#
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 183 ± 186
183
Winning the jackpot and depression: Money cannot buy happiness SONJA NISSLEÂ AND 2 TOM BSCHOR 1
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
1
Department of Neurology, Cantonal Hospital 2 of Aarau, Aarau, Switzerland; Department of Psychiatry, Technische UniversitaÈt Dresden, Dresden, Germany
Correspondence Address Dr. Tom Bschor, Department of Psychiatry, Technische UniversitaÈt Dresden, Fetscherstrasse 74, D-01307 Dresden, Germany. Tel: +49-351-458 3595 +49-351-458 2797 Fax: +49-351-458 5316 E-mail: [email protected]
Received 6 February 2002, revised 13 June 2002, accepted for publication 19 June 2002
Life event research examines the effect of life events on the course of psychiatric diseases, but the published literature considers almost only negative events. We describe the cases of two female patients who had to be hospitalized for depression after lottery winnings of over 1M DM. The 4-year follow-up shows a good outcome in both patients. Case analyses suggest that in both patients, winning was a life event relevant to the development of the depressive episode. Desirable life events might influence the course of a psychiatric illness just as negative events do. (Int J Psych Clin Pract 2002; 6: 183 ± 186)
Keywords life events lottery
INTRODUCTION
L
ife event research examines the effect of life events on psychological health and the course of psychiatric diseases. But almost all the literature considers negative experiences, particularly those of loss (death or separation from key persons, loss of self-esteem or narcissistic gratification). We report on two female patients who became depressed and had to be hospitalized for several months after winning millions in the lottery. Over a million Deutschmarks (*475,000 US$) are won 200 ± 300 times 1 each year in Germany, and Rodgers recently proposed to use the UK National Lottery to create a randomized trial to assess the influence of income on health improvement.2
CASE 1 The patient was born in 1957 in the former GDR, the youngest of three daughters of a nurse and a farmer. One of her older sisters suffered from depressive states not requiring treatment, while the father had been hospitalized for depression. Since her parents divorced shortly after her birth, the patient grew up with her two sisters and mother. She got
depression positive life events
married in 1975, divorced in 1982, but remarried the same man that year. The couple has two healthy sons. After completing training in business, the patient worked in the foreign trade office of the GDR. She described her mother as a strong and independent person, who was very strict and generally in a bad mood when she came back from work; the patient was afraid of her. By contrast, she idealized her father. She has a stable partnership with her husband. In contrast to her childhood experiences, her spouse cares about her and is sympathetic towards her. The patient suffered from a depressive episode in 1986 after requesting and obtaining leave of absence. The depression subsided without specific treatment after she went back to work. The foreign trade office was closed after the reunification of Germany, and then she had temporary part-time work as a saleswoman at a large store. She successfully improved her job situation by moving to the internal revenue office in mid-1992 but during her probationary period she became depressed again and required hospitalization for the first time. Her symptoms improved under treatment which included tricyclic antidepressants. She was discharged from hospital and initially remained unemployed.
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
184
S Nissle and T Bschor
At the end of 1992, the patient’s mother won DM 500 000 (*US$ 2 500 000 at that time or 1 800 000 today) in the lottery. The amount was divided among the three children, so that the patient received about DM 1M. On the basis of these winnings, the patient’s husband, who was previously employed as a foreman at a large industrial company, opened his own real estate business at the beginning of 1995. From that time, the patient worked in this office. Shortly thereafter, they lost about DM 100 000 through a business partner. Although this did not cause financial difficulties, the patient redeveloped a depressive syndrome, characterized by marked existential anxiety, lack of drive, feelings of inferiority and fear of the future, and had to stop working. In the autumn of 1996, the patient was hospitalized in the Department of Psychiatry of the Freie UniversitaÈt Berlin for 3 months.
