Bipolar Support Groups.com blog

Service dogs for Bipolar Disorder:
Updated March 09, 2015.

Can those with psychiatric disorders such as bipolar disorder or depression benefit from interaction with animals? The answer is a resounding, “YES!” “There are an increasing number of dogs being trained to assist individuals with a range of disabilities, including seizure disorders, Parkinson’s disease, heart disease, and psychiatric disorders” (Sachs-Ericsson et al, 2002). Not only can those with bipolar disorder benefit from the love of and for a pet, but they are also permitted under the Americans with Disabilities Act to employ the assistance of a service dog.

The Benefit of Animals

According to Dr. Aaron Katcher of the University of Pennsylvania and Dr. Patricia Gosner of the University of Southern Alabama, animals offer benefits to those with mental illnesses through a number of venues (Lipton, 2001):
Pet Ownership – It is common knowledge, and supported by a large body of scientific research, that owning a pet is generally good for people. There are social and emotional benefits to loving and caring for another creature and having that affection returned.

Animal-Assisted Activities – Trained volunteers hold informal activities in institutional settings such as prisons, hospitals and nursing homes. These activities provide patients with the opportunity to hold, cuddle, pet and interact with animals such a rabbits or dogs or even pigs.
Animal-Assisted Therapy – This involves the use of animals in formal therapy sessions. The presence of a friendly animal helps to ease a patient’s anxiety. This involvement can also improve social interactions and decrease aggressive behavior.

Psychiatric Service Dogs – As noted by Dr. Gosner, “These dogs perform specific tasks that mitigate the negative effects of the person’s mental illness” (Lipton, 2001).

The Law Relating to Service Dogs
It is important to note that to qualify for the protections and allowances of the Americans with Disabilities Act, both the individual and the canine, must meet specific criteria. In short, an individual must have a disability and a service dog must be specifically trained to meet the needs of that disability.
To be protected by the ADA, one must have a disability or have a relationship or association with an individual with a disability. An individual with a disability is defined by the ADA as a person who has a physical or mental impairment that substantially limits one or more major life activities, a person who has a history or record of such an impairment, or a person who is perceived by others as having such an impairment. The ADA does not specifically name all of the impairments that are covered. (Department of Justice, 2002).
The ADA defines a service animal as any guide dog, signal dog, or other animal individually trained to provide assistance to an individual with a disability. If they meet this definition, animals are considered service animals under the ADA regardless of whether they have been licensed or certified by a state or local government. (Department of Justice, 1996).

The Role of Service Dogs
Joan Froling, a trainer and consultant with Sterling Service Dogs, provides a detailed list of tasks for which service dogs are trained to assist those with psychiatric disabilities. A few of the overall tasks include:
Assistance in a Medical Crisis – Service dogs are trained to retrieve medications, beverages and telephones. They can bark for help, answer a door bell, and even dial 911 on special K9 speaker telephones.
Treatment Related Assistance – These special animals can be trained to deliver messages, remind individuals to take medications as specific times, assist with walking as well as alerting sedated individuals to doorbells, phones or smoke detectors.
Assistance Coping With Emotional Overload – Service dogs can be taught to prevent others from crowding their owner. They can be taught to recognize a panic attack and nuzzle a distraught owner to help with calming.
Security Enhancement Tasks – These canines are often trained to check the house for intruders. They can turn on lights and open doors. They can assist with leaving a premises during an emergency.

In summation, service dogs are of considerable benefit to those with psychiatric disabilities. As noted in their study reviewing the benefits of assistant dogs, Natalie Sachs-Ericsson et al write, “Through clinical observation, anecdotal reports, and retrospective and cross-sectional studies, preliminary support was found for the conclusion that ADs have a positive impact on individuals’ health, psychological well-being, social interactions, performance of activities, and participation in various life roles at home and in the community” (2002).

Managing Weight Gain on Mental Health Medications:

Updated March 26, 2015.
One of the challenges faced by people with mood disorders is weight gain from their medications. I myself gained 80 pounds on psychotropic meds. In addition to being physically dangerous, weight gain is a stumbling block to good mental health, because being overweight is depressing!
We try — oh, how we try! — to lose the weight. Over the years I’ve tried walking 80 minutes a day for three months; a rigorous exercise program for ten weeks; the South Beach Dietfor a short time; and a $2,000 diet plan for three months.

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I lost weight for a time with South Beach but couldn’t handle the practical difficulties, and virtually no weight with any of the other programs. The most I lost on any of them was two pounds. My weight has been stable at 205 pounds for about a year. I looked great at 130 — and not so great at just 145.

If your meds have made you gain a lot of weight, your story is probably similar. You’ve tried and tried, and the weight just keeps creeping up. Maybe you’ve given up.

Well, there’s hope.

I recently viewed a presentation by Dr. Rohan Ganguli and Nurse Practitioner Betty Vreeland on this subject. Dr. Ganguli began by saying he had treated many obese patients for years without really thinking about their weight.

Then a colleague did a survey that found that of their patients diagnosed with schizophrenia, less than 20%were in the normal weight range, and fully 60% were obese.

He said that, unfortunately, “… it has been assumed that people with schizophrenia are socially unaware and that, unlike the rest of us, this really does not matter to them.” Yet when they asked these patients how they felt about their weight, a wide majority of the overweight and obese patients said they wanted and had tried to lose weight.

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And in another study, patients said the #1 worst thing about taking medications was weight gain. Clearly, the attitude that those with schizophrenia don’t care about their weight was completely wrong.
Dr. Ganguli and his fellows developed a program that clinicians could easily provide. It involved 14 weeks of group sessions with training in such areas as developing good eating habits, burning more calories, and changing snacking habits. Self-monitoring in the form of daily weighing and records of food eaten and physical activity was found to be very important.

They lost weight

The results after the 14 weeks were very encouraging — two-thirds of patients lost at least 3% of body weight and around 40% lost 5% of body weight or more. This may not sound like a lot, but for me, 3% would mean a little over six pounds in 2 1/2 months — a lot more than I’ve been able to do in all these years!

One of the program’s ideas was that of “wasting” food. Many people with schizophrenia eat at fast food restaurants because these are inexpensive and convenient. A key issue in their strategy was teaching people not to eat the entire meal — that it was okay to throw part of the food away.

Preventing weight gain

Finally, they tested the program with patients who were just starting on some of the medications that are known to cause weight gain, including Seroquel (quetiapine), Risperdal (risperidone), Clozaril (clozapine) and Zyprexa (olanzapine). In all cases, intervention was found to prevent weight gain in more patients than in the control group, although the success rate depended on the medication. In this small study, the most dramatic difference was with Seroquel, where more than 60% of the control group gained significant weight, while only about 10% of those in the intervention group gained.

Another successful program

Ms. Vreeland’s Healthy Living study was another test of intervention to promote weight loss in the mentally ill. In this program, the key points were:
Use the food label
Pay attention to portion size
Eat more slowly
Make healthy snack choices
Differentiate between stomach and psychological hunger
Reduce fast food intake
Keep food/activity diaries
Increase physical activity
Minimize soft drinks with sugar

This program, using patients with schizophrenia and schizoaffective disorder, resulted in an average 6.6 pound weight loss for those in the intervention group, with a 7 pound weight gain in the control group.

The message
First, mental health practitioners of all kinds need to pay more attention to the problem of overweight/obesity in their patients. We are not in a state where we don’t care. We care — a lot. And they can help. A doctor who just says, “Join Weight Watchers” isn’t getting it. Many of us aren’t up for going to meetings when depressed. Some, like me, are not “group” people. A therapy group, with people like me who have gained weight because of their psychotropic meds, would be different.

But just knowing what made these programs successful can help. Knowing that there is solid research to show it is possible to lose weight and still take my Seroquel makes a difference to me.

Now, I know keeping a calorie and exercise diary is no fun. The easiest way is to get software that has a food database that keeps being updated with more foods. But still, you have to figure out how much of a food you ate, and if the food isn’t in the list, you have to add it yourself from the food label. And you have to do it every day, every time you eat. It gets old, fast. (In the sidebar is an article about keeping a food diary if you don’t want to buy software.)

But it works better than anything else I’ve found. Having made a lot of diet changes already, I recently I started keeping such a diary. I find out what I eat that piles up the calories. And after learning that general housework burns about 240 calories an hour, I’m doing a lot more of that now as well.

My scale says I’ve lost four pounds as of this morning.

Weight loss for those of us on psychotropic meds isn’t going to be fast. But if I get tired of keeping a food/exercise diary, or just don’t want to wash the dishes, I have the encouragement of knowing it’s been proved possible to lose weight with this approach. I hope it helps you, too.

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Mental Health by the Numbers:

Prevalence of Mental Illness

Approximately 1 in 5 adults in the U.S.—43.7 million, or 18.6%—experiences mental illness in a given year.1

Approximately 1 in 25 adults in the U.S.—13.6 million, or 4.1%—experiences a serious mental illness in a given year that substantially interferes with or limits one or more major life activities.2

Approximately 1 in 5 youth aged 13–18 (21.4%) experiences a severe mental disorder in a given year. For children aged 8–15, the estimate is 13%.3

1.1% of adults in the U.S. live with schizophrenia.4
2.6% of adults in the U.S. live with bipolar disorder.5
6.9% of adults in the U.S.—16 million—had at least one major depressive episode in the past year.6
18.1% of adults in the U.S. experienced an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder and specific phobias.7

Among the 20.7 million adults in the U.S. who experienced a substance use disorder, 40.7%—8.4 million adults—had a co-occurring mental illness.8

Social Stats
An estimated 26% of homeless adults staying in shelters live with serious mental illness and an estimated 46% live with severe mental illness and/or substance use disorders.9

Approximately 20% of state prisoners and 21% of local jail prisoners have “a recent history” of a mental health condition.10

70% of youth in juvenile justice systems have at least one mental health condition and at least 20% live with a serious mental illness.11

Only 41% of adults in the U.S. with a mental health condition received mental health services in the past year. Among adults with a serious mental illness, 62.9% received mental health services in the past year.8
Just over half (50.6%) of children aged 8-15 received mental health services in the previous year.12

African Americans and Hispanic Americans used mental health services at about one-half the rate of Caucasian

Americans in the past year and Asian Americans at about one-third the rate.13

Half of all chronic mental illness begins by age 14; three-quarters by age 24. Despite effective treatment, there are long delays—sometimes decades—between the first appearance of symptoms and when people get help.14

Consequences of Lack of Treatment

Serious mental illness costs America $193.2 billion in lost earnings per year.15

Mood disorders, including major depression, dysthymic disorder and bipolar disorder, are the third most common cause of hospitalization in the U.S. for both youth and adults aged 18–44.16

Individuals living with serious mental illness face an increased risk of having chronic medical conditions.17

Adults in the U.S. living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions.18

Over one-third (37%) of students with a mental health condition age 14­–21 and older who are served by special education drop out—the highest dropout rate of any disability group.19

Suicide is the 10th leading cause of death in the U.S.,20
the 3rd leading cause of death for people aged 10–2421 and the 2nd leading cause of death for people aged 15–24.22

More than 90% of children who die by suicide have a mental health condition.23

Each day an estimated 18-22 veterans die by suicide.24

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About this leaflet

This is one in a series of factsheets for parents, teachers and young people entitled Mental Health and Growing Up.

