Omega-3 fatty acids 

Omega-3 fatty acids are nutrients that are naturally occurring and found in the form of EPA and DHA in foods like salmon, tuna, sardines, free-range chicken and omega-3 fortified eggs. A third form of omega-3 called ALA is found in dark green leafy vegetables like spinach, walnuts, flaxseeds and soybean.

Only small amount of dietary ALA can be converted into useful EPA and DHA. It is thought most people in the United States get enough ALA from the foods they eat, as well as small amounts of EPA and DHA[5].

Some research suggests that there is body inflammation in acute mania, and to a lesser extent, in bipolar depression[4]. It is possible that omega-3 fatty acids may reduce inflammation in the nervous system[8].

However, though there are conflicting studies on whether omega-3 helps treat or prevent episodes of mania or depression[6], Dr. Jeffrey Rakofsky (Assistant Professor in the Mood and Anxiety Disorders Program at Emory University School of Medicine in Atlanta, Georgia, USA) and Dr. Boadie Dunlop (Director of the Mood and Anxiety Disorders Program at Emory University) reviewed data from multiple trials and felt there was reasonably strong evidence compared to other supplements for bipolar depression[7].

Dr. Candida Fink, an experienced psychiatrist in New York (who co-authored a book for patients along with John Kraynak, who has lived experience of bipolar disorder) writes that most doctors would suggest 1-2 grams daily EPA for antidepressant effect[8].
 

SAMe 

SAMe is found in the body and is made from methionine, an amino acid found in foods. It has been widely studied in people with unipolar depression and bipolar disorder.

It has been advised that SAMe should not be taken for bipolar depressive symptoms as SAMe may induce or worsen symptoms of mania. There is also concern that SAMe may interact with other supplements and medications by increasing levels of serotonin (a chemical produced by nerve cells), such as antidepressants, L-tryptophan, and St. John’s wort[9].

Dr William Walsh even states that some people with bipolar disorder could already have excessive SAMe in their bodies[3].
 

St. John’s Wort 

This yellow flower has been used as a medicine since ancient times as “the devil’s scourge” to ward off evil spirits. It was popular in the early 2000’s but popularity has waned due to concerns about lack of efficacy and risk of interaction with other medications[8] e.g. may reduce benzodiazepine effectiveness. 

Although many studies suggest St. John’s Wort can help treat mild-moderate unipolar depression, there doesn’t seem to be any strong evidence for treatment of bipolar depression. It is also risky to take along with other antidepressants due to the possibility of developing serotonin syndrome (this can cause tremor, diarrhoea and confusion) or triggering mania[1O].


Melatonin 

Melatonin is produced by the brain in reaction to the amount of ambient light, and thus helps us regulate our circadian rhythm. In turn, it is possible that the body rhythm helps regulate mood and vice versa.

In people with mania, some studies suggest there is an early rise of lower melatonin levels, compared to healthy people and those with unipolar depression[11].  

Early research shows that taking melatonin at bedtime increases sleep duration and reduces manic symptoms in people with bipolar disorder who also have insomnia. But there is also a risk that taking melatonin might make symptoms worse in some people with bipolar disorder[12].

For now, there is a lack of clear consensus on whether melatonin is helpful in bipolar disorder[11].
 

Other supplements 


Coenzyme Q10 - This vitamin-like substance is found in the body, and in small amounts in meats and seafood. It is commonly used for heart health. Early research shows that taking coenzyme Q10 may improve symptoms of depression in people over 55 years of age with bipolar disorder, but more research is needed[13].


5-HTP – This substance is produced by the body and present in the seeds of an African plant called Griffonia simplicifolia. It increases serotonin production which itself affects mood, sleep and other body functions. There is a little evidence it can help with depression, anxiety and sleep, but just as with St. John’s Wort, if taken along with other antidepressants there is a risk of developing serotonin syndrome[8,14].


GABA – Made by the brain, GABA is thought to help anxiety and mood by blocking brain signals. However, there is little evidence to confirm its efficacy for mood and anxiety, nor consensus on safe dosage[15].


Inositil[7,8] – Mood stabilising medication like lithium and valproate are thought to work by stabilising the vitamin-like inositol’s signals within cells. Dr. Jeffrey Rakofsky and Dr. Boadie Dunlop found just one study that showed possibly efficacy. There is also a risk of triggering mania.


Kava – Part of the pepper family, this herb is native to islands in the South Pacific. Many people take this for anxiety. There are mixed conclusions about efficacy, and it has been linked to severe liver injury, especially if combined with alcohol[16].


NAC – this substance is used by the body to make antioxidants (such as glutathione) that help the body’s cells recover from stress and damage. A group of researchers reviewed multiple studies and could not advise NAC as a safe, effective treatment for bipolar disorder[17].


Valerian - this has a distinctive odour and is extracted from a plant native to Europe and Asia. Out of 250 species V. officinalis is most commonly used. A review of nine trials was inconclusive for valerian’s sleep benefits. It can interact with benzodiazepines and other supplements such as St. John’s wort, kava, and melatonin[18].
 