CLINICAL FINDINGS The psychopathological examination revealed particularly marked financial worries and severe existential anxiety, in addition to her considerably depressed mood and a pronounced lack of drive. She had no delusions. Formal thought was retarded, and restricted to the abovementioned anxieties, as well as feelings of inferiority. The patient also reported suicidal thoughts and impulses, difficulty in falling asleep, interrupted sleep, and early waking, as well as a definite low point in the morning. There were no psychotic or cerebro-organic symptoms. Results of the physical examination, ECG, EEG and routine laboratory tests were normal. The patient’s depressive symptoms improved considerably under supportive psychotherapy, drug therapy with amitriptyline (up to 300 mg/day) and subsequent lithium augmentation, as well as sleep deprivation.
FOUR-YEAR FOLLOW-UP About 9 months after discharge, medication was gradually reduced, with no problems. The patient took part in weekly psychodynamic psychotherapy for about 3‰ years. There were no new episodes of depression. Results of the most recent psychopathological examination were normal. It is not possible to determine lifelong phases of (hypo-)mania. Since her hospitalization, the patient has not worked, but she can now consider working part-time. The couple’s financial situation is stable; her husband continues to work in his own real estate office. In retrospect, the patient regards winning in the lottery as a stroke of good luck, but it did not significantly change her life.
CASE 2 The patient was born in 1942 in Berlin, the oldest of three daughters of a cleaning woman and a truck driver. Her
parents divorced in 1951 and she grew up with her younger sisters and mother in West Berlin. Except for her mother’s winter depression, which did not require therapy, the family psychiatric history was normal. After dropping out of a tailoring apprenticeship, the patient was employed as an industrial worker. In 1963, she got married and had a daughter; two years later, she had another healthy daughter. After 8 years as a housewife and mother, she started unskilled work at a hospital in 1971. Her husband has run a newspaper and lottery shop for 25 years. According to the patient’s own report, there was little emotion in her relationship with either her mother or her father. The father was violent towards her mother and herself. After the divorce of her parents when she was aged nine, there was no contact between her and her father for 20 years. She always felt that her mother preferred the other two sisters. She accuses her of only caring about the school progress of the sisters, and therefore being responsible for the patient having to repeat one year at school. As the oldest of the three daughters, she had a lot of housekeeping duties. Tenderness was scarce in her family. Later on, in her own family, she had a comparable function, spending most of the time outside her work caring for her two daughters and five grandchildren, but rather neglecting her own needs. The partnership with her husband is stable. He expressed astonishment about her depression, because he always knew his wife as being tough in managing life. Due to changing somatic symptoms (e.g. headache and stomach ache), she has occasionally received fluspirilene injections (1.5 mg i.m.) from a psychiatrist in private practice since 1993. In December 1994, she and her husband won DM 1 600 000 (over US$ 1 000 000 at that time or 820 000 today) in the lottery. The couple had played lotto regularly, spending an average of 10 DM a week. The patient suffered her first depressive episode during a vacation in Mallorca in January 1995, but it subsided spontaneously without any specific treatment. She then developed agoraphobic symptoms, showing anxiety in crowds (department stores, subways, crowded elevators, festivals) and increasing avoidance behaviour. In July 1996, she began outpatient behavioural therapy and drug treatment with trimipramine (75 mg/d) and alprazolam (initially 0.5 mg/d). She rapidly developed a secondary benzodiazepine dependency. Her anxiety symptoms increased when the couple decided to use the lottery winnings to build a house. Building began in the middle of 1996. The patient considered the building-related tasks to be extremely stressful. In mid-December 1996, she again suffered from depression, with severely interrupted sleep, obsessive rumination about the seemingly insurmountable problems related to their building plans, and obsessive thoughts of suicide. She was hospitalized for 3 months in the Department of Psychiatry of the Freie UniversitaÈt Berlin.
