Depression and Bipolar info explaining the latest research in everyday English

1Oct/13Off

Bipolar in the new DSM-5

Windpump. Copyright Lee Hopkins 2015

The DSM-5 sees greater clarity in how Bipolar Disorder is viewed. There is now less risk of seeing oneself put in a vague NOS ‘not otherwise specified’ group, and several new subthreshold groups of depression, bipolar disorders and mixed states are now operationally defined.

These subthreshold groups will stimulate research and allow for a more dimensional view of Bipolar Disorder and Depression. For depression, for example, recurrent brief depression and even short-duration depressive episodes (4 to 13 days), as well as 2-week episodes with insufficient symptoms, now have their place.

But, for no apparent reason, DSM-5 classifies some patients as having subthreshold bipolar disorders who would formerly have been diagnosed with manic episodes or bipolar I or II disorders.

It is estimated that DSM-5 bipolar II disorder will be diagnosed about twice as often as it has previously been and will have a prevalence approaching that of bipolar I. A more frequent diagnosis of bipolar II disorder is both justified and logical: a milder condition (in this case hypomania) is usually more prevalent than a severe one (mania). Over the long-term course of their illness, bipolar patients spend much more time in milder conditions, mainly minor depression, than in major syndromes (Phillips and Kupfer 2013).

Overall, then, the growth of bipolar II disorder into a disorder recognised in its own right, rather than a ‘lite’ version of bipolar I disorder, will continue.

-------------------

Angst, J. 2013. Bipolar disorders in DSM-5: strengths, problems and perspectives. International Journal of Bipolar Disorders 2013, 1:12

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12Oct/11Off

Bipolar disorder from the clinician’s perspective

I recently came across this great video by Dr. Jeffrey Applebaum, a Family Medicine physician at UC Davis in the USA. He provides a cool, calm look at Bipolar Disorder and seems to 'get it'. Well worth the watch.


Depression from the clinician\'s perspective

4Jan/11Off

When to suspect bipolar disorder

The Journal of Family Practice has a useful practitioner’s guide to identifying when a patient may be presenting with bipolar disorder symptoms.

As the authors say, bipolar disease is often misdiagnosed, sometimes repeatedly.

The authors—Muruga Loganathan, MD, Kavita Lohano, MD, R. Jeanie Roberts, MD, Yonglin Gao, MD, and Rif S. El-Mallakh, MD—report that close to one-third of patients with bipolar disorder seek medical care within a year of the onset of symptoms, but nearly 70% do not receive an accurate diagnosis until they’ve seen four physicians.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines 4 types of bipolar illness: bipolar I, bipolar II, cyclothymia (the most mild form), and not otherwise specified The key feature of all 4 types—and the distinguishing characteristic that diagnosis typically hinges on—is a manic or hypomanic episode.

Although a full-blown manic episode may not be hard to identify, hypomania is easily missed. By definition, hypomania—with its heightened sense of well-being and productivity—is not problematic and is rarely a patient’s primary complaint.

Mixed mania, a feature of bipolar I, is the worst of both worlds: It is a state in which a full manic episode is superimposed on a full depressive episode—a depression with all the energy and force of a mania. Patients who have experienced one episode of mixed mania have a 12-fold increase in mixed states, 6.5 times more depression, and 1.7 times more dysthymia than those who experience manic episodes without the overlay of depression.

I and countless others can attest as to how horrible it is.

The authors recommend using the Mood Disorder Questionnaire (MDQ) constructed by Hirschfeld et al. as a useful guide to bipolar disorder identification. There’s a copy of the MDQ in the JFP’s article, as well as the original source article.

If you or someone you know is wondering if they might have bipolar disorder (and one psychiatrist I know of is convinced that all ‘depressive’ patients have an element of mania within their history and should therefore be considered in a new, bipolar, light) then ask their GP to administer the MDQ, or refer them to someone who can.

It could be the help they need to get them on the path to managing their illness appropriately.

Sources:

Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry.
2000;157:1873-1875.

Loganathan, Muruga; Lohano, Kavita; Roberts, R. Jeanie; Yonglin Gao; El-Mallakh, Rif S.  When to suspect bipolar disorder. Journal of Family Practice, Dec2010, Vol. 59 Issue 12, p682-688, 7p


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1Sep/10Off

A review of findings from the world’s largest study of Bipolar Disorder

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) ran from 1998 to 2005, with over 4,000 sufferers of Bipolar Disorder (BD) taking part in various trials and assessments over a two-year period.

