Please keep your appointments!

When you have bipolar disorder, it is very important to see your doctor on a regular basis, which means being sure to keep all your appointments.

It can be hard to stay motivated to see your doctor when you feel well, but this may actually be the most important time you have together. If your doctor gets to know you when you are well, they will have an easier time noticing when you don't seem yourself, perhaps indicating a change in mood or behavior that needs to be addressed.

In addition, if you take the time to get to know your doctor when you are well, then you will feel more comfortable acknowledging when you don't feel quite right, giving you the best chance of treating an episode of mania or depression before it gets out of hand.

Can A Picture of Your Mother Diagnose Depression?

Wouldn't it be nice to be able to diagnose psychiatric disorders, such as unipolar or bipolar depression, by looking at an MRI scan just like you would a bone fracture or a muscle tear? Unfortunately, at present there are no radiological tools available to help us with such diagnoses.

The Family Center for Bipolar team, in collaboration with an imaging team from Columbia University, conducted an fMRI imaging study which allows to correctly diagnose unipolar from bipolar depression in 25 out 28 young women. This is 90% accuracy!

Depression was diagnosed by the brain activity when women were looking at their mother's face compared to those of a stranger and a female friend.
 

When people get depressed, the glass always seems half-full and the whole world seems dark. It seems that this effect is very pronounced when you look at your mother.

The report is very complicated and technical -- for those interested in technical details you can read the original paper here. However, there is a much simpler article about our report in the Wired Science Blog on-line magazine that you can read here.

Enjoy!

Dr. G.

Be prepared!

Getting sick is bad, but getting sick and not having a safety plan can be even worse! Take a moment to build a plan with your loved ones that indicates what to do should you get sick and make sure everyone has a copy of the plan!

Here are some ideas for what to include in your plan:

1. List the names and contact information for all your doctors, case workers, or any other professional involved in your care
2. Make a list of all your medications you take and the reason you take each medication! Be sure to include any over-the-counter medications or supplements you take, as well as the doses of each medication and when you take them. You may want to note some possible side effects of the medications. This way you and your support network can be mindful of any side effects you could experience.
3. Write out any allergies that you have! Note any adverse reactions to medications or medications that you do not want to take and why!
4. Write down a list of people you trust who know about your disease and are willing to help you. Be sure to include their names and phone numbers! This can help you when you aren't feeling well. You may want to include a list of signs that you experience when you are starting to feel manic or depressive. Knowing these early signs that you might be getting sick can allow people to help you get care early.
5. Write down the names and numbers of any family members or employers that may need to be contacted if you experience an emergency or need to stay in the hospital for a period of time for treatment.
6. Write out your insurance plan information
7. Include in your safety plan any other directions that you have for your care. Be sure to include what kinds of medical interventions you do and do not want. You can include any "Advanced Directive" or "Living Will" documents with the plan!
8. Finally, you may want to indicate any instructions regarding the care of any pets or plants you have or regarding bills or other household matters should you need to be in the hospital.

Maybe some items above aren't for you. That's okay. This list is just to get you started on putting your plan together. You don't have to build your plan alone either. Talk with your doctor, your case manager, your family, or the other people you trust to help you build a plan that works for you. Make sure your doctor and the people on your support list have a copy of the plan so they can know how to best help you!

Mindfulness.

Do you ever take a moment to be mindful of the thoughts you are having? Sometimes people just accept the thoughts they have as facts, but this can be problematic as negative thoughts can impact our mood and lead us to act out in ways that we may later regret. We don't have to act on the thoughts we have or let them drive our mood. Learning mindfulness is all about creating a more focused state of mind that allows us to approach our thoughts calmly and with curiosity, as opposed to just reacting.
Many people who have practiced mindfulness report feeling calmer and better able to handle life's challenges. What is great about practicing mindfulness is that you can do it anywhere and there are some simple techniques that can make a big difference in your life!

Why not give mindfulness a try? 

Check out these free audio files to learn some techniques at your own pace: http://marc.ucla.edu/body.cfm?id=22

OR visit the Mindfulness Awareness Resource Center online and read more about it: http://marc.ucla.edu

Depression

Feeling depressed is a fairly late symptom of a depressive episode. Just like with manic episodes, the first signs and symptoms of depression are subtle. Your friends and relatives might notice the first signs before you. If they do they are in a position to give you a heads up that you may be starting to get depressed so you could change your medications. This is why Family Inclusive Therapy (or FIT) works, and this is why we have the Family Center.