Vitamins and minerals 


Vitamins B1, B6, B12 – there is a lack of good evidence to say these help people with bipolar disorder.


Vitamin D – some studies show a link between depression and low vitamin D. However, but there is insufficient evidence to recommend it for bipolar depression[8].


Folic acid – also known as vitamin B9 and found in the form L-methylfolate, it has been shown in some studies to enhance antidepressant response in people with unipolar depression;19]. However, in a review, Dr. Jeffrey Rakofsky and Dr. Boadie Dunlop did not find good supporting data for folic acid in bipolar depression treatment[7].

Although taking folic acid does not appear to improve the antidepressant effects of lithium in people with bipolar disorder, WebMD suggests that taking folate with the medication valproate may improve the effects of valproate[20].

Dr Walsh comments that people with bipolar disorder may have folate under- or overload, so individual tailoring of folate supplementation may be beneficial[3].


Zinc – In earlier studies, lower blood levels of zinc were linked to depression. However, evidence seems to be pointing towards a use only in unipolar depression by increasing the efficacy of antidepressant therapy.


Magnesium – A 1990 study of rapid cycling bipolar patients suggested that taking magnesium might have had an effect as strong as lithium in about half the people[21]. Another study in 2000 suggested that taking magnesium with the drug verapamil reduced manic symptoms better than verapamil alone[22]. More studies are needed.
 
In short, with this array of frequently inconclusive data, it would be advisable to have a chat with your psychiatrist first before taking supplements for bipolar disorder.

What we know 

People with bipolar disorder have a higher incidence of obesity, diabetes, high blood pressure, and unhealthy blood fat levels. The reasons for this may include:

• being less physically active,
• poorer eating habits
• medication side effects[23]

There are even less well-understood possibilities, such as deliberately increasing sugar intake to reduce high levels of stress-induced blood cortisol[24].

An interesting recent study[25] looked at the eating habits of 113 well people with bipolar and 160 people without bipolar. Those with bipolar were generally less adherent to a Mediterranean diet than the non-bipolar group, and 74% of the bipolar group were overweight versus 68% in the non-bipolar group. The levels of blood sugar and triglycerides (a type of blood fat) were also higher in the bipolar group.

A review of studies[24] looking at diet in bipolar disorder suggest the following:

• people with bipolar disorder consume more carbohydrates, and women with bipolar also have a higher total energy intake
• a larger seafood consumption is been associated with a lower incidence of bipolar disorder
• in Japan, there were more severe ratings of bipolar symptoms in those who had less frequent consumption of Mediterranean diet products

 
​
What we can do 

As well as goal-setting towards regular healthier meals and snacks and restoring a regular circadian rhythm (there is more on this is in the October 2019 BipolarLife newsletter), the amount and type of food are also important for our mood and energy levels.

Dr Ellen Frank, Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania, recommends having three to four smaller meals per day to help keep mood and energy levels stable[26].

Depression and Bipolar Support Alliance (DBSA) suggests keeping a food and mood journal to see if a symptom is triggered by something dietary[27]. An example might be agitation and nervousness after a certain amount of caffeine, or broken sleep, low mood and poorer impulse control after alcohol.

Given the above study findings, it may help to follow a portion-controlled Mediterranean-type diet (definitions vary) to help with mood and energy.

This diet typically looks like this:

HIGHER AMOUNTS:
fruits, vegetables, legumes
wholegrains and cereals
nuts and seeds

LOW-MODERATE AMOUNTS:
healthy fats like olive oil and avocado instead of butter
seafood, poultry, dairy
little or no red meat
 
If there are additional challenges to meet such as medication-related weight gain, you could also get support from your doctor and/or dietician. Don’t forget to check out online resources including:

• The Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST B.D.) and
• Depression and Bipolar Support Alliance (DBSA)

 

​
Disclaimer: this content is not a substitute for individual medical advice.

Abbreviations used: EPA = Eicosapentaenoic acid, DHA = Docosahexaenoic acid, ALA = Alpha-Linolenic Acid, SAMe = S-adenosyl-L-methionine 5-HTP = 5-Hydroxytryptophan GABA = Gamma aminobutyric acid, NAC = N-acetyl cysteine

Identification of values helps us work out our personal wishes and motivations, regardless of expectations from other people or society.

It is important to note that values are not describing our internal states (thoughts, feelings and emotions) as it would soon become clear that having a value of wanting to be happy and to always have positive thoughts would be impossible. Values are also not descriptions of how others behave towards us, as that is another thing we don’t have a great deal of control over either e.g. I want to be loved by person X.

By seeing where our current actions are aligned with our values, we are more confident in continuing and strengthening those actions. On the other hand, where we are not heading towards a value we feel is important, this can help focus our efforts. And if we are feeling ‘stuck’ and unsure as to what our values are, it can stimulate a thinking process to move us forwards.

