Dr Alice Lam, GP & Health Writer
  • Home
  • Blog
  • Useful Websites
  • Health Writer Service
  • Articles
  • Contact Me
  • About Me

The Write Action

​Photo by Hugo Jehanne on Unsplash - Oeschinen Lake, Kandersteg, Switzerland

Bipolar Medications and their Side Effects

23/4/2020

0 Comments

 
Picture
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.
Picture
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
return to articles homepage
previous article
next article
0 Comments

Hepatitis B and relationships

25/3/2020

0 Comments

 
Picture
Photo by Shelby Deeter on Unsplash
​First published on Hepatitis Australia's website in March 2020
"Having HBV is only a small facet of who you are, and not a reason to give up on a loving relationship. A partner who accepts you as you are and wants the best for you is someone who will not see HBV as a barrier to getting to know you.”

​– Lindsey [1], member of the Hepatitis B Information and Support List, Hepatitis B Foundation blog
Although most people get hepatitis B at birth, it can be transmitted in other ways including sex. This article contains information about how it is spreads, and how you can keep your partner safe.

How Hepatitis B is spread through sex

Hepatitis B contained in blood, semen or other fluids can be spread through unprotected vaginal, anal or oral sex. As it is very infectious, it transmits easily through breaks in the skin or mucous membranes (the lining of the nose, mouth, eyes and other soft tissues) [2].
​
We also need to remember that hepatitis B infection can occur through non-sexual contact such as sharing toothbrushes, razors or contact with an infected open wound.
​
However, it is not spread through normal hugging or kissing, or sharing meals, showers or toilets with someone who has hepatitis B [3].

How can we prevent the spread of hepatitis B?

The best way to prevent hepatitis B infection, is to get vaccinated. Given hepatitis B can be spread in many different ways, it is strongly advised that all household contacts and sexual partners should be vaccinated, as well as using condoms with sexual partners [4]. By the way, vaccination is usually free for the above groups [5].
​
If you are concerned you may have been put at risk of hepatitis B, or that you may have put someone else at risk, contact your GP or local sexual health clinic straight away. Your doctor can also contact a sexual partner for you, without including your details if you wish to stay anonymous.

Telling others about your diagnosis

After you have had time to come to terms with your diagnosis [6], you may wish to start thinking about disclosing your condition to others.There are many possible reasons for disclosure, such as:
  • one or more sexual partners have been possibly exposed to the virus during sex without a condom
  • you are embarking on a new relationship.

Knowing when and how to disclose can be difficult. Some people may be supportive, whereas others may withdraw or even be angry. Often this is due to their lack of knowledge about the condition. Be prepared that a relationship may change or even end.
​

Here are some tips that may help with the process [7]:
​
  • Make sure you know the basics about hepatitis B so you can answer some of the more common questions.
  • Before you speak to them, practise how the conversation might go with a good friend, considering both best and worst scenarios.
  • Choose a meeting place where you feel comfortable and safe. Face-to-face is usually best, rather than through email, for instance.
  • Ask them to keep your diagnosis confidential.
  • Bring something you can show like a leaflet or point them to a website like Hepatitis Australia or the National Hepatitis Infoline phone number 1800 437 222.
  • Give the person time and space to digest what you tell them.
  • Look after your own mental health during and after disclosing.​
Finally, you may find these insights help you to negotiate your own relationships and communicate your diagnosis.
“My personal philosophy and method is to be selective about the people I choose to date.  To me, it is important if the potential date has common sense and good character. Once I feel this person is worthy of my time and attention, I have the talk about my hepatitis B, and that HBV is vaccine preventable.  If they are interested in continuing a romantic relationship with me, they need to be vaccinated to protect against HBV.  Some may have already been vaccinated, and if so, HBV is no longer an issue.” 
​
​– Lindsey [1], member of the Hepatitis B Information and Support List, Hepatitis B Foundation blog
 “You need to approach dating, not as who will ‘accept’ you, but rather who ‘deserves’ you. Perspective is everything. If you see a health issue like HBV as a unique barrier to intimacy others will not understand and might reject you for, you will create self-defeating thoughts that not only limit your happiness, but are inaccurate. Everyone has issues. Whether it is health, mental, social or financial, we all feel alone at times and want a connection with another soul.”

​– Lindsey [1], member of the Hepatitis B Information and Support List, Hepatitis B Foundation blog
If you think this article might help someone else too, please like and share

References

  1. Hepatitis B Foundation. 2020. Dating and Hepatitis B – A Personal Perspective. [ONLINE] Available at: https://www.hepb.org/blog/dating-and-hepatitis-b-a-personal-perspective/. [Accessed 11 March 2020].
  2. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Disease Control and Prevention. 2010. When Someone Close To You Has Chronic Hepatitis B. [ONLINE] Available at: https://www.cdc.gov/hepatitis/HBV/PDFs/HepBWhenSomeoneClose.pdf  [Accessed 24 February 2020].
  3. Hepatitis Australia. 2019. What is hepatitis B? [ONLINE] Available at: https://www.hepatitisaustralia.com/what-is-hepatitis-b  [Accessed 24 February 2020].
  4. Hepatitis B Foundation. 2020. Prevention Tips. [ONLINE] Available at: https://www.hepb.org/prevention-and-diagnosis/prevention-tips/  [Accessed 24 February 2020].
  5. Australian Government Department of Health. 2018. Hepatitis B immunisation service. [ONLINE] Available at: https://www.health.gov.au/health-topics/immunisation/immunisation-services/hepatitis-b-immunisation-service  [Accessed 24 February 2020].
  6. Hepatitis Australia. 2019. Dealing with your hepatitis B diagnosis. [ONLINE] Available at: https://www.hepatitisaustralia.com/dealing-with-your-hepatitis-b-diagnosis. [Accessed 24 February 2020].
  7. Hepatitis NSW. 2019. Hepatitis factsheet: Disclosure. [ONLINE] Available at: https://www.hep.org.au/wp-content/uploads/2019/11/Factsheet-Hep-disclosure.pdf. [Accessed 24 February 2020].
return to articles homepage
previous article
next article
0 Comments

Stigma and Bipolar Disorder

24/9/2019

0 Comments

 
Picture
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].
return to articles homepage
previous article

next article
0 Comments

    Dr Alice Lam

    I'm a doctor who is passionate about writing quality health content.

    Archives

    January 2021
    June 2020
    May 2020
    April 2020
    March 2020
    February 2020
    January 2020
    December 2019
    November 2019
    October 2019
    September 2019
    May 2019

    Categories

    All
    Antidepressants
    Anxiety
    Apps
    Atypical Antipsychotics
    Bipolar Disorder
    CBT
    Collaboration
    Communication
    Coronavirus
    Counselling
    Covid-19
    Depression
    Detox
    Disclosure
    General Practice
    Goals
    Healthcare
    Hepatitis B
    Hospital
    Incontinence
    Interferons
    Involuntary
    Lithium
    Mental Health
    Mental Wellness
    MHealth
    Mood Stabilisers
    Patient Advocacy
    Patient Experience
    Patient Safety
    Primary Healthcare
    Psychiatric
    Psychotherapy
    Routine
    Safety
    SANE
    Self Harm
    Side Effects
    SMART Goals
    Stigma
    Stress
    Suicide
    Supplements
    Trackers
    Traditional Chinese Medicine
    Urology
    Values

    RSS Feed

Powered by Create your own unique website with customizable templates.
  • Home
  • Blog
  • Useful Websites
  • Health Writer Service
  • Articles
  • Contact Me
  • About Me