Bipolar4LifeSupport

http://www.bipolar4lifesupport.co

Phelps is a one of the most informative psychologist on line and he offers us his information now for free, I will be posting a lot of information for us here and through the Bulk Mail System from Bipolar4lifesupport TEAM…….

Where can I buy the yellow eyeglasses?

All you need to try this idea is a pair of glasses with yellow
lenses that will block blue wavelengths. Careful, however: you need 100%
blockade of the blue wavelength, while allowing all of the other wavelengths to
be transmitted. Typical “blue blockers”, widely available on the Internet for
about $10, only block a fraction of blue light. So far, I know of two sources
of lenses that block >90% of blue light. You can go to the original source,
http://www.lowbluelights.com. Their amber
lenses are about $50. But…

Here is another approach. A local sleep specialist found a way to
get the same lenses for $7, instead of $50. A company called UVEX, which makes
ski goggles, also makes safety lenses for all sorts of purposes. They have just
the right lens tint in a pair of safety glasses for welders, sold in places like
Airgas.

If you do not wear corrective lenses, you can use the SKYPER in
the SCT Orange lens, model # 3S1933X. If you wear corrective lenses
(eyeglasses), here’s a pair of amber lenses that seem to fit over my glasses
quite well: the Ultraspec 2000 in the SCT Orange lens, model # S0360X.

[Update 4/2010: don’t buy the cheaper Airgas-sold Radnor
sport glasses with amber lenses. They look cool and they only cost $2.19, but
the tint is not deep enough, so they won’t block enough blue for our purposes
here.]

If you live in Corvallis: Both models are usually in stock
at Airgas, 405 NE Circle, across from McGrath’s, behind Main Auto Repair (a
little tricky, look closely, they are there). Ask very specifically for the
model that you need. Each are about $7.

If you do not live in Corvallis: Amazon has them (they have
everything?): the Skyper
and the Ultraspec
2000 that fits over your glasses if needed.

Update 10/2011: Not the Readers Digest version!
A
reader (thanks!) notes that this approach has reached the Readers Digest.
Amazing. Except their author didn’t really grasp the key idea: blocking
specific wavelengths is crucial, and you need to know the glasses will do that.
We’re lucky that UVEX just happened to make the right tint to fully block blue,
for $7.

I like $2.50 , the price at the link Readers Digest suggested, but there is
only one pair on the suggested webpage that looks anywhere near as amber as the
UVEX, and the thing is, we don’t know if that’s amber enough without seeing the
wavelength blockade it produces. Why save just $5 and not know?

Besides, although their glasses look much cooler, I grant you — that’s
actually a problem, not a benefit. Their model is going to allow a lot of light
to leak around the lens, and that defeats the purpose, right? Okay, now you can
have a look yourself. /www.safetyglassesusa.com/checamlen.html

F.lux, a computer program to shift light
Update
9/2011: If light matters so much, and blue light matters most regarding mood
and sleep — how about just taking out the blue at night automatically? Someone
built a program for this. I’ve been waiting for some users to comment, and so
far it’s been positive. Not “you gotta have this” but “I can tell the
difference”. A reader just wrote “it has helped me to fall asleep earlier.”
Okay, time to let you readers know, then. Here’s the link to the f.lux program. I’m
using it as I write this: only if I look for the difference in screen color can
I detect it, at 9:50 pm. In other words, it’s subtle but theoretically it’s
absolutely the right idea. And free.

Light Therapies: dawn simulators, light boxes

Finally, what about light? A regular rhythm of light in the
morning would be good, by this analysis. How are you going to arrange that? Here
we’ve left the realm of good solid research. So you don’t have to go buy one of
these, just think about it: what about a “dawn simulator” for use when the sun
is coming up long after your alarm? This is not a light box. It costs about
$100. It’s just a light next to your bed that gradually comes on over about 45
minutes, while you’re asleep. Your regular bedside lamps can be part of
it. The light will go through your eyelid and your brain will see it, even
though your eyes are still closed (remember that special light receptor that
connects straight to your biological clock; it works with eyelids closed!) You
probably won’t need it in the summer; but depending on how far North you live,
you might need it in the winter to have a more summer-like light exposure in the
morning. (Link to options at the bottom of this page)

Then there’s a true “light box”. These used to be big,
suitcase-sized boxes, very bright, hard to tote around, and hard to situate near
your breakfast table or bed (we’re talking morning light, right?). But now
there’s a tiny one, about the size of your hand, the “little blue one”. If
you’re not almost asleep already, and you’re interested in light as therapy,
learn why blue light is so important.
Consider a light box if you have repeated winter sag in mood and energy. Here’s
the
full story on light therapy.