This leaflet gives some basic information about bipolar disorder and some advice on how to get help.

What is bipolar affective disorder?

What are the symptoms?
Bipolar disorder (BD) is a condition in which a young person has extreme changes of mood – periods of being unusually happy (known as ‘mania’ or ‘hypomania’), and periods of being unusually sad (‘depression’). It is sometimes called’ manic depressive disorder’,’ bipolar affective disorder’ or ‘bipolar mood disorder’.
The mood-swings are way beyond what would be considered normal for a particular individual, and are out of keeping with their personality.

Hw common is it?
Bipolar disorder is extremely rare in young children, but there are quite a few studies that suggest that it may start in teenage years and in early adult life. It affects about one in 100 adults.

The condition can be hard to recognise in teenagers because more extreme behaviour can be part of this stage of life.

In BD, a person can have:
manic or hypomanic periods (or ‘episodes’)
depressive periods
mixed periods.
Below is a list of the symptoms in each episode. A young person needs to have at least one manic or hypomanic episode to be diagnosed with BD.
Symptoms that can occur during a ‘high’ or manic episode

Symptoms that can occur during a depressive episode

feeling incredibly happy or ‘high’ in mood, or very excited
feeling irritable
talking too much -increased talkativeness
racing thoughts
increased activity and restlessness
difficulty in concentrating, constant changes in plans
over confidence and inflated ideas about yourself or your abilities
decreased need for sleep
not looking after yourself
increased sociability or over-familiarity
increased sexual energy
overspending of money or other types of reckless or extreme behaviour.

‘Hypomania’ is a milder form of mania (less severe and for shorter periods). During these periods, people can actually become very productive and creative and so see these experiences as positive and valuable. However, hypomania, if left untreated, can become more severe, and may be followed by an episode of depression.

At the extreme end, some people also develop something called psychosis. This is when someone has strong, bizarre beliefs e.g. that they have superhuman powers or are being watched or followed.

feeling very sad most of the time
decreased energy and activity
not being able to enjoy things you normally like doing
lack of appetite
disturbed sleep
thoughts of self-harm or suicide.
On the milder end, you may just feel sad and gloomy all the time. Here too, at the extreme end, some people can develop psychosis.

Symptoms that can occur during a mixed episode
A mixture of manic symptoms and depressive symptoms at the same time.

What effects can bipolar disorder have?

Where can I get help?

The exaggerated thoughts, feelings and behaviours can affect many aspects of life and can lead to:
problems in relationships with friends and family
interference with concentration at school or work
behaviour that places the young person’s health or life at risk
a loss of confidence and a loss of the sense of control the person feel over their life.
The longer the condition continues without treatment, the more harmful it is likely to be to the life of the young person and to their family.

The first step towards getting help is to recognise that there might be a problem. Seeking medical advice early on is very important. If the bipolar illness can be identified and treated quickly, this reduces its harmful effects.

How is it treated?
You should contact your GP first. If necessary, they can then make a referral to your local child and adolescent mental health service (CAMHS), who can offer more specialist help.
In the short term, depending on whether you are high or low and how severe it is, you may need different treatments.

When you have severe symptoms, you may need medications and also sometimes admission to hospital to help your symptoms and also keep you safe.

In the long term, the goal of treatment is to help you have a healthy, balanced and productive life. This would include understanding the condition, controlling the symptoms and preventing the illness from coming back.

Medication

Medication usually plays an important role in the treatment of bipolar disorder, especially if episodes are severe. In the initial stages of the illness, medication helps to reduce the symptoms.

The choice of medication can depend upon the type of episode (manic or depressed). Everyone is different and so the type of medication that is recommended will also be different.
The three main types of medication that are helpful are:
antipsychotic medication: risperidone, olanzapine and aripiprazole are types of antipsychotics.
mood stabilizers: Lithium is a type of mood stabiliser.
antidepressants: fluoxetine is a type of antidepressant.

It is important that medications are not taken only when the problems are serious. If your child has had more than one severe episode of illness, staying on medication is important to reduce the risk of further episodes.

Medication may be needed for months or even years. Some people may, under medical supervision, be able to stop their medication when they have recovered and have felt well for a while.

They may need physical examinations and tests (like blood test) before starting or while on medication. It is important that if prescribed medication, you are regularly seen by your doctor or psychiatrist.
Side-effects of the medication can occur, some of which are quite serious. The psychiatrist will be able to advise about what they are and about what can be done to help. The risk of side-effects needs to be balanced against the risk of the damaging effects of the illness on a person’s life.
No young person should be taking medication unless they are reviewed by a health professional regularly. This is to monitor the dose of the drug and to check for side-effects.

Talking treatments (also known as ‘psychotherapies’)
It is crucial that drug treatments are combined with practical help for the young person and their family.
Help with understanding the illness (psycho education)

It is very important that the young person with bipolar disorder and their family are helped to understand the condition, how best to cope and what to do to reduce the chances of it recurring.

The young person and their family may notice particular ‘triggers’ to their episodes and/or early warning signs that an episode may be starting – being aware of these can help reduce the chance of episodes occurring, and getting help in the earliest stages of an episode can stop it from escalating.
Family-focused treatment

Stress at home can worsen the situation and can even trigger an episode of the illness. Talking therapy in which the whole family is helped to find ways of reducing stress, solving problems and communicating more effectively has been shown to help young people with BD get better, and stay well.
Cognitive-behavioural therapy (CBT)

This is another type of talking therapy in which the young person, sometimes with their family, learns to understand the links between their feelings and thoughts and how this affects their behaviour.

Some young people may need to go into hospital for intensive support if the symptoms are severe.

Recovery
It is important for the young person to recognise that they are not alone and to keep up hope.
Many people only have a few mood swings and then the problem goes away. For others, it becomes a lifelong pattern which they learn to live with and manage.

An episode of bipolar disorder can interfere with education because it is difficult to learn when they are unwell. An important part of recovery is to begin to plan returning to education or to think about working.

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Sleeping Well :

About this leaflet

If you have trouble sleeping – or know someone who has – this leaflet may be helpful. It covers some common problems with sleep, as well as some more unusual ones. There are some simple tips on how to sleep better, and how to decide if you need more help.

Introduction

You don’t usually need to think very much about sleep. It’s an ordinary part of life, but sometimes you just can’t sleep properly (we call it insomnia). It’s usually just for a short time, perhaps when you’re worried or excited. When things settle down, you start to sleep properly again. If you can’t sleep properly, it can be a real problem because we all need sleep to keep healthy.
Sleeping well final

What happens during sleep?

You become unconscious, unaware of what’s going on around you. As you sleep, you pass through different stages – and there are two main ones:

Rapid Eye Movement (REM) sleep
This comes and goes throughout the night, and makes up about one fifth of your sleep. The brain is very active, your eyes move quickly from side to side and you dream. Although your brain is active, your muscles are very relaxed.

Non-REM sleep
Your brain is quiet – you are still unconscious – but your body moves around more. Hormones are released into the bloodstream and your body repairs itself after the wear and tear of the day. There are 3 stages of non-REM sleep:

‘Pre-sleep’ – your muscles relax, your heart beats slower and your body temperature falls.
‘Light sleep’ – you can wake up easily without feeling confused.
‘Slow wave’ sleep – your blood pressure falls, you may talk or sleep walk and it’s hard to wake up. If somebody does wake you, you feel confused.
You move between REM and non-REM sleep about 5 times during the night, dreaming more towards the morning.

On a normal night, most people wake up for one or two minutes every 2 hours or so. You aren’t usually aware of these ‘mini wakes’, but may remember them if you feel anxious or there is something else going on – noises outside, a partner snoring etc.

How much sleep do I need?

This mainly depends on your age.

Babies sleep for about 17 hours each day.
Older children only need 9 or 10 hours each night.
Most adults need around 8 hours sleep each night.
Older people need the same amount of sleep, but will often only have one period of deep sleep during the night, usually in the first 3 or 4 hours. After that, they wake more easily. We tend to dream less as we get older.
Even so, we are all different, even people who are the same age as us. Most of us will need 8 hours a night, but some (a few) people can get by with only 3 hours a night.

But I never sleep …

The short periods when you are awake (every couple of hours) can feel much longer than they really are. So you can feel that you are not getting as much sleep as you really are.

What happens if I don’t sleep?

The occasional night without sleep will make you feel tired the next day, but it won’t affect your health.

However, after several sleepless nights, you will start to find that you:
feel tired all the time
drop off during the day
find it difficult to concentrate
find it hard to make decisions
start to feel depressed
start to worry about not being able to sleep.
This can be very dangerous if you are driving or operating heavy machinery. Many people are killed each year when they fall asleep while driving.

Lack of sleep can make you more likely to get high blood pressure, diabetes and to be overweight.

Sleeping too little (insomnia)

You may feel that you aren’t getting enough sleep or that, even if you do get the hours, you just aren’t getting a good night’s rest.

