Bipolar Disorder FAQ - Part I

John McMa

This FAQ is intended to give you an introductory overview of bipolar disorder. The FAQ is divided
into three parts. Part I discusses the nature of bipolar disorder, its symptoms and causes, how it affects both mind and body, its impact on kids, and seeking out treatment. Part II deals with medical and therapeutic treatments. Part III focuses on natural treatments, lifestyle, coping, and suicide prevention. All links but one are to articles on this site. What is bipolar disorder? Bipolar disorder, also known as manic depression, is a mood disorder characterized by extreme shifts in mood, from depressive lows to manic highs. What are the different types of bipolar disorder? The American Psychiatric Association's Diagnostic and Statistical Manual Fourth Edition (DSM-IV) has divided bipolar disorder into two types, Bipolar I and Bipolar II, both which are severe and debilitating. In addition, the DSM-IV lists as separate disorders "Cyclothymia," which can be described as a "bipolar lite," and schizoaffective disorder, which borders on schizophrenia. What are the symptoms of bipolar I? Bipolar I requires only the presence of a single manic episode, though just about all people with bipolar I experience major depressive episodes, as well. The DSM describes a manic episode as "a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week" (or requiring hospitalization). In addition, the DSM requires at least four of the following seven symptoms (three if merely irritable): 1) Inflated self-esteem or grandiosity, 2) decreased need for sleep, 3) More talkative than usual, 4) Flight of ideas, racing thoughts 5) Distractibility, 6) Increase in goal-setting activity or psychomotor agitation 7) Excessive involvement in pleasurable activities (such as buying sprees, sexual indiscretions, or foolish business investments). The DSM goes on to say that the symptoms must be severe enough to interfere with work or social relations or necessitate hospitalization to prevent harm to one's self or others. Those manic highs must be a lot of fun. Not really. People on manic highs are out of control, and people out of control quickly get into trouble. Ruined careers, personal bankruptcy, and wrecked relationships are par for the course, and hospitalization, incarceration, and homelessness are far too common. Moreover the intoxicating high of mania (euphoria) can turn on itself into a raging agitation (dysphoria) that creates a state of internal hell. Also, most people in a manic episode experience at least one psychotic symptom (such as delusional thoughts or hallucinations). Finally, there are "mixed" states where one is literally both manic and depressed. What are the symptoms of bipolar II? The DSM mandates the presence or history of at least one major depressive episode. Because major depression is such a common feature of bipolar II, it is a mistake to regard bipolar II as somehow milder than bipolar I. The DSM also mandates the presence or history of at least one hypomanic episode. Hypomania can be described as "mild" mania, with the same symptoms, but where the symptoms are not severe enough to interfere with work or social functioning, though they are observable by others.

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Those hypomanic highs must be fun. Yes, definitely, but we are learning that many people who are hypomanic can be irritable, your classic road rage cases. Otherwise, one can define hypomania as "life of the party" behavior with "salesperson of the month" productivity. Unfortunately, because everything seems so "right" in a state of hypomania, people experiencing these episodes are unaware that there is anything wrong, and fail to seek help. Nothing lasts forever, however, and inevitably there is a crash into depression or an escalation into mania. People with bipolar I often experience hypomania as a prelude to mania. Can you elaborate on nothing lasts forever. Let me qualify my statement above. There are some people whose success seems attributable to a perpetual state of hypomania. Because they are successful they don't come to the attention of the psychiatric profession. Noted bipolar authority Kay Jamison PhD at a conference in 2002 described Teddy Roosevelt as "hypomanic on a mild day." And Bill Clinton, one could argue, is a walking hypomania poster boy.. What are the symptoms of cyclothymia? One can think of cyclothymia as "bipolar lite," characterized by mood swings from hypomania to mild depression. What are the symptoms of schizoaffective disorder? The DSM lists schizoaffective disorder under "Schizophrenia and Other Psychotic Disorders," but a strong body of opinion suggests that even though bipolar and schizophrenia are distinct disorders, they form part of a spectrum with overlapping features. Schizoaffective disorder occupies the middle ground between bipolar and schizophrenia, characterized by mania and depression as well as psychosis (delusions, incoherent speech, hallucinations) or other features of schizophrenia. I have my up moods and down moods, my bad days and good. Does this mean I have bipolar disorder? Not necessarily. Mood swings are normal, as are the many features of mood, including elation, grief, and anger. But when your behavior begins to affect your work and social relations or is noticeable by others, you may have a problem. So with mania and hypomania we're talking over the top behavior. Here's how one reader describes the experience: "Thursday night I was so angry it was difficult to keep from throwing and breaking everything within reach. Friday I was elated, giddy, fun to be around. Saturday seemed fine, happy but calm. Sunday morning I woke up and started cleaning the apartment...I moved furniture, on hands and knees I scrubbed every bit of carpet and floor, I vacuumed, I mopped, I took the vacuum and cleaned out all the vents and heaters, I reorganized my closets ..." Can you talk about the depression side of the equation? By all means. Mania gets all the attention, but bipolar patients are actually depressed three times more than they are manic, and the depressed phase of the illness results in more hospitalizations than the manic side. Moreover, depression accounts for nearly all of the bipolar suicides, one in five among those untreated. This amounts to double decimation, as decimation literally means one in ten.

