DEPRESSION AND ANXIETY SUPPORT GROUP
o
How to Recognise
Bipolar
o
Where to approach for
treatment
o
Treatment Options
o
Self Help
1999 / 2000
“… screeching
thoughts race on the road to oblivion…”
“Mania:
The fast ideas become too
fast and there are far too many … overwhelming confusion replaces clarity… you
stop keeping up with it – memory goes.
Infectious humor ceases to amuse.
Your friends become frightened… everything is now against the grain… you
are irritable, angry, frightened, uncontrollable, and trapped”
“Hypomania:
At first when
I’m high, it’s tremendous… ideas are fast… like shooting stars you follow until
brighter ones appear… all shyness disappears, the right words and gestures are
suddenly there… uninteresting people, things, become intensely interesting. Sensuality is pervasive, the desire to
seduce and be seduced is irresistible.
Your marrow is infused with unbelievable feelings of ease, power,
well-being, omnipotence, euphoria…you can do anything…but, somewhere this
changes.”
Descriptions offered by patients themselves offer valuable insights into
the various mood states associated with bipolar disorder.
Symptoms of the
manic phase include behaviour that is out of proportion to how you would
normally act. You feel excessively
good, “on top of the world,” and nothing will change your happiness. You are optimistic to the extreme. You may even have grandiose
delusions. Nothing can stop you
from accomplishing anything you want.
Nothing can go possibly go wrong.
You spend money like the proverbial “drunken sailor”. Sex is great, fabulous, you can’t get
enough. You good judgement and
caution have vanished.
You can be so
hyperactive you can literally go for days with little or no sleep. You mind races. It is full of ideas like a car without
brakes. In conversation you change
from topic to topic in rapid fire fashion.
You speak too loudly and rapidly.
Others fail to understand you as your thoughts and speech become
disorganised and incoherent. At
times you can become enraged for not reason or when someone suggests you plans
are unreasonable. If not treated,
this phase can last as long as three months. But typically the depressive phase of
the illness sets in. The symptoms of this phase of the disease are the same as
the “regular” clinical or major depression.
Although
manic-depressive illness can be disabling it also responds well to
treatment. Since many other
diseases can masquerade as manic-depression, it is important you or your loved
on receive a competent medical evaluation as soon as possible.
Now
let’s talk about how we can help.
This booklet
will help answer that question and others related to treatment for bipolar
disorder. It was created to help
you understand how treatment may make living with bipolar disease easier:
And you will also learn about ways to help yourself. At the back of this booklet you will
find basic guidelines, a chart to help monitor your moods and a list of
resources to help you learn more about bipolar disorder.
Bipolar
disorder is a physical illness marked by extreme changes in mood, energy and
behaviour. That’s why doctors
classify it as a mood
disorder.
Bipolar disorder typically begins in adolescence or early adulthood and
continues throughout life. It is
often not recognised as an illness, and people who have it may suffer needlessly
for years or even decades.
Effective treatments are available that greatly alleviate the suffering
caused by bipolar disorder. This
brochure contains some frequently asked questions about bipolar disorder.
The
exact cause of manic depression is not known, but it is believed to be a
combination of biochemical, genetic and psychological factors.
Biochemistry
Research has shown that this
disorder is associated with a chemical imbalance in the brain, which can be
corrected with appropriated medication.
Genetics / Herediatry
Bipolar disorder tends to run in
families. Researchers have
identified a number of genes that may be linked to the disorder, suggesting that
several different biochemicals problems may occur in bipolar disorder (just as
there are different kinds of arthiritis).
However, if you have bipolar disorder and your spouse does not, there is
only a 1 in 7 chance that your child will develop it. The chance may be greater if you have a
number of relatives with bipolar disorder or depression.
Mania and depression are often
cyclical, occurring at particular times of the year. Changes in biological rhythms, including
sleep and hormone changes, characterise the illness. Changes in the seasons are often
associated triggers.
People who are genetically
susceptible may have a faulty “switch-off” point – emotional excitement may keep
escalating into mania: setbacks may worsen into profound depression.
Research continues to be needed to identify more clearly the causes, of
manic depression and to find better ways of treating it.
The
earlier treatment is started, the more effective it may be in preventing future
episodes.
Manic
depression is common – affecting about 1% of the population. Men and women are equally affected. While the disorder has been seen in
children, the usual age of onset is late adolescence and early adulthood. Mania, occasionally appears for the
first time in the elderly, and when it does, it is often related to another
medical disorder. Manic depression
is not restricted to any social or educational class, race, or nationality. Although an equal number of men and
women develop the illness, men tend to have more manic episodes. Women experience more depressive
episodes. Many people with bipolar
disorder are very well known. Some
have won Academy Awards; others have created literary and fine-art masterpieces,
or led their nations in critical times of history.
Very
effective treatments for bipolar disorders are available.
Fortunately, the answer to this question is “yes”. Treatment in the form of medication and
counselling can be effective for most people with manic depression.
On the
other hand, if not diagnosed and not treated, the impact of the illness can be
devastating to the individual, significant others, and society in general.