We can prioritise the goals which will lead us to values we find most important. They can help us with time management. For instance, we may decide that initially we need to set aside ten minutes a day on a goal.

It’s also useful if we can keep an open mind for what comes up for us when we plan a goal or are actioning the goal. For instance, we may need to deal with negative thinking like “this needs to be perfect or there will be consequences” or cognitive fusion like “I’m too lazy to do Y”. Or we might spot potential barriers and decide how to work around them.

Some examples of personal values include

• Creative values e.g. to be imaginative, resourceful
• Experiential values e.g. to appreciate beauty in art, music etc., to love wholeheartedly
• Attitudinal values e.g. to be accepting of myself, to be accepting of others, to be fair, to be appreciative of things I have in life, to be open-minded
• Relationship values e.g. to be caring towards my partner/spouse, to bring up my child in a responsible manner, to be a loyal friend
• Achievement values e.g. to work hard, to improve my knowledge and skills
• Recreation values e.g. to regularly timetable leisure activities
• Health values e.g. to improve physical fitness, to look after mental health, to live life in a way that brings me spiritual meaning (e.g. regularly practising gratitude and patience, yoga, volunteering)
  
  

For a list of many more possible values, you could look at the ‘Card Sort’ exercise[9] for inspiration and ideas.
​
From identifying which values are most important to you, and ones that could benefit from more attention, you have a starting point from which you can begin to set meaningful goals. You might simply categorise your values into Very Important all the way through to Not Important, or just choose the 5-10 most important to you today. As with all things, they are subject to change so review them when you feel ready. 

Fortunately, clinicians and researchers in many countries are increasingly aware of the rise of stigma and driving ongoing important work in this field. Though there is no one simple solution, here are some helpful, evidence-based suggestions for moving forward.

A Canadian study recommended six approaches to stigma reduction:

• Education
• Protest
• Contact-based education
• Legislative reform
• Advocacy
• Stigma self-management
  
  

Education could be directed at the public or specific groups such as within schools or the workplace. Protest could be in the form of formal objection to stigmatising individuals or groups. Contact-based education has been found to be particularly useful, where a member of the public hears the personal story of someone with mental illness; this person should be doing well and be successfully managing their condition. It is not necessary for the contact to be in person, and could be via an online video, though this may be less effective. Stigma self-management should include education (for example peer-supported self-learning and recovery-orientated supports and services).

Individuals, friends and family

On an individual level, it should be noted that self-stigma can manifest and be managed in different ways. In CREST.BD's Stigma123 Webinar, Natasha Kolida, a student and researcher with bipolar disorder, encourages education as well as being holistic and self-compassionate in one’s journey. More about CREST.BD in a moment.

Dr. Jamison advises:

• Patients and family members should be aware of their political strength as they make up a large percentage of voters.
• There needs to be more work with medical and mental health communities, including open discussion and change. In particular, work needs to be done in the area of medical care for health care providers, who currently risk penalties in disclosure that are often not in keeping with their quality as practitioners.
• Public campaigns should be on a more positive note, with more emphasis on neuroscience research and the benefits of treatment.

​
In 2014 Dr. Roumen Milev, Professor of Psychiatry and Psychology at Queen’s University, Canada ran a CREST.BD webinar about overcoming stigma in bipolar disorder. In this presentation, he describes a fascinating community-based recovery-orientated course provided to 8-10 participants with mood and anxiety disorders. Comprising seven closed two-hour sessions, content included education about stigma (covering self-stigma, family, friends and medical settings; education, housing and the workplace); some sessions taking the form of group workshops with brainstorming and role play.

Perhaps this is the sort of course we could make widely available in Australia to complement our current inpatient and community programmes for those with bipolar disorder.

Who is CREST.BD?

CREST.BD describes itself as “The Collaborative RESearch Team that studies psychosocial issues in Bipolar Disorder...CREST.BD is a multidisciplinary collaborative network of researchers, healthcare providers, people living with bipolar disorder, their family members and supporters.” Bipolar Life’s patron, Professor Greg Murray, is Deputy Lead and a key researcher with this inspiring international team.

CREST.BD’s website includes excellent resources and tools including videos on stigma, cognition, sleep, mood, physical health, home, self-esteem, leisure, relationships, spirituality, money, independence, identity, work and study for people with bipolar disorder. 

Media and beyond

Finally, looking at how we can make a difference on a larger scale, StigmaWatch is a constructive program run by national mental health charity, SANE Australia. Its aim is to promote responsible reporting of mental illness and suicide in Australian media and is supported by Mindframe, an Australian Government initiative. This is a great example of protest being used as a tool to improve public perception of mental illness. SANE encourages anyone to report to StigmaWatch if they see inaccurate or inappropriate terminology or reporting of mental illness or suicide.

SANE’s website states that “Mindframe has also developed resources for media professionals, journalism students, scriptwriters, police and courts, and conduct briefing sessions with media organisations to discuss issues relating to mental illness and suicide”.