Is bipolar depression different than unipolar depression? Unfortunately, bipolar depression has been little studied, as the depressive side of the equation until very recently was taken for granted by researchers and clinicians. Based on what we know, it appears many people with bipolar suffer from "atypical" depression rather than "melancholic" depression, such as eating and sleeping too much (as opposed to eating too little and insomnia), sensitivity to rejection, and leaden paralysis. It also appears bipolar depression may be even more severe and debilitating than unipolar depression, if such a thing is possible. For a full discussion of depression, please see Part I of the Depression FAQ. Tell me about rapid-cycling. The DSM's idea of rapid is at least four episodes over one year. Rapid-cyclers, however, tend to change form one mood to the other and back again at far shorter intervals, sometimes several times a day and even several times an hour and in rare cases in the space of minutes. Because those who rapid-cycle represent a moving target, and because of the instability of their condition, this group of people are notoriously difficult to treat, with high rates of failure. Women are more likely than men to be rapid-cyclers. So bipolar is just a mood disorder. Simple as that, right? Wrong. The conventional wisdom has been that bipolar is an episodic illness affecting mood, with often long periods of remission between moods while an illness such as schizophrenia is a chronic illness affecting cognition that progressively worsens. Now psychiatry is revisiting that distinction. What the experts are finding is that even between episodes, many people with bipolar experience residual symptoms and subtle cognitive deficits that can get worse over time. That's the last thing I need to hear. Don't panic. The brain also has infinite ways of repairing itself. But brain imaging studies and studies of post-mortem brains do show smaller volumes in certain parts of the brain and larger volumes in others for bipolar patients, which may affect learning and memory and function. The good news is that some of the medications for bipolar may protect against further deterioration and even reverse the damage. Studies on rats have found that two bipolar meds, lithium and Depakote, cause new brain cells to grow, and a study on humans found lithium produced the same result. Also, nutritional supplements may be good brain food. Is there anything else I should know about the nature of bipolar disorder? Yes. People with bipolar disorder tend to suffer from at least one other mental illness, as well, including anxiety and panic, and alcohol and substance dependence. According to one major study, 61 percent of people with bipolar I have a lifetime substance dependence disorder (note, the percentage at any one time would be a lot smaller). What if I have bipolar disorder and a substance use problem? The Substance Abuse and Mental Health Services Administration recommends treating both illnesses simultaneously, ideally in an integrated setting in the same facility, at the very least with the different treatment providers working together. I heard marijuana can really help. Only if you believe that being stoned out of your mind is the price you're willing to pay for temporary relief from your symptoms. One's complete inability to think straight and function would never be

tolerated in a drug by any other name. However, if you trust your ability to limit your consumption, a reader who uses the drug reports that very small doses - as little as one-tenth of what it would take to get stoned - can restore mental clarity and improve function for some people. Nevertheless, until the drug is studied for treatment of mania and is made legal, with evenness of quality, marijuana use should be regarded as problematical. Does bipolar disorder affect other areas of the body? Yes, unfortunately. People with bipolar disorder die seven years younger than those in the general population, independent of suicide. Most of the research on the mind-body connection relates to depression, but we can apply much of those findings to bipolar. Such as? The risk of heart disease is doubled in people with depression, and a previous depression is often the greatest risk factor for heart disease and other ills, over smoking, drinking, high blood sugar, and previous heart attacks. Depression has also been connected to diabetes, bone loss, stroke, irritable bowel syndrome, and possibly cancer. How serious a problem is bipolar disorder? The Stanley Bipolar Foundation Network, which admittedly gets the sickest patients in its clinics, recently released this data: 85.1 percent had been hospitalized in the past, on average three times. The rate of suicide attempts was 50.3 percent. A third were currently married, another third single, and the rest were separated, divorced, or widowed. Despite the fact that approximately 90 percent had high school diplomas and a third had completed college, almost 65 percent were unemployed and 40 percent were on welfare or disability. According to Mark Bauer MD of Brown University, speaking at a conference in 2001, thirty to 50 percent of bipolar patients remain chronically ill. That's pretty depressing news. Yes it is. The good news is we can dramatically improve our chances by being smart in managing our illness, which involves a good working relationship with your psychiatrist to get you on the right meds (and then being compliant with those right meds), and making treatment and lifestyle choices that contribute to our mental and physical well-being (more on this in Part II and Part III). Can you talk about the demographics of bipolar? Yes. Approximately one to two percent of the population suffers from bipolar disorder, but some experts push the figure up to as high as five percent by adopting softer criteria for the illness. Equal numbers of men and women suffer from the illness. People tend to have their first episode in their late teens or early twenties, though they may have experienced some of the symptoms much earlier. Can kids get bipolar? Yes, and sad to say it appears to be far more frequent than in the past. Moreover, studies are finding that bipolar kids are sicker than bipolar adults. A bipolar kid can rage out of control for hours on end and literally hold his family hostage. Because the illness on the surface appears similar to ADHD or conduct disorder, kids are usually misdiagnosed - often by psychiatrists who refuse to believe that kids can get bipolar - and are treated with the wrong drugs that make their condition worse.

