Bipolar Support Groups.com blog

Picking up the pieces after a mood episode can be hard. The people you need most — especially your friends and family — may be angry with you or reluctant to help.

The best way to avoid these mood episodes is to get treatment for bipolar disorder. But unfortunately, periods of hypomania, mania, or depression aren’t completely preventable. Even people who always take their medication and are careful with their health can still have mood swings from time to time.

That’s why it’s important to catch changes in your mood, energy levels, and sleeping patterns before they develop into something serious.

Mood Swing Triggers in Bipolar Disorder

At first, mood swings may take you by surprise if you have bipolar disorder. But over time, you might start to see patterns or signs that you’re entering a period of mania or depression. Aside from a shift in your mood, look for changes in your:

• Sleep patterns
• Energy level
• Alcohol or drug use
• Sex drive
• Self-esteem
• Concentration

Mood episodes in bipolar disorder often occur spontaneously, for no particular reasons. Sometimes, however, you may discover particular “triggers” — situations or events that can provoke a period of mania or depression, such as sleep deprivation, changing seasons, or crossing multiple time zones when traveling. Some people find they’re more likely to become depressed or manic during stressful times at work or during holidays. Many people see seasonal patterns to their mood changes. Of course, not everyone can identify triggers. Also, some triggers can’t be anticipated or avoided, like a serious illness or a traumatic event.

One good way to see patterns or triggers in your bipolar disorder is to keep a journal. Make note of big events, stresses, your medication dosage, and the amount of sleep you’re getting. Over time, you might see some patterns emerge.

If you can recognize triggers for periods of mania or depression, you can prepare for times when you might be most vulnerable. Ask for more help from co-workers. Have your family and friends check in more often so you get extra support.

If you see the signs of potential trouble, get help. Don’t wait for the mood episode to pass on its own. With quick intervention, you might be able to stop a very minor mood swing from becoming a serious problem.

The Appeal of Mania in Bipolar Disorder

When people with bipolar disorder are depressed, they almost always know that something is wrong. Nobody likes feeling that way.

But it’s different for people who are hypomanic or manic. Often, they don’t think anything is wrong. Or if they notice a difference in their mood and personality, they think it’s an improvement.

Mania and hypomania can be seductive. You might feel more energized, creative, and interesting. You might be able to get extraordinary amounts of work done. So what’s the problem?

Manic phases often turn destructive. Some consequences of a manic episode can’t be undone. You can wipe out your savings account. You can have affairs that ruin your marriage. You can lose your job. Most dangerous of all, mania can make you do things that risk your life or the lives of others. And manias are often followed by depressive episodes. Effectively treating a mania or hypomania may help reduce the risk of developing a future depression.

Although hypomania or mania can feel good at the moment, in the long run, you’ll be happier, healthier, more productive, and more successful if you can maintain a stable mood.

Anyone who has experienced two or more episodes of bipolar disordergenerally is considered to have lifelong bipolar disorder, where the goal focuses not only on treating current symptoms but also preventing future episodes. That person should have maintenance therapy. Once your doctor has helped stabilize the moods of the acute phase of the disorder (either a manic or depressive episode), drug therapy is continued indefinitely — sometimes at lower doses.

It is important to remember this: Even if you have been without bipolar symptoms for several months, do not stop taking your medications. Your doctor may lower your doses, but discontinuation of medications will put you at risk for recurrence of bipolar symptoms.

Aripiprazole (Abilify), lamotrigine (Lamictal),  lithium ,  olanzapine(Zyprexa),  risperidone (Risperdal) Consta, and  quetiapine (Seroquel) or ziprasidone (Geodon), (either one in combination with lithium or valproate) are the only drugs that have been approved by the FDA specifically for maintenance therapy for bipolar disorder. These medications can differ in their ability to prevent manic versus depressive episodes, as well as in their side effects. However, many other drugs used to treat manic episodes are also used for maintenance treatment.

These drugs include:

• Antipsychotic medication
• Antidepressants
• Carbamazepine (Tegretol)
• Valproate (Depakote)

A combination of these drugs may also be used.

