Bipolar Disorders: Torn Two Ways

By Carey A. Krause, D.O.

It has not been a good year for John. He was so excited as he started college last fall, but within weeks, trouble developed. He started missing classes. On several occasions his roommate found him in bed, shades drawn, in the middle of the day. Despite this, he was sleeping less; he could not shut down the anxious, ruminative thoughts in his brain. He stopped playing basketball and guitar, formerly his passions. He could not concentrate on homework, and he quickly fell behind in classes. By late October, he felt like a failure. Every waking moment was bleak, and the thought of being anywhere else, even nowhere, seemed preferable.

Fortunately, he made it to his family doctor, who quickly recognized the symptoms of depression, and had John start an antidepressant medication. Within three weeks he felt much better, and was able to salvage some of his classes, and defer the rest.

By spring though, something completely different happened to him. At first, his friends were thrilled to see how lively and talkative John had become. But they soon tired of his intrusiveness, and his flood of constantly changing ideas. Then he dropped out of school completely. He said he was starting his own business, and would be rich within a year.

As if he already had the money, his first "business" purchase was a sports car. When his parents finally tracked him down, he was living in an empty storefront, and looked as if he hadn't slept in a week. He talked non-stop on the way to the psychiatric hospital. When he realized where they were taking him, he accused his parents of being "corporate spies," and tried to jump out of the car.

The psychiatrist told John's parents that he had a classic presentation of "bipolar I disorder." She assured them that with medication, John would most likely be back to near normal within weeks. For his parents, though, this was less than reassuring. What on earth had happened to their son, and what would prevent it from happening again?

WHAT IS BIPOLAR DISORDER?

Like most diagnoses in behavioral health, bipolar disorder (formerly known as manic-depression) is a diagnosis based on symptoms. In other words, physicians are not sure exactly what goes wrong in the brain to cause bipolar disorder, but they have seen the signs and symptoms often enough to be sure that it does represent a definite illness, or cluster of illnesses. At first, John exhibited signs of depression, including a lack of interest, concentration difficulty, sleep difficulty, and an overwhelming sense of hopelessness. His family doctor deserves credit for getting him started on antidepressants as soon as he was seen. But as is the case with at least 10 percent of those initially diagnosed with depression, it was the first warning of a bipolar disorder. Within weeks, he was starting to exhibit many of the symptoms of mania. His thoughts were racing from subject to subject. He began taking unacceptable risks and he believed he needed less and less sleep. He started developing grandiose beliefs about himself, which easily morphed into paranoid thoughts about everyone else.

Over their lifetime, about one to two percent of the population will develop bipolar symptoms as severe as John's. To some extent, it is an inherited disease: one's risk jumps from one percent to 15 percent if a close family member has bipolar illness. For some, the initial presentation is an episode of major depression. Within a few years, occasionally as quickly as within a few months, these individuals will cycle into an episode of mania, and the diagnosis will become obvious. Without proper treatment, though, they are destined to repeat the episodes in succeeding years. Many may have mostly depressed episodes while others may have repeated manic episodes. Left untreated, the episodes will become worse, and occur more frequently, leaving that individual's entire existence in shambles. At least 60 percent of those with bipolar illness abuse alcohol or street drugs, often in an attempt to "self-medicate" the symptoms. The lifetime risk of suicide is as high as for any other psychiatric illness. Even with treatment, it approaches 15 percent of those affected.

BIPOLAR DISORDER VERSUS "MOODINESS"

There is a distinct difference between the mood swings that any one of us experience from day to day, and the diagnosis of bipolar disorder. Bipolar illness is not moodiness; rather it is sustained episodes of manic or depressed behavior. These episodes have one thing in common: they are destructive to the life of the sufferer. Bipolar episodes, either depressed or manic, lead to job losses, broken relationships, disrupted families, and financial disaster. Ultimately it is this destruction, along with the threat of suicide, which demands the medical community step in and provide treatment.

John's illness was "classic," as his psychiatrist said, but not all bipolar illnesses are as easy to identify. Many individuals have what is called a "mixed" illness, where they exhibit symptoms of both a manic and a depressed episode at the same time. These individuals may have racing thoughts and a high level of distraction, but are distinctly irritable and unhappy. They may have distorted or frankly paranoid thoughts about their world. A mixed illness is harder to diagnose, and requires the efforts of a skilled psychiatrist to treat.

Over the past thirty years, broader definitions of bipolar illness have led to the concept of the bipolar spectrum disorders. Bipolar II disorder refers to an illness of repeated, severe episodes of depression, with at least one episode of hypomanic behavior. Hypomania is much like mania, in that the individual involved may appear over-energized, with pressured speech and driven behavior. It is different in that it does not lead to the same severe social and personal destruction that a fully manic episode will cause. Bipolar II disorder is more common than bipolar I, and there is evidence that many individuals who have suffered from repeated episodes of depression likely are undiagnosed bipolar II sufferers. Bipolar II is a distinct illness; it is not simply a less severe form of bipolar I. In fact, individuals who have a close family member with a bipolar II diagnosis have a statistically higher risk of developing a bipolar II illness themselves, but not a higher risk of bipolar I.

Recent studies indicate up to half of adults who are diagnosed with a bipolar disorder may have shown symptoms of the illness before age 18. Many children who are being treated for depression, attention deficit disorder, or conduct disorder, may actually have an emerging bipolar disorder. Efforts to improve diagnoses are vital, as mistreatment with the wrong medications can aggravate symptoms. This can lead to even more trauma and life disruption at a critical period in a child's social development.