So how do you tell a bipolar kid from one who has ADHD or conduct disorder? Only by careful observation and long conversations with the parents. As opposed to those with ADHD or conduct disorder, for example, bipolar kids tend to be risk-seeking and grandiose, with nonstop flight of thoughts. How controversial is the topic of bipolar disorder in kids? Very. Fortunately, the problem has been recognized, psychiatrists are waking up to the situation, and a lot of new research is underway. Much of the controversy centers on whether we should be giving kids meds that are intended for adults. What causes bipolar disorder? We don't really know, though we do know that genes predispose people to the illness, and that stress can trigger an episode. One possibility is there is an overabundance of the excitatory neurotransmitter glutamate in the synapse (the space between two neurons) due to cortisol, which is secreted as part of the "flight or fight" reaction to stress. The glia - the "other" brain cell - is thought to clear excess glutamate from the synapse, but bipolar patients have a shortage of glia. Glutamate in turn allows calcium to flow through an ion channel penetrating the cell membrane and into the neuron and activates calcium-dependent enzymes inside. There are other ion channels that may be overstimulated in response to various neurotransmitters. In addition, researchers are also looking at the neurotransmitter dopamine, with is involved in pleasure and reward. There is also some evidence that vitamin or mineral deficiencies may play a role. In all likelihood, several processes are occurring at once, and not necessarily the same ones individual to individual. I think I may have bipolar disorder. What is my first stop? If you are in a life-threatening situation, or if you may be a danger to others, your first stop is the emergency room of your local hospital. Otherwise, you should book an appointment with a psychiatrist. Why a psychiatrist? First, because medications are the cornerstone of bipolar treatment, and only medical doctors such as psychiatrists can prescribe medications, unlike a psychologist who specializes in talking therapy. Second, because of their training and experience, psychiatrists are far more likely to give a correct diagnosis than going to your family doctor. What should I expect from a psychiatric examination? You can expect questions ranging from how you are feeling to how you are faring at work and at home to any family history of mental illness, if any. All the while, the psychiatrist will be probing for unusual behavior, such as spending sprees or talking too fast. Unfortunately, it takes bipolar I patients six years and bipolar II patients more than 11 years between first contact with the medical system and a correct diagnoses. This puts a considerable onus on you to reveal as much as you can to your psychiatrist. Basically, your psychiatrist is only as good as what you tell him or her. So what should I be telling my psychiatrist? Focus on all those times you didn't feel your normal self or too much like your normal self. You might want to go back over those times in your life you would rather forget - such as embarrassing yourself in public or attacking your spouse or walking off your job or getting arrested - or where you were

unusually productive - working 20-hour days, cleaning the house in the middle of the night, writing a term paper in three hours - and try to remember what you were feeling during the time and the times that led up to these events. If you felt you were smarter than the rest of the world, describe it. If you were in a raging white heat, fill in the details. If you were in an incapacitating blue funk, describe how hard it was to get out of bed. If possible, try to write down everything you can recall in order to organize your thoughts. To paraphrase Jack Nicholson, I can't handle the truth. Admitting that there may be something wrong with you is one of the most difficult tasks there is. Add to that fear and ignorance and stigma, and you begin to appreciate why so few people seek help or get a correct diagnosis. I have been diagnosed with bipolar disorder. Who should I let know? As few people as possible, at first. It is important to know that this illness carries a much greater stigma than depression, and you run a high risk of alienating friends and associates simply by breathing the word. Legally, in the US, you should not have to reveal your illness to your employer or prospective employer, but companies may require employees to have an in-house physical where one must disclose one's medications. If there is any consolation, some of history's most talented - as well as most notorious - individuals have had bipolar, including Ludwig von Beethoven, Michelangelo, Isaac Newton, Vincent Van Gogh, Ernest Hemingway, Virginia Woolf, Hitler, Stalin, and Napoleon. Having said all that, it's essential to have support. So if you feel you can trust certain friends and are willing to take the risk of losing them, then by all means disclose your illness. Some of them may have suspected you had bipolar disorder, all along. Hopefully, enough of us will go public, which is ultimately the only way of ending the stigma and gaining acceptance for this illness. But don't feel you have be the one to change the world. For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body. Part II of this FAQ answers your questions on bipolar medications, talking therapies, and ECT. Part III of this FAQ answers your questions on alternative treatments, lifestyle choices, coping, and suicide prevention. All articles for more than 280 articles on all aspects of depression and bipolar disorder.
April 5, 2003

Part II deals with medical and therapeutic treatments for bipolar disorder, including antidepressants, mood stabilizers, antipsychotics, benzodiazepines, talking therapy, and ECT. All links but one are to articles on this site.
How is bipolar disorder treated? Ideally, by a combination of different medications, talking therapies, natural treatments and lifestyle choices. No one treatment, therapy, or lifestyle choice on its own is likely to get the job done. A number of them working as complements to each other ensures your best chance of success.

Tell me about medications treatment. Medications treatment involves three classes of drugs: antidepressants for depression and mood stabilizers and antipsychotics for mania. In addition, some patients may take a benzodiazepine to help calm them down. Patients are typically prescribed a combination of drugs referred to as a cocktail. The American Psychiatric Association in its bipolar disorder treatment guideline lists remission as the goal of medications treatment, meaning virtually no symptoms and a return to full functioning. Unfortunately, we may have to settle for less, given the imperfect nature of these medications, but what we are clearly entitled to is a best effort from our psychiatrist. Equally as important, side effects that interfere with our ability to think and function should not be regarded as an acceptable trade-off for reducing our symptoms. Tell me about antidepressants. A full discussion of antidepressants can be found in Part Two of the Depression FAQ. What you need to know about antidepressants from a bipolar perspective is there is divided opinion in psychiatry concerning the safety of bipolar patients on antidepressants. This is because an antidepressant without a concomitant antimania med is almost certain to switch a patient into mania. Some authorities contend that even with an antimania drug, the danger is there. Accordingly, the American Psychiatric Association in its bipolar disorder guidelines issued in 2002 does not recommend an antidepressant-antimania combination as a first option, and another guideline recommends tapering and discontinuing soon after remission is achieved. On the other hand, there is a smaller body of opinion that feels the risk is overstated. One study found that those who stayed on their antidepressants fared better over 12 months than those who quit on them before six months. But the same study also found that antidepressants did not work for the large majority of those in the study. There are two mood stabilizers with antidepressant properties, lithium and Lamictal. In addition, the FDA in late 2003 approved a Zyprexa-Prozac combination (Symbyax) for treating bipolar depression. Tell me about mood stabilizers. Mood stabilizers mainly keep mania in check, though we are not sure precisely how they function in the brain. Lithium, which is a common salt, was discovered as a treatment for bipolar disorder by accident, is the only mood stabilizer that works well enough for mania and depression. The other mood stabilizers - Depakote (valproic acid), Tegretol (carbamazepine), Trileptal (oxcarbazepine), Neurontin (gabapentin), Topamax (topiramate) and Lamictal (lamotrigine) first came on the market as antiseizure medications. Depakote, Tegretol, and Trileptal are used to treat mania. Neurontin is useful for co-occurring anxiety, and Topamax is effective for weight loss. Lamictal is the flavor of the month for treating bipolar depression. Because we don't know exactly how they work and what we should be targeting, it comes as no surprise that their clinical benefit leaves much to be desired, with burdensome side effects ranging from dry mouth to weight gain to tremors to sedation to skin rash. A lot of these effects go away as the body adjusts to the medication. Because of the side effects, noncompliance is common. What one needs to keep in mind is as imperfect as these meds are, they offer one a fighting chance at recovery, as well as a welcome alternative to what would have been a lifetime of institutionalization a generation ago. Tell me about antipsychotics. Antipsychotics are yet another antimania medication that first came on the market to treat another illness, in this case schizophrenia. The drugs work by binding to dopamine receptors in the brain, preventing overstimulation from the neurotransmitter dopamine. The older antipsychotics bind tightly to these receptors, resulting in considerable side effects, including