There are many everyday reasons for not sleeping well:
the bedroom may be too noisy, too hot or too cold
the bed may be uncomfortable or too small
you don’t have a regular sleep routine
you partner has a different pattern of sleep from you
you aren’t getting enough exercise
you eat too late – and find it hard to get off to sleep
you go to bed hungry – and wake up too early
cigarettes, alcohol and drinks containing caffeine, such as tea and coffee
illness, pain or a high temperature.
More serious reasons include:

emotional problems
difficulties at work
anxiety and worry
depression – you wake very early and can’t get back to sleep
thinking over and over about problems – usually without getting anywhere with them
physical problems including:
heart disease, such as angina or heart failure
breathing problems, such as chronic obstructive pulmonary disease or asthma
neurological disease, such as Alzheimer’s or Parkinson’s disease
hormone problems, such as an overactive thyroid
joint or muscle problems, such as fibromyalgia or arthritis
gastroinestonal disease, such as gastoroesophageal reflux disease or irritable bowel syndrome
genital or urinary problems, such as incontinence or an enlarged prostate
long-term pain
medications
stopping tranquillisers and sleeping tablets
slimming pills
melatonin – occasionally
many medications can do this – check with your doctor.
Here are some simple tips that many people find helpful:

Do’s
Make sure that your bed and bedroom are comfortable – not too hot, not too cold, not too noisy.
Make sure that your mattress supports you properly. If it’s too firm, your hips and shoulders are under pressure. If it’s too soft, your body sags which is bad for your back. Generally, you should replace your mattress every 10 years to get the best support and comfort.
Get some exercise. Don’t overdo it, but try some regular swimming or walking. The best time to exercise is in the daytime – particularly late afternoon or early evening. Later than this can disturb your sleep.
Take some time to relax properly before going to bed. Some people find aromatherapy helpful.
If something is troubling you and there is nothing you can do about it right away, try writing it down before going to bed and then tell yourself to deal with it tomorrow.
If you can’t sleep, get up and do something relaxing. Read, watch television or listen to quiet music. After a while, you should feel tired enough to go to bed again.
Don’ts

Don’t go without sleep for a long time. Go to bed when you feel tired and stick to a routine of getting up at the same time every day, whether you still feel tired or not.
Caffeine hangs around in your body for many hours after your last drink of tea or coffee. There are now many fizzy drinks, and even mints, that contain a lot of caffeine. Stop drinking tea or coffee by mid-afternoon. If you want a hot drink in the evening, try something milky or herbal (but check there’s no caffeine in it).
Don’t drink a lot of alcohol. It may help you fall asleep, but you will almost certainly wake up during the night.
Don’t eat or drink a lot late at night. Try to have your supper early in the evening rather than late.
If you’ve had a bad night, don’t sleep in the next day – it will make it harder to get off to sleep the following night.
Don’t use slimming pills – many of these will keep you awake.
Don’t use street drugs like Ecstasy, cocaine and amphetamines – they are stimulants, and like caffeine, will tend to keep you awake.
If you try these tips and you still can’t sleep, go and see your doctor. You can talk over any problems that may be interfering with your sleep. Your doctor can check that your sleeplessness is not due to a physical illness, a prescribed medicine, or emotional problems. There is evidence that cognitive behavioural therapy can be helpful if you haven’t been sleeping well for some time.

Psychological Treatments

Cognitive therapy is a way of changing unhelpful ways of thinking that can make you more anxious, and so stop you from sleeping.
Stimulus control helps you to:
strengthen the link of being in bed with sleeping – by only getting into bed when you feel tired, and only using your bed for sleep and sex;
weaken the link of being in bed with doing things that are likely to keep you awake – like watching exciting TV programmes, doing work, or organising things;
weaken the link of being in bed with worrying – if you can’t sleep, instead of lying in bed worrying, you get up and do something for a while until you feel tired again.
Sleep restriction helps you to go to bed later. Too much time in bed can stop you from sleeping.
Progressive muscle relaxation helps you to relax your muscles deeply. One by one, you tense and then release the muscles of your body, working up from your feet to your legs, arms, shoulders, face and neck.
What about medication?

People have used sleeping tablets for many years, but we now know that they:

don’t work for very long
make you tired and irritable the next day
lose their effect quite quickly, so you have to take more and more to get the same effect
are addictive. The longer you take sleeping tablets, the more likely you are to become dependent on them.
There are some newer sleeping tablets (Zolpidem, Zaleplon and Zopiclone), but these seem to have many of the same drawbacks as the older drugs, such as Nitrazepam, Temazepam and Diazepam.

Sleeping tablets should only be used for short periods (less than 2 weeks) – for instance, if you are so distressed that you cannot sleep at all.

If you have been on sleeping tablets for a long time, it is best to cut down the dose slowly after discussing it with your doctor.

In some cases, antidepressant tablets can be helpful.

Melatonin is a naturally occurring hormone that can help insomnia. At present, in the UK, it is only licensed for treating sleeplessness in those aged over 55. It should not be taken for more than 3 weeks, and should not be used if you have liver or kidney problems. It can make you drowsy and, occasionally, can cause:

irritability
dizziness
migraines
constipation
stomach pain
weight gain.
Over-the-counter medication

You can buy sleeping remedies at your chemist without a prescription. They often contain an anti-histamine, like you find in medicines for hay-fever, coughs and colds. These do work, but they can make you sleepy well into the next morning. If you do use them, take the warnings seriously and don’t drive or operate heavy machinery the next day. Another problem is tolerance – as your body gets used to the substance, you need to take more and more to get the same effect. It is best not to take anti-histamines for a long time.

Herbal medicines are usually based on a herb called Valerian. It probably works best if you take it every night for 2-3 weeks or more. It doesn’t seem to work as well if you take it occasionally. As with the anti-histamines, you need to be careful about the effects lasting into the following morning. If you are taking any medication for your blood pressure (or any other sleeping tablets or tranquillisers), have a chat with your doctor before using an over-the-counter remedy.

Sleeping at the wrong time – shift work and parenthood

You may have to work at night, staying awake when you would normally be asleep. If you only have to do this occasionally, it’s quite easy to adjust. It is much harder to cope with if you do it regularly. Shift workers, doctors and nurses working all night or nursing mothers may all find that they sleep at times when they ought to be awake. It’s like jet lag where rapid travel between time zones means that you are awake when everybody else is asleep.

A good way to get back to normal is to make sure that you wake up quite early at the same time every morning – whatever time you fell asleep the night before. Use an alarm clock to help you. Make sure that you don’t go to bed again before about 10 pm that night. If you do this for a few nights, you should soon start to fall asleep naturally at the right time.

A parent’s disturbed sleep usually ends as their child becomes more settled at night. Shift work, on the other hand, can go on for years. You may need to do it, to earn a living, but:
It can make you more irritable.
You may find it harder to make good decisions.
You are more likely to have a heart attack or stroke.
You may be more likely to develop diabetes.
Sleeping too much

You may find that you fall asleep during the day at times when you want to stay awake. This will usually be because you have not been getting enough sleep at night.

If you are still falling asleep in the daytime, even after a week or two of getting enough sleep, see your doctor. Physical illnesses such as diabetes, a viral infection, or a thyroid problem, can cause this sort of tiredness.

There are other conditions which make people sleep too much:

Narcolepsy (daytime sleepiness)

This is an uncommon problem, so it’s easy for a doctor to miss it.

There are two main symptoms:
you feel sleepy in the daytime, with sudden uncontrollable attacks of sleepiness even when you are with other people
cataplexy – you suddenly lose control of your muscles and collapse when you are angry, laughing or excited. This sometimes gets better with age.
You may also find that you:
can’t speak or move when falling asleep or waking up – (sleep paralysis)
hear odd sounds or see dream-like images (hallucinations)
‘run on auto-pilot’ – you have done things, but can’t remember doing them, as if you had been asleep
wake with hot flushes during the night.
The cause for this has recently been found – a lack of a substance called orexin, or hypocretin.

Treatment consists of taking regular exercise and getting yourself into a regular night-time routine. If this simple approach does not work, medication may help. These include:
Modafinil which makes you more awake in the day-time;
Antidepressants, such as Clomipramine or Fluoxetine, can help with cataplexy;
Sodium Oxybate helps the day-time sleepiness and poor sleep at night.
Sleep Apnoea (interrupted sleep)

You snore loudly and stop breathing for short periods during the night. This happens because the upper part of your airway closes. Every time you stop breathing, you wake suddenly and your body or arms and legs may jerk.
You stay awake just for a short time, then fall off to sleep again. This will happen several times during the night. You may have a dry mouth and a headache when you wake up in the morning. You feel tired in the day and may have an irresistible urge to go to sleep.
You are more likely to get sleep apnoea if you are:
older
overweight
a smoker
a heavy drinker.
The problem is often noticed by a partner. Treatment is usually simple – cut down smoking and drinking, lose weight, and sleep in a different position. If your apnoea is very bad, you may need to wear a Continuous Positive Airway Pressure (CPAP) mask. This blows high-pressure air into your nose which keeps the airway open.

Other problems with sleeping

At some point in their life, about 1 in 20 adults have night terrors, and 1 in 100 report that they sleep-walk. Both these conditions are more common in children.

Sleepwalking: when you sleepwalk, you appear (to other people) to wake from a deep sleep. You then get up and do things. These may be quite complicated, like walking around or going up and down stairs. This can land you in embarrassing (and occasionally dangerous) situations. Unless someone else wakes you up, you won’t remember anything about it. Sleepwalking sometimes happens after a night terror (see below). If your sleep is broken or you aren’t getting sleep, you are more likely to sleepwalk.

A sleepwalker should be guided gently back to bed and should not be woken up. You may need to take precautions to protect them or other people, such as locking doors and windows, or locking away sharp objects, like knives and tools.

Night terrors: can happen on their own, without sleepwalking. Like a sleepwalker, a person with night terrors will appear to wake suddenly from a deep sleep. They look half-awake and very frightened, but will usually settle back to sleep without waking up completely. All you can do is sit with them until they fall asleep again.

Night terrors are different from vivid dreams or nightmares as people don’t seem to remember anything about them the next morning.

Nightmares: most of us have had frightening dreams or nightmares. They usually happen during the later part of the night, when we have our most vivid and memorable dreams. They don’t usually cause problems unless they happen regularly, perhaps because of emotional distress. Nightmares often follow a distressing or life-threatening event such as a death, a disaster, an accident or a violent attack. Counselling may be helpful.

Restless Legs Syndrome (RLS)
You feel you have to move your legs (but also, sometimes, other parts of the body).
You may have uncomfortable, painful or burning feelings in your legs.
These feelings only bother you when you are resting.
They are generally worse at night.
Walking or stretching helps, but only for as long as you carry on doing it.
You may not be able to sit still in the daytime or sleep properly.
People usually first ask for help with this in middle age, even though they may have had symptoms since childhood. It often runs in families.

RLS usually occurs on its own. Pregnancy or a physical illness (iron and vitamin deficiencies, diabetes or kidney problems) can occasionally be responsible.

If it is not caused by another physical illness, treatment depends on how bad it is. In mild RLS, the symptoms can usually be controlled by simple steps designed to help you sleep better (see above ‘Helping yourself’). In more severe RLS, medications may help. These include medications used in Parkinson’s disease, anti-epileptic medications, benzodiazepine tranquillisers and pain-killers.

If simple measures do not help, you can be referred to a sleep or movement disorders specialist.
Autism

Some people with autism do not seem to realise that night time is for sleeping, and may be up and about when everyone else wants to sleep. This will usually need the help of a specialist.

REM Sleep Behaviour Disorder (RBD)

A person will start thrashing about during REM or dream sleep, as though responding to a dream. They may punch, kick, shout, or jump out of bed. Quite often, the person will wake and be able to remember the dream that prompted their physical reactions. Someone sharing the same bed can be disturbed and, sometimes, injured.