The first signs of depression are changes in your activity level and the type of things that you do, which could become more pensive or solitary. 

• You may want to stay at home rather then see your friends
• You may feel like relaxing instead of exercising.
• You may also start looking different before you feel depressed. You may look sadder or less cheerful then normal or wear different clothes. 
• Your thoughts may become more pessimistic or less optimistic. 
• Even changing your radio station from a news station to music could be the first sign of depression. 

Only after all these things happen, you may start to become conscious of feeling depressed.  I talk more about this in my book “Talking to Families about Mental Illness.”

Blurry Goals

While practicing I've come to realize that at times, the goals that the patient has in mind can be very different than what the goals the clinician has in mind. From a clinicians point of view it is about control of symptoms, medication side effects, and doctor patient alliance. All three I believe are essential aspects of treating patients with respect and being competent. In my experience it can be extremely frustrating when the patient is unwilling to work with you on the set goals.

Many times patients have a difficult time accepting their diagnosis and in this case treatment can become more focused on treating a specific symptom of the disease such as an inability to sleep rather than treating the mood disturbance. And while this may be what the patient wants the doctor knows that the regimen may not be working and in some cases maybe even harming the patient. Education is vital when dealing with these patients and while in certain cases it does not seem to be making a difference, it still should be done.

I've also realized that in certain cases setting firm limits and letting the patient know that this is how you believe the treatment should be and what it should focus on is important.

CLEAN UP YOUR SLEEP!!!

I am often shocked by the poor sleep habits of some of my patients with bipolar disorder. Sleep is one of the most important regulators of mood, but surprisingly, many of my patients don't give it much thought. They go to sleep only when they feel tired, they wake up only when they feel like getting out of bed, and they take naps if they feel sleepy during the day. As doctors, we call that bad sleep hygiene.

Good sleep hygiene, on the other hand, is one of the most effective ways to regulate your mood. Did you know that not getting enough sleep can actually trigger a manic episode? And once, triggered, continuing to not get enough sleep can perpetuate it, and make the manic phase more intense, and longer lasting. Conversely, getting too much sleep can cause depressive episodes. More than 80% of people who suffer from unipolar depression complain of insomnia--they don't feel like they're getting enough sleep at night, or the quality of their sleep isn't good.
But interestingly, people with bipolar depression tend to have the opposite problem. They have hypersomnia, or excessive sleeping during their depressive episodes. Getting too much sleep may cause a depressive episode to last longer!
 Also, bad sleep habits can literally be a pain. People who have poor sleep habits, whether too much, or too little, or complain of poor quality of sleep, sometimes develop a condition called fibromyalgia which is a painful, nondegenerative, muscle disorder.
Good sleep hygiene means talking with your doctor about how much sleep you need each night. For patients who are in a manic phase, a doctor may recommend getting more sleep. For patients in a depressive phase, a doctor may recommend getting a bit less sleep. So speak with your doctor about what the optimal amount of sleep would be each night, given your current mood. Then try to go to bed every night at the same time, and set an alarm so that you can get out of bed every day at the same time. And avoid taking naps.  
Stabilizing your sleep is one of the easiest ways of stabilizing your mood.  
So practice good sleep hygiene!
Sweet dreams !

From Jazz to Hip Hop - Routing the Manic Episode

Last week somebody reminded me how individual early signs of mania can be.

Insomnia is a universal late sign of the beginning manic episode. 

Almost all bipolar patients have insomnia during their manic episodes. In other words, when somebody stops sleeping, the manic episode has already begun. In this case prevention and therapy alone are no longer an option. Only aggressive medication treatment can stop a manic episode once insomnia has kicked in.

However, the very early signs of mania are very individual and could be very subtle. 

Changes in voice are common – higher pitch in particular is something to pat attention to. Also common are changes in the way people dress and in the make-up they use. A more revealing style of dress or change of lipstick to a brighter color could be very early signs of oncoming mania. Another sign of an upcoming episode is becoming critical or quarrelsome with people you usually gets along with. Some people actually change the music they listen to such as classical to pop, or jazz to hip-hop. Changes in exercise routine – the list goes on and on...