sexual dysfunction, increased lactation (which can result in loss of menses in women and lower testosterone in men), dulled cognition, sedation, and involuntary facial and muscular spasms. One of these, Haldol, is still in common use. The newer "atypical" antipsychotics bind more loosely to the dopamine receptors, resulting in less risk of these side effects, though they still remain fairly common. Nevertheless, the APA and other guidelines recommend the atypicals as a first option for treating mania in the initial phase, often in combination with a mood stabilizer. The same guidelines and product labeling on these meds also recommend gradual tapering following remission, owing to the risk of tardive dyskinesia (involuntary spasms), unless needed. The atypicals include Clozaril (clozapine), Zyprexa (olanzapine), Risperdal (risperidone), Seroquel (quetiapine), Geodon (ziprasidone), and Abilify (aripiprazole). Abilify, the newest, is thought to have the best side effects profile. Zyprexa also has a modest antidepressant effect. What do I do about sexual dysfunction? Viagra may help, for women as well as men. What about the other side effects? There are meds to treat tremors and spasms, and wakefulness agents to handle sedation. Sometimes simply lowering the dose may solve the problem, or changing to a different med. Please let your psychiatrist know of any side effects, so the two of you can work on a solution. Also keep in mind that good lifestyle choices can reduce side effects. Tell me about benzodiazepines. These include Valium (diazepam), Ativan (lorazepam), and Klonopin (clonazepam). Their main purpose is to relieve anxiety and promote sleep, but they can be very effective in quickly bringing down a person from a manic state or as an additional med in the cocktail. Their main drawback is they can be habit forming, with severe withdrawal symptoms, as well as having a depressive effect, so they are typically prescribed short-term or on an as-needed basis. What about pregnancy and breastfeeding? Please check with your doctor or psychiatrist. In general, antidepressants are considered safe through all phases of pregnancy and breastfeeding. As for the mood stabilizers, lithium runs an outside risk of heart defect in the first trimester, while the risk of spina bifida is too great to be taking Depakote or Tegretol (and possibly the other mood stabilizers) during the first trimester. Of the antipsychotics, Haldol, the most studied, can be used safely during pregnancy. Frederick Goodwin MD, author of the definitive book on bipolar disorder, at a 2001 conference stated that because of the risk of postpartum mania, it is critical for expectant mothers to get back on meds well before giving birth. Alternatives to meds include omega-3 and light therapy, and, as a last option, ECT. Drugs to avoid while breastfeeding: Lithium, Lamictal, antipsychotics. Can I drink alcohol? Not if you are expecting your meds to work. Those who find it hard to quit should bring this up with their psychiatrist. Caffeine and nicotine are other drugs you should seriously consider eliminating or cutting back on. How do I know which meds I should be on? The short answer is you don't. Every individual is unique and no two cases of bipolar are the same, so what works for one person in your support group may not work for you and vice versa. The American Psychiatric Association and other organizations implicitly recognize this