Conclusion

May I emphasize DARKNESS as the potential unsung friend of people
with bipolar disorder. Of all the things you could do for yourself to minimize
the number of medications you take, and get the best possible outcome, this
could be the easiest and it is almost certainly the safest (you can’t even twist
your ankle with this approach!). Regularly timed, light-free darkness is your
friend.

If you’re going to use light therapy, learn about the why blue light may be the key. Then learn about light therapy in general.

Now gloat, because you know a lot about light and dark that many
people with bipolar disorder don’t!

http://www.bipolar4lifesupport.co

Rapid Cycling and Mixed States as
“Waves”
(April 2006)

The three color pictures on this page are from Drs. Dean Mackinnon and Ron
Pies, used with their permission from their article on “affective
instability”.Mackinnon
This term means, roughly, unstable mood and energy. People with such
instability have big changes in their mood, or energy, or creativity over time.
They may have easy tearfulness, such as crying over a commercial on TV. They
may have extreme episodes of anger, often over a minor event. They can
sometimes have inappropriate “mirth” — laughing too loud or too long, or being
too giddy or goofy — although, isn’t it interesting, that’s not a problem I
hear about much! Drs. Mackinnon and Pies offered a new explanation for this
instability, which I have tried to “translate” in three steps below. Their
model is quite different from the current diagnostic system for bipolar
disorder.

You see, according to the current official rules of diagnosis (the DSM),
“mixed states” include only phases of full manic and full depressive symptoms..
(If the idea that these can occur together is news to you, better jump
back to the main page on diagnosis and return
here after that; for best navigation of the entire bipolar portion of this
website, use this introduction). Similarly,
those same rules only allow cycles as short as 4 days. Any shorter doesn’t fit
on the DSM map.

But patients do have other combinations of depression and hypomania,
or mania — not just the two worst phases together. And they do have
cycles shorter than 4 days. The DSM can’t really handle these variations, but
the model shown here handles them very well. When I show these pictures to my
patients, I often see the “light bulb” go on in their head.

Although these pictures are just a model, they explain how symptoms shift
over time in a way that seems a lot closer to what some people live through than
the typical stories about bipolar disorder — you know, the ones that talk about
“manic episodes” as though they were completely separate phases followed
by relatively normal functioning. For a lot of people, there are no phases of
normal functioning (or very brief ones); instead, many people have only
symptoms, varying from one kind to another. See if this model makes sense of
your experience. Although I’ve changed Dr. Pies’ and Mackinnon’s presentation a
bit, this model is still theirs (doctors and NP’s and therapists should really
try to get hold of the article
itself).

Step One: Symptoms vary separately from one another, and at different
rates.

Here the green curve represents mood, the red curve represents energy, and
the black curve represents “intellect” (speed of thought, creativity, ability to
connect ideas).
As you can see, if they all go up together — and far enough “up” — this
would be what is commonly called a manic or hypomanic episode, as shown at point
A on the graph. If they all come down together, far enough, that would be an
episode of “major depression”, as shown at point B. But now we can see how
“agitated depression” could be part of a bipolar problem, when the energy curve
is up while the others are down, as at point D.
Point C represents an unusual combination usually recognized only on
inpatient psychiatry units, when a person is agitated yet hardly moves,
so-called “manic stupor”. But imagine what a milder version of this would look
like: the person would know she needed to get moving, indeed she would be
thinking of many things she needed to be doing, and she might really want (in a
very powerful way) to be doing them, and yet her body would refuse to go along.
She would be lying there on the couch, miserable yet not really depressed,
wondering what was wrong with her and why she couldn’t get herself going.

