Category: Bipolar Disorder

Tools to help people with bipolar disorder

17/5/2020

Image by @ AliceLamWriter

In this article, we’ll look at how tracking symptoms can help, then we’ll consider the range of different tools available including apps for people with bipolar disorder.

Trackers

Many people already track their mood, sleep and energy as part of a treatment and maintenance plan. This is a good example of a way in which we can increase awareness of our moods, including early changes that might herald a mood episode, and monitor effectiveness of medications or other therapies [1]. Examples of printable trackers which you can of course customise can be found here and here. Making notes as you go along can help identify stressors and triggers too.

As a regular circadian rhythm with sufficient sleep is important in bipolar disorder, a decrease or increase in sleep could be a sign of impending mania or depression; or the other way round might be the case, that is, mania may cause decreased need for sleep or depression cause increased need. In either case, early intervention would probably be beneficial than if things were left to spiral out of control.

Perhaps you want to see the effect of walking 15 minutes a day on your mood and energy. Or you wonder if cutting out caffeine will improve your sleep. It may be that you are depressed and you’ve set a basic goal of showering three times a week because anything more feels overwhelming [2]. Recording via a paper or electronic tracker allows you to experiment with positive behavioural changes as you can measure when and how much of an effect a change makes. You can read more on how to use behavioural activation and goal-setting to beat low mood or negative thinking here and here.

It is important to note that some people with bipolar disorder may become over-energised by goal progress and rewards, which may lead to a manic episode [3]. Therefore, it is important to ensure that we avoid setting goals that will require excessive activity that could in turn affect sleep or circadian rhythms [2].

If you’re feeling overactivated, you might use a tracker to add in regular calming activities such as relaxation and meditation, as well as avoiding too much goal seeking [2]. Here’s an online module on using behaviour to prevent mania.

There are also more sophisticated trackers available, such as the Quality of Life (QoL) tool [4] produced by the Collaborative RESearch Team (CREST.BD). The QoL tool is a free online resource where you can intermittently fill in a simple questionnaire, rating satisfaction levels for energy, mood, sleep, work, money, relationships and other life domains. The tool then displays the data as a graph and table, helping you to see progress, which helps to validate your efforts and motivate ongoing efforts [5].

Regular tracking may lead you to a routine that includes a healthy lifestyle (diet, exercise, relaxation, regular sleep pattern, avoiding alcohol and drugs, minimising stress and maintaining consistent sunlight exposure throughout the year) which should help keep your symptoms and mood symptoms to a minimum [6].

Tips:

Don’t forget that trackers are also a helpful way of showing your doctor or psychologist how you’ve been doing since your last visit.
You could also ask a trusted partner or friend how they think you’re going.

"If you educate your family and friends and involve them in treatment when possible, they can help you spot symptoms, track behaviours and gain perspective."

- International Bipolar Foundation [6]

Apps

Many people with bipolar disorder turn to mobile apps and web programs (mHealth) to find information about the condition, to track symptoms, to record behavioural changes. Apps can appear attractive as they are easy to download, convenient, and are often low-cost or free.

A review by the Australian Communications and Media Authority [7] confirms how prevalent mobile devices are in society. It was found that 89% of Australian adults accessed the internet in the six months to May 2018—74% going online three or more times a day. 90% of Australian adults were using more than one device to go online at May 2018.

Researchers from the Black Dog Institute and Sydney’s School of Psychiatry decided to explore the apps aimed at bipolar disorder in both Google Play and iOS stores in Australia [8]. In particular, they evaluated the apps for features, quality and privacy.

Out of the 571 apps identified, they reviewed 82 apps. Here are some of their conclusions [8]:

Apps that provided information only covered one-third of psychoeducation needed and only 15% followed best practice guidelines. No information apps suggested action plans
None of the 35 monitoring apps had a duty-of-care alert, which was tested by entering three consecutive days of severely depressed mood and suicidal ideation. Seven of 13 monitoring apps failed to remind the user to track mood as directed.
Some symptom monitoring apps did not monitor medication (57%), sleep (51%) and most self-assessment apps did not use validated (recognised, scientific) screening measures (60%).
User reviews did not always correlate with an app’s quality or effectiveness.
Less than a quarter of apps provided a privacy policy.

This is not to say that all apps are no good, but from the research above it shows that it is a good idea to be cautious when choosing and using an app.

Update 27/5/20: The CREST.BD team is working on their Bipolar Bridges project to build an app for people with bipolar disorder. The final product aims to "empower[s] users to combine and learn from different forms of digital self-management and QoL (quality of life) data (for instance, sleep quality, mood management, activity levels, and social connectivity." You can go to their survey here to help them build a picture of how you use apps for your health and wellbeing.

References

1. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.

2. Reiser, R.P., Thompson, L.W., Johnson, S.L., Suppes, T., 2017. Bipolar disorder, 2nd edition. ed, Advances in psychotherapy--evidence-based practice. Hogrefe, Boston, MA.

3. Johnson, S., 2012. The Behavioral Activation System and mania. Annual Review of Clinical Psychology. Annu. Rev. Clin. Psychol. 8, 243–267.

4.. CREST.BD. 2015. Quality of Life Tool. [ONLINE] Available at: https://www.bdqol.com/. [Accessed 15 May 2020].

5. Morton, E, 2019. Experiences of a Web-Based Quality of Life Self-Monitoring Tool for Individuals With Bipolar Disorder: A Qualitative Exploration. Journal of Medical Internet Research, [Online]. 6(12), e16121. Available at: https://mental.jmir.org/2019/12/e16121 [Accessed 15 May 2020].

6. International Bipolar Foundation. n.d. Treatment. [ONLINE] Available at: https://ibpf.org/learn/education/treatment/. [Accessed 15 May 2020].

7. Australian Communications and Media Authority Communications Report 2017-2018. 2019. AAA, [Online]. Available at: https://www.acma.gov.au/sites/default/files/2019-08/Communications%20report%202017-18.pdf [Accessed 15 May 2020].

8. Nicholas, J., 2015. Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality. Journal of Medical Internet Research, [Online]. 17(8), e198. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4642376/ [Accessed 17 May 2020].

Bipolar Medications and their Side Effects

23/4/2020

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Image by Emilian Danaila from Pixabay

First published in Bipolar Life's April 2020 newsletter

INTRODUCTION

Most people living with bipolar disorder understand the importance of medication in the management of their condition. We know that medications are to be taken lifelong, with a few exceptions. We also understand that they are taken in addition to, not as a replacement for, other treatments such as psychotherapy, healthy lifestyle and a good routine; this includes a good sleep pattern, regular exercise, good nutrition and strong social support.