Lamotrigine (Lamictal) for Bipolar Disorder

Lamictal is approved by the FDA for the maintenance treatment of adults with bipolar disorder. It has been found to help delay bouts of depression, mania, hypomania (a milder form of mania), and mixed episodes in those being treated with standard therapy. It is especially effective in the prevention of bipolar depression. It is the first FDA-approved therapy since lithium for maintenance in bipolar disorder.

Lamictal is considered a mood-stabilizing anticonvulsant and is most commonly prescribed to prevent or control seizures in the treatment of epilepsy. Recent studies have shown it may possess antidepressanteffects in bipolar disorder.

Lamictal Side Effects

Lamictal comes in several types of tablets, such as chewable or orally disintegrating. It adds to the effects of other central nervous systemsuppressants such as alcohol — and to those found in many antihistamines, cold medications, pain medications, and muscle relaxants. Check with your doctor before taking any of these.

Three out of every 1,000 people taking Lamictal will develop a rash. Sometimes the rash can prove serious or even fatal. If a rash develops, you should consult your doctor  immediately and the drug may need to be stopped promptly.

Common side effects of Lamictal include:

• Headache
• Dizziness
• Diarrhea
• Dream abnormalities
• Itching
• Vision difficulties

Medication errors have occurred in filling Lamictal prescriptions because other drugs have similar names, like  labetalol,  Lamisil, lamivudine, Lomotil, and Ludiomil. To avoid confusion, make sure the drug name is clearly written on your prescription.

Lithium for Bipolar Disorder

Lithium (brand names include Eskalith or Lithobid) is the most widely used and studied medication for treating bipolar disorder. It has been used for more than 50 years and helps reduce the severity and frequency of manic states. It may also help relieve bipolar depression.

People with bipolar disorder may take lifelong lithium as maintenance therapy to prevent relapses. When lithium treatment stops, relapses can occur within six months in 90% of patients. Moreover, subsequent lithium treatment may sometimes be less effective, particularly if lithium is stopped abruptly rather than gradually (meaning, over a period of 2 weeks or longer).

Studies show that lithium can significantly reduce the risk of suicideamong people with bipolar disorder. It also helps prevent future manic episodes.

Lithium is a simple salt that acts on a person’s central nervous system. Doctors don’t know exactly how lithium works to stabilize mood. However, it helps people with bipolar disorder have more control over their emotions and cope better with the problems of daily life.

When lithium is used as part of maintenance therapy for bipolar disorder, your doctor will want to take regular blood tests during your treatment because it can affect kidney and thyroid function. Blood tests will also help your doctor monitor the level of lithium in your blood. Your doctor also will probably suggest you drink two or three quarts of water or fluid a day during treatment and use a normal amount of salt in your food. Both salt and fluid can affect the levels of lithium in your blood, so its important to consume enough every day.

Lithium Side Effects

About 75% of people who take lithium for bipolar disorder have some side effects, although they may be minor. Sometimes side effects can be relieved by changing the dose of lithium. Never change your dose or drug schedule on your own. If you are having any problems, talk to your doctor about your options.

Common side effects of lithium include:

• Weight gain
• Impaired memory
• Poor concentration
• Confusion
• Mental slowness
• Hand tremor
• Sedation or lethargy
• Impaired coordination
• Nausea, vomiting, or diarrhea
• Hair loss
• Acne
• Excessive thirst and dry mouth
• Excessive urination
• Decreased thyroid function (which can be treated with thyroidhormone)

Particularly bothersome tremors can be treated with additional medication.

There are a few serious risks to consider. Lithium may weaken bones in children. The drug has also been linked to a specific birth defect in heartvalve formation occurring in 1 in 1000 to 1 in 2000 patients and should be administered with caution to pregnant women. Also, in a very few people, long-term lithium treatment can interfere with kidney function.

But don’t be alarmed. A diagnosis of bipolar disorder doesn’t necessarily mean that you can’t keep your job. Plenty of people with bipolar disorder work and live normal lives.