Point B represents another very important combination we psychiatrists see
commonly: the energy wave is up, but the mood wave is down (in this case, the
timing is such that the intellect wave is up too, but not as high as the energy
— yet there are many combinations, as you’ll see in a moment). This
could be called “dysphoric mania”: energized, as in a usual manic phase, but
mood is very negative.

The curves are shown here as neat, smooth waves, but reality seems to be even
more unpredictable: the waves have long humps sometimes, and short humps at
others; and long troughs, or short troughs, as well. Imagine what someone would
look like who had very long troughs of mood, and only little humps of energy
that came along rarely; and imagine if that person also had a rough childhood,
and was “temperamentally” (their style, from birth) tilted toward depression.
He might be depressed most of the time, as his “baseline”; with phases of
depression, some long, some shorter, and only rare phases of feeling like “the
rest of the human population”. His curve of mood might look like this:

That’s a Phelps’ graph, from my book, representing the experience
of a lot of patients I see — not a Mackinnon/Pies graph). Then complicate that
pattern with similarly irregular curves, varying independently, of energy and
intellect. What a mess! No wonder psychiatrists have clung to a simplifying
model like the DSM. There are nearly an infinite variety of possible
mood/energy/intellect combinations and patterns over time. However, they all
have the same three ingredients, and one common theme: cycling —
variation within a typical range over time.

Step Two: The waves can come at nearly any speed.
This might seem fairly logical and it certainly matches my experience with
patients, but it doesn’t match the official rules of diagnosis: bipolar disorder
is supposed to have phases lasting at least 4 days. Shorter than that, and it
doesn’t fit the official model. But the shorter versions are seen so often they
have their own names, as shown below.

Now one would have to admit that when the “cycles” get so short there are
multiple moods in a day, the condition gets hard to distinguish from “normal
emotions” — normal reactions to events that last a few minutes or even close to
an hour or so. Yet this ultra-ultra-rapid cycling (“ultradian”) is quite
commonly seen in kids who have bipolar disorder, where it can be so extreme as
to be clearly recognizable as “not a normal emotional reaction.”).

Now, we combine the first two steps to reach the most important implications
of the third step below.

Step Three: How waves lead to continuous — and continuously varying —
symptoms.

Many people with Bipolar II do not have the “well intervals”, in between
periods of having symptoms, that are often spoken of in websites and books about
Bipolar I. This leaves them somewhat puzzled. Do they really have “bipolar
disorder?” Why, they never really have “episodes”, let alone “manic” episodes.

Yet as the following graph shows, a rapid cycling of the individual symptoms,
at different rates, can create a varying pattern of nearly continuous
symptoms. Instead of having identifiable “episodes”, this person has almost
constantly shifting symptom phases that blend into one another.

http://www.bipolar4lifesupport.co

Unofficial but evidence-based markers of Bipolar Disorder

You have probably figured it out by now: making a diagnosis of bipolar disorder can be pretty tricky sometimes! You’re about to read a list of eleven more factors that have been associated with bipolar disorder. None of these factors “clinches” the diagnosis. They are suggestive of bipolarity, but not sufficient to establish it. They are best regarded as markers which suggest considering bipolar disorder as a possible explanation for symptoms. They are not a scoring system, where you might think “the more I have of these, the more likely it is that I have bipolar disorder.” That way of thinking about these factors has not been tested.