The problem seems to be that, unlike normal REM sleep where the muscles are relaxed, in RBD they are not. It can happen on its own or it can be a symptom of a neurological illness, so it’s best to be assessed by a specialist.

http://www.bipolar4lifesupport.co

Medications for Bipolar Disorder

Aim of this leaflet

This leaflet is for anyone who wants to find out about the medications used to help stabilise unhelpful mood swings and to control mania in bipolar disorder. It discusses how they work, why they are prescribed,ABPI: new Code of Practice for the Pharmaceutical Industry their effects, side-effects and some alternatives.

What is mania?

If you suffer from mania, you may find yourself feeling elated, over-confident and full of energy – ‘on top of the world’. You may sleep very little, talk very fast, and do things impulsively that are out of character.

In bipolar disorder, you may have both manic and depressive mood swings at different times.

These mood swings can be very unpleasant and destructive. It is important to start treatment early, before the condition becomes severe. For more information, see our leaflet on Bipolar Disorder.

Mania is a condition that can come back again and again. Many doctors will advise taking medication to prevent this happening. Medication can be used to treat mania once it has started, or to prevent it from starting.

To Treat Mania To Prevent Mania
Mood Stabilisers
Lithium

Valproate

Lithium

Valproate

Carbamazepine

Olanzapine

Antipsychotics
Atypical: Olanzapine, Risperidone, Quetiapine
Asenapine

Typical: Chlorpromazine, Haloperidol

Usually used together with a mood stabiliser, not usually on their own

Benzodiazepines
Diazepam
Lorazepam
Clonazepam
Mood Stabilisers

Lithium

Lithium has for 40 years been the most commonly used drug to prevent relapse.

How does it work?
We don’t know, but we know that it works on chemical signals in the brain and that it makes brain cells more resilient to stress.

What effect does it have?
It ‘evens out’ mood swings in either direction.

How is it taken?
In tablet form, once or twice a day. It is important to continue with the Lithium when you are feeling better – suddenly stopping it may trigger depression or mania.

What are the side effects?
You may notice:
in the first few weeks
a slight shaking of the hands
dry mouth
a metallic taste in the mouth
tiredness
later
weight gain
thirst
urinating more often
under-active thyroid gland.
Not everybody will get these side-effects. If you do have any of these, it is worth bearing in mind that most will go away with time as your body gets used to the Lithium.

Is Lithium dangerous?
No – Lithium is a safe drug when taken at the correct dose. However, you don’t have to go very far above the safe dose before it becomes unsafe. A test to measure the amount of Lithium in your blood is the best way of making sure you are getting the right dose.

The following signs suggest that your Lithium level is too high. Contact your doctor immediately if you notice:

you feel very thirsty
you have bad diarrhoea or vomiting
obvious shaking of your hands and legs
twitching of your muscles
you get muddled or confused.
Sensible precautions while taking Lithium
The body gets rid of Lithium in your urine, so the amount of Lithium in your blood is easily affected if you lose fluid. If you take in less, by drinking less, or lose more, through sweating or urinating, the higher your level of Lithium will be.

Your ability to get rid of Lithium in your urine is affected by the amount of salt in your blood – if you have less salt, you pass less Lithium in your urine, and so the level of Lithium in your blood may rise.

Some other drugs and medicines, whether prescribed by a doctor or available over‑the‑counter, may interfere with Lithium. Please check with your doctor or pharmacist before starting any new medication, wherever you have got it from.

So:
drink plenty of non-alcoholic fluids – diet drinks can help to prevent weight gain;
if you are on holiday in a hot climate, drink more fluids than usual and don’t spend a long time out in the sun;
avoid low-salt diets;
be careful if you are exercising heavily – you may get too dry or lose too much salt in your sweat;
don’t have a sauna.
Blood tests
These are needed to:
check the amount of Lithium in the body (see above);
check that your kidneys and thyroid gland are working properly.
The blood test is usually done 12 hours after the last dose of Lithium.
If you take it twice a day, and are having the test in the morning, remember to miss your morning dose on the day of the test.
At first these tests are done every week or fortnight. After the level of Lithium in your blood has become steady, they need only be done every three or four months.
Valproate

This medication is becoming more widely-used to treat mania. It is also used to prevent recurrence of extreme mood swings, and a recent study has found that the combination of valproate with lithum may be more effective than either of these medications on their own.

Like lithium, we don’t know exactly how valproate works.

What are the side effects?
Common:
sleepiness
dizziness
increased appetite and weight gain
feeling of sickness, nausea
skin rashes
changes in blood count
irregular periods.
Very rare:
pancreatitis or inflammation of the pancreas (less than 1 in 10,000 cases): abdominal pain, nausea and vomiting;
liver failure (less than 1 in 50,000 cases): weakness, loss of appetite, lethargy, drowsiness and sometimes repeated vomiting and abdominal pain. If you have any of these symptoms, get help immediately.
Your doctor will usually take blood before you start treatment, and then for the first six months of treatment to monitor your blood count and liver function.

Carbamazepine

This is usually given to people who don’t get on with Lithium. Some doctors believe that it may be better for people who have ‘rapid-cycling’ bipolar disorder (that is 4 or more episodes of depression and mania within a 12 month period).

What are the side effects?
It usually causes fewer side-effects than Lithium. The most common ones are:
feeling tired or dizzy;
blurred vision;
nausea;
stomach ache;
diarrhoea or constipation;
about 10% of people will develop a mild rash. About 1 in 200 people may develop a serious rash that requires urgent treatment;
1 in 50 people can develop changes in the blood count, but these are rarely serious. These changes are more likely to occur at the start of treatment, so your doctor may take blood tests for a while. You should consult your doctor immediately if you get a fever, sore throat, ulcers in your mouth, easy bruising, or a rash – particularly if the rash is of small purple spots.
Antipsychotics

These may be used alone, or with Lithium or Valproate. They can help if you become too active, psychotic or aggressive when you are manic.

There are two groups of antipsychotics; the older ‘typical’ group and the newer ‘atypical’ group. The older group are more likely to cause muscle stiffness or tremor. The most commonly used antipsychotics are now ‘atypical’.

What are the side-effects?
All antipsychotics may cause sleepiness or dizziness. If you take them for a long time you may put on weight. Older drugs from the ‘typical’ group, such as haloperidol, may also cause tremor or muscle stiffness.

They can be used to prevent relapse, but are usually used with one of the mood-stabilisers described above, when treatment with one drug has not been effective.

Benzodiazepines

These drugs are usually given, just for a few days, along with the drugs mentioned above. They help treat the symptoms of irritability, over-activity and lack of sleep.

What are the side effects?
sedation – reduced excitability and feeling calm
unsteadiness.
If used for more than a couple of weeks, they can be addictive.

How effective are these medications…

…in treating mania?

Lithium, Valproate, Quetiapine, Risperidone, Olanzapine and Asenapine are all probably equally effective. Carbamazepine has been used, but there is less evidence that it works. Lithium is used less as it has more side-effects and needs more careful monitoring.

Whichever drug is used, mania is not an easy condition to treat, and you may take several weeks to recover. It is important to stick with the treatment and take it regularly.

How do I choose between the different medications?
In the acute phase, you might not be well enough to be too involved in the decisions about which drug to use.
If you have been ill before, doctors will often try to treat you with what has worked for you in the past.
When you are well, it might be worth agreeing with your doctor which medication you would prefer if you become ill again.
What else can I do to get over the acute phase?
You may not believe that you are unwell when you are high.
It important that you have family or friends who you can trust to tell you how you are.
If you don’t trust the professionals treating you, tell them why.
…in preventing mania?

Lithium is probably the most effective. You have a 30–40% chance of not being unwell again.
Valproate is a little less effective on its own, but less so than Lithium. Valproate and Lithium together are probably better than either on its own.
Carbamazepine is less effective than Valproate.
Olanzapine is effective in preventing mania if you responded well to it during a manic episode, but probably less effective than lithium longer-term.
How do I choose between treatments?
Lithium will usually be recommended for long-term treatment.
Carbamazepine may be suggested if you tend to get ill again very rapidly.
Some people may need a combination of drugs.
Much depends on how well you get on with a particular medication. What suits one person may not suit another.
Breast feeding and pregnancy

Pregnancy
Some of these drugs can affect a baby, so it is very important to discuss the risks with your doctors who will help you weigh up the risks of stopping the treatment, and the risks of carrying on with it.
If you get pregnant accidentally, don’t suddenly stop your tablets as this can make you very ill.
Breast-feeding
Most drugs taken by a mother will be present in their milk, but the concentration will vary. You should discuss this with your doctor.
What happens if I don’t take medication?

In the acute phase:
Mania can be very disruptive and serious. It can alarm your family, you may lose your job, get into debt, or even get into trouble with the police. Your mood may take weeks or months to correct itself, and a lot of damage can be done during that time. On average, an untreated manic episode will last around 6 months.

In the prevention phase:
The most accurate predictor of having a manic episode is how often you have had them in the past. The more manic episodes you’ve had, the more likely you are to have another one.

For some people, episodes can tend to be more frequent as they get older.

If you have had a manic episode, it’s worth giving some thought to treatments that might stop it from happening again.

Life events and stress can precipitate relapse. If this seems to be the case in your life, then you might want to consider a course of counselling or psychotherapy. This may help you cope with stress better, and help you find more stability in life.

Other ways of controlling “highs”

Some medical treatments used to treat other conditions can cause mania, so it is important to discuss your medicines with your doctor.
If you feel you are going high, get advice early. Adjusting your medication, resting and avoiding stress may be enough to prevent a full relapse.
Find out as much as you can about the illness and its treatments.
People often have warning signs that they are going high. Not sleeping is one of the most important. It has been shown that if you can sit down with a professional and a family member, and draw up a list of warning signs and possible triggers, this can help to prevent relapses.
If you are going through a stressful time, and have early warning signs of mania such as insomnia, you may be able to prevent a relapse by taking a short course of a sleeping tablet, or an antipsychotic such as olanzapine.
Where can I find out more?

The information leaflet that comes with the tablets will describe the side-effects in more detail. If you have concerns, discuss them with your doctor.

What is a ‘licensed’ drug? Are unlicensed drugs dangerous?

In Britain, drugs are licensed by the European Agency for the Evaluation of Medicinal Products. A license is only granted if the medicine is safe and seems to help patients.
A drug may be unlicensed because there hasn’t been enough research into its effect in treating a particular condition. This doesn’t necessarily mean it is dangerous.
Drugs are commonly used to treat conditions for which they don’t have a license. For example, it is common to use benzodiazepines in the acute phase of mania, but they are not officially licensed for this condition.

http://www.bipolar4lifesupport.co

Aims of the leaflet

This leaflet is for anyone who wants to know more about antidepressants. It discusses how they work, why they are prescribed, their effects and side-effects, and alternative treatments. We have added some references and sources of further information at the end of this leaflet.

What are antidepressants?

