About Bipolar Depression

So I’m going to be talking
today about bipolar depression,in adults.,And I’m hopeful that I
can help you understand,more about bipolar disorder
in general through this talk,,and also provide an overview
about diagnosing this illness,and treating this
illness, particularly,during the depressed phase.,As Nora mentioned,
I have been here,at Stanford for quite some time.,Did my residency here and then
did a post-doctoral fellowship,doing research and clinical
work in bipolar disorder,under the mentorship
of Terence Ketter.,And for the past
couple of years,,have joined the faculty at
the Bipolar Disorder Clinic.,So I’m going to talk today
about first summarizing,clinical features of
bipolar disorder in general,for people who don’t
have a lot of familiarity,with the illness.,And then talking about the
specific challenges and issues,that come up when diagnosing
bipolar depression in adults.,And then discussing some
of the other challenges,that come when you have to
approach treatment for bipolar,depression in adults.,,So bipolar disorder is
a psychiatric illness,that involves basically what we
call in lay terms mood swings.,And more specifically
what we mean by that,is that people have fluctuating
periods of depression and mood,elevation.,And we call them mood elevation
episodes of mania or hypomania.,The illness can affect up
to 4% of the population,,depending on how
broadly you define it.,And one thing to remember
is that bipolar disorder,is a lethal illness.,It does have a risk of suicide
that’s up to 20 to 30 times,greater compared to
the general population.,So it’s an illness that
requires careful attention,,careful monitoring,
and treatment.,,Bipolar disorder,
even if it doesn’t,cause the more extreme
problems of suicide,,is also a leading
cause of disability.,And this is across the world.,Looking at the World Health
Organization’s “Global Burden,of Disease Report,” you
can see that globally,in males and females when we
look at a statistic called,Years Lost to Disability–
so basically looking,at the disability related
burden of bipolar disorder–,it is the seventh
leading cause in males,and the eighth leading
cause in females, which,is quite astounding given
that it only affects 1% to 4%,of the population.,,So how do we diagnose
bipolar disorder?,These ideas and concepts may
be familiar to some of you,,but I wanted to make sure
that everyone understands,what bipolar disorder is.,So bipolar disorder has
two major mood states.,One is depression and the
other is mood elevation.,So you can diagnose
bipolar disorder,once someone has had a major
depressive episode as well,as a mood elevation episode.,And major depressive
episodes are characterized,by at least two consecutive
weeks of sadness or loss,of interest in your
usual activities or loss,of enjoyment of things
that would normally,be enjoyable to the person, and
in addition to those symptoms,,you need to have three or
four additional symptoms, some,of which are more physical,
like change in appetite, sleep,,and energy.,And some are more psychic,
like decreased self-esteem,,feelings of excessive
guilt, suicidal thoughts.,People are often also dealing
with difficulty concentrating,,indecisiveness when
they’re depressed.,So there’s some cognitive
changes as well.,And in addition to having
a major depressive episode,,what distinguishes
bipolar disorder,from unipolar
depression– and we’ll,talk more about that– is the
presence of either a manic,or a hypomanic episode.,And for mania, you need
to have at least one week,of consecutive mood
elevation symptoms.,And for hypomania,
the requirement’s,a little bit more lenient.,You only need four days in a
row of mood elevation symptoms.,And so what are the symptoms
that we’re talking about?,There’s a mood change.,So the mood becomes either more
euphoric, giddy, excitable,,or more irritable,
very easily frustrated,,losing their temper more easily
than they normally would.,Or those two mood states could
be occurring in combination,with one another,
and they often are.,And in addition, our recent
Diagnostic and Statistical,Manual of Mood Disorders,
DSM 5, was released,,and added the criteria that
in addition to these mood,symptoms, a person
also has to be,experiencing increased
energy or increased,goal-directed activity.,And beyond these
symptoms, one also needs,to be experiencing three or
four of these other elevations,symptoms like being more self
confident, more grandiose,,needing less sleep than usual.,This is a very common symptom
during an elevated state.,Being more talkative than usual.,Feeling like your
thoughts are racing.,Being more easily distracted.,For example, starting
one thing and suddenly,getting excited about something
else and forgetting the one,thing you were doing and
kind of moving around,multitasking, but often not
in a very productive way.,One probably would also