Winning the jackpot and depression: money cannot buy happiness
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
CLINICAL FINDINGS In the psychopathological examination, the patient showed psychomotor and inner restlessness, with vague feelings of anxiety, in addition to a helpless depressed mood. The agoraphobic symptoms continued. Affective modulation was considerably reduced. Besides pressured thinking and obsessive preoccupations, formal thought was restricted to feelings of inferiority and guilt. The patient had no delusions. There was a latent suicidal potential. She also had difficulty falling asleep, and suffered from interrupted sleep, with early wakening and a morning low. There was no indication of psychotic or cerebro-organic symptoms. Results of the physical examination, ECG, EEG and routine laboratory values were normal.
THERAPY During her hospitalization, the patient underwent benzodiazepine withdrawal and started antidepressant therapy with fluoxetine. The depressive symptoms clearly subsided with this treatment. The patient interpreted her (predominantly morning) persistent shaking with inner agitation as a side-effect of the medication, and insisted on discontinuing the antidepressant after 12 weeks of administration. She underwent inpatient behavioural therapy for her anxiety disorder and was able to control her agoraphobia well. She was discharged in a stabilized condition without specific medication.
FOUR-YEAR FOLLOW-UP After discharge, the patient continued behavioural therapy once a week for another 2 years. The only psychotropic medication that she has received since her hospitalization has been fluspirilene injections (1.5 mg i.m.) at irregular intervals, when the aforementioned somatic pain occurs. She has not taken any benzodiazepine since that time. She has had neither depression nor anxiety symptoms. Results of her most recent psychopathological assessment were normal. The couple still live in their house. The youngest daughter was given a piece of their land and, with her husband, is building her own house, using their own money. The patient has not worked since being hospitalized. In retrospect, the patient regards her winning the lottery as a stroke of luck that could not be enjoyed. Apart from the fact that she was able to build her own home, her life has not changed.
DISCUSSION Both these patients became ill after winning the lottery, i.e. after a positive and desired event. Common to both patients is a rather cold-hearted family atmosphere in childhood,
185
including the absence of the father, and that they suffered from psychological symptoms before winning the lottery. A phasic, monopolar affective disorder, with a family history positive for recurrent depression, was diagnosed in the first patient. It is notable that the previous two depressive episodes occurred at the same time as preferred life changes. In each case, the patient was able to successfully realize a desired change in her work situation. On the other hand, she did not suffer from depression after losing her job subsequent to the German reunification. In the long-term view, the second patient did not have a phasic disorder with complete remission but rather a chronic mixed clinical picture consisting of somatization, anxiety and substance dependency. With outpatient therapy, however, she was able to have a stable occupational and family life. She developed severe depression with acute suicidal potential only after winning the lottery, when she required inpatient psychiatric treatment for the first and only time. Common to both patients was the fact that they were not hospitalized directly after winning the lottery, but only in connection with the plans engendered by the money and their realization. Thus, it should be considered whether it was not so much the prospect of unexpected winnings but the fear of failing at self-imposed projects, i.e. the hidden risk behind the newly won possibilities, that caused the outbreak of the depression. Four-year follow-ups after inpatient treatment showed both patients were well stabilized. Numerous studies from the 1960s to the 1980s have regularly demonstrated that sufferers from a psychiatric disorder have had an increase in life events in the preceding 6 months (particularly the last month), compared to control populations. This is truest for depressive disorders and suicide attempts (for review see Paykel3 ). Paykel calculated that the risk of becoming depressed was six 4 times higher in the 6 months after a highly stressful event. Although (according to Paykel) a `life event’ is defined as an identifiable, usually abrupt, change in the external social and personal environment of an individual, classical life event research considers almost only negative experiences. The only case descriptions, primarily from a psychoanalytical viewpoint, are of four male patients, who developed anxious-depressive syndromes due to promotion.5 In a remarkable recent investigation, Gardner and Oswald6 assumed a positive correlation between increase in income and happiness and came to the conclusion that a windfall of approximately 1M £ sterling (1.5 M US$) is needed to move a person from close to the bottom of a happiness frequency distribution to close to the top. In 1978, Brickman and colleagues published a survey of 7 22 major lottery winners. They were systematically interviewed not with regard to psychological illness, but with regard to happiness, and were compared with a group of controls and a group of paralysed accident victims. The lottery winners were not happier than the controls, but experienced less satisfaction from everyday events. The