Researchers were looking at how BD progresses through a person's life, how related it is to other psychiatric disorders, and how related it is to suicidality.

It found that few treatments alone were successful in treating BD, however psycho-social interventions (such as Cognitive Behaviour Therapy) and psycho-education interventions combined with mood stabilizers showed the most positive results.

BD was also shown to be strongly related to substance abuse and smoking, both of which affected the success or otherwise of chemical and psychological treatments.

Interestingly, paroxetine or bupropion were shown to be no more effective than a placebo in achieving sustained recovery (in this instance, determined as eight weeks of 'stable' behavior). So, too, were lamotrigine, risperidone, and inositol found to deliver minimal positive effects.

To the vexed, 'hidden', taboo subject of suicide -- the 'S' word not spoken of by the media (although thankfully that is slowly changing, at least in Australia). Suicidality persists with BD, even when treatment outcomes are good. The biggest predictor of suicidality being previous attempts.

The authors' conclusions
The authors of this review paper note seven contributions of the STEP-BD program:

1. Antidepressants remain poorly effective in treating BD;

2. BD is particularly disabling (tell me about it), and frequently doesn't respond to medications;

3. BD does respond modestly to intensive psycho-social interventions;

4. Other psychiatric disorders are common and destabilizing, yet anxiety disorders and smoking are able to be treated and when treated positively impact on BD;

5. An early age on onset of BD usually results in a more severe course of the illness, but rapid-cycling usually diminishes;

6. The sub-syndrome of Depression may be so strong as to mask the manic pole of BD, therefore careful symptom appraisal by psychiatrists is essential;

7. Suicidal thoughts persist in BD sufferers, and a previous attempt is a good indicator of a future event. However, by reducing feelings of 'hopelessness' in particular, there is the possibility of reducing the risk of suicide.

 

Source: Parikh, S.V., LeBlanc, S.R., & Ovanessian, M.M. 2010. Advancing Bipolar Disorder: Key Lessons From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The Canadian Journal of Psychiatry, Vol. 55, No 3, p.p. 136-143.

 


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23Aug/10Off

Creativity in Bipolar Disorder – are we all geniuses?

Actually, no. Sorry to burst a bubble.

It’s a good myth – that Bipolar Disorder (BD) sufferers are creative types that can burn the midnight candle and produce work that changes the world. Unfortunately, too much clinical evidence exists that points out extreme mania in BD is actually counter-productive to creative output. You might be outputting lots of work, but the quality is probably less than you would accept in normal circumstances.

Greg Murray and Sheri L. Johnson have reviewed the medical literature on BD and creativity and give us some interesting results:

  • Only 8-10% of BD sufferers can be considered ‘creative’ (put down that brush, Eugene);
  • There is an association between the psychological trait of ‘openness to new experiences’ (O) and BD, as there is with ‘psychoticism’ (P), suggesting that not only are BD sufferers more likely to be impulsive and take risks in order to do something different, but they are also more likely than the general populace to occasionally lace their impulsivity with a disregard for others;
  • If you suffer from BD and are strongly extrovert, you may well be drawn to the performance arts if you do have that creative bent;
  • Many of the creative professions can be counter-productive to the mental wellbeing of sufferers, because of disruption of sleeping patterns, irregular activity/work patterns, exposure to alcohol and narcotics, challenges to goals that are often set extremely high, an unusually strong identification with one’s occupation that allows no other income/lifestyle choice, and increased reinforcement of emotional sensitivity.

So what hope is there for creative types who have BD? Murray and Johnson suggest that we:

  • Continue our medication regime;
  • Where possible, limit the amount of travel, especially across time zones;
  • Find a psychoeducation program that will help us recognise our symptoms of mania and depression, recognise the triggers behind them and help us discover what we can do for ourselves to keep ourselves more stable;
  • Consider Interpersonal and Social Rhythm Therapy if our schedules involve intense sleep disruption or travel;
  • Consider signing up for a Cognitive Behavioural Therapy (CBT) course that will allow us to examine our thoughts and re-appraise unproductive core beliefs; and finally
  • Get some Family Focused Therapy so that we and our families can work together to manage our illness and its expression (especially because creativity seems to run in families and just because one member of the family has BD doesn’t mean that they’re alone).

Source: Murray, G. & Johnson, S.L. 2010 The clinical significance of creativity in bipolar disorder. Clinical Psychology Review 30(2010), pp.721-732


Please see our medical disclaimer.