Should I Tell my Boss About my Bipolar Disorder?

You don’t have to talk to your boss or coworkers about your bipolar disorder. Your health is your personal, private business. But if your condition has been affecting your performance at work, being open may be a good idea. Your boss and coworkers may have noticed the changes in your behavior. If you explain what’s going on, they may be more sympathetic and helpful than you expect.

Making Changes in Your Job

Some people with bipolar disorder find their current job just isn’t a good fit. Maybe it’s too stressful or the schedule is too inflexible. Maybe it doesn’t let them get enough sleep, or involves shift work that could worsen their condition. If you think your job is hurting your health, it’s time to make some changes. Here are some things to consider:

• Decide what you really need from your job. Do you need to reduce your responsibilities? Do you need extra breaks during the day to reduce stress, or need time off during the work week to keep doctor or therapist appointments?
• Make decisions carefully. People with bipolar disorder are prone to acting impulsively. Think through the effects of quitting your job — both for yourself and possibly for your family. Talk over your feelings with your family, therapist, or health care provider.
• Look into financial assistance. If you do need to take time off because of your bipolar disorder, see if your employer has disability insurance, or look into Social Security Disability Insurance, which will provide some income while you recover. You can also look into the Family and Medical Leave Act. Ask your doctor or therapist for advice.
• Go slowly. Returning to work after you’ve taken time off can be stressful. Think about starting in a part-time position, at least until you’re confident that your bipolar disorder has stabilized. Some people find that volunteer work is a good way to get back into the swing of things.

Bipolar Disorder Stigma at Work

Unfortunately, you may still run into people at work who treat you unfairly because of your bipolar disorder. Often, their behavior stems from ignorance. They might see you as “crazy” or think your condition is “all in your head.” You might be able to head off problems by teaching people a little about bipolar disorder.

But that’s not always enough, and the stigma of mental illness can hold you back. Some people with bipolar disorder feel they’re treated unfairly at work; they might be passed over for promotions or raises, for instance.

If you think you’re being treated unfairly, there are things you can do. The Americans with Disabilities Act can protect some people who are discriminated against because of a health condition. But don’t do anything rash. Research the law, and talk your situation over with friends, family, your therapist, and your health care provider before taking action.

While depression episodes are far more common than manias and have a tremendous effect on the lives of patients, there are only a few established treatments for bipolar depression.

What’s the standard treatment for bipolar depression?

Lithium and the anticonvulsants lamotrigine and valproate are mood stabilizers that are sometimes used “off label” as treatments for bipolar depression, although none of these has been established as an FDA-approved first-line treatment for bipolar depression. For many years, psychiatrists have traditionally added an antidepressant to a mood stabilizer if a mood stabilizer alone is ineffective; however, research shows that antidepressants are often not effective for bipolar depression.

A mood-stabilizing medication works on improving social interactions, mood, and behavior and is recommended for both treatment and prevention of bipolar mood states that swing from the lows of depression to the highs of hypomania or mania. According to the American Psychiatric Association (APA), lithium, lamotrigine, valproate,carbamazepine, and most atypical antipsychotic medications are approved by the FDA for treating one (or more) phases of bipolar disorder.

In some patients with bipolar disorder, a mood stabilizer may be all that’s needed to modulate the depressed mood. However, in bipolar patients who do not respond to one mood stabilizer, another mood stabilizer or an atypical antipsychotic is sometimes added to the treatment regimen.

Are antidepressants used to treat bipolar depression?

While antidepressants are effective treatment for people with major depressive (unipolar) disorder, antidepressants they are not always as effective for bipolar depression, and generally should not be given alone (monotherapy) in people with bipolar I disorder. When antidepressants are given alone to someone with bipolar disorder, there’s a risk the drug might ignite a manic episode in some patients. Knowing this, most doctors may avoid using antidepressants as monotherapy for bipolar depression.

How are antipsychotic medications used in treating bipolar depression?