The take home message is this -- try to remember the very first subtle changes (or patterns) you or your loved ones notice in you before the episode becomes severe and share them with your doctor. In this way both you (and your family) as well as your psychiatrist will be in the position to be early detectors of upcoming mania.

Similar thinking applies to depressive episodes, but I will address this next time.

Stay Healthy!

Dr. G.

Medication Non-compliance is Frustrating For You and Me!

One of the most frustrating situations a clinician encounters is dealing with a client who is habitually non-compliant with their medications.

It's frustrating for me as a clinician because when someone is non-compliant with their medications, they put

 themselves at risk for relapse, decompensation, and possibly hospitalization. I spend a lot of time talking to my patients about medications options, alternatives, and side effects. After spending all of this time with them, I feel cheated when they start to become symptomatic because they didn't take their medications the way I prescribed them. Sometimes patients are honest with me about not taking their medications, other times I find out about their non-compliance when I get the results of their blood work.

Non-compliance comes in several forms:

• Failing to fill the prescription.
• Forgetting or choosing not to take the medication.
  
• Taking a dose that is too high or too low.
  
• Taking the medication at the wrong time of day.
  
• Taking the drug only when feeling symptomatic.

Some common reasons for non-compliance are:

• Unpleasant side-effects from the medication.
• Not wanting the medication to interfere with the "high" when starting a manic cycle.
  
• Feeling that because the symptoms have subsided, there's no need for medication.
  
• Difficulty accepting that bipolar disorder is a chronic illness.
  

The often neglected medicine cabinet

Not taking medication as instructed is one of the most common factors in relapse of the illness. Sometimes people with bipolar disorder don't comply with their treatment because they do not understand the chronic nature of their illness, and sometimes, family members don't understand the illness either.



Your doctor is one of your closest allies in dealing with your illness. Your doctor's goal is to keep you well, and to help you get the most out of life that you can. If you don't like the medications you've been prescribed, or you don't understand why you need to take the medications, the best thing to do is to set up an appointment with your doctor to talk about these issues. Give your doctor the opportunity to help you make to make the best choices concerning the treatment of your bipolar disorder.

Medication Adherence

Working with patients over the last several years has taught be that while the medications that we prescribe on a daily basis have many positive effects they also can be harmful when taken erratically.

Not taking your medication regularly or taking too much at times (doubling or tripling up when you've missed a dose) can have severe side repercussions.

The fact is that we live in an imperfect world where we are constantly finding new effects of commonly used drugs.

Careful monitoring is an essential part of good clinician practice. While doctors have the responsibility to check in with patients about possible side effects and educating them on potential risks/benefits/ and alternatives of medications, it is also the responsibility of the patient to be compliant with medications.

Keeping a medication alarm has been a tip that I have heard from a few patients that prevents them from missing doses as well as sets a routine.     

                                                              
Also carrying a small number of pills in your bag or purse ensures that if by chance you're unable to get home, you can also take your medications on time.

KEEP A MOOD DIARY

Keeping a Mood Diary is a very helpful tool for managing your bipolar disorder. It not only helps you track your symptoms on a daily basis, but over time it will help you to see how your mood patterns emerge. 

• It may help you identify the onset of a new mood cycle, and guide you in taking preventative actions.
• Further, a mood diary will make speaking with your doctors easier, because when they ask you how you’ve been doing, your can pull out your mood diary and show them the actual record of how you’ve been doing mentally and physically, over the last few weeks or months.  
• Lastly, a mood diary will help you stay focused on day-to-day coping strategies, as well as long-term life goals. Keeping a mood diary helps you maintain control over your bipolar symptoms, while reminding you that you have life to live outside of your bipolar disorder.

Here are some things you might include in your Mood Diary.

Mood Chart: Create a scale of your daily mood from 1 to 10 with 5-6 being normal, 1 being very severely depressed, and 10 being severely elevated. Next to the numerical value for that day, write some words that describe how you’re feeling that day. Examples include: energized, annoyed, important, full of ideas, talkative, impulsive, spending, sleepy, sleepless, guilty, drained, apathetic, indecisive, inadequate, hopeless, suicidal.

