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.