 

7Aug/10Off

Psychoeducation intervention for bipolar sufferers

I recently completed a 10-session therapy course for bipolar suffers and can attest to the help that such courses can offer.

The course first looked at the causes of bipolar disorder, what medical treatments are available, then moved on to the individual experiences involved, including identifying triggers and relief behaviours.

Each of the sessions lasted for three hours, including a mid-session tea/coffee break, and comprised not only individual self-assessment exercises but also group discussions where we shared our experiences – the frustrations and the benefits – of our bipolar lives.

I’m sure you can understand that the ‘frustrations’ far outweighed the ‘benefits’.

But even after only 12 weeks after the end of the course I find it difficult to remember any of the material we explored, suggesting that repeat, follow-up sessions would be advantageous. Naturally, no such sessions exist because there’s no funding for them in the Australian mental health system.

Emily Griffiths and David Smith from the department of psychological medicine at the University Hospital of Wales have briefly outlined in Mental Health Practice some of the findings their own research has uncovered into psychoeducation.

Psychoeducation, they say:

involves providing clients and their families with accurate and reliable information about their diagnosis to empower them to better manage their illness.

In the course I attended there was no space for family members, nor do I think they would have been invited – self-disclosure amongst peers is fraught enough with risk; disclosing our experience of our illness to non-sufferers would have potentially generated emotional responses no one would have welcomed. As it was, of the two facilitators our group had only one was a psychologist; the mental health-trained nurse seemed less flexible and less able to comprehend – other than academically/intellectually – our psychic pain.

Griffith & Smith’s group sessions involve:

  • Introduction
  • Diagnosis of bipolar disorder
  • Causes of bipolar disorder
  • Rôle of medication
  • Rôle of lifestyle changes
  • Relapse prevention and early intervention
  • Psychological approaches
  • Women and bipolar disorder
  • Advice for family and carers
  • Conclusions

They go on to point out that the mood disorders research team at their department has developed an online interactive psychoeducational tool for bipolar disorder, currently undergoing clinical trial with a view to becoming a cost-effective way of delivering high quality education to large numbers of bipolar sufferers. You can find the tool at BeatingBipolar.org.

You can also find out more about the Hospital’s bipolar programme at bep-c.org.


Source: Griffiths, S. & Smith, D. 2010. Psychoeducation intervention for people with bipolar disorder. Mental Health Practice, 13, 9, pp. 22-23.

11Jan/10Off

The hardest post I will ever write?

the double helix splits and colours me with strong shades of night and day - and nothing in-between. Image from http://bipolar.hs.columbia.edu/This may be the hardest post I will ever to have write.

In a way, I am ‘coming out’.

No, I am not gay (although my best man at my wedding was; and so was his partner – what are the odds?!).

I have Bipolar Disorder I.

There, I said it. Publicly [phew!].

No, I don’t want pity, nor do I want to be excluded from events because someone with little or no knowledge of mental disease is worried I’ll do something dangerously psychotic (I’m not psychotic, I can assure you).

Here’s what Beyond Blue say about Bipolar Disorder:

Bipolar disorder, which used to be called manic depression, involves both periods of feeling low (depressed) and high (mania). 

Most people experience a range of moods depending on what's happening in their lives. When good things happen, like getting a new job, going on a holiday or falling in love, it's natural to feel happy. On the other hand, when there are difficulties like losing a job or a loved one, having money or family problems, it can make a person feel down. 

However, people with bipolar disorder experience extreme moods that can change regularly and may not relate to what is happening in their lives, although their mood swings may be triggered by certain events. For more information see What puts a person at Risk?

[Sydney’s Black Dog Institute is another excellent resource, as is NIMH]

What happens with me is that I can be delightful and witty and engaging one day, sunk in despair the next, maxing out the credit cards on day three, back into despair on day four, and on and on. At this stage of my just-started treatment there is little of the ‘middle ground’ that the vast majority of the population would call a ‘normal’ day.

I cycle fast through the ups and downs because I have been undiagnosed and therefore untreated for so many decades and my brain now ‘rapid cycles’, which means I could be in a ‘blue funk’ one day and buying flowers for all the women in Adelaide the next.

My emotional palette has hues far richer and more subtly nuanced than the average person could ever possibly believe; the ‘highs’ are intoxicating in their beauty and joy – everything glows with beauty, enthusiasm and positivity, my thought race at twice (if not more) the speed of the common man, I am more creative, more bottom-spankingly brilliant than just about anyone else around me.