Over
the course of bipolar disorder, four different kinds of mood episodes can
occur:
During a manic episode, the mood
can be abnormally elevated, euphoric,
or irritable. Thoughts race and
speech is rapid, sometimes non-stop, often jumping from topic to topic in ways
that are difficult for other to follow.
Energy level is high, self-esteem inflated, sociability increased, and
enthusiasm abounds. There may be
very little need for sleep (“a waste of time”) with limitless activity extending
around the clock. During a manic
episode, a person may feel “on top of the world” and have little or no awareness
that the feelings and behaviours are not normal.
Mania comes in degrees of severity
and, while a very little amount may be pleasant and productive, even the less
severe form known as hypomania can be problematic and cause social and
occupational difficulties. A manic
episode is more severe than a hypomanic episode with a magnification of symptoms
to the extent that there is marked impairment in interpersonal and social
interactions and occupational functioning.
Hospitalisation is often necessary.
Severe mania can be psychotic – the person loses contact with reality and
may experience delusions (false beliefs), especially of a grandiose (“I am the
President”), religious (“I am God”) or sexual nature, and hallucinations
(hearing voices or seeing visions).
Psychotic mania may be difficult to distinguish from schizophrenia and,
indeed, mistaking the former for the latter is not uncommon.
During a manic episode, judgement
is often greatly impaired as evidenced by excessive spending, reckless
behaviours involving driving, abuse of drugs and alcohol and sexual
indiscretion, and impulsive, sometimes catastrophic business decisions.
- Feeling
unusually “high”, euphoric, or irritable (or appearing this way to those who
know you well).
Plus at least four
(and most often all) of the following:
In
a full-blown “major” depressive episode, the following symptoms are present for
at least 2 weeks and make it difficult for you to function:
- Feeling sad, blue, or down in the dumps or
losing interest in things you normally enjoy.
Plus at least four of the following:
- Trouble sleeping or sleeping too much
- Loss of appetite or eating too much
- Problems concentrating, remembering or making
decisions
- Feeling slowed down or feeling too agitated to
sit still
- Feeling worthless of guilty or having very low
self-esteem
- Loss of energy or feeling tired
all of the time
- Prolonged sadness or crying
spells
- Pessimism, indifference
- Recurring
thoughts of suicide or death
- Severe
depressions may also include hallucination or delusions
Perhaps the most disabling
episodes are those that involve symptoms of both mania and depression occurring
at the same time or alternately frequently during the day. You are excitable, or agitated as in
mania but also feel irritable and depressed, instead of feeling on top of the
world.
Mixed episodes sometimes known as
dysphocir mania, occur in up to 40% of individuals with manic depression and can
be particularly troublesome because they may be more difficult to treat.
3. Depression (major depressive episode)
During a depressive episode, mood
is sad, blue, down-in-the-dumps, unhappy or irritable. Self-esteem is low, thoughts are
negative, and there is loss of interest in usual activities and inability to
experience pleasure. Concentrating
is difficult and decision making impaired.
Anxiety or agitation are common features of depression, although some
individuals are drained of energy and are physically inert. Feelings of hopelessness and
helplessness are common with both the present and future looking bleak. Guilt, crying and social withdrawal
are additional features. Suicidal thoughts, plans, and attempts
are common and, in fact, suicide is a cause of death in many people with
depression. Physical findings
associated with depression include sleep disturbance (either insomnia or
oversleeping), appetite and weight loss (although overeating and weight gain are
not uncommon), fatigue, loss of interest in sex, and bodily pains.
-
Extreme elation,
unco-operative, psychotic, removed from reality, not sleeping, delusions.
-
Mildly manic and
psychotic. Not sleeping, overactive
in all areas.
- Sleeping 2 hrs
or less, grandiose ideas, will work and play 24hrs a day for days at a
time. Flow of ideas not followed
through.
- Overactive,
verbally aggressive, needs less sleep.
Flow of ideas, feels great, wheeling and dealing, big spender.
- High energy,
creative, feels great, very happy, increase in perception, sex drive and new
ideas.
- Little
interest in sex, low self esteem.
Probable changes in daily routine.
- Poor energy,
sleep disturbance, poor appetite, cannot or hard to get out of bed. Changes in routine.
- Total lack of
self-esteem, withdrawn, loss or gain of weight, loss of concentration, increases
in irritability. Thoughts of
suicide.
- Incapable of
bodily functions, eating, moving, delusions.
Episodes can last days, months or sometime even years. On average, without treatment, manic or
hypomanic episodes last a few months while depression often last well over 6
months. Some individuals recover
completely between episodes and may go many years without any symptoms, while
others continue to have low-grade but troubling depression or mild swings up and
down.
Special terms are used to describe common patterns:
- In Bipolar I Disorder, a person has
manic or mixed episodes and almost always has
depression as well. If you have
just become ill for the first time and it was with a manic episode, you are
still considered to have bipolar I disorder. It is likely that you will go on in the
future to have episodes of depression, as well as mania – unless you get
effective treatment.