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
186
S Nissle and T Bschor
accident victims rated their present happiness lower, but their past happiness (before the accident) higher, than the controls. The results were explained in terms of the adaptation level theory, which states that people’s judgements of current levels of pleasure depend upon their history of experienced joy. As a result (according to adaptation level theory), the effects of a windfall such as winning a million in the lottery are weakened first of all by a contrast effect, that lessens the pleasure found in mundane events, and, in time, by a process of habituation 7 to the new, more comfortable situation. In their study in two groups of 185 subjects published in 1969, Paykel and colleagues found a predominance of negative, but not positive, life events in the group of depressives, as compared to matched individuals of the 8 general population. Almost all subsequent studies, however, focused only on experiences of loss such as death or separation from an important reference person, the loss of body parts or place of employment. Marriage problems, family conflicts or financial difficulties were also recorded. Life events questionnaires, e.g. that developed and 9 validated by Brugha and Cragg, do usually not include positive life events. However, parallels after negative life events could be found in the life situations of both our patients. Unexpectedly winning millions is in itself a dramatic change to the life situation to which one is accustomed and has imagined will continue to its conclusion, and the magnitude of this change may even equal that of events of severe loss. On the other hand, of course, several important factors, such as the winner’s families or other key persons,
remain constant. In a systematic interview of 22 major lottery winners, only 23% stated that their lifestyle in general had changed.7 In addition, it is well-known from life event research (with negative experiences) that persistent vulnerability factors clearly increase the risk of 3 reacting to a stress situation with a depressive syndrome. As presented, the psychiatric history of the two patients we reviewed, before they won money, shows that such factors do seem to exist: of a rather endogenous character in patient 1 and of a rather neurotic one in patient 2. On the basis of the now revised classification into endogenous and reactive or neurotic, it has repeatedly been shown that the effect of life-altering events on the disease course is not associated with a particular subtype of depression.3 Just as the above definition of life event fits very well with the winning of millions, the histories of the two patients whose cases are described suggest that research findings on the effect of negative life events may also be valid for unexpected positive events. Future studies examining lottery winners without a history of psychiatric illness are needed to obtain a fuller picture.
KEY POINTS . Desirable or positive life events might influence the course of a psychiatric illness just as do negative ones
REFERENCES 1. Der Spiegel 25, 13 June 2000 [German weekly newspaper]. Spiegel-Verlag, Hamburg. 2. Rodgers A (2001) Income, health, and the National Lottery. Br Med J 323: 1438 ± 9. 3. Paykel ES (2001) The evolution of life events research in psychiatry. J Affect Disord 62: 141 ± 9. 4. Paykel ES (1978) Contribution of life events to causation of psychiatric illness. Psychol Med 8: 245 ± 53. 5. Perris C, Espvall M (1973) Depressive-type psychic reactions caused by success. Psychiatr Clin (Basel) 6: 346 ± 56. 6. Gardner J, Oswald A (2001) Does money buy happiness? A longitudinal study using data on windfalls. University of Warwick Economics Department Research Paper. http:// www.warwick.ac.uk/fac/soc/Economics/oswald/marchwindfallsGO.pdf
7. Brickman P, Coates D, Janoff-Bulman R (1978) Lottery winners and accident victims: is happiness relative? J Pers Soc Psychol 36: 917 ± 27. 8. Paykel ES, Myers JK, Dienelt MN et al (1969) Life events and depression. A controlled study. Arch Gen Psychiatry 21: 753 ± 60. 9. Brugha TS, Cragg D (1990) The List of Threatening Experiences: the reliability and validity of a brief life events questionnaire.Acta Psychiatr Scand 82: 77 ± 81.