So, what happens if we don’t treat bipolar disorder in the right way, for instance self-treating? The following scenarios could happen [1]:

More frequent and severe mood episodes
Damaged relationships
Loss of job or damaged career
Money problems
Problems with thinking and memory

Therefore, it makes sense for you to work with your doctor to ensure the medications prescribed are right for you. As all medications can cause side effects, it is essential to be open and honest with your prescribing doctor if you are experiencing any problems. It is inadvisable to reduce or stop a medication without consulting with your doctor first.

In this article we are going to look at:

the possible side effects of the most commonly used medications
medication interactions with illicit drugs/alcohol
regular monitoring as a way of reducing medication problems
coping strategies for less severe issues, and
what to do if you feel you cannot continue the medication

Bipolar disorder is treated with three main classes of medication: mood stabilisers, antipsychotics and antidepressants. Sometimes your doctor may prescribe (usually short term) anti-anxiety and sleep aids–benzodiazepines and Z drugs. In this article we won’t go into much detail how they are used, such as acute treatment versus maintenance, or what is used for mania versus depression. Instead we’ll just concentrate on the side effects aspect to keep the article reasonably short.

MOOD STABILISERS – LITHIUM [1,5]

Around 75% of people of people taking lithium for bipolar disorder get side effects [2]. It is effective for mania, and is gold standard for maintenance therapy, and may help bipolar depression [1].

Important note on lithium toxicity

This can be caused by various factors such as taking too many tablets, dehydration, or having a sudden drop in kidney function. This can be a dangerous condition and needs urgent medical attention. Symptoms can include nausea, vomiting, diarrhoea, drowsiness, unsteadiness, confusion, agitation, blurred vision, severe tremors, muscle jerks or seizures [4].

People taking lithium are recommended to have regular blood tests to check lithium levels, kidney and thyroid function [5].

How to avoid dehydration

To avoid dehydration, it’s important to keep well hydrated especially if exercising, or in hot weather. Try not to have too much caffeine or alcohol as they can dehydrate. Medications such as diuretics and non-steroidal anti-inflammatory drugs (such as ibuprofen) can also cause lithium levels to rise so care is needed.

We’ll now look at the anticonvulsants which are also used as mood stabilisers.

MOOD STABILISERS – ANTICONVULSANTS [1,6]

Important note on Stevens-Johnson syndrome

This is a rare, serious disorder of the skin and mucous membranes. It usually begins with flu-like symptoms (such as fever, fatigue, cough), then a red or purplish blistering rash that spreads over the body. The mouth, eyes, nose and genitals can be affected [7]. You must seek immediate medical attention if you suspect you are having this reaction to a medication.

ANTIPSYCHOTICS [1,8]

The first antipsychotics developed, now known as first-generation typical antipsychotics (FGA), were used to treat people with schizophrenia in the 1950s. The second-generation antipsychotics (SGA) came out in the 1980s, and are commonly known as atypical antipsychotics [9]. The SGAs are helpful in reducing mania and in strengthening antidepressant treatment [1].

The SGAs generally are far less likely to cause a particular class of side effects, the extrapyramidal side effects such as restlessness, muscle stiffness, involuntary neck spasm, Parkinson’s like movements, involuntary facial and mouth movements [10].

It is recommended that people taking antipsychotics should have 6-12 monthly monitoring to check weight, blood pressure, fasting glucose and cholesterol, and ECG (heart trace) [11].

ANTIDEPRESSANTS [1,12]

Treating depression in someone with bipolar disorder is less straightforward than for unipolar depression. For instance, in type 1 bipolar, antidepressants may be less effective [1]. Also, mania can be triggered by use of an antidepressant, particularly if the person is not also taking a mood stabiliser. There are several classes of antidepressant. Some of their brain actions are similar, some are different, and this is reflected in the differing side effect profiles in the table below.

There are some less commonly used antidepressants available in Australia. These include mirtazapine, trazodone, the Tricyclic Antidepressants (TCAs, such as amitriptyline and nortriptyline) and MAOIs (monoamine oxidase inhibitors such as phenelzine and tranylcypromine). You can read more about TCAs here [15] and MAOIs here [16].

ANTI-ANXIETY AND SLEEP MEDICATIONS

Anti-anxiety medications (anxiolytics) and sleep aids (hypnotics) can be immensely helpful in the acute phase of depression and mania treatment. These are generally within the class of benzodiazepines (such as diazepam, temazepam, lorazepam) or Z drugs (such as zopiclone, zolpidem).

Both benzodiazepines (“benzos” for short) and Z drugs pose a risk of dependence, so these medications are usually prescribed for as short a time as possible. Some people do require them longer term, but this requires strict monitoring by their doctor.

Side effects can range from mild to severe. This can include daytime sedation, or impaired ability to drive, operate machinery or perform certain tasks.

In overdose, or if taken with certain other drugs (prescribed, over-the-counter or illicit), or alcohol, adverse effects can be severe and even result in coma or death. The elderly are also at particular risk from these medications.

It is possible to become dependent after just a few weeks of taking them regularly [17]. Signs of this process happening include:

a strong psychological or physical need to keep taking the medication even when the initial symptoms have disappeared
a need to take higher doses to achieve the same effect (this is known as tolerance)
anxiety, panic attacks, feeling spaced out, insomnia, sweating, tremor, nausea, palpitations, headaches, over-sensitivity to light/sound/touch, or weakness [18,19]

Withdrawal from benzos needs to be done with regular review by your doctor. Some people can feel unwell if reducing too quickly, and may experience agitation, insomnia, hallucinations and seizures [17].

WHO MIGHT BE AT INCREASED RISK FOR SIDE EFFECTS?

Older people are less able to metabolise their medications through the kidney and liver. At any age, but often more commonly seen in the elderly, being on a cocktail of medications can increase the risk for drug interactions and adverse effects. This is an important issue that needs regular monitoring by their doctor [20].

People who have pre-existing medical conditions may find them aggravated by weight gain, increased glucose or cholesterol. These conditions include high blood pressure, heart disease, history of stroke, diabetes, liver disease, kidney disease and arthritis.

Substance use disorder can be seen in one-third to one-half of people with bipolar disorder [1]. People who drink alcohol, particularly if in excess of recommended levels, or take illicit drugs, may be at higher risk for side effects–in addition to the drugs and alcohol potentially worsening control of their bipolar disorder. Alcohol may cause dangerous interactions, especially when taken with lithium and benzodiazepines [1].

WHAT TO DO IF YOU ARE EXPERIENCING SIDE EFFECTS

Keeping a journal when you start or change a drug regimen can be helpful in working out if a symptom is really a side effect or whether it is the illness, or something else entirely.

If you think you are getting side effects, regardless of whether they are new or longstanding, it is a good idea to check in with your doctor. It might be decided that they side effects are mild and non-serious, and the benefits of the medication outweigh the adverse effects, in which case you could opt to continue.

