BIPOLAR DISORDER IN OUR WORLD TODAY

So what really is Bipolar Disorder?

Bipolar Disorder,  also known by its older name "manic depression," is a mental disorder that is characterized by serious mood swings. A person with bipolar disorder experiences alternating “highs” (what clinicians call “mania“) and “lows” (also known as depression). 

Causes of Bipolar Disorder

Some of the known causes of Bipolar disorder include:

Genetics

Bipolar disorder tends to run in families. People with certain genes are more likely to develop bipolar disorder than others. Children with a parent or sibling who has bipolar disorder are much more likely to develop the illness, compared with children who do not have a family history of bipolar disorder. However, not all children with a family history of bipolar disorder develop the illness.

Genes however, are not the only risk factor for bipolar disorder. Studies of identical twins have shown that the twin of a person with bipolar illness does not always develop the disorder, despite the fact that identical twins share all of the same genes. Research suggests that factors besides genes are also at work. It is likely that many different genes and environmental factors are involved.

Brain structure and functioning

Studies on the brains have shown that prefrontal cortex in adults with bipolar disorder tends to be smaller and function less well compared to adults who don't have bipolar disorder. The prefrontal cortex is a brain structure involved in "executive" functions such as solving problems and making decisions. This structure and its connections to other parts of the brain mature during adolescence, suggesting that abnormal development of this brain circuit may account for why the disorder tends to emerge during a person's teen years. Pinpointing brain changes in youth may help us detect illness early or offer targets for early intervention.

Some individuals also develop Bipolar disorder as a result of injury to the brain especially those parts of the brain that are responsible for our moods.

Symptoms of Bipolar Disorder

In everyday life, people have a variety of moods and feelings. These feelings include frustration, joy and anger. Usually these moods last one day rather than several days. For people with bipolar disorder, however, moods usually swing from weeks of feeling overly “high” and irritable to weeks of feeling sad and hopeless with normal periods in between.

An important distinction between bipolar disorder and the normal emotions of life is that bipolar disorder results in an inability to handle daily activities. The person cannot work or communicate effectively and may have a distorted sense of reality (for example, unrealistically high or low opinion of one’s skills).

Bipolar disorder often is not recognized by the patient, relatives, friends or even physicians. However, recognizing the mood states that occur is essential. Treatment can help a person with bipolar disorder avoid harmful consequences such as destruction of personal relationships, job loss and suicide.

During a manic phase, symptoms include:

• heightened sense of self-importance
• exaggerated positive outlook
• significantly decreased need for sleep
• poor appetite and weight loss
• racing speech, flight of ideas, impulsiveness
• ideas that move quickly from one subject to the next
• poor concentration, easy distractibility
• increased activity level
• excessive involvement in pleasurable activities
• poor financial choices, rash spending sprees
• excessive irritability, aggressive behavior

During a depressed phase, symptoms include:

• feelings of sadness or hopelessness
• loss of interest in pleasurable or usual activities
• difficulty sleeping; early-morning awakening
• loss of energy and constant lethargy
• sense of guilt or low self-esteem
• difficulty concentrating
• negative thoughts about the future
• weight gain or weight loss
• talk of suicide or death

Bipolar disorder may also be present in a mixed state, in which one might experience both mania and depression at the same time. During a mixed state, one might feel very agitated, have trouble sleeping, experience major changes in appetite, and have suicidal thoughts. People in a mixed state may feel very sad or hopeless while at the same time feel extremely energized.

Sometimes, a person with severe episodes of mania or depression has psychotic symptoms too, such as hallucinations or delusions. The psychotic symptoms tend to reflect the person's extreme mood. For example, if you are having psychotic symptoms during a manic episode, you may believe you are a famous person, have a lot of money, or have special powers. If you are having psychotic symptoms during a depressive episode, you may believe you are ruined and penniless, or you have committed a crime. As a result, people with bipolar disorder who have psychotic symptoms are sometimes misdiagnosed with schizophrenia.

People with bipolar disorder may also abuse alcohol or substances, have relationship problems, or perform poorly in school or at work. It may be difficult to recognize these problems as signs of a major mental illness.

Bipolar disorder usually lasts a lifetime. Episodes of mania and depression typically come back over time. Between episodes, many people with bipolar disorder are free of symptoms, but some people may have lingering symptoms.

Diagnosis

Doctors diagnose bipolar disorder using guidelines from the Diagnostic and Statistical Manual of Mental Disorders (DSM). To be diagnosed with bipolar disorder, the symptoms must be a major change from your normal mood or behavior. There are four basic types of bipolar disorder:

1. Bipolar I Disorder: This defined by manic or mixed episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks.
2. Bipolar II Disorder: This is defined by a pattern of depressive episodes and hypomanic episodes, but no full-blown manic or mixed episodes.
3. Bipolar Disorder Not Otherwise Specified (BP-NOS): This is diagnosed when symptoms of the illness exist but do not meet diagnostic criteria for either bipolar I or II. However, the symptoms are clearly out of the person's normal range of behavior.
4. Cyclothymic Disorder, or Cyclothymia: This is a mild form of bipolar disorder. People with cyclothymia have episodes of hypomania as well as mild depression for at least 2 years. However, the symptoms do not meet the diagnostic requirements for any other type of bipolar disorder. 