2002 Martin Dunitz Ltd
International Journal of Psychiatry in Clinical Practice 2002 Volume 6 Pages 183 ± 186
183
Winning the jackpot and depression: Money cannot buy happiness SONJA NISSLEÂ AND 2 TOM BSCHOR 1
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
1
Department of Neurology, Cantonal Hospital 2 of Aarau, Aarau, Switzerland; Department of Psychiatry, Technische UniversitaÈt Dresden, Dresden, Germany
Correspondence Address Dr. Tom Bschor, Department of Psychiatry, Technische UniversitaÈt Dresden, Fetscherstrasse 74, D-01307 Dresden, Germany. Tel: +49-351-458 3595 +49-351-458 2797 Fax: +49-351-458 5316 E-mail: [email protected]
Received 6 February 2002, revised 13 June 2002, accepted for publication 19 June 2002
Life event research examines the effect of life events on the course of psychiatric diseases, but the published literature considers almost only negative events. We describe the cases of two female patients who had to be hospitalized for depression after lottery winnings of over 1M DM. The 4-year follow-up shows a good outcome in both patients. Case analyses suggest that in both patients, winning was a life event relevant to the development of the depressive episode. Desirable life events might influence the course of a psychiatric illness just as negative events do. (Int J Psych Clin Pract 2002; 6: 183 ± 186)
Keywords life events lottery
INTRODUCTION
L
ife event research examines the effect of life events on psychological health and the course of psychiatric diseases. But almost all the literature considers negative experiences, particularly those of loss (death or separation from key persons, loss of self-esteem or narcissistic gratification). We report on two female patients who became depressed and had to be hospitalized for several months after winning millions in the lottery. Over a million Deutschmarks (*475,000 US$) are won 200 ± 300 times 1 each year in Germany, and Rodgers recently proposed to use the UK National Lottery to create a randomized trial to assess the influence of income on health improvement.2
CASE 1 The patient was born in 1957 in the former GDR, the youngest of three daughters of a nurse and a farmer. One of her older sisters suffered from depressive states not requiring treatment, while the father had been hospitalized for depression. Since her parents divorced shortly after her birth, the patient grew up with her two sisters and mother. She got
depression positive life events
married in 1975, divorced in 1982, but remarried the same man that year. The couple has two healthy sons. After completing training in business, the patient worked in the foreign trade office of the GDR. She described her mother as a strong and independent person, who was very strict and generally in a bad mood when she came back from work; the patient was afraid of her. By contrast, she idealized her father. She has a stable partnership with her husband. In contrast to her childhood experiences, her spouse cares about her and is sympathetic towards her. The patient suffered from a depressive episode in 1986 after requesting and obtaining leave of absence. The depression subsided without specific treatment after she went back to work. The foreign trade office was closed after the reunification of Germany, and then she had temporary part-time work as a saleswoman at a large store. She successfully improved her job situation by moving to the internal revenue office in mid-1992 but during her probationary period she became depressed again and required hospitalization for the first time. Her symptoms improved under treatment which included tricyclic antidepressants. She was discharged from hospital and initially remained unemployed.
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
184
S Nissle and T Bschor
At the end of 1992, the patient’s mother won DM 500 000 (*US$ 2 500 000 at that time or 1 800 000 today) in the lottery. The amount was divided among the three children, so that the patient received about DM 1M. On the basis of these winnings, the patient’s husband, who was previously employed as a foreman at a large industrial company, opened his own real estate business at the beginning of 1995. From that time, the patient worked in this office. Shortly thereafter, they lost about DM 100 000 through a business partner. Although this did not cause financial difficulties, the patient redeveloped a depressive syndrome, characterized by marked existential anxiety, lack of drive, feelings of inferiority and fear of the future, and had to stop working. In the autumn of 1996, the patient was hospitalized in the Department of Psychiatry of the Freie UniversitaÈt Berlin for 3 months.