If only I could permanently live in that ‘hypo’ state, but alas I can’t. The ‘mini-highs’ mutate into mania – where thoughts run too fast to capture, where irritation starts to become outright anger, where sleep is what ‘mere mortals’ do.

After which, of course, comes the inevitable ‘crash’. As in science, what goes up must come down; the higher the flight, the deeper and longer the trudge through the valley floor.

My depths are soul-wrenching and almost beyond bearance. In fact, sufferers of bipolar disorder have a vastly higher rate of suicide than the ‘common man’. You’re not going to convince me that Albinoni’s famous ‘Adagio’ wasn’t written when the man was sobbing his heart out – you can hear the strings weeping! Similarly with Barber’s Adagio for Strings, Opus 11 – whilst it *is* a tad more optimistic than Albinoni’s heart-tearer, you can ‘feel’ the grief. Well, I can, anyway.

 

image
Image courtesy K&J Investigations

All is not lost

But all is not lost. It is only early days of my diagnosis (finally; I’ve suffered from BP since I was a child, but it’s only recently been diagnosed) so my team and I are still working out the right medications and dosages for me.

The list of creative people who have made an impact on the world whilst still suffering from this dreadful, incurable disease is long, including: Adam Ant, Russell Brand, Michael Costa (Australian politician), Ray Davies (the Kinks), Patty Duke, Carrie Fisher, Stephen Fry, Paul Gascoigne (English footballer), Mel Gibson, Macy Gray, Graham Greene, Linda Hamilton (Terminator movies), Kay Redfield Jamison, Andrew Johns (Aussie rugby player), Kerry Katona, (English television presenter), Vivien Leigh, Jenifer Lewis (US actress), Kristy McNichol (actress), Edvard Munch, Florence Nightingale (yes, *that* Florence Nightingale), Sinéad O'Connor, Ozzy Osbourne, Jane Pauley, Edgar Allan Poe, Charley Pride, Axl Rose, Michael Slater (Australian cricketer), Margaret Trudeau, Jean-Claude Van Damme, Kurt Vonnegut, Brian Wilson

Well, you get the idea. The disease, whilst something that will be with me forever, is not the end of the world. It is manageable and treatable, and I am fortunate to have a great team around me helping me do just that: manage it.

Does it hurt my consultancy work or any job prospects?

Are you kidding me? I’m 51 years of age – job prospects were something one had in one’s 30s! No one hires 50-somethings these days. So the consulting life is probably going to be mine unless someone does something unheard of and hire a 50-something for more than just greeting people as they enter the supermarket.

But the medication and the therapy and the maintenance team I have built up around me means that the ‘average’ person (who didn’t know my past, nor my present condition) would have no clue as to the disease playing ‘hidey’ with what some have laughingly called my ‘brain’.

So why ‘come out’, Lee?

I wanted to be ‘out and proud’, as it were. Having only recently been diagnosed with Bipolar, I wanted to let the world and my friends know that I suffer from a disease, but that I am *not* the disease.

In other words, “Lee Hopkins suffers from Bipolar Disorder, not Lee Hopkins is Bipolar”. Just like diabetes, Bipolar Disorder is manageable, treatable but also incurable. Like a diabetic I have to watch what stimulants I intake (endless coffees, late nights and bucket loads of alcohol are three that will have to go), but in return I get to live a life with far less of the crushing burden of depression, far fewer times when I can turn around and see the ‘black dog’ faithfully padding along just behind me.

Far fewer times, too, when my thoughts race like a shotgun cartridge of pellets let loose in a paint tin on a paint tin shaker at the hardware shop.

So all I ask is that you understand if I leave your party early, just as it’s getting interesting. Or that you understand when takes me a couple of days to respond to your email or voicemail that it’s not a deliberate snub – just my disease telling me to ‘slow down and smell the roses’.

Or that you understand that my wearing by ear buds whilst working at your premises is also not a snub, or me trying to be ‘hip’; it’s just me listening to something soothing to stop the thoughts racing, or else it’s just me listening to something positive to stop a slide down the snake before it gets going.

So there you have it: “Lee Hopkins has Bipolar Disorder.” Just sayin’…


25Sep/09Off

It’s ‘All in the Mind’

Lee and some of his alts

Query: can the ‘alts’ of Second Life and other virtual worlds be akin to ‘alters’, the various alternative states of sufferers of Dissociative Identity Disorder and Multiple Personality Disorder?