Possible other scenarios include:

Your doctor might advise you to wait and see. Some side effects can improve with time, such as the nausea and tremor associated with lithium [3], or the nausea of SSRIs [13].
Your doctor might advise you that the drug regimen needs changing. That could entail a reduced dose, a change of timing (e.g. night versus morning dosing), or a change to a slow or extended release formulation.
Your doctor might advise you that the medication should be stopped.
Your doctor might advise you the medication should be switched to another one, sometimes within the same class.

TIPS FOR SPECIFIC SIDE EFFECTS

Here are some tips for specific issues. Once again, these are ideas for you to discuss with your doctor first.

TREMOR [3]

Watchful waiting may be sufficient where tremor is mild as it may resolve in time
Reducing caffeine as this can aggravate tremor
Changing lithium salt (e.g. from carbonate to citrate)
Changing lithium from long- to short-acting
Reducing the daily dose
Splitting the daily dose
Adding a beta-blocker to treat the tremor

NAUSEA [3]

Watchful waiting may be sufficient where nausea is mild as it often resolves in time
Taking medication with or after food
Taking sustained release rather than fast release formulation
Reducing the daily dose
Splitting the daily dose

SEDATION [1]

Taking medication later in the day or before bed
Taking a short nap during the day if needed
Taking regular light-moderate exercise such as walking

WEIGHT GAIN

Monitor your weight regularly, say twice a week. This way you can monitor the effects of your efforts with diet and exercise.
Some people find keeping a food diary helps. This can also help us realise when we are “emotional eating” or eating out of boredom.
Eating mindfully may help with weight loss. It takes about twenty minutes to feel full, so savour every mouthful. This article [21] explains this in more detail and includes helpful tips on how to eat mindfully.
Make changes gradually and set realistic, achievable goals. Set yourself up for success! You can read more about SMART goals here.
A nutritious, portion-controlled diet with adequate exercise is key.
There are many resources available to support you on your journey. This could include seeing your GP, dietician and/or exercise physiologist. There are also great online resources such as this general guide [22], or this free 12-week weight loss plan [23] produced by the NHS.

SEXUAL DYSFUNCTION

Sexual dysfunction includes problems with libido, arousal or orgasm.
This side effect is a particularly important one as it can affect relationships, and unfortunately many people may be too embarrassed to report it. One source suggests about half of people taking SSRIs experience this, and that it occurs in the atypical antipsychotics at incidences ranging from 16-27% (aripiprazole) to 50-60% (olanzapine, quetiapine, ziprasidone) to 60-70% (paliperidone, risperidone)24.
Reducing the dose can help [1].
Switching medication, sometimes within the same class can help [1].
Following a drug holiday e.g. not taking the problem medication one day a week, as long as the regime doesn’t affect the bipolar disorder [1].

MEMORY AND COGNITIVE ISSUES [3]

Discuss this with your doctor as it is sometimes tricky to work out whether poor memory or foggy thinking are due to the bipolar disorder or the medication. If related to the bipolar, it may get better in time as the treatment starts to work.
Lithium-induced cognitive impairment can often lead to people stopping their medication. If someone is also taking antipsychotics, antidepressants or benzodiazepines then the foggy thinking could worsen. Foggy thinking is also thought to be worse at higher doses and may get worse over time.
If the foggy thinking is due to the medication, your doctor might suggest reducing the dose, splitting the dose and possibly stopping other medications that may be aggravating the issue.
In addition, timetabling in mental or physical activity to stimulate the brain may be beneficial [1].

HAIR LOSS (SODIUM VALPROATE]

Hair loss is generalised, rather than patchy, and does not scar the scalp. It is reversible upon stopping the medication, and may stop with dose reduction [25].

Conclusion

Medication is vital to most people’s bipolar treatment plan. It is important to be aware of possible side effects and to bring them to your doctor’s attention as soon as possible, so that you can both decide on the best course of action for your health.

If you think this article might help someone else too, please like and share.

All content within this article is for informational purposes only and is not intended to serve as a substitute for individual consultation with a qualified physician.

References

1. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.

2. WebMD. 2018. Lithium for Bipolar Disorder. [ONLINE] Available at: https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-lithium#2. [Accessed 22 March 2020].

3. UpToDate. 2019. Bipolar disorder in adults and lithium: Pharmacology, administration, and management of side effects. [ONLINE] Available at: https://www.uptodate.com/contents/bipolar-disorder-in-adults-and-lithium-pharmacology-administration-and-management-of-side-effects?search=lithium&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H182696807. [Accessed 22 March 2020].

4. UpToDate. 2018. Lithium poisoning. [ONLINE] Available at: https://www.uptodate.com/contents/lithium-poisoning?search=lithium&topicRef=15317&source=see_link#H5. [Accessed 22 March 2020].

5. UpToDate. 2019. Unipolar depression in adults: Treatment with lithium. [ONLINE] Available at: https://www.uptodate.com/contents/unipolar-depression-in-adults-treatment-with-lithium?search=lithium&source=search_result&selectedTitle=4~148&usage_type=default&display_rank=3#H2519581674. [Accessed 22 March 2020].

6. UpToDate. 2020. Antiseizure drugs: Mechanism of action, pharmacology, and adverse effects. [ONLINE] Available at: https://www.uptodate.com/contents/antiseizure-drugs-mechanism-of-action-pharmacology-and-adverse-effects?search=valproate&source=search_result&selectedTitle=3~148&usage_type=default&display_rank=2#H1398705747. [Accessed 22 March 2020].

7. Mayo Clinic. 2018. Stevens-Johnson syndrome. [ONLINE] Available at: https://www.mayoclinic.org/diseases-conditions/stevens-johnson-syndrome/symptoms-causes/syc-20355936. [Accessed 22 March 2020].

8. UpToDate. 2020. Second-generation antipsychotic medications: Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/second-generation-antipsychotic-medications-pharmacology-administration-and-side-effects?search=antipsychotic&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H466014692. [Accessed 22 March 2020].

9. National Center for Biotechnology Information. 2012. First-Generation Versus Second-Generation Antipsychotics in Adults: Comparative Effectiveness [Internet].. [ONLINE] Available at: https://www.ncbi.nlm.nih.gov/books/NBK107237/. [Accessed 22 March 2020].

10. UpToDate. 2020. Second-generation antipsychotic medications: Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/second-generation-antipsychotic-medications-pharmacology-administration-and-side-effects?search=extrapyramidal%20side%20effects&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H191681745. [Accessed 22 March 2020].

11. National Prescribing Service Limited. 2011. Antipsychotic monitoring tool. [ONLINE] Available at: https://resources.amh.net.au/public/antipsychotic-monitoring-tool.pdf. [Accessed 22 March 2020].

12. Hu, X., 2004. Incidence and duration of side effects and those rated as bothersome with selective serotonin reuptake inhibitor treatment for depression: patient report versus physician estimate.. Journal of Clinical Psychiatry, [Online]. 65(7), 959-65. Available at: https://www.ncbi.nlm.nih.gov/pubmed?term=15291685 [Accessed 22 March 2020].

