Bipolar Disorder Part 7

This is the last in a series on bipolar disorder. We recently went over the medications used to treat this condition but now I would like to focus on what I call the "other two pillars" of treatment; avoidance of alcohol and substance abuse and management of stress and anxiety.

As I mentioned before the two main reasons that someone with bipolar disorder is not responding to treatment are they either are not taking their medication or there is a drug and/or alcohol problem. Over 50% of patients with bipolar disorder have some sort of a substance abuse problem and this must be dealt with for effective bipolar treatment to occur. Some people are sensitive to even small amounts of alcohol and even intermittent use can cause a problem with mood instability.

Handling stress and anxiety involves some simple things that are often overlooked. Deep breathing techniques are useful. Maintaining a regular sleep schedule and daily routines are good. Patients need to avoid periods of frenetic activity whether at work or home. Daily exercise is important as is good nutrition. Educating family members about bipolar disorder is needed. It is very useful to have a family member accompany the patient to medication follow-up appointment as they may notice early signs of mood disturbance, particularly mania which is not often recognized well by the patient. Learning to recognize early signs of mood disturbance is vital to ongoing recovery.. I always encourage my patients to learn as much as they can about the disorder. This is a lifelong disorder and there may be many different psychiatrists one could see over the course of a life. The only constant factor is the patient him/her self.

I hope this series on bipolar disorder has been helpful in some way. Again, any comments or questions are always welcomed.

Thought for the day

Compassion not judgment

Bipolar Disorder Part 6

Today I will continue to talk about medications to treat bipolar disorder. We have discussed lithium and the antiepileptic drugs and today we will review the third class of medications, the second generation antipsychotics which include some of the newer medications available to treat bipolar disorder.

The second generation antipsychotics are referred to as such in that although they initially came out to treat schizophrenia and partially work like previous antpsychotics in terms of blocking the neurotransmitter dopamine they have some different properties as well which sets them apart from the older antipsychotics or the "first generation". They have some action at serotonin type 1 and serotonin type 2 receptors as well as at dopamine receptors and they bind more at dopamine type 4 receptors and are less active at dopamine 2 receptors resulting in a much reduced tendency for neuromuscular side effects than our older drugs.

These medications include risperidone(Risperdal),quetapine(Seroquel),olanzapine(Zyprexa),ziprasidone(Geodon),Aripiprazole(Abilify), and the newest one paliperidol(Invega). They are very effective antimanic medications, we believe prevent mania and depression to some degree and unlike the other bipolar medications treat depression as well. These medications all have some different properties but tend to have the same set of side effects and risks so I will talk about them as a group.

The main side effects are neuromuscular side effects and metabolic effects. Like the older antipsychotics there is a small risk for a life threatening condition, neuroleptic malignant syndrome, as well as for tardive dyskinesias which are potentially irreversible abnormal involuntary muscle movements. The other much more common and troubling side effects are metabolic. They cause weight gain, increased triglycerides and increased blood sugar leading to possible cardiovascular disease and diabetes.They are not associated with birth defects if used during pregnancy though there is a national registry to monitor this. Geodon and Abilify have much less tendency than the others to cause this metabolic triad. So why use the others? Some people will not respond to Abilify or Geodon and do respond to the others. In fact I have never seen a patient whose acute mania did not respond to Zyprexa. Because of the least amount of side effects and risks I tend to use Abilify as first line treatment because if it works there are not the problems the more severe problems we have with lithium the, aniepileptic drugs s and the other second generation antipsychotics. Geodon could also be a first line treatment for the same reasons but tens in some people to cause sedation.

So, lithium, the antiepileptic drugs and the second generation antipsychotics are what we have available to treat bipolar disorder. I hope that there will be continued development of medications with greater effectiveness and lower side effects. Tomorrow I will talk about some of the non pharmacological treatments that are helpful in bipolar disorder.

Thought for the day

"He whose heart is in the smallest degree set upon goodness will dislike no one".