Studies have shown that some (but not all) antipsychotic drugs are in themselves effective treatments for bipolar depression. Seroquel and Seroquel XR are used for the treatment of depressive episodes associated with bipolar disorder. Another effective drug with rapid onset for the treatment of bipolar depression is Symbyax, a combination medication of the atypical antipsychotic Zyprexa (olanzapine) and the selective serotonin reuptake inhibitor (SSRI) Prozac (fluoxetine), an antidepressant. The atypical antipsychotic Latuda(lurasidone) is FDA-approved for use alone or with lithium or valproate for treating bipolar depression. These three drugs are currently the only FDA-approved treatments for bipolar depression.

These medications work by affecting brain receptors involved in mood and behavior, and helping to restore the balance of certain natural chemicals in the brain (neurotransmitters).

Your doctor will weigh the benefits and risks of the available medications to help you get relief from the bipolar depression without the risk of mania and/or drug interactions.

How do the CNS depressants help with bipolar disorder depression?

Central nervous system (CNS) depressants, which include the benzodiazepines, act on neurotransmitters to slow down normal brainfunction. CNS depressants are commonly used to treat anxiety and sleep disorders and may be an effective alternative or adjunctive therapy in some bipolar patients with acute mania.

Some commonly used benzodiazepines include clonazepam (Klonopin), lorazepam (Ativan), alprazolam (Xanax), and diazepam (Valium). These drugs all can be habit-forming/addictive and can cause sluggish thinking. They generally should be used only to treat agitation or sleep problems during the acute phase of the illness and not as long-term medications. They typically should be tapered off rather than stopped abruptly, in order to minimize the risk of drug withdrawal.

Is electroconvulsant therapy (ECT) a viable treatment for bipolar depression?

Guidelines from the American Psychiatric Association suggest that ECT is a reasonable alternative in those patients who may have suicidal ideation or psychosis. In addition, ECT may benefit women who are pregnant and suffer with severe bipolar depression or mania.

What about psychotherapy for help with bipolar depression?

Along with medications for bipolar depression, patients may benefit from ongoing psychotherapy. This one-on-one therapy combines interpersonal psychotherapy with behavioral techniques to help patients learn how to diminish interpersonal problems, stay on their medications, and normalize their lifestyle habits. The STEP-BD study mentioned earlier found that in addition to medications, adding a structured psychotherapy — such as cognitive behavioral therapy, interpersonal/social rhythm therapy, or family-focused therapy — can speed up treatment response in bipolar depression by as much as 150%.

How Is Depression Diagnosed?

Although very common, depression is often ignored or misdiagnosed and left untreated. Such inattention can be life-threatening; major depression, in particular, has a high suiciderate.

If you or a loved one have symptoms of depression, seek help from a qualified health careprovider. Many primary care doctors diagnose and treat depression. Screenings for depression are now often part of a routine visit to your doctor. But if your symptoms get significantly worse or do not improve within four to eight weeks of treatment, ask your health care provider for a referral to a psychiatrist for diagnosis and treatment. Clearly, for more severe symptoms — and always if you have thoughts about death or hurting yourself or someone else — you should see a psychiatrist as soon as possible.

To diagnose depression, your health care provider will ask you questions about your symptoms and family history. You may be asked to fill out a questionnaire about your symptoms. You may be given medical tests to rule out other conditions that may be causing your symptoms, such as nutrient deficiencies, underactive thyroid or hormone levels, or reactions to drugs (either prescription or recreational) and/or alcohol.

What Are the Treatments for Depression?

The stigma depression carries drives many people to hide it, try to tough it out, or misuse alcohol, drugs, or herbal remedies to get relief. To effectively treat depression, it is important to seek care from a health care provider such as your primary care doctor or a licensed mental healthprofessional. Both of these types of providers can help you get a correct diagnosis and develop a treatment plan. Many treatments for depressionare available and typically include a combination of psychotherapy and medication.

Psychotherapy teaches patients how to overcome negative attitudes and feelings and helps them return to normal activities.

Drug therapy is intended to treat symptoms that are thought to result from abnormalities in brain circuits that regulate mood, thinking and behavior. It may take several weeks for an antidepressant to fully work to ease depression symptoms, so it’s important to stay on the medication.