A severe form of the disorder is called Rapid-cycling Bipolar Disorder. Rapid cycling occurs when a person has four or more episodes of major depression, mania, hypomania, or mixed states, all within a year. Rapid cycling seems to be more common in people who have their first bipolar episode at a younger age. One study found that people with rapid cycling had their first episode about 4 years earlier—during the mid to late teen years—than people without rapid cycling bipolar disorder. Rapid cycling affects more women than men. Rapid cycling can come and go.

When getting a diagnosis, a doctor or health care provider should conduct a physical examination, an interview, and lab tests. Currently, bipolar disorder cannot be identified through a blood test or a brain scan, but these tests can help rule out other factors that may contribute to mood problems, such as a stroke, brain tumor, or thyroid condition. If the problems are not caused by other illnesses, your health care provider may conduct a mental health evaluation or provide a referral to a trained mental health professional, such as a psychiatrist, who is experienced in diagnosing and treating bipolar disorder.

The doctor or mental health professional should discuss with you any family history of bipolar disorder or other mental illnesses and get a complete history of symptoms. The doctor or mental health professional should also talk to your close relatives or spouse about your symptoms and family medical history.

People with bipolar disorder are more likely to seek help when they are depressed than when experiencing mania or hypomania. Therefore, a careful medical history is needed to assure that bipolar disorder is not mistakenly diagnosed as major depression. Unlike people with bipolar disorder, people who have depression only (also called unipolar depression) do not experience mania.

Bipolar disorder can worsen if left undiagnosed and untreated. Episodes may become more frequent or more severe over time without treatment. Also, delays in getting the correct diagnosis and treatment can contribute to personal, social, and work-related problems. Proper diagnosis and treatment help people with bipolar disorder lead healthy and productive lives. In most cases, treatment can help reduce the frequency and severity of episodes.

Substance abuse is very common among people with bipolar disorder, but the reasons for this link are unclear. Some people with bipolar disorder may try to treat their symptoms with alcohol or drugs (self- medication). However, substance abuse may trigger or prolong bipolar symptoms, and the behavioral control problems associated with mania can result in a person drinking too much.

Anxiety disorders, such as post-traumatic stress disorder (PTSD) and social phobia, also co-occur often among people with bipolar disorder. Bipolar disorder also co-occurs with attention deficit hyperactivity disorder (ADHD), which has some symptoms that overlap with bipolar disorder, such as restlessness and being easily distracted.

People with bipolar disorder are also at higher risk for thyroid disease, migraine headaches, heart disease, diabetes, obesity, and other physical illnesses. These illnesses may cause symptoms of mania or depression. They may also result from treatment for bipolar disorder.

Treatment

Bipolar disorder cannot be cured, but it can be treated effectively over the long-term. Proper treatment helps many people with bipolar disorder—even those with the most severe forms of the illness—gain better control of their mood swings and related symptoms. But because it is a lifelong illness, long-term, continuous treatment is needed to control symptoms. Treatment is more effective if you work closely with a doctor and talk openly about your concerns and choices. An effective maintenance treatment plan usually includes a combination of medication and psychotherapy.

Medication

Different types of medications can help control symptoms of bipolar disorder. Not everyone responds to medications in the same way. You may need to try several different medications before finding ones that work best for you.

Keeping a daily life chart that makes note of your daily mood symptoms, treatments, sleep patterns, and life events can help you and your doctor track and treat your illness most effectively. If your symptoms change or if side effects become intolerable, your doctor may switch or add medications.

The types of medications generally used to treat bipolar disorder include:

• mood stabilizers
• atypical antipsychotics
• antidepressants.

Psychotherapy

When done in combination with medication, psychotherapy can be an effective treatment for bipolar disorder. It can provide support, education, and guidance to people with bipolar disorder and their families. Some psychotherapy treatments used to treat bipolar disorder include:

• Cognitive behavioral therapy (CBT), which helps people with bipolar disorder learn to change harmful or negative thought patterns and behaviors.
• Family-focused therapy, which involves family members. It helps enhance family coping strategies, such as recognizing new episodes early and helping their loved one. This therapy also improves communication among family members, as well as problem-solving.
• Interpersonal and social rhythm therapy, which helps people with bipolar disorder improve their relationships with others and manage their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
• Psychoeducation, which teaches people with bipolar disorder about the illness and its treatment. Psychoeducation can help you recognize signs of an impending mood swing so you can seek treatment early, before a full-blown episode occurs. Usually done in a group, psychoeducation may also be helpful for family members and caregivers.