in their treatment guidelines, which set out a number of first options for meds treatment, graduating to a stepped series of different options should those first options fail. As a general rule, finding the right combination of meds takes time. Patience and persistence are required. You may have to preserver through a number of failures or partial successes before you and your psychiatrist (it's a team effort) hit upon a satisfactory solution). This sounds very discouraging. Only if you believe you should sit back and let your meds do all the work. Smart lifestyle choices and various coping techniques can make a world of difference. Meds treatment can also be combined with talking therapy to great effect. What is cognitive therapy? Cognitive therapy - also called cognitive behavioral therapy - works to change erroneous thoughts (such as "It's the end of the world.") into more positive ones (such as, "Let's find a solution.") Once one is thinking and behaving in a positive way - such as working toward a solution rather than bewailing the end of the world - one actually begins feeling better. The therapy applies equally well to depression and mania. The therapy typically lasts 10 to 20 sessions, and involves active participation and homework. Various studies have found cognitive therapy to be as effective as antidepressant treatment. One major study found that a type of cognitive therapy combined with an antidepressant produced better results that either therapy or antidepressant treatment alone. What are behavioral therapy and interpersonal therapy? These are also short-term, manual-based therapies that focus on coping skills. By changing destructive behaviors and dealing better with people, one can successfully negotiate the stressful situations that can trigger a mood episode. What about other types of talking therapy? Before you engage in therapy that involves working on painful issues or suppressed memories, it is very important that your mood be stabilized, as otherwise these therapies can cause your condition to deteriorate. Some talking therapists take a dim view of medications, and their opinions on the subject are the last thing you need to be exposed to while you are still recovering and vulnerable. Having said that, if your boss is making you unhappy and your family is causing you stress, simply taking meds only invites another episode. These situations represent very dangerous triggers that need to be addressed. Long-term talking therapy that can help you resolve these issues may literally save your life. What about ECT? Electro-convulsive therapy, also known as shock treatment, has been used successfully to treat both depression and mania, but because of risk of short-term memory loss - and in rare cases long-term memory loss - is regarded as a treatment of last resort, except if the patient's condition puts him or her in a life-threatening situation where achieving a quick response is vital. Patients are typically given a course of several or more ECTs spaced over several weeks. Treatment involves being given anesthesia and muscle relaxants. Electrodes are placed to one side or both sides of the skull and a current is switched on. The treatment is controversial, though much of the opposition comes from groups opposed to all forms of psychiatry. Unfortunately, the psychiatric profession has been less than candid over the memory loss element, and neglects to mention that relapses are common, which necessitates additional periodic "booster" treatments.

Keep in mind that the middle of a raging depression is not the time to be making decisions about ECT. People with their bipolar in remission should do their research now and make their decision accordingly, while they have their wits about them. You can state your wishes in the form of a psychiatric advance directive, which you can find more about at http://www.bazelon.org/advdr.html For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body. Part III of this FAQ answers your questions on alternative treatments, lifestyle choices, coping, and suicide prevention. All articles for more than 280 articles on all aspects of depression and bipolar disorder.
April 5, 2003

Part III concludes with alternative treatments, lifestyle choices including diet, exercise, sleep,
and religious/spiritual practice, coping skills, and suicide prevention. Much of the material duplicates Part III of the Depression FAQ. All links but one are to articles on this website. Are there alternative or complementary treatments for bipolar disorder? Yes. These include omega-3 fatty acids, vitamin and mineral supplements, and acupuncture. Tell me about omega-3 fatty acids. Omega-3 is found in deepwater fish such as salmon and in flax. One study found that countries with low fish consumption coincided with high depression rates. A pilot study using omega-3 in conjunction with normal meds found the substance to be effective in treating the depressed phase of bipolar disorder. Until we know more, it is advised that omega-3 be considered as a complement to, rather than as a replacement for, one's normal meds. Buy only preparations that have more EPA than DHA. Tell me about vitamins and mineral supplements. Unfortunately, much of the food we eat comes from soil depleted of nutrients. The raw materials for producing neurotransmitters are nutrients. A deficiency of vitamin B6, for instance, may affect how serotonin is synthesized. Various small studies are finding single nutrients or nutrient combos can have affects ranging from subtle to pronounced. One pilot study found a certain supplement combination dramatically improved symptoms in bipolar patients. Larger studies are planned. And it isn't just about mood. Antioxidants, for example, can improve memory and protect against free radicals that can damage neurons. Use under a doctor's supervision. Consulting a nutritionist is also recommended. It is advisable to use supplements as a complement to meds rather than as a replacement. What about acupuncture? A pilot study comparing depression treatment (where the needles were placed at specific "depression" points) to sham treatment (the needles were randomly applied) found those in the depression treatment group experienced a 42 percent reduction in symptoms compared to 22 percent for the controls, with virtually no side effects. A larger study is underway, as is an acupuncture study using bipolar patients. What about lifestyle choices? These include diet, exercise, sleep, avoiding stress, and religious or spiritual practice.

What about diet? Diet is crucial to good mood. When choosing a healthy diet, there are no right or wrong choices, though in general high fat, high sugar, and high carb diets should be avoided, and junk foods, caffeine and alcohol restricted. Folate (from leafy green vegetables) deficiency and high sugar intake have been linked to depression. Carbohydrates get processed into sugar, which can boost serotonin but also induce mood-busting sugar crashes. Chocolate can act as a tasty antidepressant, with an endorphin-like effect, but can also set one up for a sugar crash. Paradoxically, eating too much sugar can lower blood sugar levels in some people, which results in further unhealthy cravings. Be mindful about switching to NutraSweet, however. One small study of patients with depression found they had severe reactions to its working chemical, aspartame. What about exercise? Numerous studies have found aerobic exercise works as effectively as antidepressants. Generally, the last thing you want to do when you're depressed is exercise, but even a five minute walk can help. Exercise restores regular sleep and eating, raises energy levels, generates endorphins, boosts serotonin levels, and may stimulate new brain cell growth. What about sleep? Too little or too much sleep affects just about everyone with a mood disorder. Missing a night's sleep can trigger a manic episode. For most of us, sleep is half the battle, and for many of us the full battle. Conquer sleep and you may conquer your mood disorder. A major key to establishing good sleep hygiene is going to bed and waking up at a regular hour. For those who continue to experience difficulties, talking therapy can help, as well as sleeping pills and wakefulness agents. What about avoiding stress? Stress is toxic to anyone with a mood disorder, so every effort needs to be made to reduce stressful situations from one's life and develop appropriate skills for coping. This may involve major life decisions regarding work and personal relationships. Numerous talking therapies can help people work through difficult job and relationship situations so that stress is less of a factor in one's life. Therapy can also teach a range of coping skills. Other coping strategies include exercise, meditation, yoga, and relaxation exercises. What about religious or spiritual practice? A multitude of studies have found those who are religious or spiritual live longer, are healthier, recover from illnesses quicker, and are less depressed. Much of this undoubtedly has to do with the support one gets from one's religious community, as well as the more healthy lifestyles these people tend to lead, not to mention the comfort that belief in a higher power can bring. In addition, the exercises and practices associated with religion and spirituality such as meditation, prayer, and yoga have positive benefits on mental and physical health. Scientists also speculate the immune system and other biological processes may be enhanced by religious or spiritual practice. Finally, don't rule out pure God-power. What about attending a support group? A major study found that online support groups have a positive impact on depression. Face to face support groups have a similar benefit. At a support group, you meet people who have walked in your shoes, who have unique insights into the illness that they are all too happy to share, and are willing to be with you in a time of crisis. In lieu of a support group, family support and support from trusted friends is crucial. What about journaling?

