Homeland is not only one of the best shows on television, but one of the best fictional portrayals of mental illness. Why do I say this? The award-winning Showtime cable TV series starring Claire Danes as Carrie Mathison, a CIA agent with bipolar disorder (formerly called manic-depressive illness), tells a spellbinding story of espionage and counterterrorism in the middle and Far East, but also accurately depicts mental illness as it occurs in real life (albeit in the shadowy subculture of clandestine operations). Despite her bipolar-induced volatility and unpredictability, Carrie is tops in her field. Far from being portrayed as a social misfit with few skills or without potential for employment, she is a high-ranking CIA operative in charge of recruiting and managing assets. With the help of her long-time mentor Saul Berenson (Mandy Patinkin), she fearlessly risks everything, including her personal wellbeing and even sanity, at every turn. Although the plot line “jumps the shark” several times, Carrie’s character remains faithful to the clinical dimensions of the illness. Every aspect of her behavior is illustrative and consistent with the symptoms, psychological characteristics and emotional nuances of people with bipolar disorder. Even the medications that she takes (clozapine, lithium, nortriptyline, clonazepam), prescribed by her psychiatrist sister, are appropriate and realistic. Spoiler alert: the balance of the article contains information that will reveal the plot and events in the series.

Bipolar disorder is caused by a brain disturbance in mood regulation that can induce in its victims soaring flights of excitement and euphoria, and, alternately, crushing feelings of sadness and hopelessness. The cause of bipolar disorder is believed to be genetic as it runs in families and various genes have been associated with the condition. And although high “doses” of susceptibility genes can spontaneously precipitate these bouts of emotional excess, they are more often provoked by environmental stress and disruptive life events (e.g. death of a loved one, loss of a job, interpersonal conflicts, recreational drug use).

That is what makes Carrie’s character in Homeland so thrilling and adds to the dramatic tension. She is in, perhaps, the highest stress job there is, yet she carries it off (no pun intended), brilliantly, either in spite of, or because of, her mental illness. In fact it’s hard to tell what aspects of Carrie’s mercurial behavior are due to her bipolar disorder and what is inherent in her personality, which is often the case in real-life instances of bipolar disorder.

On other occasions we see her being flirtatious and engaging in risky behaviors such as when she goes to a bar and picks up a guy who she sleeps with; or when she flirts with Saul and tries to kiss him. It’s hard to know whether her seductions of Brody (season one) and Ayam (season four) are the result of zealous dedication to her job or bipolar-driven promiscuity.

The writers also effectively weave the overt manifestations of Carrie’s illness into the plot. In the final episode of season one, Carrie’s becomes paranoid, grandiose, and disorganized, leading to her hospitalization and electroshock treatment (ECT); despite its notorious reputation, a very effective and safe treatment for bipolar disorder. In season 4, her adversaries use her illness to undermine her by sabotaging her medication and causing her to relapse.

Another quality of Carrie is her keen intuition and unshakable belief in her own views of the espionage landscape. (As we learn in season one she is right about Brody, the ostensible returning war hero turned congressman, having been “turned by the enemy.”) Is this incorrigible confidence the delusional conviction of her bipolar disorder or belief in her intellectual acumen? And then there is her self-centered nature, which leads her to perceive anyone who disagrees with her, as an implacable foe. Carrie also engages in irrational denial such when she abandons her baby daughter and saddles her sister with the responsibility of caring for her, so she can return to active duty in Afghanistan. Is this narcissism part of her character or bipolar megalomania?

Carrie seems to create conflict wherever she goes (another characteristic of bipolar disorder). However, despite this ostensibly maladaptive and self-defeating behavior, she is extremely successful. In fact she may be an espionage genius. Immense talent and creative energy is another quality commonly found in people with bipolar disorder. These can be used productively provided that their illness does not interfere and if they receive effective treatment such as is the case with my good friend and colleague Kay Jamison, the esteemed writer and psychologist. In the absence of good treatment, a person with bipolar disorder may soar to creative heights and then go off the rails and self destruct, either in a chaotic mania or devastating depression, as was the case with the poet George Gordon (Lord) Byron and the actress Patty Duke among others.

What makes Homeland work so well in terms of its psychiatric realism, is that Carrie’s illness is an aspect of her character and a realistic part of the story, rather than her illness being the story and inaccurately portrayed. This works because in real life people, who suffer from mental illnesses like bipolar disorder, can and do lead lives that are normal and productive, rather than sensationalized and distorted.

Rumor has it that the idea for Carrie to have bipolar disorder was inspired by the producer’s sibling, who is similarly afflicted. If so it's reasonable to speculate that his or her ability to observe bipolar disorder in-vivo enabled him to create a character that was dynamic and interesting from an artistic perspective but also faithful to the clinical reality. On both counts Homeland gets it right and we should be immensely grateful.

Jeffrey A. Lieberman, M.D., Professor and Chair of Psychiatry, Columbia University Medical Center New York Presbyterian Hospital, Immediate Past President of the American Psychiatric Association.

Lieberman is the author of Shrinks: The Untold Story of Psychiatry.

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