Here’s the list of items which are found with bipolar disorder more often than you would expect by chance alone. This list is adapted from a landmark article by Drs. Ghaemi and Goodwin and Ko. (Drs. Goodwin and Ghaemi are among the most respected authorities on bipolar diagnosis in the world. This important article is online).
1.The patient has had repeated episodes of major depression (four or more; seasonal shifts in mood are also common).
2.The first episode of major depression occurred before age 25 (some experts say before age 20, a few before age 18; most likely, the younger you were at the first episode, the more it is that bipolar disorder, not “unipolar”, was the basis for that episode).
3.A first-degree relative (mother/father, brother/sister, daughter/son) has a diagnosis of bipolar disorder.
4.When not depressed, mood and energy are a bit higher than average, all the time (“hyperthymic personality”).
5.When depressed, symptoms are “atypical”: extremely low energy and activity; excessive sleep (e.g. more than 10 hours a day); mood is highly reactive to the actions and reactions of others; and (the weakest such sign) appetite is more likely to be increased than decreased. Some experts think that carbohydrate craving and night eating are variants of this appetite effect.
6.Episodes of major depression are brief, e.g. less than 3 months.
7.The patient has had psychosis (loss of contact with reality) during an episode of depression.
8.The patient has had severe depression after giving birth to a child (“postpartum depression”).
9.The patient has had hypomania or mania while taking an antidepressant (remember, severe irritability, difficulty sleeping, and agitation may — but do not always — qualify for “hypomania”).
10.The patient has had loss of response to an antidepressant (sometimes called “Prozac Poop-out”): it worked well for a while then the depression symptoms came back, usually within a few months.
11.Three or more antidepressants have been tried, and none worked.

There is a very radical idea buried in these 11 items, which we should look at before going on, but you should be aware that this idea is likely be dismissed with a “hmmmph” by many practicing psychiatrists. The idea is this: Dr. Ghaemi and colleagues propose that there might be a version of “bipolar disorder” that does not have any mania at all, not even hypomania. They call it “bipolar spectrum disorder”.

This is strange, you are saying to yourself. “I thought bipolar disorder was distinguished from ‘unipolar’ depression by the presence of some degree of hypomania. Don’t you have to have some hypomania in order to be bipolar? How could it be ‘bi’ – polar if there is no other pole!?”

But Dr. Ghaemi and colleagues assert that there are versions of depression that end up acting more like bipolar disorder, even though there is no hypomania at all that we can detect (or, as in item #9, only when an antidepressant has been used). These conditions often do not respond well, in the long run, to antidepressant medications (which “poop out” or actually start making things worse). They respond better to the medications we routinely rely on in bipolar disorder, the “mood stabilizers” you’ll be introduced to in the Treatment section of this website (including several non-medication approaches). And these patients have other folks in their family with bipolar disorder or something that looks rather more like that (e.g. dramatic “mood swings”, even if the person never really gets ill enough to need treatment).

In Dr. Ghaemi’s description, then, there are people whose depression looks so “unipolar” that even a “fine-toothed comb” approach to looking for hypomania will not identify it as part of the “bipolar spectrum”. According to Ghaemi and colleagues, these people should be regarded as “bipolar”, in a sense, because of the way they will end up responding to treatment. In other words, there is something in these people which doesn’t look like our old idea of bipolar disorder, or even our newer idea of bipolar disorder (bipolar II, etc.), but will still better describe their future (their prognosis) and the medications that are most likely to help them. Remember that this is the very purpose of “diagnosis”, to describe the likely outcomes with and without treatment, and to identify effective treatments. So, on that basis, it seems reasonable to include these patients on the “bipolar spectrum”, like this:

The idea that someone can “have” bipolar disorder and yet not have any hypomania at all is not widely understood. You probably would get blank looks from most psychiatrists if you mention it, and frank disbelief from nearly all primary care doctors, who don’t have time to read the literature on the diagnosis of bipolar disorder. So, if you mention this idea to anyone, be prepared for some serious resistance. As of 2005 the Harvard-associated Mood Disorder program started using this approach to diagnosis. They call it the Bipolarity Index.

Other researchers are also beginning to use the same framework of thought. For example, one research group just reported that patients with migraine headaches are much more likely to have these bipolar spectrum traits.Oedgaard (Migraines are much more common in patients with unipolar and Bipolar II than in Bipolar I, interestingly.Fasmer) One recent summary article for primary care doctors, about bipolar disorder, discusses these “soft signs” in considerable detail.Swann The concept of a bipolar “spectrum” is supported by work from a research group calling themselves the Spectrum Project.e.g. Cassano

Probably better not to raise this issue unless you have to, but if you must, cite the source. Here’s that article link again.Ghaemi Dr. Ghaemi is the chairman of the committee on diagnosis for the International Society for Bipolar Disorder. One of his two co-authors is Dr. Frederick Goodwin, who wrote the “bible” of bipolar disorder for our lifetime (Manic-Depressive Illness, with Dr. Kay Jamison). These are highly respected researchers amongst mood experts. Dr. Ghaemi emphasizes the need to rely on evidence in all his papers on diagnosis and treatment and is very frequently cited by other authors on this topic (you’ll see quite a few references to him on this website, e.g. see Antidepressant Controversies). But he is certainly not the only such voice. If you haven’t seen enough references yet, here’s another similar recent one, by other international mood experts.Mitchell

Anxious depression could be “bipolar”?!