Ancient Chinese

Bipolar Disorder Part 5

This is the fifth in a series about bipolar disorder. I have been talking about the dilemma of finding effective medication without undue side effects or toxicity and talked before about lithium which remains the "gold standard". Today I will discuss three more medications, carbamazepine (Tegretol), valpoate (Depakote), and lamotrigine (Lamictal). All three belong to the class of medications referred to as AED's or antiepileptic drugs. They initially were designed to stop seizures in epileptic patients before they were found to have significant mood stabilizing properties. Again, like lithium we do not know the mechanism of action in bipolar disorder.

Tegretol was the first one of these three medications found to be effective in bipolar disorder. It does a good job of treating mania and preventing further manic episodes, is not so good at preventing depression and does not at all treat depression. It generally is fairly well tolerated in terms of day to day side effects and blood levels can be monitored. There is sometimes an allergic rash,it can cause hyponatremia or low sodium levels, and is teratogenic, potentially causing congenital abnormalities if taken while pregnant. It also reduces the effectiveness of birth control pills. The most serious potential side effect though is the possibility of bone marrow suppression, impairing the ability to make white blood cells needed to fight off infections so the white blood cell count needs to be monitored on a regular basis.

Depakote was the next AED available to treat bipolar disorder. Like Tegretol it is a very effective antimanic medication, can prevent mania from recurring but does less well in preventing depression and does not at all treat depression. It is as effective as lithium in treating mania and sometimes more effective. Common side effects can be weight gain (at times quite significant) and tremor. It can cause some hair loss, alter menses, increase risk of polycystic ovary syndrome and is very teratogenic. Like Tegretol it can be monitored with blood levels. Rare but serious side effects can be drug induced hepatitis or pancreatitis or quite rare liver failure. Liver function tests need to be routinely monitored.

Lamictal is much different than any other bipolar medication. It does not treat mania nor depression but is very effective in preventing further manic episodes as well as further depressed episodes. It is extremely well tolerated day to day, is not associated with weight gain, is not teratogenic, and is not associated with the risk of bone marrow suppression or liver problems. It has a rare (but potentially fatal) risk of inducing a Stevens - Johnson reaction which is a severe rash affecting not only the skin but the mucous membranes as well. Because of it's properties of preventing mania and depression it is often used as a second medication in many cases.

As I mentioned before these medications can sound quite bad in terms of side effects and risks but in most cases the benefits of preventing the devastating consequences of untreated bipolar disorder outweigh the risks. Tomorrow I will talk about the third group of bipolar medications, the second generation antipsychotic medications.

Thought for the day

"The thought never came to mind that I too am a brief and passing thing and so, through hatred ,lust, and ignorance I have committed many sins".

The Way of the Bodhisattva

Bipolar Response

A reader posted a question on our Facebook site asking about the difference between bipolar I disorder and bipolar II disorder. I have not yet gotten to that point in the series but I will answer briefly as well as I can.

What I have been talking about so far is what we call bipolar I disorder which has previously been called manic - depressive illness. Bipolar II disorder is a cycling mood disorder in which there are episodes of depression, including chronic depression with episodes of what we refer to as hypomania or "under mania". These are periods in which there are manic like symptoms but not of the severity of full blown mania and not resulting in so many life destructive events. Most people with bipolar II disorder spend the majority of their time in depression.

I hope this helps answer the question and we will discuss this more in detail on a later post.

Bipolar Disorder Part 4

This is the fourth in a series of didactic posts on bipolar disorder. I want to talk a bit about medication treatment as it is an essential component of treatment For patients making informed decisions about these medications requires education as many of the medications that we use to treat this disorder have significant adverse side effects, can be toxic, and can have long term negative effects on different organ systems. I call it the bipolar medication dilemma as there are no easy answers, there is no one size fits all treatment, and decisions need to be made on an individual basis taking into account health risks and other health conditions that a patient may have. It is a true dilemma as these medications that I will talk about have a lot of problems and yet without medication an untreated course of bipolar disorder is a disaster. So for now we have to use them. I would like readers to keep that in mind when I discuss all the potential negative effects.