experience an increase,in their activity level.,Suddenly wanting to write
a novel, join 20 clubs,,stay up all night doing
some kind of new project,or cleaning the house.,So that’s the kind
of thing that might,happen when someone’s elevated.,They might also just
be physically restless,,needing to pace, walk around.,They can’t sit still.,And impulsivity or risk taking
is also another common symptom,during an elevated state.,People will, for example, just
spend down their credit cards,or drive dangerously,
get into legal trouble,because they feel like
nothing could stop them,or they’re not thinking
about consequences.,,So mania, as opposed
to hypomania,,is really distinguished
by the severity level.,In addition to this
increased duration that’s,required, in order to
qualify as a manic episode,the episode should be
pretty severe, enough,that it requires them to be
hospitalized for the episode.,They’re psychotic
during the episode.,Or they’re experiencing
really major problems,as a result of it.,For example, having
to declare bankruptcy,because they overspent too
much, losing their job, getting,divorced because they
created too many problems,in their marriage,
getting into jail.,These are the types
of severe consequences,that would accompany
a manic episode.,,So putting that
all together, I’ve,talked about bipolar
disorder in terms,of major depressive episodes
and either manic or hypomanic,episodes.,And we divide bipolar disorder
into two key subtypes.,Bipolar I is someone who’s
had at least one manic episode,in their lifetime.,They don’t even have
to have had depression.,As long as they’ve had one
mania, they are considered,Bipolar I. Bipolar II
disorder is characterized,by having depressive
episodes as well,as at least one hypomanic
episode in one’s lifetime.,And unipolar depression or
major depressive disorder,is characterized by having
only major depressive episodes.,And so what you can see is that
all of these mood disorders,are characterized
by fluctuations,from a person’s baseline.,So if that black line is where
the person is when they’re,feeling normal or well, you
can see in Bipolar type I,,you’re getting these wide
fluctuations up and down.,In Bipolar II, you’re
getting the downs and maybe,more mild fluctuations
above the baseline.,That’s the hypomanias.,And in unipolar
depression, you’re,really just getting
the down fluctuations.,They’re not getting elevated.,,So what can be
difficult about when,you’re sitting in
a doctor’s office,and they’re trying to
determine if you have bipolar,disorder or unipolar or
major depressive disorder,,the challenge is that depression
looks pretty much the same,,more or less, whether
you’re bipolar or unipolar.,,And as a result, 40% to 60% of
patients with bipolar disorder,will get misdiagnosed
with unipolar depression,and subsequently
get, perhaps, a delay,in the appropriate treatment
that they should be receiving.,So why does this happen?,Maybe the patient can’t remember
or isn’t aware that they’ve,ever had mania or hypomania.,Maybe the psychiatrist
doesn’t ask about it,or they’re focused
on the depression.,There could be a lot
of different reasons.,Another big reason
is that about half,of bipolar disorder patients
experience depression,as their very
first mood episode.,So they’ve never even
had a mania or hypomania.,That’s not going to
happen until later,in their course of illness.,And at the time they’re
sitting in the doctor’s office,,nobody knows yet that they
have bipolar disorder.,Now, that being said,
there are certain clues,that a person might, if
they’re sitting in your office,,they’re depressed,
and they may never,have been manic or hypomanic,
that they might actually,have bipolar disorder.,So there are
certain risk factors,that have been established.,If your first major
depressive episode,occurred at under
25 years of age,,that increases the
likelihood that you’re,bipolar by two-fold.,If you have a first degree
relative with bipolar,disorder– this would
be a parent or a sibling,or a child– you’re
two and a half times,more likely to be bipolar.,If you’ve had a
history of psychosis,,whether the psychosis occurred
during depression or mania,or hypomania– and
in this case, we’re,talking about
someone who’s maybe,been psychotic during
depression– then that’s,a three-fold increase
in the likelihood,that you actually
have bipolar disorder.,,Another thing to bear in
mind is that bipolar disorder,is a heritable illness much
more so than major depressive,disorder.,So if you compare
the two illnesses,,major depressive disorder
is much more prevalent,in the population.,As many as 10% to
17% of individuals,will have an episode
of major depression.,Bipolar I disorder, having
had a manic episode,,only occurs in about
1% of the population.,If you have a first
degree relative with one,of these disorders–
major depressive disorder,,if you have a first degree
relative with major depression,,your odds of having
