http://www.bipolar4lifesupport.co

One approach that is crucial for most patients with bipolar disorder is to maintain a regular daily schedule, especially regular patterns of sleep. An entire therapy for bipolar disorder is organized around this daily schedule idea (“social rhythm therapy”) — especially around having a regular time to go to sleep, and a regular time to wake up and get out of bed. Yes, sorry to say, it would be best to do that same routine even on weekends.

Talk about lifestyle change! This idea of a regular sleep schedule could be very difficult for some people. Unfortunately, the most important steps you can take, without medications, can seem quite restrictive. Many people resist these restrictions, which is understandable. But that often means they will have to rely more heavily on medications, which can mean having to deal with more side effects or risks.

For many people, a very important part of bipolar disorder treatment is getting help coming to terms with having the illness at all. Accepting the illness, and accepting some limitations in order to deal with it — sometimes getting some help with this makes a huge difference. Call it “psychotherapy”, or just call it getting some help: either way, it can make this important step much easier. I hope this is obvious: if you are still spending all your energy trying to resist the fact that you have a mood problem, you won’t be able to accept some of the lifestyle changes that could make your mood problem much easier to manage.

In fact, multiple research studies have shown that using a therapist to help you with this acceptance stage, and then with making some of the necessary changes in your routines, leads to much better long-term outcomes. Three major forms of bipolar-specific psychotherapy emphasize this process of acceptance and change. All of them are variations on techniques which have been around for a long time: cognitive behavioral therapy, interpersonal therapy, and family therapy. Most therapists you can find will be familiar with one or several of these techniques. The bipolar-specific versions simply incorporate some special features pertinent to people with bipolar disorder.

Unfortunately, most psychotherapists (as of 2008) are not specifically trained in the bipolar-specific versions of these therapies. Unless you live near one of the training centers for these methods, you may not be able to find a therapist who who has had specific training on using such an approach. Worse yet, the training manuals for these therapies, which are easily obtained, tend to focus on Bipolar I. The emphasis is on preventing subsequent severe episodes of mania or depression. For people with Bipolar II, these psychotherapies require some adaptation. For now, the easiest way to do this is to work closely with a good therapist, emphasizing the following (you can even point out to your therapist where to find more information on these, using the resources in the right-hand column):

Principle B: Medications — use evidence-based Mood Stabilizers

In addition to these non-medication approaches, most people with bipolar disorder also need to use medications — although if more people were really rigorous about the non-medication approaches, and I mean really rigorous, perhaps we’d be able to use less medications. But that’s really tough, especially since motivation goes missing during bipolar depression, and most of those approaches require either motivation or a really good system of habits.

The main medications for bipolar disorder are called “mood stabilizers”. There are at least 5 options, and the list continues to grow. Your doctor will choose, or help you choose, based on her/his sense of what will work best for your set of symptoms; or what has worked for others in your family, which is often a huge clue; or based on your preferences, looking at the potential side effects and risks.

You might think “whoa, I’m being offered medications they use for people with serious mental illnesses — look, there’s lithium!” But you didn’t know that lithium is commonly used as a booster for antidepressants in plain old depression. It even works by itself as an antidepressant. So taking lithium is not a marker for “serious” mental illnesses (whatever that means.

Here’s my little essay about “Normal — or Mentally Ill?” ). But what about side effect risks from mood stabilizers? Are they worse than antidepressants?

Some mood stabilizer options carry significant risks, unfortunately. Many doctors shy away from talking about bipolar disorder as a possible diagnosis because the think the risks of the treatments are much greater than the risks of antidepressants, for example. But if you read Prozac Backlash, which offers an extreme view of the possible risks of antidepressants, you’d probably think at least some of the mood stabilizers look better, by comparison. If you include the risk of antidepressants making bipolar disorder worse, then the risks of the mood stabilizers could be regarded as roughly in the same realm as the risks of antidepressants. Update 7/2006: when I wrote that last sentence, this view was pretty radical. But listen to this statement from one of the most widely respected bipolar experts in the world, Dr. Fred Goodwin, who said that doctors and patients tend to think of antidepressants:

“…as light, easy uncomplicated drugs; and mood stabilizers as heavy drugs that should be reserved for use as a last resort. But in fact, recent data suggest that we may have to reverse that order of preference, or at least put them on an equal plane.” (interview, Primary Psychiatry, 2005)

Dr. Goodwin is saying the same thing I’ve been saying for over 5 years — but neither of us has very solid data to go on, unfortunately. We’re worrying, more than we’re saying we know.