Warning: leaving DSM-IV territory

The remainder of this “diagnosis” discussion cannot be found in the DSM. I will repeatedly reference mood disorder experts, but many of these views are controversial. You must evaluate for yourself the validity of what follows.

Unfortunately, “hypomania” is quite a mis-naming. There are many patients whose “hypomanic” phases are an extreme and very negative experience. As noted above by Dr. Jamison, mania can be negative as often as it is positive. The “racing thoughts” can have a very negative focus, especially self-criticism. The high energy can be experienced as a severe agitation, to the point where people feel they must pace the floor for hours at a time. Sleep problems can show up as insomnia: an inability to sleep, rather than decreased need. (If you or a friend or doctor is skeptical about anxiety as a “bipolar” symptom, try that link for more details and references.)

In my experience most of these people come to treatment with a combination of agitation, anxiety and self-criticism — and they can’t sleep well. Is this “anxiety?” Is this some mood variation? How could you tell the difference? Is there a difference? What is really going on chemically? Unfortunately, this is still almost completely unknown. See the appendix “What’s the latest on why?”, which I will try to keep updated frequently, for the latest research about the cause of this illness.

Again, my opinion: you can’t easily distinguish “anxious depression” from bipolar II in a mixed state. I doubt that there is a distinction to be made, ultimately (when we know, hopefully someday relatively soon, what the chemical basis for anxiety with depression really is). For example there is nearly complete overlap between Generalized Anxiety Disorder and Bipolar II.

For now, the only way to tell is by how treatment turns out. Depression that is not bipolar can get better and stay better: with time, or counseling, or formal psychotherapy, or antidepressants. If you get better — great! If you don’t, you may need this new understanding of mood disorders in order to consider mood stabilizers medications, discussed in detail below, as an option.

Meanwhile, at least one experienced mood researcher warns that anxiety in someone who is depressed is associated with a high suicide risk.Fawcett(B) So although there is diagnostic confusion, there are tremendous stakes involved. Approaching this situation with an open mind seems wise, given this risk.

What does Hypomania actually feel like?
(revised 3/2010)

It’s true that hypomania is a milder version of mania — just how mild, you’ll see in a moment. Mind you, Bipolar II is not a milder version of Bipolar I, though it is very often described that way, to my utter dismay. The suicide rate in Bipolar II is the same or higher than the rate for Bipolar I, for example.Dunner So the BP II version is definitely not a “mild” illness. The depression phases are as bad as in BP I, and often more common (that is, they occur more frequently and represent a more dominant part of the person’s life).

Nevertheless, hypomania can indeed by subtle, certainly by comparison with full mania, as shown in this graph (from Smith and Ghaemi). Here are the symptoms which people with clear-cut hypomania actually experience — and how often. For example, at the bottom of the graph you see that nearly 100% of people with hypomania will have an increase in their activity. By comparison, optimism is prominent only about 70% of the time in hypomania.

As you can see, these “symptoms” are not clearly abnormal. Everyone experiences these feelings from time to time. When they are extreme; and when they show up over and over again in cycles of mood/energy change; when they are accompanied by other signs of bipolarity, such as phases of depression; that’s when we should think of this as “abnormal”, or at least as warranting caution if someone wants to treat those depressed phases with an antidepressant.

However, hypomania is not always positive. Just as manic phases can be very negative (so-called “dysphoric mania”), hypomania also can be very unpleasant. Here is an example of how hypomania can change from a positive experience to a very negative one (from a blogger who writes eloquently about bipolarity).