major depression,go up about three-fold.,If you have a first degree
relative with bipolar disorder,,your odds go up tenfold
of having bipolar illness.,The identical twin risk.,You can see if you
have an identical twin,with major depressive disorder,
the chances of the other twin,having it are 20% to 45%.,Whereas in Bipolar
I disorder, it’s,significantly
higher, 40% to 70%.,Although it’s not
100%, which suggests,that there’s more than
just genes involved,in the cause of
bipolar disorder.,And we don’t fully
understand this illness,and the causes of it.,But what we do know, from
estimates of large data sets,,is that the heritability
of bipolar disorder,,which means that the
amount of the risk that’s,due to genetic factors, is about
85% compared to only 30% to 40%,of major depressive disorder.,So what we can say to distill
it down to the simplest terms,is that in major
depressive disorder,,genetics and
environment probably,have a similar level of impact
on your risk for the illness.,Whereas in bipolar
disorder, genetics,have a far greater
amount of impact,on your risk of getting the
illness than your environment.,But the environment
still probably matters.,,So talking more now
about bipolar depression.,Depression does account for the
majority of the illness burden,amongst patients with
bipolar disorder.,So these are based on
some longitudinal studies,in the NIMH collaborative
depression study,where patients were
followed over time,with sequential interviews.,And they were able to
estimate how much percentage,of time they spent in
different mood states.,And they separated this out
by Bipolar I and Bipolar II,disorder.,And as you can see in both
types of bipolar disorder,,about half the time
people are actually,symptom-free on average.,In Bipolar I disorder,
then another third,of the time they’re depressed
and about 15% of the time,they’re manic or mixed.,In Bipolar II disorder, you
can see it’s almost like 50/50.,They’re either depressed
or they are symptom-free,,with a very small
proportion of the time being,spent in a hypomanic
or elevated state.,And so this is important,
as patients with Bipolar II,disorder might
question whether they,have bipolar disorder
because they’re,just always either
OK or depressed,and not the high periods.,And this really emphasizes
that that’s classic.,That’s not out of the ordinary.,Patients with
Bipolar II disorder,will tend to have a greater
burden of depression,in their illness than Bipolar
I. But you can see here,that depression in both
types of bipolar disorder,does predominate the
course of the illness.,,Another important
thing to know is,that if you look at studies of
functioning in bipolar disorder,and you look at the impact
of depression on functioning,,it really has a dramatic
impact on occupational and just,general life functioning.,And it seems to be more
pronounced than the impact,that mania or hypomania
would have on functioning.,And it’s important to
see here in this graph,that as you get more
symptoms of depression,,your overall functional
impairment increases.,But you can start seeing
that increase even,at milder sub-syndromal
levels of depression.,And so what’s
going on this scale,is a depression rating score.,The higher numbers
are more severe.,And as you go up on
the y-axis, you’re,seeing percent of people
impaired in their functioning.,And even at sub-threshold
levels of depression,,you’re seeing a dramatic
increase in how many people are,impaired in their functioning.,So treating even milder
sub-threshold depression,symptoms can be an
important target.,,And bipolar depression,
as you might expect,,has a large impact
on risk of suicide.,Now, what the
table shows is just,the risk of suicide in
bipolar disorder in general.,Attempted suicide, estimated
annual rate of 3.9%.,And death by suicide, the
estimated annual rate is 1.4%.,While these numbers, they’re
all less than 5% or so,,you can still see compared
to the general population,they’re manifold higher.,And suicide attempts
in bipolar disorder,are far more likely to occur
when people are depressed,or in a mixed state with
some symptoms of depression,along with mood
elevation rather than,in a manic or hypomanic state.,And individuals who over time
have more of a depression,predominant illness
that experience,a lot more depression
than mood elevation,are more likely to
attempt suicide than those,who tend to have more manias.,,And depression and
bipolar disorder,affects not only the patients,
but their caregivers,,the family and friends who take
care of them when they’re ill.,Bipolar depressive
episodes appear,to be associated with
a greater caregiver,burden than manic or
hypomanic episodes.,And increased
caregiver burden is,associated with
even the caregivers,becoming more depressed and
having more health problems.,So it’s an important
thing to remember,that treating the
bipolar depression,,it’s about treating the patient