Anxiety Chart: Chart you level of anxiety and/or irritability. Use a scale of 1 to 4 with 1 being not very anxious/irritable, and 4 being severely anxious and irritable.

Events Chart: Make notes of important events in your life. Include joyful events like a birthday celebration, and stressful events like getting reprimanded at work. Also make a note of how your mood that day had a positive or negative impact on that event.

Coping Chart: If you’re experiencing mood symptoms, either depression or elevation, chart something that has helped you cope with these symptoms in the past. Examples include: contacting your doctor or family/friends, identifying the triggers, avoiding drugs and alcohol, maintaining your normal activities, maintaining good sleep habits, identifying any changes in medications that may be impacting your mood.

Sleep Chart: Chart the time you went to sleep, the time you woke, and rate the quality of your sleep on a scale from 1 to 10, with 1 being very poor sleep with frequent awakening, and 10 being very deep sleep with difficulty awakening.

Medication Chart: Keep a record of your current meds and their dosages and whether you took them, forgot to take them, or chose not to take them.

Body Chart: Rate how you feel physically on a scale of 1 to 3, with 1 being feeling bad, 2 being feeling ok, and 3 being feeling good physically. Also write a word that describes how you feel that day. Examples include: sick, sleepy, sore, strung-out, stable, strong, sexy. Record your weight every day, and for women, chart your period.

Goals Chart: Every month set a goal, or continue to pursue an existing goal. Each day write down anything you did that moved your closer, or further away from achieving that goal.

Notes: Be sure to leave a little space at the bottom just for notes that you’d like to remember about that day.

The Doctor's Perspective

I think as a physician one of the scariest things is watching your patient not do well. Whether it be because they are not taking their medications or that they are just having another manic or depressive episode, it's very difficult to stand and watch helplessly.

While medications can help, sometimes the illness is just too strong and takes time to get under control. In my own experiences when seeing a patient de-compensate, I automatically feel that I'm not doing something I should be. 

In these instances I find it particularly helpful to speak with patients families about what we can do to help get the patient well. I also find that getting input from colleagues has helped.

Ultimately, I've found that asking for help is never a bad thing. One of the prior blogs mentioned the importance of utilizing patient family and friends as a resource for education which I absolutely second!

Support Networks

Dear Reader,

While all of us need them, for patients with bipolar disorder, support networks can be an essential part of the maintenance of this illness. People with bipolar disorder, when either in manic or depressed states, can often lose touch with reality and lack insight into how they are functioning. An aware and reactive support network can be essential during these times.

Who’s in a support network?

Support networks can be as big or as small as one chooses. Often they can include parents, siblings, close friends and even co-workers. Whomever is in your support network, these are people that you feel comfortable sharing the various facets of your illness with. These are people that often have known you for years and can offer acceptance and support if you become ill. Often patients will tell me who the key people in their support networks are. They will also give these people permission to notify me, as their doctor, if they notice any of the more dangerous symptoms of bipolar disorder appearing, such as risky or dangerous impulsive behavior or intense thoughts of self harm in the patient. Oftentimes, when these symptoms start to appear, the person living with bipolar disorder may not be as attune to them as a friend or family member who is able to see symptoms from a more objective perspective.

How to build a support network?

It’s important for people who are diagnosed with bipolar disorder to engage the family members and friends whom they trust from the beginning of a diagnosis. These are the people who love and care about you. These should be people who are there for you in both your joyous moments, and times of illness or despair.

In what ways can people in support networks be helpful?

When a person with bipolar disorder becomes sick, it sometimes may be difficult to listen to advice from multiple new sources. Sometimes these new sources may be doctors, whom the person suffering may or may not know very well. Friends and family in your support network can often act as a liaison between you and your doctors. The people who know you well are often the first to notice when your mood is not as it normally is and are often able to share these thoughts with you. When this information is coming from trusted sources, it is often easier to understand and interpret at a time where in may be difficult to process what is happening to you. Often the people in your support network can help you make the initial steps to contact your healthcare provider when symptoms arise, and this may allow you to treat symptoms before they escalate and in some cases may require more intensive treatments. Anything that can be done to lessen the amount of manic or depressive episodes, will be of benefit to the person suffering from bipolar disorder in the years after a diagnosis is made.