Antidepressants are drugs that relieve the symptoms of depression. They were first developed in the 1950s and have been used regularly since then. There are almost thirty different kinds of antidepressants available today and there are five main types:
SSRIs (Selective Serotonin Reuptake Inhibitors)
SNRIs (Serotonin and Noradrenaline Reuptake Inhibitors)
NASSAs (Noradrenaline and Specific Serotoninergic Antidepressants)
Tricyclics
MAOIs (Monoamine oxidase inhibitors)
How do they work?

We don’t know for certain, but we think that antidepressants work by increasing the activity of certain chemicals work in our brains called neurotransmitters. They pass signals from one brain cell to another. The chemicals most involved in depression are thought to be Serotonin and Noradrenaline.

What are antidepressants used for?

Moderate to severe depressive illness (Not mild depression).
Severe anxiety and panic attacks
Obsessive compulsive disorders
Chronic pain
Eating disorders
Post-traumatic stress disorder.
If you are not clear about why an antidepressant has been suggested for you, ask your doctor.

How well do they work?

After 3 months of treatment, the proportions of people with depression who will be much improved are:

50% and 65% if given an antidepressant
compared with
25 – 30% if given an inactive “dummy” pill, or placebo

It may seem surprising that people given placebo tablets improve, but this happens with all tablets that affect how we feel – the effect is similar with painkillers. Antidepressants are helpful but, like many other medicines, some of the benefit is due to the placebo effect.

Are the newer ones better than the older ones?

Yes and no. The older tablets (Tricyclics) are just as effective as the newer ones (SSRIs) but, on the whole, the newer ones have fewer side-effects. A major advantage for the newer tablets is that they are not so dangerous if someone takes an overdose.

What kind of antidepressant have I been recommended?

At the end of the leaflet you can find a list of the common antidepressants, their trade names in the UK, and their type.

Do antidepressants have side-effects?

Yes – your doctor will be able to advise you here. You should always remind him or her of any medical conditions you have or have had in the past. Listed below are the side effects you might experience with the different types of antidepressant:

SSRIs
During the first couple of weeks of taking them, you may feel sick and more anxious. Some of these tablets can produce nasty indigestion, but you can usually stop this by taking them with food. More seriously, they may interfere with your sexual function. There have been reports of episodes of aggression, although these are rare.

The list of side-effects looks worrying – there is even more information about these on the leaflets that come with the medication. However, most people get a small number of mild side-effects (if any). The side-effects usually wear off over a couple of weeks as your body gets used to the medication. It is important to have this whole list, though, so you can recognise side-effects if they happen. You can then talk them over with your doctor.

The more serious ones – problems with urinating, difficulty in remembering, falls, confusion – are uncommon in healthy, younger or middle-aged people. It is common, if you are depressed, to think of harming or killing yourself. Tell your doctor – suicidal thoughts will pass once the depression starts to lift.
SNRIs
The side-effects are very similar to the SSRIs, although Venlafaxine should not be used if you have a serious heart problem. It can also increase blood pressure, so this may need to be monitored.

NASSAs
The side-effects are very similar to SSRIs. They can make you feel drowsy, and cause weight gain, but they cause less sexual problems.

Tricyclics
These commonly cause a dry mouth, a slight tremor, fast heartbeat, constipation, sleepiness, and weight gain. Particularly in older people, they may cause confusion, slowness in starting and stopping when passing water, faintness through low blood pressure, and falls. If you have heart trouble, it may be best not to take one of this group of antidepressants. Men may experience difficulty in getting or keeping an erection, or delayed ejaculation. Tricyclic antidepressants are dangerous in overdose.

MAOIs
This type of antidepressant is rarely prescribed these days. MAOIs can give you a dangerously high blood pressure if you eat foods containing a substance called Tyramine. If you agree to take an MAOI antidepressant your doctor will give you a list of foods to avoid.

For a full list of side effects please visit emc.medicines.org.uk and type in the name of the medicine in the ‘Search for:’ section at the top of the page.

What about driving or operating machinery?

Some antidepressants make you sleepy and slow down your reactions – the older ones are more likely to do this. Some can be taken if you are driving. Remember, depression itself will interfere with your concentration and make it more likely that you will have an accident. If in doubt, check with your doctor.

Are antidepressants addictive?

Antidepressant drugs don’t cause the addictions that you get with tranquillisers, alcohol or nicotine, in the sense that:

you don’t need to keep increasing the dose to get the same effect;
you won’t find yourself craving them if you stop taking them.
However, up to a third of people who stop SSRIs and SNRIs have withdrawal symptoms which can last between 2 weeks and 2 months.

These include:
stomach upsets
flu like symptoms
anxiety
dizziness
vivid dreams or nightmares
sensations in the body that feel like electric shocks (see references)

In most people these withdrawal effects are mild, but for a small number of people they can be quite severe. They seem to be most likely to happen with Paroxetine (Seroxat) and Venlafaxine (Efexor). It is generally best to taper off the dose of an antidepressant rather than stop it suddenly. You might like to read our leaflet about ‘Coming off antidepressants’.

Some people have reported that, after taking an SSRI for several months, they have had difficulty managing once the drug has been stopped and so feel they are addicted to it. Most doctors would say that it is more likely that the original condition has returned.

SSRI antidepressants, suicidal feelings and young people

There is some evidence of increased suicidal thoughts (although not actual suicidal acts) and other side-effects in young people taking antidepressants. So, SSRI antidepressants are not licensed for use in people under 18. However, the National Institute for Health and Care Excellence (NICE) has stated that Fluoxetine, an SSRI antidepressant, can be used in the under-18s.

There is no clear evidence of an increased risk of self-harm and suicidal thoughts in adults of 18 years or over. But, people mature at different times. Young adults are more likely to commit suicide than older adults, so a young adult should be particularly closely monitored if they take an antidepressant.

What about pregnancy?

It is always best to take as little medication as possible while you are pregnant. However, if you are one of those people who may need medication to stay well, it’s best to discuss the benefits and risks with your doctor. There are a number of issues to consider. For example, you will need to think about:
how ill you have been in the past
the effect that being ill could have on you and your baby
up-to-date information about the safety of antidepressants in pregnancy
other treatments you could try such as Cognitive Behavioural Therapy.
For further information, see our leaflet on Mental health in pregnancy.

What about breastfeeding?

Many women do breastfeed while on antidepressants but, again, it’s worth discussing it with your doctor. As well as the issues listed above, you will need to think about:

the advantages of breastfeeding
how much antidepressant enters your milk
the risk of getting unwell again if you want to switch to a different medication after you’ve had your baby
whether your baby is premature or has any health problems.
What about the baby?

A baby will get only a small amount of antidepressant from mother’s milk. Babies older than a few weeks have very effective kidneys and livers. They are able to break down and get rid of medicines just as adults do, so the risk to the baby is very small.

Some antidepressants, like imipramine, nortriptyline and sertraline only get into the breast milk in very small amounts – it is worth talking this over with your doctor or pharmacist.

How should antidepressants be taken?

Keep in touch with your doctor when you start treatment. They will monitor you for side-effects and how you feel. They may advise you to change the dose. It doesn’t help to increase the dose above the recommended levels. If you are being given the drug for anxiety, your doctor may suggest that you start on a very low dose for the first few weeks.

Try not to be put off if you get some side-effects. Many of them wear off in a week or so. Don’t stop the tablets unless the side-effects really are unpleasant. If they are, get an urgent appointment to see your doctor. If you feel worse it is important to tell your doctor so that he can decide if the medicines are right for you. Your doctor will also want to know if you get increased feelings of restlessness or agitation.
Take them every day – if you don’t, they won’t work.

Wait for them to work. They don’t work straight away. Most people find that they take 1-2 weeks to start working and maybe up to 6 weeks to give their full effect.
Persevere – stopping too early is the commonest reason for people not getting better and for the depression to return.

Try not to drink alcohol. Alcohol on its own can make your depression worse, but it can also make you slow and drowsy if you are taking antidepressants. This can lead to problems with driving – or with anything you need to concentrate on.
Keep them out of the reach of children.

Tempted to take an overdose? Tell your doctor as soon as possible and give your tablets to someone else to keep for you.

Tell your doctor about any major changes in how you feel when the dose of antidepressant is changed.
How long will I have to take them for?

Antidepressants don’t necessarily treat the cause of the depression or take it away completely.

If you stop the medication before 6 to 9 months is up, the symptoms of depression are more likely to come back. The current recommendation is that it is best to take antidepressants for at least six months after you start to feel better. It is worthwhile thinking about what might have made you vulnerable, or might have helped to trigger off your depression. There may be ways of making this less likely to happen again.

If you have had two or more attacks of depression then treatment should be continued for at least two years.

What if the depression comes back?

Some people have severe depressions over and over again. Even when they have got better, they may need to take antidepressants for several years to stop their depression coming back. This is particularly important in older people, who are more likely to have several periods of depression. For some people, other drugs such as Lithium may be recommended. Psychotherapy may be helpful in addition to the tablets.

What will happen if I don’t take them?

It’s difficult to say – so much depends on why they have been prescribed, on how bad your depression is and how long you’ve had it for. Sometimes depressions get better by themselves. If your depression is mild it is best to try some of the other treatments mentioned later in this leaflet. If you can’t decide, talk it over with your doctor.

What other treatments of depression are available?

It is not enough just to take the pills. It is important to find ways of making yourself feel better, so you are less likely to become depressed again. These can include finding someone you can talk to, keeping physically active, drinking less alcohol, eating well, using self-help techniques to help you relax and finding ways to solve the problems that have brought the depression on. For some tips on self-help, see our leaflet on depression.

Talking treatments
There are a number of helpful talking treatments for depression. Counselling is useful in mild depression. Problem solving techniques can help where the depression has been caused by difficulties in life. Cognitive Behavioural Therapy helps you to look at the way you think about yourself, the world and other people. For information about these and other forms of psychotherapy, see our leaflets on Psychotherapy and Cognitive Behavioural Therapy.

Herbal remedies
There is also a herbal remedy for depression called Hypericum. This is made from a herb, St Johns Wort, and is available without prescription. Because it is a herbal treatment, it is less well researched and there may be variations in the preparations on sale. Another problem is that it can interfere with other medicines like ‘the pill’. If you are taking other medication, you should discuss it with your doctor.

Light
You may find that you get depressed every winter but cheer up when the days become longer. This is called seasonal affective disorder (SAD). If so, you may find a light box helpful – this is a source of bright light which you have on for a certain time each day and which can make up for the lack of light in the winter.

How do antidepressants compare with these other treatments?

Over a period of a year, many talking treatments are as effective as antidepressants. However, antidepressants may work faster (see references). Some studies suggest that it is best to combine antidepressants and psychotherapy. Unfortunately there can be a waiting list for talking treatments in some parts of the country.

Hypericum, or St John’s Wort, seems to be as effective as antidepressants in milder depression, although there is little evidence that it works in more severe depressions.