There are four goals in medication treatment of bipolar disorder. We need to treat mania without causing depression, treat depression without causing mania, prevent depression, and prevent mania. It is unusual for one medication to carry out all four of these tasks so combination medication is the rule, rather than the exception which increases the potential for medication side effects. There are three different types of medication which have clearly shown effectiveness; lithium, anti epileptic drugs used to treat seizure disorders, and the second generation anti psychotic medications. I will talk about lithium to day and cover the others later.

Lithium remains the "gold standard " for treatment of bipolar disorder. No medication has been shown to more effective than lithium which we have had available to use since the mid 70's. Lithium is not a drug. It is a basic element which binds to other molecules to become a salt just as the sodium we use for table salt does. Usually the lithium we use comes in the form of lithium carbonate. The mechanism of action is unknown. It effectively treats mania and does work to prevent mania and depression but by itself is not a good antidepressant. We have more medications available to treat mania than we do bipolar depression. There is a narrow range between therapeutic levels and toxic levels so lithium blood levels do need to be obtained. Toxic lithium levels can result in kidney failure which is not always reversible. Lithium can cause diabetes insipidus which is the inability of the distal tubules in the kidney to reabsorb fluid resulting in excessive urination. Fortunately this can be treated strangely enough by adding a diuretic. Lithium also interferes with the release of thyroid hormone leading to hypothyroidism so thyroid levels need to be monitored. The most worrisome effect though is the evidence that long term lithium use (30 years or more) results in some kidney damage and impaired kidney function. We are now beginning to see this since we have had lithium available now for 35 years. No one really knows whether or not this will result in progressive renal failure or not. Some common day to day side effects are nausea, tremor, development of acne and weight gain.

So you can see that lithium has a lot of problems but I want to state again that it is very effective. It to me is still a "miracle" in that it can stabilize a disorder that otherwise would result in chronic mental illness and difficulty or inability to live in the community. I do not like to use lithium though for milder cases of bipolar disorder but for the more serious cases with the most complications or to use lithium when other treatments are not effective. I will talk about some of the other medication treatments in my next post.

Thought for the day

"Live a life worthy of the calling to which you have been called".

St. Paul

Bipolar Disorder Part 3

I have been talking about bipolar disorder the past two days and want to look at what it takes for effective treatment. There are three main things that must be done to prevent relapses and avoid the devastating consequences of both the mania and depression. The first is adequate medication. The second is avoidance of alcohol and drugs, and the third is management of stress and anxiety. Chances of full and long lasting recovery are slim if one of these things are left out of treatment.

First is adequate medication. Unlike non bipolar depression bipolar disorder cannot be treated with cognitive behavioral and other psychosocial treatments alone. Medications are required and need to be taken lifelong. Bipolar disorder is a progressive disease with deterioration over time if left untreated. There are problems though with the medications that are available to treat bipolar disorder. Many have significant side effects and are associated with long term health risks. I will discuss the bipolar medication dilemma tomorrow.

Second is avoidance of alcohol and drugs. Unfortunately over 50% of individuals with bipolar disorder have an alcohol or other substance abuse problem. There tends to be a continuous negative cycle in which the alcoholism worsens the disorder and the disorder reduces chances of long term abstinence. Except for non adherence to medication alcohol abuse and dependence are the number one reason for failure of adequate treatment or so called treatment resistance. I cannot overemphasize this. Bipolar disorder cannot be stabilized in the presence of an active substance abuse problem and co-occurring treatment is required.

The third main pillar of treatment is management of stress and anxiety. High levels of stress can trigger either manic or depressed episodes as well as times of interpersonal conflict. Persistent insomnia which often accompanies stress can trigger manic episodes. Regular sleep, good diet, and exercise are helpful in this regard.

Thought for the day

"God is our refuge and strength, an ever present help in times of trouble"

The Psalmist

Bipolar Disorder Part 2

This is the second part of a series on bipolar disorder which is a common mood disorder affecting about 1% of the population. I indicated that the hallmark of this disorder is episodes of mania that are not due to substance abuse or medical problems. So what exactly is mania?