CLINICAL FINDINGS The psychopathological examination revealed particularly marked financial worries and severe existential anxiety, in addition to her considerably depressed mood and a pronounced lack of drive. She had no delusions. Formal thought was retarded, and restricted to the abovementioned anxieties, as well as feelings of inferiority. The patient also reported suicidal thoughts and impulses, difficulty in falling asleep, interrupted sleep, and early waking, as well as a definite low point in the morning. There were no psychotic or cerebro-organic symptoms. Results of the physical examination, ECG, EEG and routine laboratory tests were normal. The patient’s depressive symptoms improved considerably under supportive psychotherapy, drug therapy with amitriptyline (up to 300 mg/day) and subsequent lithium augmentation, as well as sleep deprivation.
FOUR-YEAR FOLLOW-UP About 9 months after discharge, medication was gradually reduced, with no problems. The patient took part in weekly psychodynamic psychotherapy for about 3‰ years. There were no new episodes of depression. Results of the most recent psychopathological examination were normal. It is not possible to determine lifelong phases of (hypo-)mania. Since her hospitalization, the patient has not worked, but she can now consider working part-time. The couple’s financial situation is stable; her husband continues to work in his own real estate office. In retrospect, the patient regards winning in the lottery as a stroke of good luck, but it did not significantly change her life.
CASE 2 The patient was born in 1942 in Berlin, the oldest of three daughters of a cleaning woman and a truck driver. Her
parents divorced in 1951 and she grew up with her younger sisters and mother in West Berlin. Except for her mother’s winter depression, which did not require therapy, the family psychiatric history was normal. After dropping out of a tailoring apprenticeship, the patient was employed as an industrial worker. In 1963, she got married and had a daughter; two years later, she had another healthy daughter. After 8 years as a housewife and mother, she started unskilled work at a hospital in 1971. Her husband has run a newspaper and lottery shop for 25 years. According to the patient’s own report, there was little emotion in her relationship with either her mother or her father. The father was violent towards her mother and herself. After the divorce of her parents when she was aged nine, there was no contact between her and her father for 20 years. She always felt that her mother preferred the other two sisters. She accuses her of only caring about the school progress of the sisters, and therefore being responsible for the patient having to repeat one year at school. As the oldest of the three daughters, she had a lot of housekeeping duties. Tenderness was scarce in her family. Later on, in her own family, she had a comparable function, spending most of the time outside her work caring for her two daughters and five grandchildren, but rather neglecting her own needs. The partnership with her husband is stable. He expressed astonishment about her depression, because he always knew his wife as being tough in managing life. Due to changing somatic symptoms (e.g. headache and stomach ache), she has occasionally received fluspirilene injections (1.5 mg i.m.) from a psychiatrist in private practice since 1993. In December 1994, she and her husband won DM 1 600 000 (over US$ 1 000 000 at that time or 820 000 today) in the lottery. The couple had played lotto regularly, spending an average of 10 DM a week. The patient suffered her first depressive episode during a vacation in Mallorca in January 1995, but it subsided spontaneously without any specific treatment. She then developed agoraphobic symptoms, showing anxiety in crowds (department stores, subways, crowded elevators, festivals) and increasing avoidance behaviour. In July 1996, she began outpatient behavioural therapy and drug treatment with trimipramine (75 mg/d) and alprazolam (initially 0.5 mg/d). She rapidly developed a secondary benzodiazepine dependency. Her anxiety symptoms increased when the couple decided to use the lottery winnings to build a house. Building began in the middle of 1996. The patient considered the building-related tasks to be extremely stressful. In mid-December 1996, she again suffered from depression, with severely interrupted sleep, obsessive rumination about the seemingly insurmountable problems related to their building plans, and obsessive thoughts of suicide. She was hospitalized for 3 months in the Department of Psychiatry of the Freie UniversitaÈt Berlin.