-
In Bipolar II Disorder, a person has
only hypomanic and depressive episodes, not full manic of mixed episodes. This types is often hard to recognise
because hypomania may seem “supernormal”, especially if the person feels happy,
has lots of energy, and avoids getting into serious trouble. If you have bipolar II disorder, you may
overlook hypomania and seek treatment only for your depressions. Unfortunately, if the only medication
you receive is an antidepressant, there is a risk that the medication may
trigger a “high” or set off more frequent cycles.
- Schizoaffective Disorder:
This term is used to describe a condition that in some ways overlaps with
bipolar disorder. In addition to
mania and depression, there are persistent psychotic symptoms (hallucinations or
delusions) during times when mood symptoms are under control. In contrast, in bipolar disorder, any
psychotic symptoms that occur during severe episodes of mania or depression end
as mood returns to normal.
- Cyclothymid can be diagnosed if a person has a low
grade, chronic and fluctuating disturbance. In cyclothymid there are mild highs
and lows, which are not severe enough to be diagnosed as a full manic or
depressive disorder.
If you
are not happy with physician or therapist, don’t be afraid to speak up or seek a
second opinion. Many people go
through more than one mental health professional before developing a comfortable
partnership. Most of us are
probably more aggressive about our choice of hairdresser or car mechanic. What could be more important than your
health?
Since
proper diagnosis is essential for effective treatment, see someone who is
knowledgeable about manic depression.
Psychiatrists are medical doctors who specialize in the diagnosis and
treatment of mental illness. In
addition to providing counselling, they are the only mental health professionals
who can prescribe medication.
Clinical psychologists, clinical social workers and nurse specialists can
also diagnose and provide counselling and psychotherapy. Mental health counsellors can be useful
sources of counselling, support and education. The best treatment is sometimes provided
by several professionals working together to address the varied needs of an
individual.
The
outlook for people with bipolar disorder today is optimistic. Many new and
promising treatments are being developed and with the right treatment most
should be able to lead full and productive lives.
How
often should I talk with my doctor?
During
acute mania or depression, most people talk with their doctor at least once a
week, or even daily, to monitor symptoms, medication doses, and side
effects. As you recover, contact
becomes less frequent; once you are well, you might see your doctor for a quick
review every few months.
Regardless of scheduled appointments or blood tests, call your doctor if
you have:
- Suicidal or violent feelings
- Changes in mood, sleep, or
energy
- Changes in medication side
effects
- A need to use over-the-counter medications such
as cold medicine or pain medicine
- Acute general medical illnesses or a need for
surgery, extensive dental care, or changes in
other medicines you take.
How
can I tell the difference between bipolar disorder or ordinary mood swings?
Mood
swings that come with bipolar disorder are severe, ranging from extremes in
energy or “highs” to deep despair.
The severity of the mood swings and the way they disrupt normal
activities distinguish clinical mood episodes from ordinary mood changes.
When
the mood swings are charted over time, daily, weekly, and seasonal patterns
become evident. Doctors may
diagnose bipolar disorder in patients with who have had one or more manic or
hypomanic episodes. In many cases,
these patients have also experienced one or more major depressive episodes. Manic episodes last at least one week;
major depressive episodes last at least two weeks. Both types of episodes often last much
longer. Many people have severe
episodes of mania and depression in a single year. Others live for years without a new
episode.
The most
important types of medication used to control the symptoms of bipolar disorder
are mood stabilizers. Your doctor may also prescribe other
medications to help with depression, insomnia, anxiety, restlessness, or
psychotic symptoms.
What are mood stabilizers?
- Lithium (Camcolith, Lentolith and
Quinolum)
- Valproate (most commonly used as convalex or
epilim)
- Carbamazephine (Tegretol)
Many new medicines are under study as mood stabilisers. These
include Lamotrigine (lamictin), topamax (topiramate), gabapentin (neurontin) and
olanzapine (zyprexa).
Your
doctor may prescribe some of these medicines, particularly if the standard
medications have not been as effective as they can be, or if they have caused
problems.
Fortunately each of the three mood stabilizers has different chemical
actions in the body. If one does
not work for you, or you have persistent side effects, your doctor can suggest
another, or combine two medications at doses you can manage. For all three mood stabilizers, blood
tests are used to determine the correct dose and to monitor safety.
Selecting a mood stabilizer for an acute manic episode
Acute treatment
with lithium or valproate usually helps significantly in a few weeks. However, if the first medication does
not work well enough, your doctor may switch you to the other or combine
them. Carbamazepine is also useful
as a backup, especially for mixed episodes or rapid cycling.
Selecting additional
medications for a manic episode
Two
types of medications are used for insomnia and agitation during a manic
episode:
-
Anti-anxiety medicines such as
lorazepam (Ativan) and clonazapam (Rivotril)
- Anti-psychotic medicines such as
haloperidol (Haldol) and olanzapine (Zyprexa) and
risperidone
(Risperdal)
During
acute treatment of mania, you may need one of these to help you sleep and to
reduce your mental or physical agitation.