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision(DSM-IV-R) defines mania as follows;

Manic episodes are characterized by at least one week of profound mood disturbance characterized by elation, irritability, or expansiveness that causes significant impairment in occupational or social functioning or represents a danger to self or others that has at least three of the following symptoms;

Grandiosity
Diminished need for sleep
Excessive talking or pressured speech
Racing thoughts or flight of ideas
Clear evidence of distractibility
Increased level of goal directed activity at home, at work, or sexually
Excessive pleasurable activities, often with painful consequences

This definition I suppose is ok but it doesn't capture the essence of mania which includes significant impairments in appearance, mood, thought content, perceptions, self destructiveness, aggression and judgment and insight so I will try to describe common changes we see in these areas.

Appearance - we see hyperactivity, hypervigilance, restlessness, excessive energy and activity. Thinking and talking are very fast, the person will often interrupt or talk over everyone else, will have no sense of social boundaries and be behaviorally intrusive. Attire may be very disorganized or very bright, colorful, or garish and they frequently attract attention because of the way they dress. Being with a manic person makes you want to find the "off button".

Mood - we see a tendency to be inappropriate in terms of being elated, jubilant, or euphoric or a high degree of easy annoyance or irritability that seems totally out of proportion to what is actually happening.

Thought content - We see expansive and overly optimistic thinking, inappropriate self confidence or grandiosity, high distractibilty, quickly shifting from one thought to another and, can be very hard for one to follow their train of thought. Often there are thoughts that the manic person has of being special or having some sort of special knowledge and these can become very delusional. There is an apparent need to excitedly tell others about this specialness or the grandiose insights.

Perceptions - We often see overt delusions which reflect perceptions of power, prestige, self worth, or glory and will sometimes move to extreme paranoia or hallucinations.

Self destructiveness - there can be suicidality although most suicide attempts in bipolar disorder occur in the depressed phase of the illness.

Aggression - we see at times aggression and combativeness, demandingness, and acting out of the grandiose belief that others need to obey their commands or wishes with anger and irritability when someone doesn't obey.

Judgment and Insight - It is the impaired judgment that really differentiates mania from normal "highs". Patients with mania have generally no insight. They rarely see anything wrong with themselves and resist efforts at treatment not seeing any need for it. Serious mistakes are frequently made in regard to finances, marriage and relationships, and occupation, refusing to listen to any one's advice often with devastating consequences.

This is a rather long post but I wanted to describe what mania is really like and I don't think the DSM-IV-TR really describes what goes on in mania.

I will discuss tomorrow some options for treatment. Again I welcome any questions or comments.

Thought for the day

Without treatment bipolar disorder can be a devastating disease.

Bipolar Disorder

From time to time I do a series of teaching posts dealing with a particular psychiatric disorder. I encourage any readers to post any comments and questions as we go along and I hope that I can be of use to someone who is interested in knowing more about a particular topic. I have decided to focus for a short time on bipolar disorder which is a common psychiatric problem and one of the most severe, persistent, and often disabling disorders that we treat.

Bipolar disorder used to be referred to as manic depressive illness. It has been described in medical literature as far back as Hippocrates in ancient Greece. It is common, affecting approximately 1% of the population with men and women being equally affected. There have been no race or ethnicity correlations. Bipolar disorder appears to be an equal opportunity disorder. It is chronic, persistent, and associated with a variety of complications including suicide attempts and suicide, child or spousal abuse or other violent behavior, school failure, occupational failure, divorce, and alcoholism and drug addictions. Untreated it tends to worsen over a person's life. It is considered the most severe mental illness after schizophrenia and often associated with lifelong disability. Over 50% of those affected will develop alcoholism and 11% will die by suicide. It's onset is usually in late adolescence or early adulthood although it can present later in some people. It is strongly genetically linked. First degree relatives of someone with bipolar disorder are 7 times more likely than the general population to have bipolar disorder.

So what exactly is bipolar disorder and what are the features of this problem? The hallmark of bipolar disorder is episodes of mania. Bipolar disorder is diagnosed in anyone with a manic episode that is not induced by drugs or alcohol or a medical disorder, whether or not there are episodes of depression. More commonly though the person will suffer from both depressed episodes as well as mania and the majority of the time the patient will be in the depressed phase of the illness. So if mania is the hallmark what exactly is mania? It is much more than an elevated mood but affects appearance, mood, thought content, perceptions, anger or aggression, judgment, and insight Usually impairments in orientation and memory are not present.