13. UpToDate. 2020. Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/serotonin-norepinephrine-reuptake-inhibitors-snris-pharmacology-administration-and-side-effects?search=venlafaxine§ionRank=1&usage_type=default&anchor=H276509267&source=machineLearning&selectedTitle=2~148&display_rank=1#H18324389. [Accessed 22 March 2020].

14. UpToDate. 2020. Serotonin-norepinephrine reuptake inhibitors (SNRIs): Pharmacology, administration, and side effects. [ONLINE] Available at: https://www.uptodate.com/contents/serotonin-norepinephrine-reuptake-inhibitors-snris-pharmacology-administration-and-side-effects?search=duloxetine§ionRank=1&usage_type=default&anchor=H1409194297&source=machineLearning&selectedTitle=3~99&display_rank=2#H1409194297. [Accessed 22 March 2020].

15. myDr.com.au. 2018. Tricyclic antidepressants. [ONLINE] Available at: https://www.mydr.com.au/mental-health/tricyclic-antidepressants. [Accessed 22 March 2020].

16. myDr.com.au. 2018. Monoamine oxidase inhibitors (MAOIs) for depression. [ONLINE] Available at: https://www.mydr.com.au/mental-health/monoamine-oxidase-inhibitors-maois-for-depression. [Accessed 22 March 2020].

17. benzo.org.uk. 2002. Benzodiazepines: how they work and how to withdraw. [ONLINE] Available at: https://www.benzo.org.uk/manual/bzcha00.htm. [Accessed 22 March 2020].

18. Patient. 2017. Benzodiazepines and Z Drugs. [ONLINE] Available at: https://patient.info/mental-health/insomnia-poor-sleep/benzodiazepines-and-z-drugs. [Accessed 22 March 2020].

19. WebMD. 2019. Benzodiazepine Abuse. [ONLINE] Available at: https://www.webmd.com/mental-health/addiction/benzodiazepine-abuse#2. [Accessed 22 March 2020].

20. Dols, A., 2013. The prevalence and management of side effects of lithium and anticonvulsants as mood stabilizers in bipolar disorder from a clinical perspective: a review.. International Clinical Psychopharmacology, [Online]. 28(6), 287-96. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23873292 [Accessed 22 March 2020].

21. Nelson, J., 2017. Mindful Eating: The Art of Presence While You Eat. Diabetes Spectrum, [Online]. 30(3), 171–174. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556586/ [Accessed 22 March 2020].

22. Better Health Channel. 2012. Weight loss - a healthy approach. [ONLINE] Available at: https://www.betterhealth.vic.gov.au/health/healthyliving/weight-loss-a-healthy-approach. [Accessed 22 March 2020].

23. NHS. 2019. Start losing weight. [ONLINE] Available at: https://www.nhs.uk/live-well/healthy-weight/start-losing-weight/. [Accessed 22 March 2020].

24. La Torre, A., 2013. Sexual dysfunction related to psychotropic drugs: a critical review part II: antipsychotics.. Pharmacopsychiatry, [Online]. 46(6), 201-8. Available at: https://www.ncbi.nlm.nih.gov/pubmed?term=23737244 [Accessed 22 March 2020].

25. Kakunje, A., 2018. Valproate: It's [sic] Effects on Hair. International Journal of Trichology, [Online]. 10(4), 150–153. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6192236/ [Accessed 22 March 2020].

@BipolarLifeVic @finkshrink @WebMD @UpToDate @MayoClinic @NPSMedicineWise @mydrwebsite
@patient @BetterHealthGov @NHSuk

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Thriving with bipolar disorder

1/3/2020

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Image by Gerhard Gellinger from Pixabay

First published in Bipolar Life's newsletter in February 2020

It is so important to remember that you are not defined by your illness. Though bipolar disorder is thought to be biological in origin, with changes in genes accounting for maybe 60-70% of BPAD [1], it is also believed that the other factors are environmental, meaning there is so much that you can do to get better and stay well.

Making use of the medical model

The medical model emphasises regular monitoring, medications and psychotherapy to treat the condition in the acute and maintenance phase. Side effects such as weight gain or tremor from medications may need to be addressed in a collaborative manner with your doctor. Regular testing for medication levels, organ health (like kidney and liver function, cholesterol and sugar may also be necessary, especially as it has been found that there are higher rates of diabetes and cardiovascular disease in people with bipolar disorder [1].

Your team may include a psychiatrist, GP, psychologist, dietician, exercise physiologist and more. It’s important to find the right health care professionals so that you can feel comfortable and confident working with them towards your health goals. This article [2] might help you with some ideas on what to look for in your healthcare provider.

In addition to talking therapy with your psychiatrist and one-to-one sessions with a psychologist, therapy may be available in the form of inpatient or outpatient group programs. Depending on where you live in relation to public and private psychiatric facilities, available programs might include: Cognitive Behavioural Therapy (CBT), Mindfulness, Schema therapy, Acceptance and Commitment Therapy (ACT), Interpersonal therapy, Art and Music therapy to name a few. Many people have found such courses invaluable, not just because they are taught in a kind, supportive environment but also because the benefits of these tools can last a lifetime. Ask your psychiatrist about these if you are interested.

You can also speak to your GP about the following Care Plans, which can help eligible persons with allied health costs:

GP Mental Health Care Plan – you can read more on this here [3].
GP Management Plan – you can read more on this here [4].

Bringing in a wellness and recovery focus

A more person-centred, holistic approach complements your other treatments by strongly encouraging appropriate lifestyle modifications and personal strategies.

Some of these personal stories [5] on the Depression and Bipolar Support Alliance (DBSA) website by people with lived experience of bipolar disorder may inspire you further on your own journey. Here are some of their experiences:

Enjoying a safe space to share stories and be more open about the condition
Feeling it was cathartic to be able to speak about the condition
Feeling they were not helpless or worthless
Being able to share both the struggles and the journey
Being able to celebrate small successes to build strength and hope
Finding it helpful to learn about topics such as self-management, new research etc.

Remember you are not alone – a helpful exercise might be to write down the people who are in your support network. This might include a partner, peers from a local group (or online forum), friends, family, doctor or psychologist. These people can offer not only a listening ear but can also help you reach your goals.

Dr.Holly Swartz, Professor of Psychiatry at University of Pittsburgh School of Medicine, U.S.A. highly recommends optimising lifestyle factors given bipolar disorder doubles the rate of cardiovascular disease and medications exacerbate it. Healthy schedules, routine and sleep are all therefore needed to support bipolar disorder recovery and to achieve goals [6].

The Quality of Life Tool (QoL) tool [7] was produced by The Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder. It is a free online resource for a user to intermittently fill in a simple questionnaire where they can rate satisfaction levels for energy, mood, sleep, work, money, relationships and other domains. The tool then displays the data as a graph and table where the user can easily see where they’ve progressed, and where they might want to focus more attention.