Anti-psychotic medication is helpful if you have delusions,
hallucinations, or severe agitation.
These additional medicines may also be needed because it may take a few
weeks to get the full effect of mood stabilizers. Fortunately, anti-anxiety and
anti-psychotic medicines work rapidly and can be given by mouth or by
injection. If you are so severely
manic that you don’t recognise the symptoms of your illness and refuse
medication, injections may literally help save your life by
preventing you from acting in impulsive, irrational, or dangerous
ways.
Both
anti-anxiety and anti-psychotic medicine can cause drowsiness as a side
effect. Anti-psychotic medicines
may also cause muscle stiffness, restlessness, and other side effects. If you have problems with side effects,
be sure to tell your doctor, who can adjust the dose or add another medication
to help. As you recover, doses of
these medicines are usually lowered.
They may be discontinued within a few week or months.
Selecting an antidepressant
Although mood stabilizers by
themselves, especially lithium, can sometimes pull you out of a depression, you
may also need to take a specific antidepressant medication to treat the
depressive episode. However, if
given alone, antidepressants can sometimes cause problems in bipolar disorder by
pushing you mood up too high (causing hypomania, mania, or even rapid
cycling). Therefore, in bipolar
disorder antidepressants often are given together with a mood
stabilizer to prevent an “overshoot”.
Antidepressants usually take several weeks to begin showing full effects
– so don’t get discouraged if you don’t feel better right away. Although the first drug tried will work
for the majority of patients, it is common to go through two or three trials of
antidepressants before finding one that is right for you. While waiting for the antidepressant to
work, your doctor may also give you a sedating medication to help with sleep,
anxiety, or agitation. After you
recover from the depression, your doctor will help you decide whether to taper
off the antidepressant.
Many
types of antidepressants are available with different chemical mechanisms of
action. All can be effective, but
most experts consider the following two types to be first choices in bipolar
disorder:
- Bupropin (Wellbutrin)
- Selective serotonin reuptake inhibitors: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Aropax), sertraline (Zoloft) and citalopram (Cipramil).
If
these do not work, or if they cause unpleasant side effects, the other choices
are:
- Mirtazapine (Remeron)
- Monoamine oxidase inhibitors: phenelzine (Nardil), tranylcypromine (Parnate). These may be very effective if other drugs do not help, but also requires you to stay on a special diet to avoid dangerous side effects. (Your doctor will give you a list of foods and medications to be avoided)
- Nefazodone (Serzone)
- Tricyclic antidepressants: amitriptyline (Tryptanol), imipramine (Tofranil). Tricyclics may be more likely to cause side effects, or to set off manic episodes or rapid cycling
- Venlafaxine (Effexor)
- Learn about your medications, how
they work, what to expect, possible side effects and dietary/lifestyle
restrictions.
- Take them only as prescribed.
- Use a daily reminder/medication saver system to insure regular use.
- Discard medications you are no longer using.
- Don’t expect medications to fix a bad diet, lack of exercise or an abusive or chaotic lifestyle.
Treatments for people suffering from depressive illnesses are successful in alleviating symptoms over 80% of the time.
Treatment in the hospital is
sometimes needed but is usually brief (1-2 weeks). Hospitalisation can be essential to
prevent self-destructive, impulsive, or aggressive behavior that the person will
later regret. Manic patients often
lack insight that they are ill and require hospitalisation. Research has shown that after recovery,
most manic patients are grateful for the help they received, even if it was
given against their will at the time.
During depression, hospitalisation is also used for individuals who have
medical complications that make it harder to monitor medication and for people
who cannot stop using drugs or alcohol.
Remember, early recognition and treatment of manic and depressive
episodes can lower the chances of hospitalisation.
|
Common annoying side effects you might see early in treatment, depending on dose |
Long-terms problems to watch for (there are often solutions without changing medicine) |
Lithium |
Tremor Muscle Weakness Upset stomach, diarrhea Thirst, increased urination Trouble concentrating |
Weight gain Thyroid problems Kidney problems Acne |
Valproate |
Drowsiness Upset stomach, diarrhea Dizziness Tremor |
Weight gain Hair thinning Mild changes in liver functions tests |
Carbamazepine |
Drowsiness Dizziness Headache Blurry vision Upset stomach |
Lowered counts of white blood cells Mild changes in liver function tests |
Are there side effects which
warrant contacting a doctor immediately?
Yes, If you or your family
act early you may avoid a serious situation. Some potentially serious side effects to be
aware of include:
· Unusual bleeding or bruising
· Dark urine or pale stools
· Yellowing of the skin or eyes
· Sever upper abdominal pain
· Skin rash or hives
· Confusion
· Fever
· Noticeable fatigue and weakness
· Pain, tenderness, or bluish cast in a leg or foot
· Difficulty urinating
· Sores in mouth
· Inflamed throat
· Continual diarrhea
· Vomiting
· Violent trembling of limbs
· Garbled speech
WHAT TO DO ABOUT SIDE
EFFECTS?