as well as people around them,,making sure everyone
has support.,There’s a lot of
great support groups,out there, if you’re familiar
with NAMI or the DBSA,,Depression Bipolar
Support Alliance.,If you’re a family
member dealing,with bipolar disorder
in a loved one,,it’s really important
to get support,that you need because
this illness affects,everyone who’s in the
circle around the patient.,,Now, how do we treat
bipolar depression?,I’m going to provide a little
bit of an overview of bipolar,treatment in general,
but then hone in,on what we do for depression.,This is a lot more detailed
than you need to understand,,but the key takeaway
points from this chart,are that when we approach
the treatment of bipolar,disorder as doctors,
we tend to approach it,based on what phase of the
illness the person is in.,So it’s not like there’s one
treatment for bipolar disorder,period and you just use it.,You have to think about
what state the patient’s in.,And so a lot of
the drugs are meant,to target the acute phase
of bipolar disorder,,and that can either be acute
mania or acute depression,or it could be an
acute mixed state.,And so drugs that get
FDA approval will get,approved for one
of those states.,Either they’re
approved for mania,or they’re approved
for depression,because the clinical
trials specifically,went after that mood state.,Once you’re recovered from the
acute phase, then what you do,is you shift into this
what we call maintenance,phase of treatment
where the goal is not,to get you out of
the illness phase,,but really to prevent
or delay recurrence,of the depression or the mania.,And so there are specific drugs
that are FDA approved just,for maintenance.,And often, it’s
the same drugs that,are used for the acute
phase will get also used,in the maintenance phase.,,So these are the different
FDA approved agents,for bipolar disorder separated
out by the phase of illness.,One of the things to notice
here is that in 1970,,all we had was lithium, really.,And then chlorpromazine
came along in ’73,and got approval for mania.,And then there was
a really long lag,there where there was really
nothing else going on.,And then in the mid ’90s,
we realized that Depakote,worked for acute mania.,And then a lot of
interest came about,after that to look at the
other anti-convulsants,and see whether they might
work in bipolar disorder.,A lot of that didn’t
really pan out.,It did turn out
that lamotrigine,,which you can see on
the longer term list,,looked very promising initially
for bipolar depression,,but it didn’t really
separate from placebo,,but ultimately got FDA approved
for longer term maintenance,treatment of bipolar disorder.,And then most of the action
really happened in the 2000s,when the anti-psychotics
started getting approvals one,after another for acute mania at
first and also for maintenance,treatments.,But what you can really see
here is under acute depression,,we only have three FDA
approved treatments.,This is really the huge
unmet need in pharmaceuticals,for bipolar disorder.,And it’s not that they haven’t
tried some of these agents,for depression.,It’s a lot of them
haven’t proven to be,more effective than placebo.,So what we have now is
three FDA approved agents,for bipolar disorder.,Only three, despite
the fact that this,is the most prominent illness
phase in bipolar disorder.,,So what I talked about in this
slide is efficacy, really.,So what drugs work,
what drugs beat placebo,in the clinical trials.,But the other side of
the coin is tolerability,,and this is a huge challenge
in treating bipolar disorder.,A lot of the
medications that we use,have really bad side effects.,,And so one way to think about
it is the schematic here.,There’s a pyramid showing
you at the bottom what,are the medications that tend
to have the fewest side effects.,And these will be things
like antidepressants,or newer mood stabilizers
like Lamictal or lamotrigine.,As you start going
up the pyramid,,you get drugs that have a more
moderate level of side effects.,And this would be older mood
stabilizers like lithium,,divalproex, carbamazepine.,And some of the more recently
approved second generation,anti-psychotics like
aripiprazole, ziprasidone,,asenapine, and lurasidone.,And then at the
top here, that tend,to have the highest
liability for side effects,are the older second generation
anti-psychotics, risperidone,,olanzapine, quetiapine, and
clozapine are listed there.,And if we were to put an
arrow showing efficacy,,it might go in the
opposite direction.,You tend to get the most
robust efficacy up at the top,and it tends to
get a little weaker,as you get to the bottom.,So we’re always doing
this balancing act,of how to get efficacy
balanced with tolerability,with the medications
that we use.,And so that’s really
one of the challenges,in treating this illness.,So what I’m showing you
here are the three FDA,approved treatments
for bipolar depression.,Olanzapine fluoxetine