You can find some tips in our October [8] newsletter on Routine, Goal Setting and Values and the DBSA has some useful information here too [9].

Check the BipolarLife newsletter for the next monthly support group meeting.in your area.

If you think this article might help someone else too, please like and share

References

Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey,
John Wiley & Sons, Inc.
Dr Alice Lam, GP & Health Writer. 2020. How To Get The Best Out Of Your GP. [ONLINE] Available at: https://www.dralicelam.com/the-write-action/how-to-get-the-best-out-of-your-gp. [Accessed 17 January 2020].
healthdirect. 2020. Mental health care plan. [ONLINE] Available at: https://www.healthdirect.gov.au/mental-health-care-plan. [Accessed 17 January 2020].
The Department of Health. 2020. Chronic Disease Management Patient Information. [ONLINE] Available at: https://www1.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdisease-pdf-infosheet. [Accessed 17 January 2020].
Depression and Bipolar Support Alliance. 2020. Videos. [ONLINE] Available at: https://www.dbsalliance.org/education/educational-materials/videos/. [Accessed 17 January 2020].
Depression and Bipolar Support Alliance. 2020. Videos: Thriving with Bipolar – Treatment plans and collaborating with your doctor. [ONLINE] Available at: https://www.dbsalliance.org/education/educational-materials/videos/. [Accessed 17 January 2020].
CREST.BD. 2020. CREST.BD Quality of Life Tool. [ONLINE] Available at: https://www.bdqol.com/. [Accessed 17 January 2020].
BipolarLife. 2020. Newsletter – October 2019. [ONLINE] Available at: http://bipolarlife.org.au/values-goals-and-routine-dr-alice-lam/. [Accessed 17 January 2020].
Depression and Bipolar Support Alliance. 2020. Setting & Achieving Goals. [ONLINE] Available at: https://www.dbsalliance.org/wellness/wellness-toolbox/setting-achieving-goals/. [Accessed 17 January 2020].

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Diet and supplements for Bipolar Disorder

21/11/2019

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Image by Monfocus from Pixabay

First published on Bipolar Life's website in November 2019

Do you already use supplements, or are you thinking of trying some for your bipolar disorder?

A study in the USA found that one in five people with bipolar used a supplement long term. The most commonly taken supplements were fish oil, B vitamins, melatonin and multivitamins[1].

Even with such popular usage and marketing messages like “safe” and “natural”, one should bear in mind that many supplements:

are unproven
have side effects especially in large amounts
can interact with medications or supplements

In addition:

because they are not officially medications, regulations regarding quality and quantity of active ingredients are variable and difficult to enforce
marketing terms may be misleading e.g. “certified” and “verified” (not being legally recognised terms)[2]

Because the amount of information can be quite confusing, in this article we’ll try to summarise current knowledge. You can read all the way through or just skip to the section that most interests you. Abbreviations are expanded in the footnotes.

As an aside, diet and supplements are not recommended as replacements for medication. However, there is hope that in the future, individual dosing could be used to minimise or possibly eliminate medication, according to Dr William Walsh, scientist and expert in nutritional medicine of the Walsh Research Institute[3].

Supplements

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.

Diet

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)

If you think this article might help someone else too, please like and share

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

References

1. Bauer, M., 2015. Common use of dietary supplements for bipolar disorder: a naturalistic, self-reported study. International Journal of Bipolar Disorders, [Online]. 3, 12. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4451053/ [Accessed 27 October 2019].

2. Depression and Bipolar Support Alliance (DBSA). 2019. What You Need to Know About Dietary Supplements. [ONLINE] Available at: https://secure2.convio.net/dabsa/site/SPageServer/TR/pdfs/pdfs/devo/PageServer;jsessionid=00000000.app274a?NONCE_TOKEN=BB856198664DE4815756376A410964EA&pagename=wellness_depression_dietary_supplements]. [Accessed 27 October 2019].

3. International Bipolar Foundation. (2019). Biochemistry Features of Bipolar Disorders and Advanced Nutrient Therapies. [Online Video]. 1 October 2016. Available from: https://www.youtube.com/watch?v=rQdsWVm9-sw. [Accessed: 27 October 2019].

4. Muneer, A., 2019. Bipolar Disorder: Role of Inflammation and the Development of Disease Biomarkers. Psychiatry Investigation, [Online]. 13(1), 18–33. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4701682 [Accessed 27 October 2019].

5. US Department of Health and Human Services, Office of Dietary Supplements, National Institutes of Health. 2019. Omega-3 Fatty Acids. [ONLINE] Available at: https://ods.od.nih.gov/factsheets/Omega3FattyAcids-Consumer/. [Accessed 27 October 2019].

6. WebMD. 2018. Bipolar Disorder Supplements. [ONLINE] Available at: https://www.webmd.com/bipolar-disorder/guide/bipolar-disorder-supplements#3. [Accessed 27 October 2019].

7. Psychiatric Times. 2014. To Supplement or Not to Supplement: That Is the Bipolar Depression Question. [ONLINE] Available at: https://www.psychiatrictimes.com/psychopharmacology/supplement-or-not-supplement-bipolar-depression-question. [Accessed 27 October 2019].

8. Fink, C. and Kraynak, J., 2016. Bipolar Disorder for Dummies. 3rd ed. New Jersey, USA: John Wiley & Sons, Inc.

9. National Center for Complementary and Integrative Health (NCCIH). 2017. S-Adenosyl-L-Methionine (SAMe): In Depth. [ONLINE] Available at: https://nccih.nih.gov/health/supplements/SAMe. [Accessed 27 October 2019].

10. Pipich, M, 2018. Owning Bipolar, How Patients and Families Can Take Control of Bipolar Disorder. Citadel Press.

11. De Berardis, D., 2015. The role of melatonin in mood disorders. ChronoPhysiology and Therapy, [Online]. 2015:5, 65-75. Available at: https://www.dovepress.com/the-role-of-melatonin-in-mood-disorders-peer-reviewed-fulltext-article-CPT [Accessed 27 October 2019].

12. WebMD. 2018. Melatonin. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-940/melatonin. [Accessed 27 October 2019].

13. WebMD. 2018. Coenzyme Q10. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-938/coenzyme-q10. [Accessed 27 October 2019].

14. WebMD. 2018. 5-HTP. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-794/5-htp. [Accessed 27 October 2019].

15. WebMD. 2018. GABA (Gamma-aminobutyric acid). [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-464/gaba-gamma-aminobutyric-acid. [Accessed 27 October 2019].

16. National Center for Complementary and Integrative Health (NCCIH). 2016. Kava. [ONLINE] Available at: https://nccih.nih.gov/health/kava. [Accessed 27 October 2019].

17. Zheng, W., 2019. N-acetylcysteine for major mental disorders: a systematic review and meta-analysis of randomized controlled trials. Acta Psychiatrica Scandinavica, [Online]. 137(5), 391-400. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29457216 [Accessed 27 October 2019].