TREATING BIPOLAR DISORDER

John's psychiatrist started him on lithium, the first medication noted to be effective for treatment of bipolar disorders, and still the standard by which other medications are measured. Within a few days, he was talking less and listening more, and his intrusive behavior had improved. Lithium is one of the simplest of elements, and its effectiveness as a treatment for bipolar disorder continues to fascinate scientists. They have identified its role in changing the rate at which neurons create new proteins and operate internal chemical pathways, but it is a mystery as to how this leads to improvement of behavior. In addition to lithium, physicians have identified a handful of drugs, initially introduced to control epileptic seizures, that are often as effective as lithium in controlling bipolar behavior extremes. These include valproic acid (commonly known by the brand name Depakote), carbamazepine, and lamotrigine. The latter may be particularly beneficial in treating bipolar II disorder. It will be vital for John to understand that lithium is his ticket to ongoing stability. He will need to plan to take this medication for the foreseeable future, even when his symptoms are fully controlled, to minimize the risk of a future manic or depressive episode.

In addition to the lithium, John's doctor also prescribed an "atypical" antipsychotic medication. The antipsychotic quickly reduced John's paranoid and grandiose thoughts, and he was able to recognize the need to agree to ongoing treatment. The atypical antipsychotic medications have become an important part of treating severe bipolar episodes. There is evidence they may also be useful long term to maintain stability.

Finally, John's antidepressant medication was stopped, but his psychiatrist would not want the family doctor to think it had been a mistake to prescribe it for John's depression. There is evidence that antidepressants, especially the older tricyclic antidepressants, can push a depressed bipolar patient into an episode of mania. However, a bipolar patient's depression must still be treated. An individual suffering from a bipolar II illness is over 30 times more likely to suffer a repeat depression episode than an episode of hypomania. For them, timely use of an antidepressant may be life-saving. John's psychiatrist will watch closely for depressive episodes in the future. She may treat them with an antidepressant, but will stop the antidepressant once symptoms have improved, to lessen the risk of a manic overshoot.

Medications used to treat bipolar disorder have risks associated with them, and John's doctor will carefully go over those with him. With long term use, lithium can affect kidney and thyroid function, so those will be periodically monitored with blood tests in the future. Valproic acid can cause weight gain, and has (very rarely) been associated with liver inflammation or pancreatitis, which also means periodic laboratory monitoring is appropriate. In addition to the slight but ever-present risk of developing involuntary muscle movements, all of the atypical antipsychotics have been implicated in causing increases in blood sugar and blood lipid levels, which requires even more monitoring.

OVERCOMING ROADBLOCKS TO SUCCESSFUL TREATMENT

In fact, the biggest risk for John, as he stabilizes in the hospital and begins to plan for discharge, is that he will find his ongoing treatment too daunting or too burdensome, and he will stop treatment after he leaves the hospital. Non-compliance with maintenance therapy is a huge part of the ongoing debilitation caused by bipolar illnesses. John may admit he is more functional on medication, but he may remember that he felt more energized, more productive, perhaps even invincible, when he was manic. He will have a powerful urge to escape the "dulling" sensation of medication and feel that manic euphoria again. Or he may be frightened of the risks associated with medications, and frustrated that he has to "take a pill" to feel normal. The urge to be like everyone else will be strong; he may succumb to the everpresent societal judgment that something is "wrong" with him if he cannot take care of himself without meds. His risk of relapse will be highest during his first six months out of the hospital.

Fortunately, John's hospital treatment team has taken steps to reduce that risk. His inpatient case manager has set up follow-up appointments in the community with a psychiatrist who is expert in managing medications. In addition, John is scheduled to see a skilled therapist. The therapist will at first focus on basic strategies John needs to employ to re-integrate himself into society and get back into school. Cognitive therapy techniques will help John avoid feelings of inadequacy and shame due to his illness. Finally, the therapist may plan to meet with John's family as well. The goals would be to help them understand bipolar illness, and to teach them to recognize clues of an emerging manic or depressed episode so they can intervene quickly.

SOME FINAL THOUGHTS

Throughout history, physicians have recognized that a distinct group of their patients suffered from this unique illness of repeated manic or depressed spells. Arataeus wrote about the illness almost two thousand years ago in Alexandria. In the mid - nineteenth century, French physicians debated the origin of "circular insanity." In our time, we continue to search for the "lesions" within the brain and the mistakes in our genes that lead to this severe and potentially disabling disorder. In the meantime, we fight to get effective treatments to sufferers, and to get them to stay in treatment.

I will sometimes tell my patients that a bipolar illness is the most severe illness of the brain one can have and still potentially lead a "normal" life. Indeed, several famous individuals have led remarkable lives while suffering from a bipolar disorder, and some have written about their trials. Kay Redfield Jamison, a psychologist at Johns Hopkins University, has written about her own struggle with bipolar illness in her memoir, An Unquiet Mind. Young authors, such as Lizzie Simon and Andy Behrman, have written contemporary accounts of their own illnesses. All tell of struggles and disappointments, but the fact that each has reached the point where they could write about their illness and have their manuscript published speaks to the potential for leading a productive life.

I predict success for our imaginary patient John. Hopefully the same is true for all of the very real individuals who are suffering from some form of a bipolar illness today. Fortunately, we have effective treatments, even as we struggle to understand the nature of the disease. Ultimately, the prescription is straightforward: stick with treatment, keep those appointments. The future is full of hope.