Tell your doctor right away
about any side effects you have.
Some people have different side effects than others and one person’s side effect (e.g., unpleasant sleepiness) may actually help another person (e.g., someone who suffers from insomnia). The side effects you may get from medication depend on:
- The type and amount of medicine take
- Your
body chemistry (including water loss due to hot weather)
- Your
age
- Other
medicines you are taking
- Other
medical conditions you have
- At least half of those who take mood stabilizers have side effects (see table above). These are especially common if high doses and a combination of medicines are needed during the acute phase of treatment. Lowering doses and decreasing the number of medicines usually helps, but some people may have severe enough side effects to require a change of medicine. Side effects tend to be worse early in the treatment, but some people who have taken lithium for 20 years or longer with good results develop problems with side effects or toxicity as they become older. Fortunately, Valproate or carbamazepine are often excellent alternatives as long the switch is made gradually. Valproate appears to cause the fewest side effects during long-term treatment.
- If side effects are a problem for you, there are a number of approaches your doctor may suggest:
- Reducing the amount of medicine you take
- Trying a different medicine to see if there are fewer or less bothersome side effects
- Taking your medicine at night
Remember: Changing medicine
is a complicated decision. It is
very dangerous to make changes in your medicine on your own!
HOW QUICKLY DOES MEDICINE
WORK?
Some
patient’s symptoms may begin to improve within several days. Others may take up to several weeks to
see maximum effects from the medication.
Some physicians will prescribe an additional medication temporarily.
How often does preventative medication work?
What if I start to feel symptoms?
Mood
stabilizers (lithium, valproate, carbazepine) are the core of prevention. About one in three people with bipolar
disorder will be completely free of symptoms by taking mood stabilizing
medication for life. Most people
experience a great reduction in how often they become ill or in the severity of
each episode. Don’t be discouraged
if you occasionally feel that you might be going into a manic or depressive
episode. Always report changes to
your doctor immediately, because adjustments in your medicine at the first
warning signs can usually restore a normal mood. Sometimes it just takes a slight
increase in the blood level of your mood stabilizer, or other medicines may need
to be added. Medication adjustments
are usually a routine part of treatment (just as insulin doses are changed from
time to time in diabetes). Never be
afraid to report changes in symptoms – they usually don’t require any very
dramatic change in treatment and your doctor will be eager to help.
Take your medicine as directed even if you have
felt better for a long time.
Sometimes people who have felt well for a number of years hope that the
bipolar disorder has gone away and that they don’t need medicine anymore. Unfortunately, the medications do not
“cure” bipolar disorder. Stopping
them even after many years of good health can lead to a disastrous relapse,
sometimes within a few months.
Generally, the only times you should seriously think of stopping
preventive medication are if you want to become pregnant or have a serious
medical problem that would make the medicines unsafe. Even these may not be absolute reasons
to stop. Always talk these
situations over carefully with your doctor. If you are going to stop, it is
important to taper the medicines very slowly (over weeks to months).
It is
normal to have occasional doubts and discomfort with treatment. Be sure to
discuss all your concerns and any discomforts with your doctor, therapist and
family. If you feel a treatment is not working or is causing unpleasant side
effects, tell your doctor – don’t stop or adjust your medication on your own.
Symptoms that come back after stopping medication are sometimes much harder to
treat. You and your doctor can work together to find the best and most
comfortable medicine for you. Also, don’t be shy about asking for a second
opinion from another clinician. Consultations can be a great help.
WILL I HAVE TO TAKE
MEDICATION FOR MY WHOLE LIFE?
Successful management of bipolar disorder requires a great deal from
patients and families. There will almost certainly be many times when you will
be sorely tempted to stop your medication because 1) you feel fine, 2) you miss
the highs or 3) you are bothered by side effects. If you stop your medication,
you probably won’t have an acute episode immediately in the next days or weeks,
but eventually you will probably have a relapse. There is a well studies model
of bipolar disorder that suggests that each episode worsens your chances of
having a smooth long-term course.
Sometimes the diagnosis is uncertain after a single episode and it is
possible to taper the medication after about a year. However, if you have had
only one episode of mania but have a very strong family history (suggesting you
may have inherited the disorder), or if the episode was so severe that it almost
ruined your life, you should strongly consider taking medication for several
years if not for life. If you have had two or more manic or depressive episodes,
experts strongly recommend taking preventive medication indefinitely.
What are the early warning signs of a new mood
episode?
Early
signs of a mood episode differ from person to person and are different for mood
elevations and depressions. The better you are at spotting your own early
warning signs, the faster you can get help to prevent a full-blown episode. Each
person gets to know certain inner feelings that indicate when a mood change is
developing. Slight changes in mood, sleep, energy, self-esteem, sexual interest,
concentration, willingness to take on new projects, thoughts of death (or sudden
optimism) and even changes in dress and grooming may be early warnings of an
impending high or low. Pay special attention to a marked change in your sleep
pattern, since this is a common clue that trouble is brewing. Since a loss of
insight may be an early sign of an impending mood episode, don’t hesitate to ask
your family to watch for early warnings that you may be missing.