First, the positive phase:

Increased energy. A extraordinary feeling of happiness with myself and the world. A very loving feeling towards the people I care about. An uncommon ability to get things done. A huge burst of energy from the moment I awaken until I go to bed. An expanded ability to multi-task. An organizational acuity that is second to none. A willingness to engage with people. A desire to spend more time with people I care about–and even those I don’t.

Then, the negative phase of hypomania (still pretty subtle):

I start feeling burned out. While I still have a lot of energy, I don’t have that “I love the world” feeling. If I’ve been playing my Autoharp at my mother’s assisted living facility, and jumping up and down to help all the participants turn the pages and stay with me, I suddenly feel that the staff should be more helpful in doing this.

… things don’t just slide off my back. While I try not to “snap” back at people, I am not always successful. I am certainly less willing to ignore things that days or weeks earlier wouldn’t have bothered me at all.

I become far less happy, joyful, and kind. I dislike being criticized in any which way.

How short can an episode of hypomania be?

Officially, the answer is “four days”, according to the DSM. But in real life, it’s very clear that episodes can be shorter, and that’s agreed upon by nearly all mood experts I’ve ever heard. They might disagree whether we should shorten the required duration in the DSM, as that would “admit” a lot more people into the bipolar camp which is already a controversial issue. But no one really seems to think that a hypomanic episode lasting only 3 days instead of four is anything other than hypomania; it just doesn’t “meet criteria”, that’s all.

Indeed, a recent studyBauer showed that episodes lasting as little as one day are common. So don’t get hung up on length of episodes as an issue if you’re trying to figure out if you “have bipolar disorder” or not. Remember, that’s the wrong question anyway… Instead, it’s “how bipolar are you?” as affirmed in a recent editorial Smith in the British Journal of Psychiatry (one of the biggies…).

What does bipolar depression actually feel like?
(added 6/2011)

Theoretically, bipolar depression is exactly the same as “unipolar” or straight Major Depression. Theoretically, you can’t distinguish between the two, so you can’t tell if someone has bipolar disorder just by looking at their depressions.

But I think there is a different quality to the depressions that people with bipolar disorder experience, because before they start feeling sad and having difficulty experiencing pleasure from their usual activities, they very often have problems with energy. To emphasize this I’d just like you to look at this list of symptoms which people with bipolar disorder said they have when they’re just starting to get depressed.

If you think “that’s me!”, careful: this does not mean you have bipolar depressions. But it might help to see what people with bipolar disorder have said about their experience. I don’t hear about these symptoms so much when people have a more purely “unipolar” — not bipolar — depression.

(from Lobban and colleagues, 2011)

Granted, people in this study also endorsed “loss of interest in activities” and “feeling sad, wanting to cry” but these are her typical symptoms in official “Major Depression”. And low energy can also be seen in Major Depression. But look at how prominent it is in this study. I think that might be telling us something about the nature of bipolar depression. Certainly matches what I hear from patients.

Finally, the original intent of this list was to help people identify symptoms that mark the beginning of another episode of depression. He might find it useful in that respect also.

Diagnosis: Summary

I hope it may now make sense to you to think of mood symptoms as falling on a continuum between plain depression and “depression plus”, the far end of which is Bipolar I, with many variations falling in between.

If you are wondering whether what you’ve just read is “mainstream” or “fringe” (that’s a good thing to wonder), you’ll find the same “spectrum” concept coming from the head of the Harvard Bipolar Clinic, in this 2005 interview: Sachs.

By contrast, another mood disorder expert has shown that bipolar disorder is overdiagnosed (Zimmerman, 2008; here is a close examination of his findings). He’s certainly right, if one sticks to the DSM rules (although his paper also shows a notable underdiagnosis rate as well). And there are quite a few people getting this diagnosis who might be better understood with a different diagnostic framework, like Post-Traumatic Stress Disorder (PTSD). But in my view, one of the things that can help you figure out what’s going on is to learn more about “bipolarity”, as you have done here. You are an important part of the diagnostic process.

Is there a test for bipolar disorder? Can you be sure if you have it or not?