Winning the jackpot and depression: money cannot buy happiness
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
CLINICAL FINDINGS In the psychopathological examination, the patient showed psychomotor and inner restlessness, with vague feelings of anxiety, in addition to a helpless depressed mood. The agoraphobic symptoms continued. Affective modulation was considerably reduced. Besides pressured thinking and obsessive preoccupations, formal thought was restricted to feelings of inferiority and guilt. The patient had no delusions. There was a latent suicidal potential. She also had difficulty falling asleep, and suffered from interrupted sleep, with early wakening and a morning low. There was no indication of psychotic or cerebro-organic symptoms. Results of the physical examination, ECG, EEG and routine laboratory values were normal.
THERAPY During her hospitalization, the patient underwent benzodiazepine withdrawal and started antidepressant therapy with fluoxetine. The depressive symptoms clearly subsided with this treatment. The patient interpreted her (predominantly morning) persistent shaking with inner agitation as a side-effect of the medication, and insisted on discontinuing the antidepressant after 12 weeks of administration. She underwent inpatient behavioural therapy for her anxiety disorder and was able to control her agoraphobia well. She was discharged in a stabilized condition without specific medication.
FOUR-YEAR FOLLOW-UP After discharge, the patient continued behavioural therapy once a week for another 2 years. The only psychotropic medication that she has received since her hospitalization has been fluspirilene injections (1.5 mg i.m.) at irregular intervals, when the aforementioned somatic pain occurs. She has not taken any benzodiazepine since that time. She has had neither depression nor anxiety symptoms. Results of her most recent psychopathological assessment were normal. The couple still live in their house. The youngest daughter was given a piece of their land and, with her husband, is building her own house, using their own money. The patient has not worked since being hospitalized. In retrospect, the patient regards her winning the lottery as a stroke of luck that could not be enjoyed. Apart from the fact that she was able to build her own home, her life has not changed.
DISCUSSION Both these patients became ill after winning the lottery, i.e. after a positive and desired event. Common to both patients is a rather cold-hearted family atmosphere in childhood,
185
including the absence of the father, and that they suffered from psychological symptoms before winning the lottery. A phasic, monopolar affective disorder, with a family history positive for recurrent depression, was diagnosed in the first patient. It is notable that the previous two depressive episodes occurred at the same time as preferred life changes. In each case, the patient was able to successfully realize a desired change in her work situation. On the other hand, she did not suffer from depression after losing her job subsequent to the German reunification. In the long-term view, the second patient did not have a phasic disorder with complete remission but rather a chronic mixed clinical picture consisting of somatization, anxiety and substance dependency. With outpatient therapy, however, she was able to have a stable occupational and family life. She developed severe depression with acute suicidal potential only after winning the lottery, when she required inpatient psychiatric treatment for the first and only time. Common to both patients was the fact that they were not hospitalized directly after winning the lottery, but only in connection with the plans engendered by the money and their realization. Thus, it should be considered whether it was not so much the prospect of unexpected winnings but the fear of failing at self-imposed projects, i.e. the hidden risk behind the newly won possibilities, that caused the outbreak of the depression. Four-year follow-ups after inpatient treatment showed both patients were well stabilized. Numerous studies from the 1960s to the 1980s have regularly demonstrated that sufferers from a psychiatric disorder have had an increase in life events in the preceding 6 months (particularly the last month), compared to control populations. This is truest for depressive disorders and suicide attempts (for review see Paykel3 ). Paykel calculated that the risk of becoming depressed was six 4 times higher in the 6 months after a highly stressful event. Although (according to Paykel) a `life event’ is defined as an identifiable, usually abrupt, change in the external social and personal environment of an individual, classical life event research considers almost only negative experiences. The only case descriptions, primarily from a psychoanalytical viewpoint, are of four male patients, who developed anxious-depressive syndromes due to promotion.5 In a remarkable recent investigation, Gardner and Oswald6 assumed a positive correlation between increase in income and happiness and came to the conclusion that a windfall of approximately 1M £ sterling (1.5 M US$) is needed to move a person from close to the bottom of a happiness frequency distribution to close to the top. In 1978, Brickman and colleagues published a survey of 7 22 major lottery winners. They were systematically interviewed not with regard to psychological illness, but with regard to happiness, and were compared with a group of controls and a group of paralysed accident victims. The lottery winners were not happier than the controls, but experienced less satisfaction from everyday events. The
Int J Psych Clin Pract Downloaded from informahealthcare.com by Nyu Medical Center on 11/03/14 For personal use only.