Many people with bipolar keep a mood journal or a daily diary of their ups and downs. Mood journals can help you spot patterns to your episodes, as well as a depression or mania in the making. How do I cope day to day? Over time, you will develop your own personal bag of tricks. These can range from prayer to keeping a journal to taking some time out for yourself to volunteer work. In general, any project that makes it worth your while to get out of bed or any activity that induces you to get out of the house and be with other people should be regarded as beneficial. I am feeling suicidal. What should I do? Get help immediately. Treat this as a crisis every bit as life-threatening as a heart attack, which it is. Every year, one million people worldwide die by their own hand, most as a result of depression or bipolar disorder. The true figure is probably many times higher, disguised as death by accident or death by risky behavior. Contact a trusted friend or family member. In the US, the national suicide hotline is 1 800 SUICIDE. Just as someone with a heart attack goes to the emergency room, that is where you should be, unless someone competent has decided you are not in danger. How should I prepare for a suicidal crisis? Have a good support network in place, people you can contact at a moment's notice. Have a good relationship with your doctor or psychiatrist, as you may need to call him or her in the middle of the night. Commit the national suicide hotline to memory, if you live in the US, and have local hotline numbers handy. How can I help others in a suicidal crisis? Be supportive. Do not be judgmental. Treat the situation as life-threatening, which it is. Ask if he or she has a plan - this can determine how serious the problem is. If you are in a position to do so, offer to take positive action, such as calling his psychiatrist or driving him to the emergency room. Bipolar disorder has ruined my life. It has destroyed my relationships and my career. It is pointless to disregard the full destructive power of bipolar disorder, and because of it some people may have to considerably scale back their expectations in life. On the positive side, you have survived one of the most malevolent forces on the planet, and you are a much stronger person as a result, in closer touch with your own humanity and divinity. Please do not underestimate these gifts and the power you now have to lead an even deeper and more meaningful life, however different it may be from the one you had been pursuing. Do you have any final thoughts? Yes. Bipolar disorder may be one of the worst illnesses we know, and the treatments may leave a lot to be desired, but you are not powerless. Learn everything you can and apply your knowledge to fighting this illness with everything you've got, with every weapon available. Measure personal success on your own terms, not on society's. Simply living with this illness is a major achievement, so give yourself credit. To those who haven't sought out help, please do. As imperfect as the treatments are, they offer you an excellent chance of winning back your life. To people still struggling with their treatments, do not abandon hope. New meds are hitting the market all the time, and we are getting smarter every day about using the current meds and natural treatments, so you may be the next beneficiary.

For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body. Depression FAQ - In three parts, answering your questions on diagnosis, medical treatments, alternative treatments, lifestyle choices, coping, and suicide prevention. All articles for more than 250 articles on all aspects of depression and bipolar disorder.

Omega-3 for Depression and Bipolar

Have we been fishing in all the wrong places for the magic bullet for depression and bipolar? Have
scientists been turning a blind eye to a well-known elixir that works well for other diseases and conditions? Ever since psychiatry threw Freud and his couch in the rubbish bin a couple of decades back, the profession has been oriented toward prescription drugs. Now, their focus appears to be widening. In 1999, a Harvard University study generated a buzz throughout the bipolar community with the prospect of a natural substance that worked - fish oil. After years of being bombarded by industrialstrength pharmaceuticals and toxic salts, people with bipolar and possibly depression could possibly look forward to a kinder and gentler treatment. In 1996, the Journal of the American Medical Association published a study comparing the prevalence of depression across ten nations. The survey yielded eye-opening results in showing how the lifetime and annual rates for depression vary widely from country to country (eg 1.5 in every 100 adults in Taiwan experience depression in their lifetimes while the figure is 19 for every 100 adults in Beirut). A 1998 study published in The Lancet compared this data with fish consumption, finding the higher consuming populations experienced less depression. A 2003 study published in the American Journal of Psychiatry compared similar cross-national epidemiological data - this time involving bipolar disorder - and seafood consumption, again finding a strong correlation. The working ingredient of fish oil is omega-3, a polyunsaturated fatty acid which is also found in certain plants such as flaxseed, pumpkin seed, and walnuts. According to Joseph Hibbeln MD of the NIH, who authored the two fish-consumption studies: "In the last century, [Western] diets have radically changed and we eat grossly fewer omega-3 fatty acids now. We also know that rates of depression have radically increased by perhaps a hundred-fold." In a NY Times article, Dr Hibbeln noted: Infant monkeys fed baby formula supplemented with omega-3 are stronger and more alert even at less than a week than monkeys given standard baby formula. Depression is 60 times higher in New Zealand, where the average consumption of seafood is 40 pounds a year compared to Japan, where a person consumes nearly 150 pounds of seafood a year. Postpartum depression is 50 times more common in countries with low levels of seafood consumption. During pregnancy, a womans body becomes depleted of fatty acids, which are transferred to the fetus. Omega-3 seems to be critical to the growth and maintenance of brain cells, especially cell membranes. When omega-3 is not available, the body uses omega-6, which produces cell membranes less able to cope with neurotransmitter traffic. And of course the famous 1999 Harvard pilot study.