I will discuss tomorrow what these multiple changes are.

Thought for the day

"No power of hell or scheme of man can ever pluck me from His hand".

The Newsboys

Attention Deficit Hyperactivity Disorder part 7

This is a last in a series on Attention Deficit Hyperactivity Disorder (ADHD). I would like to talk a bit on psychosocial treatments which are very effective when combined with medication use. The focus is on various aspects of behavior modification which includes behavioral treatment, parent education and training, school interventions, and home interventions. Various other "talk therapies" have been tried but behavioral modification is the only treatment that has shown effectiveness with this disorder.

What is behavioral modification? It is a treatment where parents, teachers, and children learn specific techniques and skills which are used consistently in daily interactions. Behavioral modification focuses on identifying things that set off troublesome behavior, the behaviors themselves, and the consequences of the behavior such as how parents and teachers act in response to the behavior. The idea is to teach everyone skills in how to react differently and make the child's environment and experiences better when the good behavior that is desired is engaged in by the child. The only problem I have seen with behavioral interventions is that some people make them too complex. They must be simple and easy to implement and easily sustained over long periods of time. Many of them seem to be common sense approaches but parents and teachers must be encouraged to use the interventions as many of the behaviors with ADHD are very trying and tend to bring about negative reactions from parents and teachers.

Some behavioral interventions include ignoring mild inappropriate behaviors (choose your battles) use many more praises than negative comments, use clear short and specific instructions, reprimands should be brief, clear, neutral in tone, and as immediate as possible, placing the student's desk near the teacher, computer assisted instruction, simple behavior charts with points or tokens that can later be exchanged for rewards and many others. Again a lot of common sense approaches. I think one of the most difficult things is keeping reprimands brief and neutral in tone. We tend to speak angrily and give too many long explanations for why we are criticizing the behavior.

For more information on ADHD and behavioral strategies you can go to http://www.help4adhd.org/.

Thought for the day

Everyone deserves respect.

Depakote, Pregnancy, Epilepsy, Bipolar Disorder. IQ

I read the other day that there has been shown to be a link between use of Depakote in pregnancy and lower IQ in the offspring of those who were on the medication. This has been suspected for some time but now has been demonstrated. Depakote has other risks and this is just one more.

Depakote is an anticonvulsant medication used to treat seizure disorders. It also was the third medication after Lithium and Tegretol to be approved by the FDA to treat bipolar disorder and for years has been one of the mainstay treatments for this disorder. Depakote is a good example of the difficulty with medication treatment for bipolar disorder in that it carries significant side effects and health risks. One problem in treating bipolar disorder is that there are four tasks; treating mania, treating depression, preventing further mania, and preventing further depression. There is no one medication good for all treatment goals and most people with bipolar disorder will end up on a combination of medication to cover all phases of treatment. This of course increases potential side effects and risks.

Depakote is a very effective antimanic agent. It also seems to do well in reducing risk of further mania, but is not a good antidepressant and may do nothing to prevent bipolar depressed episodes. It can cause side effects of sedation, significant weight gain and occasional hair loss. It is potentially toxic to the liver and liver function tests need to be monitored regularly. In addition for women there can be changes in the menstrual cycle as well as development of polycystic ovary disease. Depakote has long been known to be related to a variety of birth defects and has been avoided in pregnant women and those of childbearing age who might become pregnant. So lowered IQ in offspring is one more issue to add to the list. Unfortunately there are some women whose epilepsy can be controlled by no other anticonvuslant and there are women with bipolar disorder who cannot be stabilized enough to live in the community without Depakote.

I am writing this mostly to help people understand that treatment of bipolar disorder can be very difficult and fraught with risks. I hope that newer and better treatments will continue to be developed.

Thought for the day

Medications are neither good nor bad in themselves but every treatment carries potential risks as well as benefits.