Ahem, back to the mood stabilizer options. While your mind may leap to considering the risks, you should step back first and consider the evidence for effectiveness, of any treatment you’re considering. Will it work? If that evidence isn’t very strong, then the risk side of the equation may not matter much — unless the treatment is cheap, harmless, and may have other benefits. There are several such options, it turns out. But you won’t like the sound of them, when described. Too bad.

Wait a minute, wait a minute. What is he talking about: cheap, harmless, other benefits? Okay, try this one: “exercise” (it’s like invoking the name of the devil, in some circles, to say that). Or this one: “sleep” . Or rather, “about 8 hours of sleep on a regular schedule”, that’s the hard part. Even good old fish oil has remarkably good evidence for a “mood stabilizer” effect, but you have to take a lot. So it’s not entirely “cheap”. But it does appear to be nearly harmless and have other benefits.

Ahem again (why is this so hard to stay on track here? Well, there is just so much to say about all this. You won’t see them all but this website now has about 300 pages, many on very specific topics with only a single path that will take you there. So I’ve buried a lot of information. Let’s get back to the basics, shall we?)

My main point about choosing a medication: become familiar with at least some of the evidence for the options you’re being offered, or should be offered. Some doctors don’t keep up with that evidence; or are too swayed by pharmaceutical company pitches; or just use what they are comfortable with. The more you learn the more you’ll be in a position to help determine your own treatment. (Not that it will be an easy negotiation with your doctor all the time. Read my hints about Talking with Doctors.)

Principle C: Beware of Antidepressants

Depression is the big problem in non-manic versions of bipolar disorder (these versions include Bipolar II, and “softer” versions, as described in the Diagnosis section of this website). Thus many people with bipolar mood problems are offered antidepressants at some point. Seems logical, yet research does not strongly support this approach. Worse yet, antidepressants can make some people with bipolar disorder worse. Therefore most mood experts recommend using antidepressants only when one or several of the mainstay medications, the “mood stabilizers” discussed below, have not been able to prevent or relieve a bipolar depression. In other words, there is general agreement that antidepressants are not the first thing to turn to in the treatment of bipolar depression.

However, beyond that general agreement, controversy abounds. Some experts think that antidepressants do not have a role at all in treating bipolar depression, except perhaps as a maneuver of last resort. Such experts point either to the lack of evidence for sustained benefit, or the several lines of evidence that they can do harm. More details about the role of antidepressants in bipolar disorder treatment, including links to relevant articles that form the basis of my view, and a summary of an alternative point of view, can be found on the

Because antidepressants are so widely used, I will take this opportunity here to make sure that you are familiar with the concerns about antidepressants. First let us look at the generally agreed upon risks of antidepressants– although even these are somewhat controversial, because some doctors think they are not common; and some think that if they occur, then one simply treats them and continues the antidepressant.

1.Antidepressants can cause “rapid cycling”. Technically this means more than 4 mood episodes per year, of any type (depressed or manic or mixed), but cycles can be as often as every day or few days and a few people can go even faster, so-called “ultradian (more than one per day) cycling”.
2.Antidepressants can cause hypomanic or manic symptoms (sometimes called “switching”, meaning from depressed to manic). Overall, this is thought to occur between 20 and 40% of the time when a depressed patient with bipolar disorder is given an antidepressant. Though one review found much smaller percentages, the first study dedicated to looking for this rate came out with a switch rate of 20-30% in the first 10 weeks.
3.Antidepressants can cause “mixed states”. Remember, bipolar disorder is not like the north and south pole; hypo/manic symptoms can occur while depressed symptoms are also present. In a way, this is the same problem as #2 above, except that instead of switching from one state to another, you have both at the same time. Usually this looks like agitation or anxiety, or irritability; and difficulty sleeping; and depression, all at the same time.

Secondly, here are the more controversial risks.

1.Antidepressants may cause “mood destabilizing” — increasing cycle frequency over a longer period of time; in other words, having more mood episodes than before, or more rapid switches from one mood state to another. This is regarded as worsening the mood condition overall, making it less stable. This is one of the main concerns expressed by one of the lead experts on this issue, Dr. Ghaemi, whose work is cited extensively in the Antidepressant Controversies essay.
2.

3.Finally, could antidepressants cause “kindling”, in which the illness worsens more quickly with time than it might have if antidepressants weren’t there? I don’t hear too many other experts fretting about this as I do, so I won’t worry you with it here.

Whatever you do with antidepressants, you really need to work closely with your doctor on this. DO NOT STOP your antidepressant. It must be tapered at minimum, if you’re going off, or you could — for sure; I’m not making this up — actually end up quickly worse. You have to plan this out with your doctor. If you have trouble getting your concerns or ideas heard, here are some ideas on talking with doctors.

Meanwhile, however, the good news is that we have at least ten different ways of treating depression in bipolar disorder, without using antidepressants.