Physical activity and self-help books based on Cognitive Behavioural Therapy can be effective treatments for depression.

If you have any further questions about antidepressants which haven’t been covered in this leaflet, take a look at the further reading section and have a word with your doctor or psychiatrist. It’s also good to talk things over with your family or friends.

Antidepressants in common use:

Medication Trade name Group
Amitriptyline Tryptizol Tricyclic
Clomipramine Anafranil Tricyclic
Citalopram Cipramil SSRI
Dosulepin Prothiaden Tricyclic
Doxepin Sinequan Tricyclic
Duloxetine Cymbalta, Yentreve SNRI
Fluoxetine Prozac SSRI
Imipramine Tofranil Tricyclic
Lofepramine Gamanil Tricyclic
Mirtazapine Zispin NaSSA
Moclobemide Manerix MAOI
Nortriptyline Allegron Tricyclic
Paroxetine Seroxat SSRI
Phenelzine Nardil MAOI
Reboxetine Edronax SNRI
Sertraline Lustral SSRI
Tranylcypromine Parnate MAOI
Trazodone Molipaxin Tricyclic-related
Venlafaxine Efexor SNRI

SSRI = Selective Serotonin Reuptake Inhibitor
SNRI = Serotonin and Noradrenaline Reuptake Inhibitor
MAOI = Monoamine oxidase inhibitor
NaSSA=Noradrenergic and Specific Serotonergic Antidepressant

http://www.bipolar4lifesupport.co

Cognitive Behavioral Therapy:

This leaflet is for anyone who wants to know more about Cognitive Behavioural Therapy (CBT).CBT leaflet It discusses how it works, why it is used, its effects, its side-effects, and alternative treatments. If you can’t find what you want here, there are sources of further information at the end of this leaflet.

What is CBT?

It is a way of talking about:

how you think about yourself, the world and other people
how what you do affects your thoughts and feelings.
CBT can help you to change how you think (‘Cognitive’) and what you do (‘Behaviour’). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the ‘here and now’ problems and difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.

When does CBT help?

CBT has been shown to help with many different types of problems. These include: anxiety, depression, panic, phobias (including agoraphobia and social phobia), stress, bulimia, obsessive compulsive disorder, post-traumatic stress disorder, bipolar disorder and psychosis. CBT may also help if you have difficulties with anger, a low opinion of yourself or physical health problems, like pain or fatigue.

How does it work?

CBT can help you to make sense of overwhelming problems by breaking them down into smaller parts. This makes it easier to see how they are connected and how they affect you. These parts are:

A Situation – a problem, event or difficult situation. From this can follow:
Thoughts
Emotions
Physical feelings
Actions
Each of these areas can affect the others. How you think about a problem can affect how you feel physically and emotionally.

All these areas of life can connect like this: 5 Areas

What happens in one of these areas can affect all the others.

There are helpful and unhelpful ways of reacting to most situations, depending on how you think about it. The way you think can be helpful – or unhelpful.

An example:
The Situation

You’ve had a bad day, feel fed up, so go out shopping. As you walk down the road, someone you know walks by and, apparently, ignores you. This starts a cascade of:

Unhelpful
Helpful
Thoughts: He/she ignored me – they don’t like me He/she looks a bit wrapped up in themselves – I wonder if there’s something wrong?
Emotional:
Feelings Low, sad and rejected Concerned for the other person, positive
Physical: Stomach cramps, low energy, feel sick None – feel comfortable

Action: Go home and avoid them Get in touch to make sure they’re OK

The same situation has led to two very different results, depending on how you thought about the situation.

How you think has affected how you felt and what you did. In the example in the left hand column, you’ve jumped to a conclusion without very much evidence for it – and this matters, because it’s led to:

having a number of uncomfortable feelings
behaving in a way that makes you feel worse.
If you go home feeling depressed, you’ll probably brood on what has happened and feel worse. If you get in touch with the other person, there’s a good chance you’ll feel better about yourself.

If you avoid the other person, you won’t be able to correct any misunderstandings about what they think of you – and you will probably feel worse.

This ‘vicious circle’ can make you feel worse. It can even create new situations that make you feel worse. You can start to believe quite unrealistic (and unpleasant) things about yourself. This happens because, when we are distressed, we are more likely to jump to conclusions and to interpret things in extreme and unhelpful ways.

CBT can help you to break this vicious circle of altered thinking, feelings and behaviour. When you see the parts of the sequence clearly, you can change them – and so change the way you feel. CBT aims to get you to a point where you can ‘do it yourself’, and work out your own ways of tackling these problems.

What does CBT involve?

The sessions
You can do CBT individually or with a group of people, or even a self-help book or computer programme.

In England and Wales, two computer-based programmes have been approved for use by the NHS. Fear Fighter is for people with phobias or panic attacks; Beating the Blues is for people with mild to moderate depression.
If you have individual therapy:

You will usually meet with a therapist for between 5 and 20, weekly, or fortnightly sessions. Each session will last between 30 and 60 minutes.
In the first 2-4 sessions, the therapist will check that you can use this sort of treatment and you will check that you feel comfortable with it.

The therapist will also ask you questions about your past life and background. Although CBT concentrates on the here and now, at times you may need to talk about the past to understand how it is affecting you now.
You decide what you want to deal with in the short, medium and long term.
You and the therapist will usually start by agreeing on what to discuss that day.

The work
With the therapist, you break each problem down into its separate parts, as in the example above. To help this process, your therapist may ask you to keep a diary. This will help you to identify your individual patterns of thoughts, emotions, bodily feelings and actions.
Together you will look at your thoughts, feelings and behaviours to work out:
if they are unrealistic or unhelpful
how they affect each other, and you.

The therapist will then help you to work out how to change unhelpful thoughts and behaviours.
It’s easy to talk about doing something, much harder to actually do it. So, after you have identified what you can change, your therapist will recommend ‘homework’ – you practise these changes in your everyday life. Depending on the situation, you might start to:
question a self-critical or upsetting thought and replace it with a more helpful (and more realistic) one that you have developed in CBT
recognise that you are about to do something that will make you feel worse and, instead, do something more helpful.

At each meeting you discuss how you’ve got on since the last session. Your therapist can help with suggestions if any of the tasks seem too hard or don’t seem to be helping.
They will not ask you to do things you don’t want to do – you decide the pace of the treatment and what you will and won’t try. The strength of CBT is that you can continue to practise and develop your skills even after the sessions have finished. This makes it less likely that your symptoms or problems will return.
How effective is CBT?

It is one of the most effective treatments for conditions where anxiety or depression is the main problem.
It is the most effective psychological treatment for moderate and severe depression.
It is as effective as antidepressants for many types of depression.
What other treatments are there and how do they compare?

CBT is used in many conditions, so it isn’t possible to list them all in this leaflet. We will look at alternatives to the most common problems – anxiety and depression.

CBT isn’t for everyone. Another type of talking treatment may work better for you.
CBT works as well as antidepressants for many forms of depression. It may be slightly better than antidepressants in helping anxiety.
For severe depression, CBT should be used with antidepressant medication. When you are very low, you may find it hard to change the way you think until the antidepressants have started to make you feel better.
Tranquillisers should not be used as a long term treatment for anxiety. CBT is a better option.
Problems with CBT

CBT is not a quick fix. A therapist is like a personal trainer that advises and encourages – but cannot ‘do’ it for you.
If you are feeling low, it can be difficult to concentrate and get motivated.
To overcome anxiety, you need to confront it. This may lead you to feel more anxious for a short time.
A good therapist will pace your sessions. You decide what you do together, so you stay in control.
How long will it last?

A course may be from 6 weeks to 6 months. It will depend on the type of problem and how it is working for you. The availability of CBT varies between different areas and there may be a waiting list for treatment.

What if the symptoms come back?

There is always a risk that the anxiety or depression will return. If they do, your CBT skills should make it easier for you to control them. So, it is important to keep practising your CBT skills, even after you are feeling better. There is some research that suggests CBT may be better than antidepressants at preventing depression coming back. If necessary, you can have a “refresher” course.

So what impact would CBT have on my life?

Depression and anxiety are unpleasant. They can seriously affect your ability to work and enjoy life. CBT can help you to control the symptoms. It is unlikely to have a negative effect on your life, apart from the time you need to give up to do it.

How can I get CBT?

Speak to your GP. They may refer you to someone trained in CBT – for example, a psychologist, nurse, social worker or psychiatrist.
The British Association for Behavioural and Cognitive Psychotherapies keeps a register of accredited therapists.
You can try ‘self-help’ – using a book, internet programme or computerised CBT. This is more likely to work if you also receive support from a professional.
What will happen if I don’t have CBT?

It depends very much on the problem. You could:
Wait to see if you get better anyway – you can always ask for CBT later if you change your mind.
Talk over some alternatives with your doctor.
Read more about CBT and its alternatives. (see below).
If you want to “try before you buy”, get hold of a self-help book or CD-Rom and see if it makes sense to you.
CHANGE VIEW: 10 KEY FACTS ABOUT CBT

Change: your thoughts and actions

Homework: practice makes perfect

Action: don’t just talk, do!

Need: pinpoint the problem

Goals: move towards them

Evidence: shows CBT can work

View: events from another angle

I can do it: self-help approach

Experience: test out your beliefs

Write it down: to remember progress

http://www.bipolar4lifesupport.co

Abstract

Background

Individuals with a mental health disorder appear to be at increased risk of medical illness.

Aims

To examine rates of medical illnesses in patients with bipolar disorder (n = 1720) and to examine the clinical course of the bipolar illness according to lifetime medical illness burden.

Method

Participants recruited within the UK were asked about the lifetime occurrence of 20 medical illnesses, interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and diagnosed according to DSM-IV criteria.

Results

We found significantly increased rates of several medical illnesses in our bipolar sample. A high medical illness burden was associated with a history of anxiety disorder, rapid cycling mood episodes, suicide attempts and mood episodes with a typically acute onset.

Conclusions

Bipolar disorder is associated with high rates of medical illness. This comorbidity needs to be taken into account by services in order to improve outcomes for patients with bipolar disorder and also in research investigating the aetiology of affective disorder where shared biological pathways may play a role.