This used to be simple. When “manic” only meant one thing (classic mania) one could ask “have you ever had a manic episode?” and many people knew what was being asked:
•Mood much better than normal
•Rapid speech
•Little need for sleep
•Racing thoughts, trouble concentrating
•Continuous high energy
•Overconfidence
•Loss of contact with reality (delusions)

As you now know (start this section on diagnosis afresh if you came from elsewhere), this list looks for obvious mania. It misses all the complexity we have just discussed. What you might be wanting is a “no way!” bipolar test. Something to provide a clear statement, like: “no, you don’t have it, or anything like it”. Or you might be looking for the opposite: “you definitely have bipolar II”. Sorry, that is not possible, but please read on.

On other websites you’ll find a test called the Mood Disorders Questionnaire (MDQ) which is supposed to give you a “yes or no” answer. But another test came along after the MDQ which is better suited to looking for subtle versions of bipolar II.

Think about it: if by this point on this website you’re saying to yourself “that’s me!”, which some people do, then you really don’t need some test to tell you that you should go ahead and consider treatment. Or that the diagnostic basis for that treatment should include a consideration of bipolar II. On the other hand, if someone else thinks you might have it, but you don’t think you do, is a test result going to make a difference to you? If so, go ahead and take one of these tests.

Family or friends could “take the test”, answering as if they were you, on the basis of what they’ve seen you do or heard you say. And then they could gently wonder out loud if perhaps the test might mean something, who knows, no one can tell for sure, but darn it sure seems like your life is a struggle sometimes, wow, what if there was a tool out there that would make life a bit smoother sometimes, not even necessarily a medication treatment, oh well, just thinking about this, of course you’d want to decide for yourself, not for me to say of course, etc. etc.

The people who are in a position to benefit from taking one of these diagnostic tests are those who are wondering if a “bipolar” variation might be worth considering to explain their symptoms. Here’s the test I’d recommend for you, called the Bipolar Spectrum Diagnostic Scale. It won’t give you a yes-or-no answer. I hope by this point you understand why that’s a good thing. If after all that you still want to use a “fine-toothed comb” to look for hypomanic/manic symptoms, as I sometimes do when people are still wondering about the diagnosis after learning all this, here is a 32-item checklist of such symptoms.

Thank you for patiently reading all the way to this point. It’s a lot to swallow at once, isn’t it? From here you can review, or read more about diagnosis issues in the Diagnosis Details section, or go on to Treatment.

http://www.bipolar4lifesupport.co

Breaking News: Two Psychiatrists Agree on 31 Points!

Hard enough to get agreement on anything important, let alone 31 different items. But on this issue, my colleague Tam Kelly (Fort Collins, CO) and I are in complete agreement.

Dr. Kelly evolved these 31 recommendations during 20+ years of seeing patients. Like me he has become a mood and anxiety disorders specialist, not entirely on purpose, but because we both found that some people with mood and anxiety problems were not getting better with standard approaches. (Obviously many people have gotten better with standard approaches, which is great; but for those who don’t, well, that’s where these 31 recommendations come in).

One of these days I’m going to write this up in detail, but until then, here is Dr. Kelly’s list, unedited [with just a few explanations from me in brackets]. As you’ll see, he has a dry sense of humor and likes to speak plainly.

A. Guidelines for when to stop antidepressants in people with bipolar disorder

1. If they have been on them a short time I stop them.

2. If less than 2-3 weeks and they are suffering from the antidepressant, taper quickly.

3. Less than a week, stop: two weeks then cut in ½ , a week later stop.

4. Likewise if they just increased their dose I will do the above, decreasing to their previous dose and get rid of the rest later.

5. If the pt is doing well, no mixed state symptoms or cycling, leave it.

6. If manic or severely hypomanic, get rid of them now. Usually can stop abruptly.

7. If cycling get rid of them.

8. If mixed get rid of them.

9. I usually wait until the patient is doing better to much better. Trust is an issue. If the first thing we do is make them suffer more they will be unlikely to stay around long or even go to another psychiatrist. Even though we know the antidepressant is causing harm oft time the patient thinks either that the antidepressant is helping or that every time they try to go off they feel much worse. Waiting until they are better is usually a good thing.