We eat far greater amounts of other damaging fatty acids. A healthy diet should provide for at least five grams daily of essential fatty acids, divided between omega-3 and omega-6. A quick Medline search turns up several studies that show depleted omega-3 levels in the blood, cell membranes, and brains of depressed patients, suggesting that an intake of omega-3 could help reverse the process, though this has yet to be proved in large-scale clinical trials. A 2003 Chinese study of 28 patients with major depression found that those taking 9.6 grams/day of omega-3 had "a significantly decreased [Hamilton] score" after eight weeks. The 1999 Harvard study that started it all was conducted on 30 patients with bipolar disorder, generally in stable condition but with a history of relapses (all had experienced bipolar episodes over the past year). All but eight of the subjects were on medications, which were left unchanged. Half the subjects were given 9.6 grams of fish oil capsules, the other half received olive oil. Andrew Stoll MD, who conducted the study, admits the olive oil, which did not have a fishy taste, was not a perfect placebo. In one case, a person's cat actually attacked the fish oil capsules. But, as he jokingly confessed in a session at the 2000 DBSA annual conference, "you want a flawed study. That way, you get money to do another study." The trial was supposed to go on for nine months, but was stopped after four due to its outstanding results, with the omega-3 group staying in remission significantly longer than the placebo patients. By two months, half of the placebo group had dropped out compared to two in the fish oil group. The omega-3 group actually did less well in lowering their mania scores than those taking placebos, but fared much better getting their depression down. Some patients experienced nausea, diarrhea, and fishy aftertaste, not surprising considering the high doses. Currently Dr Stoll is conducting a much larger and longer (three year) study that should conclude fairly soon. Other researchers are undertaking their own studies. Other studies: Eicosapentaenoic acid (EPA) is one of the active ingredients of omega-3 fish oil. An Israeli study of 20 patients with major depression found that EPA resulted in "highly significant benefits" compared to a placebo by week three. A 2001 study of 70 depressed patients who had not responded to other treatments were randomized into three groups taking different doses of refined EPA (one, two, or four grams a day) or a placebo. Six of the 52 patients on the EPA dropped out before 12 weeks. The one gram group did "dramatically better" than the placebo group, but surprisingly the two and four gram groups fared only modestly better than the placebo group. Much higher doses (eight to 10 gm/day) have been found effective in treating bipolar. The higher dose paradox was borne out in a 2003 Stanley Foundation Bipolar Network study of 59 depressed bipolar patients, which found that those on 6 gm/day EPA did no better than those taking the placebo over four months, with CGI-BP depression scores dropping from 4.1 to 2.7 for EPA vs 3.6 to 2.7 for the placebo. A second study on 62 rapid-cycling patients produced similar results. An NIH study tracking 14,541 women from their eighth week of pregnancy to eight months after giving birth found those who had no seafood - rich in omega-3 - had nearly twice the rate of depression as those who ate 10 ounces of fish daily, leading the authors to conclude: "Omega-3 fatty acids have beneficial health effects with no adverse side effects." A Finnish/National Cancer Institute survey of 29,133 Finnish men, aged 50 to 69, has found that "there were no associations between the dietary intake of omega-3 fatty acids or fish consumption and depressed mood, major depressive episodes, or suicide."

The two active ingredients of omega-3 fish oil are EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). EPA is considered to be the ingredient with the therapeutic effect, so it is

important to buy omega-3 that contains more EPA than DHA. A pilot study of EPA on depressed patients produced a beneficial effect while in another study DHA proved a total dud. Fish oil has been highly touted as a prevention for heart disease and a host of other ills, so there was a ready-made supply on the market long before Dr Stoll's study. At a seminar at the May 2004 American Psychiatric Associations annual meeting, Jerry Cott PhD, an FDA researcher, had this to say about omega-3. Omega-3, he said, is a fatty acid that appears to work much like a calcium channel blocker. Not uncoincidentally, he related, Joseph Hibbeln MD of the NIH, who has led the way in omega-3 research, had been working on a calcium channel blocker study. Omega-3 competes with its sister fatty acid, omega-6, for the same enzyme chain. From there, omega3 and omega-6 are metabolized, then stored as highly unsaturated fatty acid in tissue phospholipids.. The ideal ratio of omega-6 to omega-3 is one to one, but with modern diets favoring omega-6 at 20 to one its fairly obvious which fatty acid is going to win the battle of the enzyme chain. Less may also be more. Large doses may result in oxidative stress as omega-3 is being metabolized.. This may explain why some studies using EPA (see above) failed at higher doses. Accordingly, Dr Cott recommends omega-3 be taken with vitamins C and E. Dr Stoll also recommends taking vitamins C and E with omega-3 (1.5 to 3.5 grams of omega3 a day, taken with food). He does not suggest using cod liver oil, as high amounts can lead to hypervitaminosis A. In buying fish oil, make sure you receive a 90 percent concentration (in the past only 30 percent was available.) Be sure it contains more EPA than DHA, and that it has no heavy metal concentrations. Dr Stoll recommends fish oil capsules over a diet of cold water fish such as salmon or tuna, citing toxic ingredients as a reason for not going with fish. Even one can of tuna a week is too much, he asserts. Andrew Weil MD - the natural health guru recommends eating fish twice or three times a week, and cautions against capsules that may contain toxic contaminants. Both doctors agree that any fish you eat should be ocean fish rather than farm-raised fish. This is because omega-3 travels up the food chain from algae, while farm-raised fished are fed grains, which do not contain omega-3. Dr Stoll also favors fish oil over flaxseed oil, as fish oil is more proven at this point. Dr Weil says it's okay to go with flaxseed oil, which will make vegetarians happy. An article in the Minneapolis Star Tribune waxes eloquent on the benefits of flax, which is rich in omega-3. The Emperor Charlemagne was such a great fan of the grain that he required his subjects to eat it. Ground flax seed can be sprinkled on yogurt and a dash of flax oil can fortify a smoothie. According to the article, flax seed contains just one type of omega-3, so it is advisable to keep eating fish. Most capsules contain 1,000 mgs of flax oil, although it is not yet clear how much flax the body needs. Flax seed is also a rich source in ligands (which may prevent some hormonally-related cancers) and fibers (the oil alone does not have ligands or fiber). If you buy flax seeds, be sure they are ground or that you grind them, as the body cannot digest the seed's outer hull. The active ingredient in flax oil is alpha-linolenic acid, which is converted to EPA and DHA in the body. Whether as fish or flax oil, omega-3 has a blood thinning effect, but this is weaker than aspirin. Please notify your doctor before you use the two together, and stop taking if you feel any ill effects. Finally, keep in mind that although omega-3 looks like a promising way to treat depression and bipolar disorder, there are no major clinical trials to guide us. We are barely aware of its putative efficacy, much less its optimal dosage, much less how it actually works on the brain. Accordingly, omega-3