Estimates suggest that those with serious mental illness are now dying approximately 25 years earlier than the general population and that up to 60% of premature deaths in those with serious mental illness are as a result of general medical conditions.1 Studies have shown that not only do patients with mood disorders have more comorbid medical illnesses than mentally healthy individuals,2-4 but also a greater medical illness burden (a greater number of medical illnesses) seems to be associated with a more severe clinical presentation of the mood illness.5 Traditionally, the high prevalence of medical illness in those with mental health problems has been viewed as a consequence of psychotropic medications and an unhealthy lifestyle.6 However, recent research has suggested that exposure to psychotropic medication does not worsen mortality risk in patients with psychiatric illness7 and that there may be underlying biological mechanisms linking mood disorder and many medical illnesses.8,9

We have previously described the rates of physical disorders in large samples of patients with recurrent depression (n = 1547) and psychiatrically healthy controls (n = 884).10 The current study will examine the rates of physical disorders in a large, well-defined, sample of patients with bipolar affective disorder. These patients were recruited and assessed using the same standardised procedures as our recurrent depression and control participants mentioned above. This will allow us to directly compare the rates of each physical illness in our newly recruited bipolar sample with our previously described recurrent depression and control samples. In addition, the current study will investigate whether the presence of medical illness in individuals with bipolar disorder is associated with a more severe bipolar illness course. This is the first study in a UK clinical population to assess rates of physical illnesses in patients with a diagnosis of bipolar disorder and make direct comparisons with unipolar and control samples.

Method

Participants

Participants were recruited at three UK sites (Birmingham, Cardiff and London) as part of ongoing molecular genetic and clinical studies of affective disorders.11,12 Individuals meeting DSM-IV13 and ICD-1014 criteria for bipolar disorder (n = 1720) were included in the study. All participants were aged 18 years or older and, because they were recruited for molecular genetic studies, they were required to be of White European ethnicity. Individuals were excluded if they: (a) had a lifetime diagnosis of intravenous drug dependency; (b) had only experienced affective illness as a result of alcohol or substance dependence; (c) had only experienced affective illness secondary to medical illness or medication; or (d) were biologically related to another study participant. After complete description of the study to participants, written informed consent was obtained.

Study assessment

Participants were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN).15 Psychiatric and family practice case-notes were reviewed for the majority of participants. Based on the SCAN interview information, and where available the case-note information, lifetime diagnoses were made according to DSM-IV and ICD-10 and ratings were made for key clinical variables (for example, age at onset, presence of psychosis). Where there was doubt regarding the diagnostic and clinical ratings the case was rated independently by two research psychologists/psychiatrists and consensus was reached. Regular interrater reliability meetings were held within and across the three sites to ensure consistency in diagnostic and ratings procedures.

Interrater reliability was formally assessed using joint ratings for a subset of 20 participants with a range of mood disorder diagnoses. Mean overall kappa statistics of 0.85 and 0.83 were obtained for DSM-IV and ICD-0 diagnoses, respectively. Mean kappa statistics and intraclass correlation coefficients (ICCs) for other key clinical variables ranged from 0.81 to 0.99 and 0.85 to 0.97, respectively.

In order to establish the lifetime presence of physical health disorders, a short self-report questionnaire was completed by participants asking whether they had ever been told by a health professional that they have any of the following 20 health problems: asthma, cancer, diabetes type 1, diabetes type 2, elevated lipids/high cholesterol, epilepsy, gastric ulcers, heart disease, hypertension, kidney disease, liver disease, memory loss/dementia, migraine headaches, multiple sclerosis, osteoarthritis, osteoporosis, Parkinson’s disease, rheumatoid arthritis, stroke, thyroid disease. Responses were scored as ‘yes’, ‘no’ or ‘uncertain’. Where an individual was coded ‘uncertain’ for a particular illness, they were excluded from analyses for that medical illness. The study received all necessary Multi-Region and Local Research Ethics Committee (MREC and LREC) approval.

The unipolar and control samples used as comparison groups have previously been described in Farmer et al.10 In brief, participants meeting DSM-IV and ICD-10 criteria for recurrent major depression (unipolar depression: n = 1737) were recruited and assessed (as part of the Depression Case Control DeCC study) using the procedures and assessments described above for the bipolar sample. In addition, individuals in the unipolar group were excluded if they (a) had a first- or second-degree relative with a diagnosis of bipolar affective disorder, schizophrenia, schizotypal disorder, delusional disorder, acute and transient psychotic disorders or schizoaffective disorder, or (b) had ever experienced mood incongruent psychosis or psychosis outside of mood episodes.

The control group (n = 1340) were recruited to the London site via the Medical Research Council (MRC) general practice research framework (n = 846) or were staff or student volunteers of King’s College London (n = 494). Individuals were included if they were 18 years or older and were of White European origin. Control participants recruited via the MRC general practice research framework were screened using the Sham et al16 composite index (G) of depressive and anxiety symptoms and then telephone interviewed using the Past History Schedule (PHS)17 to screen for lifetime absence of psychiatric disorder. The volunteers from King’s College London were interviewed in person and screened using the PHS (n = 494).

The control group also completed the short self-report medical illness questionnaire described above.

Data analysis

Rates of medical illnesses across the bipolar, unipolar and control groups.

Sociodemographic characteristics were compared between the bipolar, unipolar and control groups using chi-squared tests for categorical variables and Kruskal-Wallis tests for non-parametric continuous variables. Group comparisons of the lifetime prevalence of each of the different medical conditions were performed using chi-squared tests and pair-wise binary logistic regression analyses for each medical condition, with diagnostic group as the outcome variable. As there were significant gender differences between the three groups, gender was also entered into the logistic regression models as a cofactor. Since medical disorders occur more frequently with increasing age and there were significant differences in age at interview between the groups, age at interview was also included as a cofactor.

We used the Bonferroni method to conservatively correct for multiple testing. As there were three groups with 20 medical illnesses (3×20 = 60), P-values from the logistic regression analyses were multiplied by 60.

Rates of medical illness according to bipolar subtype

We then compared the lifetime prevalence of each of the different medical conditions in the bipolar I disorder (bipolar I) group and the bipolar II disorder (bipolar II) group using chi-squared tests and logistic regression. Again, gender and age were included as cofactors in the logistic regression models and the Bonferroni method was used to correct for multiple testing. As we were comparing 20 medical illnesses, P-values from the logistic regression analyses were multiplied by 20.

Clinical characteristics of bipolar disorder according to medical illness burden

For a subsample of the bipolar group (n = 1216), detailed clinical information regarding the course and clinical features of the bipolar illness was available. As previous studies have shown that a higher burden of medical illness is associated with a more severe illness course in bipolar disorder, we compared sociodemographic and clinical features in those bipolar participants with a high medical illness burden (history of three or more medical illnesses (bipolar+3M)) to those with no history of medical illness (bipolar+0M) using chi-squared tests for categorical variables and Mann-Whitney U-tests for non-parametric continuous variables. A cut-off of three or more medical illnesses was selected as previous studies have shown that patients with multiple conditions (defined as three or more medical conditions) are significantly more likely to have a mental illness18 and that, when focusing on the number of either medical or psychiatric illnesses, the lifetime presence of three or more conditions is associated with increased disability, lower life expectancy and increased health spending.19

A binary logistic regression analysis was carried out with group status (bipolar+3M/bipolar+0M) as the outcome variable. Gender, age at interview and the clinical features that were significantly different between the two groups (Pcontrol: Pcontrol: P<0.0001), with women comprising 70%, 71% and 57% of the bipolar, unipolar and control groups respectively.

Rates of medical illnesses across the bipolar, unipolar and control groups

The lifetime rates of self-reported medical illnesses in the bipolar, unipolar and control groups are shown in Table 1. Significant differences between groups were found in the lifetime prevalence of all medical illnesses with the exception of type 1 diabetes.

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Table 1
Lifetime rates (%) of self-reported medical illnesses in bipolar, unipolar and control groups

To examine differences in the rate of each medical illness between the three groups, accounting for gender and age at interview, binary logistic regression was carried out for all medical illnesses showing a significant (P<0.05) between-group difference in the univariate analyses. Diagnostic group was entered as the outcome variable and presence/absence of the medical disorder, gender and age at interview were entered as cofactors. Odds ratios, 95% confidence intervals and P-values for each logistic regression analysis are shown in Table 2. Following correction for multiple testing, using the Bonferroni method, statistically significant differences in the rates of ten medical illnesses remained between the three groups (Fig. 1).

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Table 2
Binary logistic regression with diagnostic group (bipolar/unipolar, bipolar/control, unipolar/control) as the outcome variable and presence/absence of the medical disorder, gender and age at interview as cofactors (prior to Bonferroni correction)a

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Fig. 1
Rates of medical illnesses showing statistically significant differences between groups following Bonferroni correction for multiple testing.

Statistically significant between group differences (Punipolar disorder, control group: asthma, elevated lipids; bipolar disorder >control group: diabetes type 2, epilepsy, kidney disease; unipolar, bipolar disorder>control group: gastric ulcers, hypertension, osteoarthritis; unipolar>bipolar disorder, control group: multiple sclerosis; bipolar>unipolar>control group: thyroid disease.

Rates of medical illness according to bipolar subtype

Table 3 shows the lifetime rates of self-reported medical illness according to bipolar subtype and the results of the binary logistic regression analyses with diagnostic group (bipolar I v. bipolar II) as the outcome variable and presence/absence of each medical disorder, gender and age at interview as cofactors. The rates of gastric ulcers, heart disease, Parkinson’s disease and rheumatoid arthritis were significantly higher in the bipolar II group. There was a significantly higher rate of kidney disease in the bipolar I group. These differences were not statistically significant following correction for multiple testing using the Bonferroni method.

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Table 3
Lifetime rates (%) of self-reported medical illness according to bipolar subtype and binary logistic regression with diagnostic group (bipolar I v. bipolar II) as the outcome variable and presence/absence of the medical disorder, gender and age at interview as cofactors (prior to Bonferroni correction)

Clinical characteristics of bipolar disorder according to medical illness burden

In order to investigate whether a greater burden of medical illness is associated with a more severe bipolar illness course, we compared those participants who had a history of three or more medical illnesses (bipolar+3M: n = 202) with those with no medical illnesses (bipolar+0M: n = 440) (Table 4, see online Table DS1 for a more detailed version of this table). A number of variables appeared to be associated with an increase in medical illness burden. These included: a longer illness duration, a typically acute onset of mood episodes, a greater number of psychiatric in-patient admissions, deterioration in functioning, increased rates of anxiety disorder, suicide attempt, rapid cycling, and treatment with anxiolytics, mood stabilisers and electroconvulsive therapy (ECT). When controlling for age at interview, the association with each of the following three variables was no longer statistically significant: number of admissions, lifetime treatment with mood stabiliser or ECT.

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Table 4
Clinical features and course of bipolar illness in participants with bipolar disorder with a high burden of comorbid medical illness (three or more medical illnesses, bipolar+3M) compared with those participants with bipolar disorder with no history of medical illness (bipolar+0M) (see online Table DS1 for a more detailed version of this table)

To identify the clinical characteristics of bipolar illness that best predict medical illness burden group, we entered the variables that were statistically significant at the P<0.05 level in the univariate analyses, shown in Table 4, into a logistic regression model. Age at interview and gender were also entered into the model. The clinical characteristics that best predicted high medical illness burden group were having a lifetime history of anxiety disorder (OR = 2.76, 95% CI 1.49-5.13, P = 0.001), rapid cycling mood episodes (OR = 2.25, 95% CI 1.20-4.25, P = 0.012), suicide attempt (OR = 2.39, 95% CI 1.30-4.39, P = 0.005) and mood episodes with a typically acute onset (within a week) (OR = 2.56, 95% CI 1.17-5.62, P = 0.019).