As with any chronic illness, getting an early medical diagnosis and medical treatment may help reduce the intensity and duration of depression symptoms. It may also reduce the likelihood of a relapse.

Medication for Depression

The group of antidepressants most frequently prescribed today consists of drugs that regulate the chemical serotonin. Known as selective serotonin reuptake inhibitors (SSRIs), the group includes Paxil, Prozac, Celexa, Lexapro, and Zoloft. Serotonin norepinephrine reuptake inhibitors (SNRIs) including Effexor, Khedezla, Pristiq, Fetzima, and Cymbalta, also act on serotonin and norepinephrine but in a different way than SSRIs. The drugs Brintellix and Viibryd affect the serotonin receptor (like SSRIs) but also affect other receptors related to serotonin function. Other antidepressants include Wellbutrin, a drug that appears to affect dopamine and norepinephrine regulation, and Remeron, which increases levels of serotonin and norepinephrine by a different mechanism than SNRIs. For children and adolescents, the SSRIs are among the best-studied and therefore often the drugs of choice.

The tricyclic antidepressants (TCAs), which have been used to treat depression since the 1950s, are another option, although they are apt to have more side effects than the SSRIs. Like all antidepressant drugs, you must take them for a while before they take effect. TCAs include Amitriptyline, Amoxapine, Desipramine, Doxepin, Imipramine, Nortriptyline, Protriptyline, and Trimipramine.

Because adolescents do not tolerate side effects well and tend to stop taking their medication, TCAs are not recommended for them as first-line treatments. In addition, heart rhythm problems have been seen in children and adolescents taking desipramine, a TCA, so caution should be taken when this medication is prescribed to this population.

The third group of antidepressants, the monoamine oxidase inhibitors (MAOIs), like Parnate, Nardil, and the skin patch EMSAM, have also proved effective. MAOIs may sometimes work more quickly than the TCAs, but they require avoiding certain foods (such as aged meats and cheeses) and certain other medicines that can also affect serotonin or raise blood pressure. MAOIs are usually prescribed only if the SSRIs and the TCAs or other depression medicines that can be simpler to take fail to bring improvement.

Lithium carbonate, which is a drug commonly used for manic depression, is also sometimes used to treat depression in combination with an antidepressant. Today, atypical antipsychotics have become the most widely prescribed class of medications that are added on to an antidepressant after an incomplete initial response. Two in particular, Seroquel XR and Abilify, are FDA-approved as add-on therapy for antidepressants, regardless of the presence or absence of psychosis(delusions or hallucinations). However, atypical antipsychotics can have many possible side effects, including weight gain, changes in blood sugarand cholesterol, sedation, and abnormal movements.

Your health care provider can recommend the best medicine for you.

Psychotherapy for Depression

Psychotherapy is an important part of treatment for depression. In cases of mild-to-moderate depression, psychotherapy may be used alone to relieve symptoms. More often, it is used in conjunction with medication to alleviate depression.

Commonly used forms of psychotherapy are cognitive, behavioral, and interpersonal therapies.

• Cognitive therapies challenge the negative thought patterns that accompany depressed moods and teach you new ways to think more positively.
• Behavior therapies concentrate on changing patterns of behavior.
• Interpersonal therapies help you examine how relationships affect your moods.

Other Treatments for Depression

Electroconvulsive Therapy (ECT)

ECT involves the application of an electric current through electrodes on the head. These are not felt by the patient, who is asleep under general anesthesia. Although doctors are still uncertain exactly how ECT works, it is thought that by producing a brief seizure, a course of several treatments of ECT conducted over a few weeks can bring about relief from depression. Its techniques have been refined in the past 20 years in order to minimize side effects, such as memory loss, and today ECT is considered to be as safe, or even safer, than many drugs used to treat depression and for some people, more effective.

ECT is usually considered after a number of other options have been tried because it may require hospitalization and general anesthesia. It’s also considered if rapid results are vital, as with suicidal patients or those who refuse to eat or drink. ECT should not be thought of as a “last resort”; it is extremely effective and may work before other treatments have been tried and failed.