Other Treatments

1. Electroconvulsive Therapy (ECT)—For cases in which medication and psychotherapy do not work, electroconvulsive therapy (ECT) may be useful. Before ECT is administered, a patient takes a muscle relaxant and is put under brief anesthesia. He or she does not consciously feel the electrical impulse administered in ECT. On average, ECT treatments last from 30–90 seconds. People who have ECT usually recover after 5–15 minutes and are able to go home the same day.
2. Sleep Medications—People with bipolar disorder who have trouble sleeping usually sleep better after getting treatment for bipolar disorder. However, if sleeplessness does not improve, your doctor may suggest a change in medications. If the problems still continue, your doctor may prescribe sedatives or other sleep medications.

Helping People with Bipolar Disorder

If you have a friend or relative suffering from Bipolar Disorder, you can:

• Offer emotional support, understanding, patience, and encouragement
• Learn about bipolar disorder so you can understand what your friend or relative is experiencing
• Talk to your friend or relative and listen carefully
• Listen to feelings your friend or relative expresses and be understanding about situations that may trigger bipolar symptoms
• Invite your friend or relative out for positive distractions, such as walks, outings, and other activities
• Remind your friend or relative that, with time and treatment, he or she can get better.

Never ignore comments from your friend or relative about harming himself or herself. Always report such comments to his or her therapist or doctor.

Common Misconceptions about Bipolar Disorder

The prevailing myths about Bipolar Disorder include:

Myth: Individuals cause their disorder.

Fact: Bipolar disorder is caused by a complex interplay of genetic, biological and environmental factors.

Myth: You can will yourself out of mood swings.

Fact: Left untreated, bipolar disorder can wreak havoc on a person’s life. It requires both medical treatment and psychotherapy.

Myth: You’ll never be normal.

Fact: Many patients in the beginning feel like they won’t be able to accomplish their goals, that bipolar will prevent them from getting married or getting the job of their dreams. Though patients’ lives might require certain changes, they can pursue their dreams. For instance, student patients might take fewer classes every semester and take longer to graduate, but they still achieve a college degree.

Bipolar is easy to diagnose.

Fact: According to Elizabeth Brondolo, Ph.D, a clinical psychologist specializing in bipolar disorder and professor at St. John’s University in New York, it’s often very difficult to diagnose bipolar disorder based on an initial visit, even a prolonged one. This typically occurs because our self-awareness changes with mood.

It can be hard to translate the experiences and moods one has into the symptoms for Bipolar Disorder. For instance, what might appear to one as confidence and clever ideas for a new business venture might be a pattern of grandiose thinking and manic behavior.

Medical treatment is worse than the disorder.

Fact: Many people perceive medication as worse than the illness. Although some people can experience a bad reaction to certain medication, you don’t get hooked on medication like you would a street drug, said Monica Ramirez Basco, Ph.D, clinical psychologist at the University of Texas at Arlington and author of The Bipolar Workbook: Tools for Controlling Your Mood Swings.

References

http://psychcentral.com/lib/living-with-bipolar-disorder

http://psychcentral.com/lib/symptoms-of-bipolar-disorder-manic-depression/000911

Next topic Anxiety panic attacks and bipolar

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Latuda and Bipolar Depression

Have you seen them? The brand new, direct to consumer (DTC), ads touting the drug Latuda for bipolar depression? The drug company just received the indication for this purpose from the FDA a very short time ago, but the drug company, Sunovion Pharmaceuticals Inc., was ready to roll.

Latuda is a dopamine blocking drug, which makes it an antipsychotic medication and not an antidepressant.  We have known since the 1950’s that all antipsychotic medications have some effectiveness in bipolar disorder, although primarily for the prevention of the manic phase of the illness. We have known that they also may augment an antidepressant for those who only get a partial response to the antidepressant in both unipolar and bipolar depression. A colleague of mine routinely used the antipsychotic Navane to augment the old tricyclic antidepressants in the 1970's.

Only two other antipsychotic medications have official FDA indications for bipolar depression, probably because the other drug companies did not spend the money to get it.  If doctors know one member of a class works, they’ll know that the others probably will too, so why bother?  One of these two drugs that has the bipolar indication is actually a combination drug containing an antipsychotic medication (Olanzepine [Zyprexa]) AND the antidepressant Prozac. The other is Quetiapine [Seroquel].

The main problem with using an antipsychotic instead of an antidepressant in this condition – aside from the unequivocal fact that antidepressants are way more effective – is that antipsychotics have much more potential toxicity. Latuda is probably one of the safer ones in this regard, having a low incidence of the two biggest concerns, metabolic syndrome (weight gain, higher cholesterol, diabetes - horrible and very common problems with Zyprexa and Seroquel) and the long-term neurological side effect, tardive dyskinesia.  Interestingly, the FDA won’t let Sunovion make that claim despite the fact that it’s true!  Go figure.