Discussion

Rates of medical illnesses across the bipolar, unipolar and control groups

The most prevalent medical conditions in the bipolar sample were migraine headache (23.7%), asthma (19.2%), elevated lipids (19.2%), hypertension (15%), thyroid disease (12.9%) and osteoarthritis (10.8%). The same six conditions were also the most prevalent conditions in the unipolar sample: migraine headache (21.9%), asthma (13.1%), elevated lipids (9.7%), hypertension (16.8%), thyroid disease (8.2%) and osteoarthritis (10.9%).

The high rates of migraine headache in these samples are consistent with previous findings.3,20 The high comorbidity between affective disorder and migraine may be because of a causal relationship, with one disorder causing (or increasing risk for) the other, or may be because of shared aetiological factors. As studies show that the combination of these two disorders cause more impairment than either disorder alone21 it is important to make sure that the patients are screened and treated appropriately to ensure the optimal outcome for the patient.

Almost a fifth of our bipolar sample (19.2%) self-reported a lifetime history of asthma. This figure is comparable to the rate of 15.9% reported by McIntyre et al20 in their bipolar sample. A recent study has suggested that childhood asthma increases the risk of bipolar disorder developing in adulthood.22 Again this leads to a number of hypotheses regarding the relationship between affective disorders and asthma in terms of aetiology and causation, with the possibility, for example, that carbon dioxide hypersensitivity and corticosteroid therapy may partly explain this association.

The increased rates of hypertension in our affective disorders samples are again consistent with previous research, although rates across studies vary according to the age ranges of participants.3,23,24 D’Mello25 found that hypertension seemed to be related to the severity of illness in bipolar disorder with increased levels of hypertension found in those patients with higher levels of mania.

The literature concerning the relationship between mood disorders and cholesterol levels is inconsistent, with studies suggesting that lower levels are associated with current suicide risk and depressive and manic symptoms26 but that people with bipolar disorder are at higher risk of metabolic abnormalities including obesity and hyperlipidemia,27 consistent with the increased rates of hyperlipidaemia found in our bipolar sample. Our finding of increased rates of thyroid disorder in those with mood disorders is not surprising, given the well-established link between thyroid dysfunction and mood disorders.28,29 Thyroid problems are a common side-effect of the drug lithium, which is a common treatment for bipolar disorder and is also used to treat severe or treatment-resistant unipolar depression. In our bipolar sample, rates of thyroid disorder were significantly increased in those who had taken mood stabilising medication during their lifetime.

A recent study highlighted that the amount of pain people with osteoarthritis feel appears to be directly related to their mental health,30 however, our study, which found significantly higher rates of osteoarthritis in patients with mood disorders compared with controls, is the first to examine the rates of osteoarthritis in people with unipolar and bipolar disorders. Studies have shown increased rates of depression in patients with arthritis (of any type) with the temporal relationship indicating that arthritis predicts new onset of psychiatric disorder.31 The results of previous studies have been conflicting in terms of investigating the relationship between osteoporosis and mood disorder.32 This is the largest study to date to examine rates of osteoporosis in bipolar disorder and we found no distinction between the bipolar, unipolar and control samples in terms of the rate of osteoporosis.

We found higher rates of kidney disease in the bipolar sample compared with controls, with rates being highest in patients with bipolar I compared with bipolar II disorder. Again, this finding is consistent with previous research29 and is not surprising, given the adverse renal effects that have been associated with lithium therapy,33 which vary from the more common reversible polyuria to irreversible kidney damage. Similarly, the increased rate of Parkinson’s disease reported in our bipolar sample compared with the unipolar sample and controls may be related to the greater use of antipsychotic medications and selective serotonin reuptake inhibitors in the bipolar sample, in that patients may be reporting symptoms occurring as a side-effect of their medication, rather than Parkinson’s disease.

Our finding of increased rates of epilepsy in the bipolar group compared with controls is consistent with previous research29 including a study indicating that the rate of bipolar spectrum disorders in individuals with epilepsy is higher than that seen in the general population.34 In our study, multiple sclerosis was significantly more common in those with unipolar disorder compared with those with bipolar disorder and controls, with the rates being 7%, 0.5%, 0%, respectively; a finding not previously described. However, this finding is consistent with previous reports that have found the prevalence of major depression to be elevated in people with multiple sclerosis compared with those without multiple sclerosis and those reporting other chronic conditions.35,36 Recent studies have suggested that biological processes may account for the overlap between depression and multiple sclerosis, rather than depression simply being a psychological reaction to the burden of being ill.37

Rates of medical illness according to bipolar subtype

To our knowledge, this is the first study to look at rates of medical comorbidities across large samples of patients with bipolar I and II disorders. In patients with bipolar disorder, the type of bipolar disorder (I or II) may be associated with an increased risk of certain medical illnesses. Participants with bipolar II disorder may be more likely to have gastric ulcers, heart disease, Parkinson’s disease and rheumatoid arthritis than patients with a diagnosis of bipolar I disorder. Participants with bipolar I disorder were significantly more likely to have had kidney disease than those with bipolar II disorder. It is important to note, however, that the statistically significant differences between the bipolar I and II groups did not remain following correction for multiple testing.

Clinical characteristics of bipolar disorder according to medical illness burden

We have also demonstrated that in those with bipolar disorder, a higher burden of medical illness is associated with certain clinical features indicative of a more severe illness course, with greater impairment in functioning. These results are in agreement with previously reported findings38,39 that increased medical burden is linked with more suicide attempts, older age and longer illness duration.

Previous reports have attributed poor physical health in people with mental ill to increased rates of smoking and alcohol misuse (and other lifestyle factors).40,41 In our bipolar sample, we found no statistically significant differences between the bipolar group with no history of medical illness and those with a high burden of medical illness in terms of rates of alcohol misuse or smoking. Although this finding requires further investigation it suggests that, at least in our bipolar sample, smoking and alcohol misuse may not be the most significant factors influencing susceptibility to medical illness burden. This finding is in line with the findings of Chwastiak et al,42 who reported no association between an increased number of medical conditions and alcohol or drug misuse in patients with schizophrenia. We found higher lifetime rates of treatment with anxiolytics, mood stabilisers and ECT in those with a higher medical illness burden, although after controlling for age at interview, this finding remained only for lifetime treatment with anxiolytics, which is consistent with the higher rates of anxiety disorders found in those with a higher medical illness burden.

The mechanisms underlying the relationship between mental and physical health disorders are complex, although evidence suggests that the causal relationships are likely to be bidirectional.4,9 The existence of a medical condition may be a stress that increases the risk of developing a mood episode/disorder. Similarly, the existence of an affective disorder may increase the risk of developing a medical condition.

Research findings to date suggest that affective disorders may share some aetiological factors in common with certain medical disorders. A pathway analysis of Wellcome Trust Case Control Consortium genome-wide association study data suggested that bipolar disorder and metabolic disorders, such as coronary artery disease and diabetes type 2, have strong genetic links and may share some common pathophysiological pathways.43 Such findings suggest that subphenotypes defined by the presence of certain comorbid medical conditions are likely to be useful in studies investigating the genetic aetiology of mood disorders. The findings of Rztetsky et al8 suggest that many complex phenotypes (non-Mendelian disorders including both physical and psychiatric disorders) are probably rooted in genetic variation that is significantly shared by multiple disease phenotypes.

Strengths and limitations

The strengths of our study include the use of large, well-defined samples of patients, recruited from throughout the UK and assessed using standardised methodology. It is important to consider our findings in light of certain limitations. First, our rates of medical illness rely on a self-report measure. The accuracy of this self-report measure was assessed by Farmer et al,10 where 61 patient self-reports were compared with reports from the patient’s general practitioner (GP) about the medical illnesses the patient had been treated for. Kappa statistics for self-report compared with GP report for six of the more common disorders were calculated with results as follows: asthma κ = 0.73, diabetes κ = 0.91, hypertension κ = 0.87, hypercholesterolaemia κ = 0.65, heart attack/angina κ = 0.82 and arthritis κ = 0.74. Percentage agreement between GPs and participants for the presence or absence of a medical disorder was 93%. In addition, ten of the medical illnesses included in the current study were also included in a study by Carney & Jones3 which examined in-patient and out-patient administrative claims in the USA. The rates of medical disorders seen in their bipolar and control samples were reassuringly similar to those seen in the current study.

A second limitation is that we do not have a consistent measure of body mass index (BMI, or of waist/hip ratio) across all of our samples. When comparing BMI between participants with unipolar depression and controls, Farmer et al10 found that although the two groups were similarly represented in the overweight range, the unipolar depression group were significantly overrepresented in the obese range. In the Famer et al10 study, obesity was associated with an increase in self-reported rates of hypercholesterolaemia, type 2 diabetes and myocardial infarction. These findings suggest that some of the results from the current study may be altered if we were to control for BMI. Here, BMI could be seen as a confounding factor or an intermediate phenotype with potentially shared heritable pathogenesis. Third, our sample was restricted to a single ethnic group, limiting the generalisability of our findings. Fourth, it is possible that the voluntary nature of the control sample may have resulted in an unrepresentatively healthy sample with an artificially low prevalence of medical illnesses. Finally, we did not have data on some additional lifestyle factors such as diet or activity that may be related to medical illness burden.

Implications

These findings suggest that patients with affective disorders have an increased risk of certain medical conditions. Knowledge of the most prevalent medical conditions in patients with affective disorders and developments in the prevention, detection and treatment of such illnesses in this group are essential in improving care and prognosis. It is important to raise awareness among healthcare professionals about the risks to which patients with affective disorders are exposed. Knowing which medical illnesses are likely to coexist with a mood disorder may help to improve diagnostics and management and therefore clinical and social care for patients. Early diagnostics and treatment of medical conditions are necessary to prevent mortality and unfavourable outcomes in terms of both physical and mental health.

Although the relationship between affective disorders and physical conditions is not fully understood, it is likely that some of the risk factors for comorbid psychiatric and medical illness are modifiable. Further research on this subject may help to improve quality of life, prognosis and life expectancy for those with these illnesses. Compared with individuals with no history of mental illness, individuals with bipolar disorder are at increased risk of premature death, from both natural and unnatural causes.44 A growing evidence base suggests that more integrated ways of working, with collaboration between mental health and other professionals, offers the best chance of improving outcomes for individuals with both mental health and physical conditions.45

Acknowledgments

The authors thank all of the participants who gave their time to participate in the study.

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