should be considered a complement to medications rather than a replacement, and should not be taken without first consulting your doctor or psychiatrist. Buy Andrew Stoll's The Omega 3 Connection from Amazon.com. For free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body. For how to incorporate omega-3 into your diet, including the right kind of beef, please click here.
Updated Aug 10, 2004

Lifestyle-Alternative All articles Discussions Susan (March 22, 2001): I am bipolar and have been using Omega-3 for about a year. My psychiatrist put me on it. Since a relatively high dose of Omega-3 is required to get results, it costs me about $140 / month to maintain this regimen. Unfortunately, even though this treatment gives me a tremendous amount of mood stabilization, my insurance does not cover this. If it didn't work so well, I would give it up. Not only does it act as a mood stabilizer, it also improves my mental clarity as well. For anyone who is considering this treatment, I recommend the book "The Omega-3 Connection" by Andrew Stoll, M.D. The author headed up the study of Omega-3 at Harvard Medical School. In this book, the study particulars are documented as well as the top brands of Omega-3 supplements. Bill (May 27, 2001): I struggled with the expense of supplements until I found vitaglo.com. 1000mg of Omega 3-6-9 (250 softgels) is only $14.80. Twelve ounces of flax seed oil is $6.59. Vitaglo.com discounts NOW Foods' supplements which have been the choice of two professional alternative medicine practitioners I have gone to. Marjie (June 26, 2001): Re Susan's letter - My son has been diagnosed with bipolar disorder. We need to find a psychiatrist who will prescribe Omega 3 rather than lithium, etc. Susan mentioned that her psychiatrist put her on the Omega 3 - can you provide the name of the psychiatrist? Don't know where you're located, but maybe that doctor can give a referral to the L.A. area. Thank you - this is an urgent request because he needs to be under the care of a psychiatrist by court order, yet he refuses lithium or Depakote and Omega 3 has been working well for him but we need a psychiatrist to prescribe it. Thanks again and hope someone can follow-up quickly. e-mail: aussierover@earthlink.net Joanne (Jan 23, 2002): I thought the article was excellent. most informative. Omega 3 works well for my relative. Actually, he uses alternative therapies exclusively. They include a host of supplements and amino acids. Cheryl (Feb 7, 2002): I have been using EPA (4 2x/day) along with Lecithin to treat my daughter's bipolar disorder and it has been extremely effective. She's a teenager now, but used Depakote when she was younger and hated it. She doesn't mind the alternatives and my observation is that she is more balanced. I would be more than happy to have people contact me via email if they would like to know more about her regime. csorge@charter.net Byron (Sept 20, 2002): hello there, reading omega 3 and it confirms all my research. Two months ago I self diagnosed myself, bipolar and went searching to find out what this meant. Before this discovery I

just thought I was a little strange. Now I know I am only underpowered. In Australia pills are the only answer, as I hunt for a doctor that understands the symptoms, but all I get is "take your medication", I reply I will , which is , nuts, seeds and vegetables. They think I am nuts. I need help. Hemp seed oil contains omega 3+6, how does the structure compare to fish oil amino acid wise. McMan (Sept 20): Hi, Byron. I recommend finding a doctor who will work with you, as selfmedicating, even with natural substances, is not such a good idea. Keep in mind there are no major studies completed on Omega-3, and in the pilot study the omega-3 supplemented the medications you hate. Jan (Oct 1, 2002): Hi, I have been using the Omega-3 for about 6 months after reading a different article on the internet. I have been told by most of my family and friends that my moods are much more stable. This is great. I have been on other medications for 9 years and they were not consistent. I do have a question, has the Omega-3 been used with children at all? I have a 9 year old son that seems to be bi-polar. As he is getting older, the symptoms are becoming more clear. I have no interest in placing him on any of the strong medications I have been on, however, I would like him to be more stable in hopes that he will not experience all of the teasing and lack of friends etc. that I did in junior high school and high school. Can you contact me or put me in contact with anyone that might have a suggested level of Omega-3. Jan at csorge@charter.net