combination, quetiapine,,and lurasidone.,And I’ve listed the most
common adverse effects.,And cost is also a
concern for many people.,Olanzapine fluoxetine
combination,was the first treatment
to get FDA approval,for bipolar depression.,Olanzapine alone
and fluoxetine alone,didn’t seem to really cut it.,The combination of the
two synergistically,worked very well.,The downside, though,
is that olanzapine–,I don’t know if you’re
familiar with it–,has a huge risk of weight gain.,Upwards of half the people
who take it, maybe even more,,will experience significant
weight gain on this medication.,Metabolic side effects
go along with that.,Dyslipidemia, insulin
resistance, diabetes risk.,And it can be sedating as well.,Cost-wise, it’s kind
of in the middle.,If you had to pay out of
pocket, it might be a little bit,difficult. But usually,
it’s covered by insurance,because it is generic.,Quetiapine or
Seroquel is well known,for its sedating effects, which
sometimes is not a bad thing.,If you’re having a lot of
insomnia or a lot of anxiety,,it can be calming.,But many people find that
it’s just too sedating,to be able to tolerate.,And it can also cause
some weight gain and some,of the metabolic side effects.,Not as pronounced as olanzapine,
but the risk is still there.,And cost-wise, it’s also
available in generics,and it’s usually
covered by insurance.,Lurasidone was the most
recently FDA approved agent,for bipolar depression.,It’s looking promising
in terms of tolerability,because it seems
more weight neutral.,Some people will gain weight
on it, but it’s not common.,And it’s not
particularly sedating.,The downside of lurasidone is it
can cause a side effect called,akathisia which is really
a feeling of restlessness,,an agitation.,And so people with
anxiety may not,like this medication so much.,It can also cause nausea.,And if your insurance
covers it, that’s great.,Even if it does, you may
have a very high co-pay.,It’s still pretty expensive.,It’s not available in generic.,If you have to
pay out of pocket,,it’s probably a deal
breaker for that medicine.,So these are our three options.,As you can see, they’re
not by any means perfect.,They did prove their efficacy
in the clinical trials.,I have seen them
work in my patients.,But they have some
side effect liabilities,and/or cost liabilities.,So as clinicians, we
often start moving,to the non-FDA approved
medications as alternatives.,And I’ve listed the most common
ones here that you might see.,Lamictal or
lamotrigine, lithium,,and the antidepressants.,And lamotrigine gets commonly
used because, as I said,,in the earlier
clinical trials it,looked like there
was a signal there,where it was going to be
placebo for treating depression,in the acute phase.,And then when they
looked at more studies,,it wasn’t replicated.,But because of that and
because of the maintenance,trials which show that it has
a good depression prevention,benefit– meaning
once you’re stable,,it seems to delay recurrence of
depression– it’s commonly used,to treat bipolar depression.,It’s not an actual
antidepressant.,It’s an anti-convulsant,
which maybe helps in,that it’s not as likely to
cause a treatment related mania.,There is this rare
risk of a serious rash.,Very rare, but it’s
life threatening.,So we go up very
slowly on the dose,so it takes longer to get you to
a therapeutic dose of Lamictal,or lamotrigine.,But it is quite inexpensive.,It’s been available in
generic for quite some time,,and it’s almost always
covered by insurance.,So you might see doctors
prescribing lamotrigine often,for bipolar depression.,Lithium is tried and
true first line treatment,for bipolar disorder.,There is some
modest efficacy data,suggesting it’s better than
placebo for bipolar depression.,It’s not as robustly effective
as the FDA approved ones,that I’ve already described.,Lithium has a laundry list
of potential side effects,that not everyone
will experience.,But the most common ones being
tremor, really excessive thirst,and urination, and
potential complications,for the kidney and the thyroid
that require monitoring.,It’s very inexpensive and
almost universally covered,by insurance.,antidepressants.,Now, this is somewhat
more controversial.,They are amongst the most
commonly prescribed treatments,for bipolar disorder still.,They have some liabilities.,They tend to be
pretty well tolerated,in terms of side effects.,And this is probably
why they’re commonly,used, in addition to
the fact that we just,have a lack of adequate
treatments for bipolar,depression.,,There has in the past been
a lot of fear and concern,that giving an antidepressant
to a bipolar disorder patient,will make them manic.,This does happen.,It doesn’t happen quite as
often as we thought it did.,And so we actually
have started thinking,this is more of a rare
potential adverse effect,of antidepressants, but not the
top of our list of concerns.,And particularly if you take an