18. US Department of Health and Human Services, Office of Dietary Supplements, National Institutes of Health. 2013. Valerian. [ONLINE] Available at: https://ods.od.nih.gov/factsheets/Valerian-HealthProfessional/. [Accessed 27 October 2019].

19. Shelton, R., 2013. The Primary Care Companion for CNS Disorders. Assessing Effects of l-Methylfolate in Depression Management: Results of a Real-World Patient Experience Trial, [Online]. 15(4). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3869616 [Accessed 27 October 2019].

20. WebMD. 2018. Folic acid. [ONLINE] Available at: https://www.webmd.com/vitamins/ai/ingredientmono-1017/folic-acid. [Accessed 27 October 2019].

21. Chouinard, G., 2019. A pilot study of magnesium aspartate hydrochloride (Magnesiocard) as a mood stabilizer for rapid cycling bipolar affective disorder patients. Progress in Neuro-Psychopharmacology & Biological Psychiatry, [Online]. 14(2), 171-80. Available at: https://www.ncbi.nlm.nih.gov/pubmed/2309035 [Accessed 27 October 2019].

22. Giannini, A., 2000. Magnesium oxide augmentation of verapamil maintenance therapy in mania. Psychiatry Research, [Online]. 93(1), 83-7. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10699232 [Accessed 27 October 2019].

23. Sylvia, L., 2013. Nutrition, Exercise, and Wellness Treatment in bipolar disorder: proof of concept for a consolidated intervention. International Journal of Bipolar Disorders, [Online]. Available at: https://journalbipolardisorders.springeropen.com/articles/10.1186/2194-7511-1-24 [Accessed 27 October 2019].

24. Łojko, D., 2018. Is diet important in bipolar disorder? Psychiatria polska, [Online]. 52(5), 783–795. Available at: http://psychiatriapolska.pl/uploads/images/PP_5_2018/ENGver783Lojko_PsychiatrPol2018v52i5.pdf [Accessed 27 October 2019].

25. Łojko, D., 2019. Diet quality and eating patterns in euthymic bipolar patients.. European Review for Medical and Pharmacological Sciences, [Online]. 23(3), 1221-1238. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30779092 [Accessed 27 October 2019].

26. DBSAlliance. (2019). Treatment Choices: Options for Bipolar Disorder. [Online Video]. 2 December 2014. Available from: https://www.youtube.com/watch?v=gzgi9Sr7twY&t=1137s. [Accessed: 10 October 2019].

27. Depression and Bipolar Support Alliance (DBSA). 2019. Nutrition. [ONLINE] Available at: https://www.dbsalliance.org/wellness/wellness-toolbox/lifestyle/nutrition/. [Accessed 27 October 2019].

28. CREST.BD Bipolar Wellness Centre. 2015. Why diet and nutrition are important to your quality of life. [ONLINE] Available at: http://www.bdwellness.com/Quality-of-Life-Areas/Physical/DietAndNutrition. [Accessed 27 October 2019].

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Values, Goals and Routine

15/10/2019

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Photo by Emma Matthews Content Production on Unsplash

First published in Bipolar Life's website on 15th October 2019

Have you ever looked back on the day and wished you had done more? Or have you experienced any difficulty sticking to a waking and bedtime routine? Both are common problems, and a lack of regular circadian rhythm may significantly affect bipolar disorder.

What is circadian rhythm?

The brain’s hypothalamus gland controls the organ systems of our body via hormones, or chemical messengers. A fall in light (such as during the evening) is detected by our eyes then affects a group of cells called the Suprachiasmic Nucleus (SCN), or ‘master clock’; this in turn causes an increase in production and release of melatonin, which makes us sleepy.

This process provides us with a circadian rhythm, which can be affected by altered bedtime and waking times, shift work and jet lag.

By the way, our circadian rhythm is just over 24 hours long, as in ‘circa’ nearly and ‘dian’ day and it is believed to have significant effects on body temperature, stress-hormone cortisol, even regulation of mood and body weight[1].

Why is circadian rhythm so important?

Dr Yoshikazu Takaesu[2] of Kyorin University, Tokyo suggests “…circadian rhythm dysfunctions may act as predictors for the first onset of bipolar disorder and the relapse of mood episodes” and therefore that “treatments focusing on sleep disturbances and circadian rhythm dysfunction in combination with pharmacological, psychosocial, and chronobiological treatments are believed to be useful for relapse prevention.”

In an article published in The American Journal of Psychiatry, Dr Allison Harvey[3] states that a high proportion of people with bipolar disorder are symptomatic between episodes; even in those receiving medication and psychological treatment. In particular, sleep disturbance affects quality of life and increases risk of relapse. She also suggests that daytime mood regulation can affect sleep and vice versa.

Dr Harvey also explains that it seems sleep disturbance escalates just before an episode and worsens still further during an episode. Although there appears to be an association, it is difficult to conclude from studies whether sleep disturbance is simply a feature of bipolar disorder, or a trigger for relapse.

How much sleep is enough?

A regular sleep/wake schedule of roughly eight hours sleep a night, seven day a week is proven to help protect against relapse, according to Dr Ellen Frank[4], Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania. She explains that many people with bipolar disorder are late chronotypes (as are their relatives), which essentially means you sleep later and wake later than the average person. Dr Frank suggests if you can work your schedule around your chronotype, this could give you the most restful sleep but then make sure to stay on that schedule.

How can we optimise our circadian rhythm?

In the world of chronobiology, “zeitgeber” (German for “synchroniser”) is an external cue that affects the body clock, such as light alerting us to the time of day. Early research by physiologist Jürgen Aschoff found that social cues such as mealtimes or work schedules can also act as zeitgebers[5]. Dr Ellen Frank recommends having three to four smaller meals per day to help keep mood and energy levels stable[4].

The zeitgeber theory suggests that episodes of depression and mania or hypomania arise as a consequence of life events: a life event disturbs social zeitgebers such as mealtimes and bedtimes, and these changes then derail the circadian rhythm, triggering relapse[5].

A treatment based on this idea, called “interpersonal and social rhythm therapy” (IPSRT), has been shown as effective in reducing relapse in bipolar disorder[3]. Several studies[6,7] have shown that social rhythm therapy benefits people with bipolar disorder when added to medication.

As well as improving our circadian rhythms, having some sort of routine can assist us in setting and reaching time-based goals, which can improve mental health. For instance, small manageable goals can help lower stress from overwhelm and reduce unhelpful procrastination.

How do we end up with poorly structured days?

Routine can be disrupted through illness, whether it be physical or bipolar disorder. This can cause a multitude of symptoms such as poor motivation, low or excessive energy, low/high/unstable mood, poor concentration, and other problems with cognition such as difficulty with judgement and planning.

