Managing Bipolar Disorder

(November 2003) -- Twenty-five or so years ago, most people diagnosed with bipolar disorder were middle-age adults who had distinct euphoric episodes. Today most people identified with manic-depression present a remarkably different picture of the condition: Not only is depression the most pervasive feature of the illness, the manic phase is usually a mix of irritability, anger and depression, with or without euphoria. In fact, euphoric mania is the exception, not the rule.

Today the average age of onset of bipolar disorder is 19. It's not clear whether there is a rising incidence of the disorder in younger people or it is just being recognized more in children and adolescents.

But now as then, bipolar disorder most often remains undiagnosed and untreated. Experts say that severe manic depression afflicts 1% of the population and 5% of Americans have a less florid form of the disorder.

Consider these statistics:

• it takes an average of 20 years for a person with bipolar disorder to be correctly diagnosed
• in 37% of patients the disorder is mistakenly diagnosed as unipolar depression--even after a manic episode
• two-thirds of manic episodes do not involve elation but rather irritability or even depression.

Should a manic depressive be lucky enough to learn that his suffering has a a name and an array of treatment possibilities, there are still formidable hurdles. Surveys show that 50% of sufferers do not take the prescribed medications.

The problem may not always lie with the patient, although the manic-side energy and impaired judgment provide powerful incentives to skip medication. Getting the disorder under control typically requires use of multiple drugs, each with an array of side effects from weight gain to cognitive dulling. Prescribing tolerable drugs in tolerable dosages for each case is a psychiatric high-wire act.

The condition is still so challenging to tame that 90% of marriages involving a partner with bipolar disorder end in divorce. Researchers estimate that more than 40% of persons with bipolar disorder abuse alcohol or drugs; 15 to 25% die by suicide, accident or are killed in altercations triggered in a manic phase. Most attempted and completed suicides occur during depressive or mixed phases.

The past summer brought a major treatment advance--FDA approval of the anti-seizure drug lamotrigene (Lamictal) for bipolar disorder. It is the first drug since lithium to be approved for long-term maintenance treatment of bipolar disorder. Studies indicate that the anticonvulsant delays significantly the occurrence of repeat episodes--and especially depression--in patients treated for acute mood episodes with standard therapy.

What has many psychiatrists especially excited is that the drug appears to be a new kind of mood stabilizer--a mood-elevating mood stabilizer. "We used to just be able to bring people down from mania," explains Andrew L. Stoll, M.D., associate professor of psychiatry at Harvard and chief of the psychopharmacology research lab at Harvard's McLean Hospital. "With lamotrigene we can stabilize mood from below, bringing the person up from depression. A few years ago we would not have believed that possible. There's been a paradigm shift in a way."

Lamotrigene addresses a major concern of many experts: It may obviate the need for conventional antidepressants in treating the depressive phase. Used alone, antidepressants can induce mania. There is also concern that they accelerate mood cycling. Increasingly, psychiatrists minimize the value of conventional antidepressants for bipolar depression, although they are still widely prescribed.

Unlike most other drugs for manic depression, lamotrigene seems to cause few side effects and is well tolerated by patients. There's no weight gain, no drowsiness, no cognitive dulling, no hormonal changes. And no blood tests are required for continued treatment.

The only potentially serious problem is a kind of skin rash, but evidence indicates it is averted if doctors start the drug at extremely low doses. Nevertheless, many doctors are afraid to use the drug. Some sources report that fear of lamotrigene is deliberately whipped up by representatives of pharmaceutical companies pitching rival drugs for the disorder.

Exactly how lamotrigene works is not clear. The drug was approved for epilepsy nearly a decade ago. On the grounds that there seem to be similar electrical processes at work in the brain in both disorders, anything that works against epilepsy is now tried in bipolar disorder, although not every anti-epilepsy agent works in bipolar disorder as well.

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It is a fact that every effective mood stabilizer blocks the brain process known as kindling, a sensitizing of nerve cells so that they react to even minor provocations with a full-blown mood episode. All mood stabilizers curb hyperactive signaling in pathways that lead from neurotransmitter receptors to the nerve cell interior.

Other news on the treatment front is the emergence of nutritional approaches. "The public is ready for nutrients to be on the scene," observes Stoll. "Most medical symposia on bipolar disorder now include a section on natural treatments."

His studies, and others', have demonstrated therapeutic value in omega-3 fatty acids, notably eicosapentaenoic acid (EPA), folic acid and other B vitamins, and the mineral magnesium. Others nutrients are under study. "These are not going to work by themselves in most people," Stoll reports, "but they are adjuncts to medicines. You can get away with fewer medicines and maybe lower doses."

Most recently, Stoll has explored supplements of the amino acid taurine. The results of the study have not yet been published, but Stoll did say that "it works really well for bipolar disorder."

Helpful as nutritional support may be, it can only benefit those patients who can afford it. Nutrient use is not reimbursed by insurers, and the cost can add up. Bipolar disorder is already one of the more expensive conditions requiring treatment, with some medications ringing the cash register at $15 a pop, day in and day out. Stoll cites the case of a bipolar patient of his whose multiple medications alone cost $1100 a month.

Nevertheless, a shift in the Western diet may explain part of the changing face of bipolar disorder. "We think it's the omega-3 story, why the age of onset is dropping and the disorder is affecting more children," says Stoll.

"In the last 100 years, we've changed our diet, consuming more processed food and shifting to omega-6 fatty acids over omega-3s," with which they compete for uptake by the body. "It affects cell membranes and physiology in a way that's harming us and our children. Each generation is more depleted of omega-3s than the previous one." He points to evidence gathered by researchers at the National Institutes of Health correlating psychiatric disorders in children with a rise in omega-6 consumption, such as from soy oil, ubiquitous in fried foods.

Difficult as bipolar disorder is to control in adults, it's even more daunting in children and adolescents. The irritability, excitability and impulsivity that mark the disorder often overlap with the signs of attention deficit hyperactivity disorder. But treatment for the latter can kick off frankly manic episodes.

And to what adolescent striving to define an identity do inflated self-esteem and grandiosity not appear attractive? To say nothing of the boost in energy and reduced need for sleep? It is the depression phase that generally motivates them to accept care.

Increasingly, experts agree that in both children and adults the course of the disorder depends not merely on correct diagnosis and medication but on extensive education and psychotherapy involving the whole family. The goal is to lessen the stress level impinging on patients. "Stress definitely worsens the disorder," says Stoll.

At the very least, proven psychotherapies, such as cognitive behavioral therapy, interpersonal therapy and especially family-focused therapy, help patients resolve the work and relationship problems that are both cause and effect of episodes. Studies show such treatment reduces the number of mood episodes patients experience.

Psychotherapy appears to be especially useful in teaching self-management skills, basic equipment for keeping everyday ups and downs from becoming full episodes. Valuable as drug treatment is, it will never carry sufferers completely to the finish line.

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