186
S Nissle and T Bschor
accident victims rated their present happiness lower, but their past happiness (before the accident) higher, than the controls. The results were explained in terms of the adaptation level theory, which states that people’s judgements of current levels of pleasure depend upon their history of experienced joy. As a result (according to adaptation level theory), the effects of a windfall such as winning a million in the lottery are weakened first of all by a contrast effect, that lessens the pleasure found in mundane events, and, in time, by a process of habituation 7 to the new, more comfortable situation. In their study in two groups of 185 subjects published in 1969, Paykel and colleagues found a predominance of negative, but not positive, life events in the group of depressives, as compared to matched individuals of the 8 general population. Almost all subsequent studies, however, focused only on experiences of loss such as death or separation from an important reference person, the loss of body parts or place of employment. Marriage problems, family conflicts or financial difficulties were also recorded. Life events questionnaires, e.g. that developed and 9 validated by Brugha and Cragg, do usually not include positive life events. However, parallels after negative life events could be found in the life situations of both our patients. Unexpectedly winning millions is in itself a dramatic change to the life situation to which one is accustomed and has imagined will continue to its conclusion, and the magnitude of this change may even equal that of events of severe loss. On the other hand, of course, several important factors, such as the winner’s families or other key persons,
remain constant. In a systematic interview of 22 major lottery winners, only 23% stated that their lifestyle in general had changed.7 In addition, it is well-known from life event research (with negative experiences) that persistent vulnerability factors clearly increase the risk of 3 reacting to a stress situation with a depressive syndrome. As presented, the psychiatric history of the two patients we reviewed, before they won money, shows that such factors do seem to exist: of a rather endogenous character in patient 1 and of a rather neurotic one in patient 2. On the basis of the now revised classification into endogenous and reactive or neurotic, it has repeatedly been shown that the effect of life-altering events on the disease course is not associated with a particular subtype of depression.3 Just as the above definition of life event fits very well with the winning of millions, the histories of the two patients whose cases are described suggest that research findings on the effect of negative life events may also be valid for unexpected positive events. Future studies examining lottery winners without a history of psychiatric illness are needed to obtain a fuller picture.
KEY POINTS . Desirable or positive life events might influence the course of a psychiatric illness just as do negative ones
REFERENCES 1. Der Spiegel 25, 13 June 2000 [German weekly newspaper]. Spiegel-Verlag, Hamburg. 2. Rodgers A (2001) Income, health, and the National Lottery. Br Med J 323: 1438 ± 9. 3. Paykel ES (2001) The evolution of life events research in psychiatry. J Affect Disord 62: 141 ± 9. 4. Paykel ES (1978) Contribution of life events to causation of psychiatric illness. Psychol Med 8: 245 ± 53. 5. Perris C, Espvall M (1973) Depressive-type psychic reactions caused by success. Psychiatr Clin (Basel) 6: 346 ± 56. 6. Gardner J, Oswald A (2001) Does money buy happiness? A longitudinal study using data on windfalls. University of Warwick Economics Department Research Paper. http:// www.warwick.ac.uk/fac/soc/Economics/oswald/marchwindfallsGO.pdf
7. Brickman P, Coates D, Janoff-Bulman R (1978) Lottery winners and accident victims: is happiness relative? J Pers Soc Psychol 36: 917 ± 27. 8. Paykel ES, Myers JK, Dienelt MN et al (1969) Life events and depression. A controlled study. Arch Gen Psychiatry 21: 753 ± 60. 9. Brugha TS, Cragg D (1990) The List of Threatening Experiences: the reliability and validity of a brief life events questionnaire.Acta Psychiatr Scand 82: 77 ± 81.