10. Also waiting longer usually means that the patient is going to be more educated about bipolar in general.

11. If they are not getting better after several add on meds then slowly decrease.

12. There are more exceptions to the above rules than there are rules.

B. Guidelines on how to get off antidepressants

1. Educate/prepare the patient well ahead of time and repeatedly.

2. Chart GAF scores [a psychiatric standard, Global Assessment of Function, a single number summarizing how you’re doing] over time. Sometimes getting off anti-depressants isn’t the right thing to do and can be used to identify “Sweet Spot” for dosing. For example, I recently had a patient who was doing poorly on 300 Effexor XR started when she was still “unipolar”. Took two years to wean off. Retrospectively I was able to see that she was doing best around 75mg. Charting the GAF at appointments and the Lowest in between is best.

3. If the patient stops them AMA [against medical advice] abruptly and they are doing well then leave them off. Watch for manic symptoms. (Sometimes patients get better despite our best efforts.)

4. If the patient stops them AMA abruptly and they are doing worse don’t jump back up to the whole dose. The longer they were at the lower without feeling bad before felling worse, the lower dose you can return to. You can sometimes use half-lives to calculate this. Calculate the dose based on when they started feeling bad. Watch patients very closely during this time, even daily by phone or at the office.

5. Warn patients that they will have mood swings if they do this. Warn patients that they will have mood swings if they don’t do this, probably worse. Warn them of this over and over again. The point is to try and stop them from major panic when they do have a down.

6. Slowly is best. The slower the better. I usually wait … at least 6 – 8 weeks between dosage decreases. Prozac/fluoxetine can be an exception to this.

7. Longer if anxiety is a major feature.

8. Faster if they feel better as they decrease dose.

9. Longer if they have difficulty with dosage decreases.

10. Longer if they are doing relatively well.

11. Never decrease before a major event or holiday.

12. Avoid decreasing during times of major stress.

13. The pt can take longer if they want to take longer for any reason.

14. Reduce in the smallest possible increments. As you approach zero then take the dose changes smaller or longer. Get out that pill cutter. If you can’t get dosage changes in small enough changes do every other day between the smaller dose and the larger dose. You would be surprised how often this works even on very short half-life drugs like Effexor XR.

15. You can go faster if they feel better as they decrease dose, but not too fast. Look for signs and symptoms of mania as well as depression. I have seen both hypomania and even mania in a [patient with Bipolar II] who stopped their antidepressant without taper. This has been reported in the literature as well. Going down slowly also avoids manic reactions

C. Special Rules:

1. Effexor XR. If the pt can tolerate doing this then this is by far the best way to do this. Open up the capsule and take one more bead out each day. Rules 11 – 13 of how to get off antidepressants apply. Pour the beads out on a creased piece of paper and count out the correct amount of beads. Then using the crease of the paper to get the beads back in the capsule. [In my town I have the advantage of a compounding pharmacist who can make small doses from the patient’s large doses and allow us to decrease]

2. If pts can’t count beads or don’t want to do this then take out about ¼ capsule for 6 – 8 weeks and repeat.

3. For any anti-depressant you can add in 20 mg of Prozac, get them off the anti-depressant, then taper the Prozac.

4. Prozac is a special case because of its long half-life. I generally will drop of one day at a time when reducing dose, e.g. decrease to 6/7 days a week for 6- 8 weeks then decrease to 5/7 days a week. Prozac is also a good candidate for every other day decreases, e.g. from a dose of 40mg a day go to 20 alternating with 40 mgs a day [to make a 30 mg-equivalent dose].

5. Every other day dosing of a medicine often work when reducing doses even when the pharmacology (“half life”) suggests it shouldn’t work. [I asked: Dr. Kelly has indeed used this technique for both duloxetine/Cymbalta and venlafaxine/Effexor, two of the trickier ones to taper. He says it works there too. ]

http://www.bipolar4lifesupport.co

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

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

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

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

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

Principle B: Medications — use evidence-based Mood Stabilizers

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

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

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

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

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

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

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

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

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

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

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

Principle C: Beware of Antidepressants

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

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

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

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

Secondly, here are the more controversial risks.

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

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

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

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