ELECTROCONVULSIVE THERAPY
Although electroconvulsive therapy (ECT) has had a lot of unfair
publicity, it can be a lifesaver and is often the safest and most effective
treatment for psychotic depression.
Although medications represent the foundation for today’s approach to
therapy of mood disorders, electroconvulsive therapy (ECT) plays a significant
role in treatment of select cases. ECT is used primarily after other treatments
have failed and in cases where patients exhibit severely suicidal behaviour,
rapid physical deterioration and inability to tolerate or benefit from
medication.
ECT
involves inducing a controlled seizure while a patient is under anaesthesia and
treated with muscle relaxants. Although this may sound extreme, the positive
effects are well demonstrated. Side effects, including transient memory loss,
are generally quite mild and are far outweighed by the swift action of the
treatment. This is especially true in cases of suicidal individuals who may have
otherwise carried out their impulses if they had waited for medication therapy
to take effect. The effectiveness of ECT in extreme cases of both depression and
mania makes it the best choice for many s
IS COUNSELING / THERAPY USEFUL FOR TREATING
BIPOLAR DISORDER
Counselling plays an important adjunctive role in the treatment of manic
depression.Therapy issues include dealing with the psychosocial stressors that
may precipitate or worsen manic and depressive episodes and dealing with the
individual , interpersonal, social and occupational consequences of the disorder
itself. Counselling can also help ensure better compliance with medication.
While there are many forms of counselling available to people with manic
depression, they all include support and education.
Three
types of psychotherapy appear to be particularly useful and may also help during
recovery:
Behavioral therapy focuses on behaviours that can increase or
decrease stress and on ways to increase pleasurable experiences that may help
improve depressive symptoms.
Cognitive therapy focuses on identifying and changing the
pessimistic thoughts and beliefs that can lead to depression.
Interpersonal therapy focuses on reducing the strain that a mood
disorder may place on relationships.
Psychotherapy can be individual (only you and a therapist); group (with
other people with similar problems); or family. The person who provides therapy
may be your doctor or another clinician (e.g. a social worker, psychologist,
nurse, or counsellor) who works in partnership with your doctor.
How to
get the most out of psychotherapy
- Keep your appointments.
- Be honest and open.
- Do the homework assigned to you as part of your
therapy.
- Give the therapist feedback on how
the treatment is working.
During
treatment psychotherapy usually works more gradually than medication and may
take two months or more to show its full effects. However, the benefits may be
long lasting. Remember that people can react differently to psychotherapy, just
as they do to medicine.
Once
the acute episode is over, long-term psychotherapy can help maintain stability
and prevent further episodes, but cannot replace long-term preventative
treatment with medication.
WHAT CAN YOU DO TO HELP YOURSELF?
First,
become an expert on your illness. Since bipolar disorder is a lifetime condition
(like many other medical disorders such as diabetes), it is essential that you
and your family or others close to you learn all about it and its treatment.
Read books, attend lectures, talk to your doctor or therapist.
Learn
as much as you can about bipolar disorder. The more you know, the more control
you have over your life. Be your doctor’s partner. Take the following steps to
keep the lines of communication open so he or she knows how you’re feeling and
how the medication is working. Take your medication as prescribed. Inform your
doctor of all the medications you are taking. Call and check before you add to
the list.
You
can help reduce the minor mood swings and stresses that sometimes lead to more
sever episodes by paying attention to the following:
- Maintain a stable sleep pattern.
Go to bed around the same time each night and get up about the same time each
morning. Disrupted sleep patterns appear to cause chemical changes in your body
that can trigger mood episodes. If you have trouble sleeping, or are sleeping
too much, be sure to tell your doctor. If you have to take a trip where you will
change time zones and might have jet lag, get advice from your doctor.
- Maintain a regular pattern of
activity. Don’t be frenetic or drive yourself imp
- Do not use alcohol or illicit drugs. These
chemicals cause an imbalance in how the brain works. This can, and often does,
trigger mood episodes and interferes with your medications. You may sometimes
find it tempting to use alcohol or illicit drugs to “treat” your own mood or
sleep problems – but this almost always makes matters worse. If you have a
problem with substances, ask your doctor for help and consider self help groups
such as Alcoholics Anonymous.
- Be very careful about “everyday” use of small
amounts of alcohol, caffeine and some over-the-counter medications for colds,
allergies, or pain. Even small amounts of these substances interfere with sleep,
mood or your medicine. It may not seem fair that you have to deprive yourself of
a cocktail before dinner or morning cup of coffee, but for many people this can
be the “straw that breaks the camel’s back”.
- Support from family and
friends can help a lot. However, you should also realize that it is not always
easy to live with someone who has mood swings. If all of you learn as much as
possible about bipolar disorder, you will be better able to help reduce the
inevitable stress and mutual criticisms that the disorder can cause. Even the
“calmest” family will sometimes need outside help in dealing with the stress of
a loved one who has continued symptoms. Ask your doctor or therapist to help
educate both of you and your family about bipolar disorder.