Usually given three times a week for two to four weeks, treatments generally involve 6 to 12 sessions and are sometimes followed by a gradual “taper down” in frequency over several weeks. Some people benefit from ongoing “maintenance” treatment over longer periods to prevent relapse when medicines alone may be ineffective.

Repetitive Transcranial Magnetic Stimulation (rTMS)

rTMS, which involves passing strong magnetic currents through the brain, is another option for treating depression. rTMS has been used effectively at times to treat major depression and depression that does not respond to other forms of treatment (treatment-resistant depression). However, to date, studies have not found rTMS to be as effective as ECT.

VNS is used to treat select cases of severe or recurrent, chronic depression that does not respond to at least two antidepressant trials. This surgical treatment involves the use of a pulse generator implanted under the collar bone that sends out pulses of electricity to stimulate the vagus nerve in an attempt to affect the brain‘s mood centers. It typically takes at least several months for VNS to begin to show a benefit for treating depression.

Exercise for Depression

Exercise should be a part of any therapy for depression. It improves bloodflow to the brain, elevates mood, and relieves stress. Even if used alone, it can often bring favorable results. Studies show that jogging for 30 minutes three times a week can be as effective as psychotherapy in treating depression. Pick an exercise you like and do it daily, if possible. Any exercise is fine; the more energetic and aerobic, the better. The key is getting your heart rate into the right range for your age for 20-30 minutes three to four times a week.

Nutrition and Diet for Depression

Because symptoms of depression can be exacerbated by nutritional deficiencies, a healthy diet is important. Eat a well-balanced diet. Some people have noticed an improvement of depression symptoms when they eliminated wheat, dairy, alcohol, sugar, and caffeine from their diets. But this is not proven to treat depression. You can try eliminating those foods one at a time from your diet and note whether your depression improves. It may help to keep a symptom diary. Quitting smoking is also advised.

Alternative Medicine for Depression

As with any alternative or complementary medicine, check with your health care provider before starting it, especially if you are taking other medications or treatments.

Herbal Remedies for Depression

Several studies show that the herb St. John’s Wort is as successful at improving symptoms of mild-to-moderate depression as prescription medications, often with fewer side effects. However, other reports show that the herb isn’t any better than placebo (or sugar pill) in treating depression. Although it is considered safe, St. John’s Wort can be potentially dangerous if taken with other antidepressants (especially SSRIs), including certain medications used for treating HIV, cyclosporine, a drug used in organ transplant patients, or anticoagulant drugs. It can also interfere with the efficacy of oral contraceptives and medications used for heart disease and seizures.

Although ginkgo biloba is typically used as an “alternative medicine” strategy that might help to improve memory and ease confusion, it has proven in some cases to work better than placebo for the symptoms of depression, and is approved by the German government’s Commission E for this purpose.

Whatever herbal remedy you may decide to take to treat a medical condition, it is always best to consult your health care provider first. This is especially true if you are taking prescription medications for the same or other conditions.

Mind/Body Medicine for Depression

Many mind/body practices can be helpful with depression. Music and dance can lift the spirits and energize the body. Meditation and relaxation techniques, such as progressive muscle relaxation, both stimulate and relax. Other choices include transcendental meditation, visualizations, and the Asian exercise techniques of yoga, tai chi, and qigong. Choose one or two that suit you and practice often.

Massage for Depression

Massage not only relaxes you, it may help reduce your anxiety and depression. When groups of depressed adolescents received massage therapy, their stress hormone levels changed, their brain activity was positively affected and their anxiety and depression eased. Because it has no side effects, massage could be a safe and positive addition to your depression treatment program. However, by itself, massage is not considered to be a proven or evidence-based treatment for depression.

Acupuncture for Depression

The World Health Organization lists depression among the conditions for which acupuncture is effective. Some studies have shown it markedly lessens symptoms of depression. Acupuncture may be a viable alternative from therapy if you are unable to take antidepressants or have not found them helpful.