of
surplus

made by myself support this notion. Responses

seem to depend
on the severity of the illness
before lithium, perhaps on the type of illness, on
habits of utilizing manic periods of inspiration
productively,
and possibly on individual
sen
sitivity
to the
pharmacological
action
of
lithium.
When
prophylactic
lithium
treatment
is
considered
for manic-depressive
persons
in
whom creativeness
is a prerequisite
for their
work, the diversity of possible responses should
be discussed with the patient.
If lithium treat
ment is started,
artist and psychiatrist
should
currently assess gains and losses of the therapy.

References
ARNOLD,

0.

H.

(1974)

Weitere

automatenhaften Dasein'
therapie.
BENSON, R.
bipolar

Beobachtungen

unter

Arzneimittd-Forschung,
(1975)
illness:

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Access the most recent version at DOI: 10.1192/bjp.135.2.97

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