Life events such as loss of job, loss of regular social contact or interpersonal problems can also upset our balance.

Unhelpful thought processes where we over-identify with our thinking, known as cognitive fusion, can make it difficult to move forwards to a helpful behaviour. Examples might include: “I’m too lazy to do X” or negative thinking like “I’ll never get through everything I need to do. Might as well give up now” or “I don’t think I’m up to doing job Z perfectly so there’s no point.”

It is common human behaviour to experience habitual leaning towards ‘avoidant’ behaviours which usually make us feel better in the immediate moment (e.g. binge-watching TV or drinking excessive amounts of alcohol); unfortunately these avoidant behaviours are performed in place of healthier actions that could build our self-esteem and self-confidence because they follow our true values (e.g. going for a daily walk to improve physical/mental health, making sure to have a daily shower to practise self-care).

However, the thought of building a healthy, meaningful routine for ourselves can sometimes feel overwhelming.

Let’s look at some recommendations in line with Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy[8] (ACT), where discovering and continually reviewing our personal values can help us to set useful personal goals.

What if I’m struggling to make changes?

Behavioural activation is an evidence-based treatment and maintenance therapy. It is one part of CBT and is used in mood disorders to increase a person’s positive behaviours and reduce negative ones.

Here’s an example of a negative behaviour cycle:
Sleep in for hours to avoid facing a task –>
Feel groggy and poorly motivated with low mood –>
Fell less able to perform the task –>
Experience low mood, motivation and feel guilty and frustrated –>
Sleep in late again.

On the other hand, a person making a conscious effort to perform a positive behaviour (even if they don’t feel very motivated and aren’t enjoying it) will usually find that when the goal has been achieved, their mood, motivation and confidence improve, making it easier to continue positive behaviours.

In addition to behavioural activation, it can help to explore our own values, in order to set meaningful goals.

Photo by Greg Rakozy on Unsplash

Values & how they can help us set goal-orientated actions

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.

Be SMART

The SMART acronym apparently first appeared in 1981 in Management Review. Since then, SMART has been used by a tool by countless organisations and individuals to help people identify and reach their goals. There are a few different versions, but we will use a commonly used one for the purposes of the article.

Don’t forget that we may need to break down a single goal into smaller ones, and more than one goal can run at the same time, so write down your ideas and plans.

To make sure your goals are clear and reachable, each one should be:

Specific (who is involved, what do I want to achieve, where will it take place, why this goal)
Measurable (how many/much or another indicator of success).
Achievable (do I have the resources and capabilities).
Realistic (is this sensible, do I have the motivation to commit to the goal). This one is especially important as people in a depressive phase might be more likely to set very low goals, and those in hypo/mania may set unrealistically high goals)
Time bound (when do I wish to achieve this goal)

Reward yourself for completion of a goal if that helps, as some tasks are an effort and not always enjoyable.

Of course, setting and achieving goals is not always straightforward. Don Kattler[10], a peer researcher for The Collaborative RESearch Team (CREST.BD) recommends that if you find yourself unable to reach a goal, first practise self-compassion (for instance “struggling to achieve is the human condition”, “I’m doing the best I can”), kindness and non-judgement. Next you could gently investigate any internal (e.g. feeling tired) and external barriers (e.g. insufficient time) that got in the way of success this time. Problem-solving an issue increases your chance of success next time. Another realisation might be that the goal was unrealistically high, so you might reduce the difficulty of the goal to maximise success.

And finally, don’t forget you can also check in with friends, family, your GP, psychiatrist or psychologist to if you need more support.

If you think this article might help someone else too, please like and share

References

1. National Institute of General Medical Sciences. 2019. Circadian Rhythms. [ONLINE] Available at: https://www.nigms.nih.gov/education/pages/factsheet_circadianrhythms.aspx. Accessed 10 October 2019].

2. Takaesu, Y., 2018. Circadian rhythm in bipolar disorder: A review of the literature.. Psychiatry and Clinical Neurosciences, [Online]. 72(9), 673-682. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29869403 [Accessed 10 October 2019].

3. The American Journal of Psychiatry. 2008. Sleep and Circadian Rhythms in Bipolar Disorder: Seeking Synchrony, Harmony, and Regulation. [ONLINE] Available at: https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2008.08010098. [Accessed 10 October 2019].

4. DBSAlliance. (2019). Treatment Choices: Options for Bipolar Disorder. [Online Video]. 2 December 2014. Available from: https://www.youtube.com/watch?v=gzgi9Sr7twY&t=1137s. [Accessed: 10 October 2019].

5. Association for Psychological Science. 2016. Controlling Mood Disorders: A Matter of Routine. [ONLINE] Available at: https://www.psychologicalscience.org/observer/controlling-mood-disorders-a-matter-of-routine. [Accessed 10 October 2019].

6. Frank, E., 2005. Two-Year Outcomes for Interpersonal and Social Rhythm Therapy in Individuals With Bipolar I Disorder. Archives Of General Psychiatry, [Online]. 62(9), 996-1004. Available at: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1108410#26048444 [Accessed 10 October 2019].

7. National Institute of Mental Health. 2007. Questions and Answers About the STEP-BD Depression Psychosocial Treatment Trial. [ONLINE] Available at: https://www.nimh.nih.gov/funding/clinical-research/practical/step-bd/questions-and-answers-about-the-step-bd-depression-psychosocial-treatment-trial.shtml. [Accessed 10 October 2019].

8. ACT Mindfully. 2019. Acceptance & Commitment Therapy. [ONLINE] Available at: https://www.actmindfully.com.au. [Accessed 10 October 2019].

9. William Miller, University of New Mexico, (2019), Personal Values Card Sort [ONLINE]. Available at: https://www.guilford.com/add/miller2/values.pdf?t [Accessed 10 October 2019].

10. Don Kattler, Collaborative RESearch Team to study Bipolar Disorder, UBC. (2015). CREST.BD Home & Bipolar Disorder Slides. [Online Video]. 6 March 2015. Available from: https://www.slideshare.net/crestbd/crestbd-home-webinar-slides. [Accessed: 10 October 2019].

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Stigma and Bipolar Disorder

24/9/2019

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Image by Free-Photos from Pixabay

First published on Bipolar Life's website on 17th September 2019

Why should we care about stigma?

Stigma affects many people in society, from race and gender inequality through to people living with mental health problems like bipolar disorder. It is a huge issue with myriad consequences, not least that individuals may experience knock-on effects of stigma that can even outweigh those of the mental health disorder itself. By extension, family and friends may also experience stigma, also known as ‘courtesy’ or ‘association stigma’.

How might an individual be affected by stigma?

An individual experiencing stigma may form negative attitudes and behaviours about him or herself (self-stigma), and may:

be less likely to acknowledge and recognise illness
be less likely to seek, accept or complete treatment
have reduced self-esteem and self-efficacy
have more problems at home
have more problems with employment
have more problems socially, in turn leading to isolation. An individual might notice friends and family withdrawing, or alternatively being overbearing / patronising, or not believing in his or her abilities.