Almost simultaneously with the start of Latuda's DTC ad campaign, two research studies of the drug’s use in bipolar depression were published in the February 2014 issue of the flagship psychiatry journal, the American Journal of Psychiatry (AJP). The studies showed that the drug was effective by itself for the disorder, and also effective as an adjunct treatment when combined with either of the two major anti-manic drugs, lithium and valproate.  Weirdly, the  “effect size” of the improvement in patients, a measure of how much better patients got, was less (0.34) with combination therapy than it was in the case of the drug by itself (0.51). Both of these effect sizes are moderate at best, btw.

That difference is particularly odd in the case of valproate, since there is zero evidence that it is effective for the depressed stage of bipolar disorder (lithium sometimes is, but not usually). Does valproate somehow make Latuda less effective than it would be otherwise?

There is a big issue here:  the question of whether antidepressants alone are the better choice for treatment of bipolar depression.

The last author of the first AJP Latuda  study is Gary Sachs, someone I have discussed previously in this blog [ 10/31/11].  He is the author of a major study that claimed to show that antidepressants were completely ineffective – worse than placebo – in the treatment of the depressed phase of bipolar disorder.  

He conveniently neglected to point out in the earlier paper that the sample of patients he used in this study had already proved to be resistant to antidepressant medication in the first place, and continued to dissemble about this omission when I had the opportunity to confront him about it. Some subjects of his had even failed a trial of a combined antidepressant and antipsychotic. The conclusion of the study as presented in the study was bogus as hell.

A defender of Dr. Sachs made this point: Dr Sachs and colleagues in the abstract did not say that they had proven that antidepressants were ineffective in bipolar depression. They reported their finding and immediately called for additional long-term well designed studies - what I have called plausible deniability.

The more recent Latuda article which Sachs co-authored did in fact state the following: “There is limited evidence of the use of standard antidepressants for the treatment of bipolar depression.”  I guess that isn’t exactlythe same as saying they don’t work, is it?  Might as well be, though! It's not what you say, it's what people hear.

Furthermore, I learned from the article that Dr. Sachs is a paid consultant for Sunovion pharmaceuticals!  

The article’s reference for the statement about antidepressants not being effective was one study that was a meta-analysis of existing studies of antidepressants in bipolar depression (a study which combines the statistics from several other studies). In an editorial in the same AJP issue publishing the Latuda studies, one R.H. Belmaker restates the opinion that “the evidence that antidepressants can be useful seems less and less convincing.”  

His reference for this statement? It is an editorial he himself wrote in the same journal as the original bogus Sachs article appeared [New England Journal of Medicine 356 (17), 4/26/07 (NEJM)]!  I went and got a copy of it.  These folks seem to all run in the same circles, as well as in the same circular reasoning.

In that editorial, he mentions the same meta-analysis that was mentioned in the AJP Sachs article.  But he also mentions that there are two other meta-analytic studies, both totally ignored in the AJP Latuda articles, that showed that antidepressants could be “highly beneficial” in bipolar depression.

There is fairly subtle obfuscation of the evidence going on here, since the other two meta-analyses never seem to be mentioned in articles touting antipsychotics for bipolar depression any more.  I wonder why that is?

In Belmaker’s original NEJM editorial, he opines that maybe the condition is heterogeneous and that subjects in studies outside of the United States may be different than they are here. The two positive metastudies were by authors from outside the USA.

Aside from the fact that there is absolutely no clinical evidence for that whatsoever, Belmaker neglects to mention that at least one of the two meta-analyses showing that antidepressants were effective did not limit itself to studies done overseas, but included studies done in the States! (I could not get a hold of the second, but this is probably also true of that one as well).

Of course, the issue of antidepressants causing bipolar patients to switch into mania is also brought up again and again ad nauseum all over the place, even though everyone agrees – even the original Sachs article in NEJM - that the anti-manic drugs like lithium and divalproate prevent this.  Since true bipolar patients should be on one of those drugs to begin with, this is a superfluous issue.

I also have my doubts that all of the subjects in the Latuda studies were even diagnosed correctly, since one of the diagnostic tools used wasthe Bipolarity Index, which includes the items, “Episodes with characteristic symptoms of hypomania, but symptoms, duration or intensity are subthreshold for hypomania or cyclothymia” and “baseline hyperthymic personality when not manic or depressed. " 

For a discussion of the significance of that nonsense, see my posts about treatment resistant depression and bipolar disease mongering.

These folks are doing nothing but trying to sell expensive and potentially toxic drugs to both doctors and the public when more effective and safer alternatives already exist.