- Family therapy or joining a
support group can be very helpful.
- Try to reduce stress at work. Of
course, you want to do your very best at work, but always remember that avoiding
relapses is job no 1 and in the long run will increase your overall
productivity. Try to keep predictable hours that allow you to get to sleep at a
reasonable time. If mood symptoms interfere with your ability to work, discuss
with your doctor whether tot “ tough it out” or take time off. How much to
discuss openly with employers and co-workers is ultimately up to you. If you are
unable to work, you might have a family member tell your employer that you
are not feeling well and that you are under a doctor’s care and will return to
work as soon as possible.
DEVELOP A WELLNESS LIFESTYLE
The
way we live our lives on a daily basis has a strong impact on how we manage our
moods and minimise our symptoms. Develop a lifestyle that supports your overall
wellness by:
- Using therapy and educational materials to
improve your self-esteem and change negative thoughts into positive ones.
- Enhancing your life with
pets, music and activities that make you feel good.
-
Having a comfortable living space
where you feel safe and happy.
- Establishing a career or
avocation that you enjoy.
- Keeping your life calm and
peaceful.
- Taking good care of yourself.
- Managing your time and energy well.
- Spending time with affirming, fun people.
- Peer counsel. Share talking and listening time with a friend
- Do exercises that help you relax, focus and
reduce stress.
- Participate in fun,
affirming, creative activities.
- Record your thoughts and
feelings in a journal.
- Create a daily planning
calendar.
- Exercise.
- Allow yourself to be
exposed to light.
- Improve your diet. Avoid caffeine, sugar and
heavily salted foods.
- Change the stimulation in
your environment.
- Stop, analyse the situation
you are in and make a positive choice.
- If you are planning dental
treatment, surgery, or go to an emergency room be sure the doctor or dentist
knows_____
- If you feel suicidal, seek help from your
doctor and support system immediately. Don’t let depression win. Suicidal
thoughts are temporary. They will go away.
- Separate the true you from
the bipolar disorder. The illness does not define who you are. You are an
individual who can manage your illness and monitor treatment.
KEY RECOVERY CONCEPTS
Five
key recovery concepts provide the foundation for effective recovery. They
are:
- Hope.
With good symptoms management,
it is possible to experience long periods of wellness.
- Personal Responsibility. It’s up to you, with the assistance of others,
to take action to keep your
moods stabilised.
- Self
Advocacy. Become an effective
advocate for yourself so you can access the services and treatment you need, and
make the life you want for yourself.
- Education. Learn all you can about depression and manic
depression. This allows you to make good decisions about all aspects of your
treatment and life.
- Support. While working toward your wellness is up to
you, the support of others is essential to maintaining your stability and
enhancing the quality of your life.
HOW CAN I MONITOR MY OWN TREATMENT
PROGRESS?
Keeping a mood chart is a good way to help you, your doctor, and your
family manage your disorder (see the sample chart below). This is a diary in
which you keep track of your feelings, activities, sleep patterns, medication
and side effects, and important life events. Often just a quick daily entry
about your mood is all that is needed. Many people like using a simple, visual
scale – from the “most depressed” to the “most manic” you ever felt, with
“normal” being in the middle. Noticing changes in sleep, stresses in your life,
and so forth, may help you identify what are the early warning signs of mania or
depression for you. Keeping track of your medicines over many months or years
will also help you figure out which ones work best for you.
Sample Mood
Chart | |||||
Day
of the week |
Medicines
I took Names
of the medicines I am taking: Lithium
300mg |
Side
effects How
the medicine made me feel |
Symptoms How
I feel on a scale of 0 to 10 Most
Depressed =
0 =
5 Most
Manic = 10 |
Activities/ Sleep/Major
Life Events Include
“homework” for psychotherapy |
Appointment
Schedule |
Sample: Monday,
May 15th |
One
pill at |
Slight
tremor |
3
– I feel better about things today |
Slept
better. Good day at work. Made a list of good things about my life. |
Dr.
Smith |
HOW TO MAKE A CRISIS PLAN
Crisis Planning
Write
a personal crisis plan to be used if your symptoms become so severe and/or
dangerous that you need others to take over responsibility for your care. Your
crisis plan may include:
-
A list of your supporters, their
role in your life and their telephone numbers.
- A list of all medications you are taking and
information on why they are being taken.
- Symptoms that indicate your need for supporters to make decisions for you and take over responsibility for your care, such as: -
- Uncontrollable
pacing.
-
Severe, agitated depression.
- Inability to stop compulsive behaviours
- Self-destructive behaviour.
- Abusive or violent behaviour.
-
Substance abuse.
-
Threats of suicide.
-
Significant changes in sleep patterns (difficulty getting out of
bed).
-
Refusal of food.
-
Instructions that tell your supporters what you need them to do for you.
- Give
completed copies of your plan to your supporters so they have easy access to it
when necessary. Update your plan as needed.
- Treat your symptoms early.
- Set up a system with others
so you are never alone when you are deeply depressed or feeling out
of control.