Isn’t stigma decreasing?

Despite the globally large number of public campaigns, high school education and media coverage about mental health, one might think that stigma would be less prevalent. However, according to the General Social Survey which collects data about U.S. residents, the public is in fact more stigmatising – despite increased knowledge about mental illness – than back in the 1950s.

The reasons for this surprising worsening of public opinion include:

Exposure to the public of high numbers of people with untreated mental illness
Lack of strict regulation on media portrayal of the mentally ill, such as over-emphasis on diagnosis in violent crime reports, use of prejudicial words such as “crazy”, inaccurate representation of mental illness in film (a study of various horror films concluded, “Homicidal maniacs are the most common stereotypes. Misinformation is often communicated. Familiar horror tropes are used to stigmatize mental health care environments.”
Stigmatisation and trivialisation of mental illness such as the common use of terms like “schizo”, “psycho”, inaccurate self-description as “bipolar” for normal mood swings or “depressed” for being simply sad.

What is stigma?

Ostracisation of members of society has existed as far back in history as ancient Greece. For example, in Athens, traitors and slaves were physically branded with ‘the mark of shame’ – ‘stigma’ in Greek.

Nowadays stigma is less visible, but most affected are those with mental illness, the homeless, and substance abusers. In one study, it was found that although people with bipolar disorders 1 and 2 experienced the same personal experience of stigma as those with unipolar depression, the impact (in terms of quality of life, social and familial relations and self-esteem) was much worse in people with bipolar disorder.

Stigma can include one or more of the following:

Stereotyped thinking (through ignorance or misinformation)
Prejudice (emotional response e.g. disgust, negative attitude)
Discrimination (behavioural response)
Globalising (generalising about the whole group an individual is deemed to be part of)

A survey by the Royal College of Psychiatrists in the U.K. looked at public perception of people with severe depression. The most commonly held beliefs were that these people:

Were unpredictable (56%)
Were unable to recover, even with treatment (23%)
Were dangerous (23%). This is disappointing as studies show people with mental illness are in fact more likely to be victims than perpetrators of violence.
Could pull themselves out of it (19%)
Had only themselves to blame (13%)

Dr Kay Redfield Jamison, Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine, U.S.A. is well known for her work on bipolar disorder as well as her autobiographical account of her own experience of the condition. She states that these study figures are even higher when applied to people with bipolar disorder.

It is possible bipolar disorder may appear unpredictable due to its sometimes-fluctuating nature, depending on whether the individual is relatively well and getting treatment and support, or experiencing a period of depression, mania or mixed state.

A little more about self-stigma

It is not uncommon for an individual with bipolar disorder to experience negative beliefs about him or herself, which may reduce self-esteem and self-confidence. Worse still, this state of mind may lead to avoidant behaviours like not pursuing opportunities, or not challenging negative self-beliefs by gathering evidence to the contrary.

Even within the medical profession there is stigma from, and towards, other healthcare providers. Compassion without sufficient knowledge may be a contributing factor in some cases.

Dr. Jamison offers an interesting observation that the ‘silently successful’ get well because they have sought and received good care, yet they remain silent for fear of personal or professional reprisal. This in turn perpetuates the public’s misconception that the mentally ill don’t get better.

Where to from here?

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”.

Conclusion

With so much research and an increasingly evidence-based approach to combating stigma, individuals have more power than ever to influence how bipolar disorder is seen in society. In addition, the many tools available can greatly assist an individual to reduce self-stigma and embrace life more fully.

If you think this article might help someone else too, please like and share

References

YouTube. 2019. Discrimination and Stigma Against Patients with Depression and Bipolar Disorder. Johns Hopkins Medicine. [ONLINE] Available at: https://www.youtube.com/watch?v=9Hc0NF89ryg. [Accessed 17 September 2019].

YouTube. 2019. Bipolar Disorder Stigma, Suicide & Families. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=_eE8YSSo-tA&t=1582s. [Accessed 17 September 2019].

YouTube. 2019. Overcoming Stigma in Bipolar Disorder: Challenges and Opportunities. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?v=yDJ4DSZ0Id0&t=2258s. [Accessed 17 September 2019].

YouTube. 2019. CREST.BD's Stigma123 Webinar Jan2016. CRESTBD. [ONLINE] Available at: https://www.youtube.com/watch?time_continue=234&v=LKkpvPD903Y. [Accessed 17 September 2019].

Goodwin, J., 2014. The Horror of Stigma: Psychosis and Mental Health Care Environments in Twenty‐First‐Century Horror Film (Part II). Perspectives in Psychiatric Care, [Online]. 50/4, 224-234. Available at: https://onlinelibrary.wiley.com/doi/abs/10.1111/ppc.12044 [Accessed 17 September 2019].

Arboleda-Flórez, J., 2012. From sin to science: fighting the stigmatization of mental illnesses.. Canadian Journal of Psychiatry, [Online]. 57(8):, 457-63. Available at: https://www.ncbi.nlm.nih.gov/pubmed/22854027 [Accessed 17 September 2019].

CREST.BD. 2019. New directions in bipolar disorder research, treatment and care. [ONLINE] Available at: http://www.crestbd.ca/. [Accessed 17 September 2019].

SANE. 2019. StigmaWatch. [ONLINE] Available at: https://www.sane.org/services/stigmawatch. [Accessed 17 September 2019].

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The Write Action

Tools to help people with bipolar disorder

Trackers

Apps

References

Bipolar Medications and their Side Effects

INTRODUCTION

MOOD STABILISERS – LITHIUM [1,5]

MOOD STABILISERS – ANTICONVULSANTS [1,6]

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ANTIDEPRESSANTS [1,12]

​ANTI-ANXIETY AND SLEEP MEDICATIONS

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​WHAT TO DO IF YOU ARE EXPERIENCING SIDE EFFECTS

​TIPS FOR SPECIFIC SIDE EFFECTS

Conclusion

References

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How do we end up with poorly structured days?

What if I’m struggling to make changes?

Values & how they can help us set goal-orientated actions

Be SMART

References

Stigma and Bipolar Disorder

Why should we care about stigma?

​How might an individual be affected by stigma?

Isn’t stigma decreasing?

​What is stigma?

​A little more about self-stigma

​Where to from here?

​Conclusion

References

Dr Alice Lam

Archives

Categories

ANTI-ANXIETY AND SLEEP MEDICATIONS

WHO MIGHT BE AT INCREASED RISK FOR SIDE EFFECTS?

WHAT TO DO IF YOU ARE EXPERIENCING SIDE EFFECTS

TIPS FOR SPECIFIC SIDE EFFECTS

Why is circadian rhythm so important?

How might an individual be affected by stigma?

What is stigma?

A little more about self-stigma

Where to from here?

Conclusion