Is the act of having several ‘alts’ a quasi-therapeutic way of dealing with those ‘alters’?

Prompted by listening to an episode of ABC Radio National’s superb show, ‘All in the Mind’.


30Aug/09Off

Bipolar disorder and family-focused treatment in Turkey

Bipolar disorder and family-focused treatment in Turkey

Ten Turkish patients with either DSM-IV I or II bipolar disorder and their families attended a 9-month, 21-session psychoeducational treatment plan that ran alongside more traditional medication treatment plans.

The plan, called 'Family Focused Therapy' (FFT), has been successful as an adjunct to medication within North America, but had never been tested outside of US borders. So it was interesting to see if the same positive results could be replicated in a non-Western culture.

It turns out that very few changes were needed to be made to 'fit' Turkish culture (principally in turning some of the written assignments into more a more culturally appropriate oral communication) and patients improved their Global Assessment of Functioning scores and Clinical Global Impression scores, pre- and post-treatment.

FFT is a family intervention for bipolar disorder designed by Miklowitz & Goldstein (1997) and runs for 21 sessions over a 9-month period. It has been been shown to be more effective than crisis management in longer-term survival without mood disorder relapse, as well as reducing the severity of depressive and manic symptoms, over a two-year period. It has also allegedly hastened the time to recovery from acute depressive episodes compared to other psychoeducative treatments.

The Turkish FFT therapist was trained by Dr Miklowitz during a weekend workshop, followed by email-based supervision. The therapist's manual was translated into Turkish by a colleague of Dr Miklowitz and reviewed and approved by other clinicians experienced in FFT.

It showed that FFT can be effectively used outside of a North American, Western culture as long as care is taken to 'fit' the therapy into the local culture, including use of language appropriate to the local culture.

References:

Miklowitz, D.J., & Goldstein, M.J. (1997). Bipolar disorder: A family-focused treatment approach. New York: Guilford Press

Ozerdem, A., Oguz, M., Miklowitz, D., & Cimilli, C. (2009). Family Focused Treatment for Patients with Bipolar Disorder in Turkey: A Case Series. Family Process, Sep2009, Vol. 48 Issue 3, p417-428


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3Aug/09Off

Comparing mood stabilizers for bipolar disorder

Comparing mood-stablising medication for sufferers of bipolar disorder.

As those who suffer from it know, bipolar disorder is characterised by cyclical swings between happy mania and unhappy depression, with periods of mental peace and tranquility in between. It apparently affects around 2% of Americans and is associated with significant treatment costs, particularly around the medications used to control its effects on sufferers.

Sometimes just one medication isn't enough; often a treating physician will test various pharmaceuticals in combination with each other to create a 'cocktail' that seems to work best for the sufferer. This is true not just for bipolar disorder, but increasingly for other medical conditions as well, including depression.

Of course, whether using one medication or a cocktail, the cost of administration of the medication can be steep: not only the cost of the medication itself but also the cost of monitoring its performance, monitoring the dosing frequency, monitoring its effectiveness, monitoring its tolerability and side effects, and so on.

Brandon Suehs and Tawny Bettinger, two pharmacologists from Austin, Texas, saw a gap in the decision-making process of which mood-stabilizing medication to use with a patient and so sought to develop a model to help their colleagues.

Working with 116 psychiatric pharmacist specialists -- pharmacists with specialist training and practice in clinical psychopharmacology -- Suehs and Bettinger sought to determine the optimum medications based on five descending criteria: Effectiveness, Safety & Tolerability, Dosing Frequency, Monitoring Burden, and Cost.

Effectiveness was a composite score based on a medication's effectiveness in 1) treating acute mania, 2) treating acute bipolar depression and 3) effectiveness in maintenance treatment.

Suehs and Bettinger found that lithium is the most effectiveness across both acute mania and maintenance treatment factors, as well as overall effectiveness; lamotrigine is the medication with the most effectiveness in treating acute bipolar depression. Aripiprazole scored moderately well as the antipsychotic of choice for safety, tolerability and maintenance factors.

Of additional interest was the finding that gabapentin and topiramate scored poorly across all three factors (acute mania, acute bipolar depression and maintenance treatment).

Source: Suehs, B.T., & Bettinger, T.L. 2009. A Multiattribute Decision Model for Bipolar Disorder: Identification of Preferred Mood-Stabilizing Medications. American Journal of Managed Care; 15(7); e42-e52

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