-
Have regularly scheduled health care appointments and keep them.
- Throw away all
old medications and have firearms locked away where you do not have access to
them.
-
Keep pictures of your favourite people in visible locations at all
times.
-
Instruct a close supporter to take away your credit cards, chequebooks and car
keys when you are feeling suicidal.
- Always have something
planned to look forward to.
If you
are a family member or friend of someone with bipolar disorder, become informed
about the patient’s illness, its causes, and its treatments. Talk to the
patient’s doctor if possible. Learn the particular warning signs for how that
person acts when he or she is getting manic or depressed. Try to plan, while the
person is well, for how you should respond when you see these symptoms. You will
be thanked later!
- Encourage the patient to stick with the treatment, see the doctor, and avoid alcohol and drugs. If the patient has been on a certain treatment for an extended period of time with little improvement in symptoms or has troubling side effects, encourage the person to ask the doctor about other treatments or getting a second opinion. Offer to come to the doctor with the person to share your observation.
-
If your loved one becomes
ill with a mood episode and suddenly views your concern as interference,
remember that this is not a rejection of you – it is the illness talking.
- Learn the warning signs of
suicide. Take any threats the person makes very seriously. If the person is
“winding up” his or her affairs, talking about suicide, frequently discussing
methods of follow-through, or exhibiting increased feelings of despair, step in
and seek help from the patient’s doctor or other family members or friends.
Confidentiality is important but does not stack up against the risk of suicide.
Call an ambulance or a hospital emergency room if the situation becomes
desperate. Encourage the person to realise that suicidal thinking is a symptom
of the illness. Always stress that the person’s life is important to you and to
others and that his or her suicide would be a tremendo
-
With someone prone to manic episodes, take advantage of periods of stable
mood to arrange “advance directives” – plans and agreements you make with the
person when he or she is stable to try to avoid problems during future episodes
of illness. You should discuss and set rules that may involve safeguards such as
withholding credit cards, banking privileges and car keys. Just like suicidal
depression, uncontrollable manic episodes can be dangerous to the patient.
Hospitalisation can be life saving in both cases.
- If you are helping care for
someone at home, try if possible to take turns “checking in” on a patient’s
needs so that the patient doesn’t overburden one family member or friend.
- When patients are recovering
from an episode, let them approach life at their own pace and avoid the extremes
of expecting too much or too little. Don’t push too hard. Remember that
stabilising the mood is the most important first step towards a full return to
function. On the other hand, don’t be overprotective. Try to do things with
them, rather than for them. So that they are able to regain their sense of
self-confidence.
- Treat people normally once
they have recovered, but be alert for telltale symptoms. If there is a
recurrence of the illness, you may notice it before the person does. In a caring
manner, indicate the early symptoms and suggest a discussion with the
doctor.
- Both you and the patient
need to learn to tell the difference between a good day and hypomania, and
between a bad day and depression. Patients taking medication for bipolar
disorder, just like everyone else, do have good days and bad days that are not
part of their illness.
- Take advantage of the help
available from support groups.
Support groups are an invaluable part of treatment. These groups provide
a forum for mutual acceptance, understanding and self-discovery. Participants
develop a sense of camaraderie with other attendees because they have all lived
with mood disorders. People new to mood disorders can talk to others who have
learned successful strategies for coping with the illness.
Helping yourself, helping
others: The value of support groups.
Spending an evening with a group of people with depressive disorders may
sound intimidating at first. But, keep in mind that support groups provide a
forum for mutual acceptance, understanding and self-discovery. Your involvement
with a group gives you something proactive to do while you’re waiting for a new
medication to take effect or your next therapy session. Buoyed by the bond of
depressive or manic-depressive illness, you may find yourself rediscovering
strength and humour which you thought you lost. As with any chronic illness or
serious injury, we can sometimes fall into the mistaken belief that we are
inherently defective people. In a support group, where you have the opportunity
to reach out to others and benefit from the experiences of people who have “been
there”, it becomes a little easier to remember that depression or manic
depression does not define who you are.
Each group
operates in a unique way suited to the people it cares for. Leadership is
typically volunteer. If you would like to start a support group in your area.
Call the Depression and Anxiety Support Group who have booklets & leaflets
available on starting a group.
The aims of the
Depression and Anxiety Support Group are to educate patients, families,
professionals and the public concerning the nature of depressive and
manic-depressive illnesses as medical diseases; to foster self-help for patients
and families; to eliminate discrimination and stigma; to improve access to
care.
Additional
reading materials can also be obtained from the Depression and Anxiety Support
Group on Tel: (011) 783-1474/6.
·
DEPRESSION AND ANXIETY
SUPPORT GROUP
·
MRC UNIT
·
FEDERATION FOR MENTAL
HEALTH
·
LIFELINE
·
REGIONAL
BIPOLAR GROUPS
The
views expressed in this booklet reflect the experience of the authors, and are
not necessarily those of GLAXO Pharmaceuticals. Drugs referred to by the authors
should be used only as recommended in the manufacturer’s local data sheets.