antidepressant with something,that is anti-manic like
lithium or an anti-psychotic,,that risk seems
to be fairly low.,Most antidepressants
are pretty cheap,except for some of the brand
new ones that have recently,come out.,Most are covered by insurance.,So I want to spend
a little more time,on the antidepressant
thing because they,are so commonly prescribed.,They are a topic of
a lot of controversy.,,The real problem
with antidepressants,is not that they’re
going to make you manic,or there is the suicide
risk in younger people,,but that also is controversial.,What’s really demonstrated
time and time again,in large studies, meta analyses,
is that they really just,don’t work for bipolar disorder.,So what you can see
here is a meta analysis,of antidepressants in
acute bipolar depression.,Antidepressants
compared to placebo,yielded very similar
rates of response,in remission from depression.,And just to go back to
my earlier point here,,this is showing rates
of switch to mania.,So how often people
on these medicines,in these clinical
trials became manic.,And you can see they’re
almost identical rates,in the antidepressant
and the placebo.,So there really
doesn’t seem to be,this dramatically increased
risk with antidepressants,of getting manic.,But the main problem is really
that they’re not effective.,We use them a lot because
certain patients do respond.,Do we know whether
they’re really responding,or whether it’s
a placebo effect?,No.,We’ll never know that.,Do we know whether
they’re responding,or if their depression was just
going to get better anyways?,We don’t know.,But we do know that
antidepressants,are easy to tolerate.,They’re cheap.,They’re something to try when
the other medications are,either not feasible
or don’t work.,We often add them to
other medications.,We do use these medicines.,I have seen them work.,But if you look at
large data sets,,it’s just not supportive
of these medications,for bipolar disorder.,,So something to bear in mind.,,I wanted to touch on
adjunct of psychotherapy,in bipolar disorder.,It’s not recommended that
someone with bipolar disorder,have psychotherapy alone
without medications.,It hasn’t proven to
be effective enough.,You tend to need medications
plus psychotherapy,,and adding psychotherapy
to medications,is highly recommended.,It can be very helpful.,A few particular
types of psychotherapy,have been studied
in bipolar disorder.,That would be
family-focused therapy,,cognitive behavioral
therapy, and interpersonal,and social rhythms therapy.,And what some
studies have shown is,that outcomes are better if
you receive psychotherapy,plus medications as
opposed to meds alone.,It seems to be
that psychotherapy,is more effective for
relapse prevention rather,than the acute episodes.,So again, in that maintenance
phase of treatments,,adding psychotherapy can
prolong wellness and keep people,well longer than
just meds alone.,If you’re actually in an
acute episode of depression,,it hasn’t really panned out
that adding psychotherapy,speeds recovery.,,There are some other
treatment modalities aside,from medications that we
might turn to if medications,aren’t working.,The one at the top,
electroconvulsive therapy–,this might be
something you might,be more familiar with, it’s
been around for a long time–,can be very effective
for treatment resistant,depression in unipolar
and bipolar disorder.,It is highly invasive.,Requires you often to be in
the hospital for the beginning,of the treatment.,You do need general
anesthesia to undergo,electroconvulsive therapy.,There are some
cognitive side effects,that some people just don’t
want to have to deal with.,You can get memory loss.,You can get anesthesia
related adverse effects.,So you go to ECT when the
medications aren’t working,and the depression
is severe enough,that both the doctor
and the patient,agree that this is
what needs to happen.,,But it can work when
everything else has not worked.,I’ve listed here repetitive
transcranial magnetic,stimulation, rTMS.,This is a newer treatment.,It’s not so new anymore.,It’s now gotten FDA
approval for treating,treatment resistant depression.,It’s a lot less invasive
and time intensive than ECT.,You can do it entirely
as an outpatient,and you don’t need anesthesia.,You basically receive
local magnetic stimulation,to the scalp.,And it’s unclear how
effective this is going,to be for bipolar depression.,There really isn’t a
lot of data out there.,More data has been available
for unipolar depression.,But it might be
something to try if you,want to go the route of a
more intense intervention,but don’t want to do the ECT.,It’s probably going
to be expensive,because it’s hard
to get insurance,to cover this treatment.,Ketamine is something that’s
very novel, very experimental.,It’s being studied.,Not available commercially
as a treatment.,But it’s shown in studies to
have very rapid antidepressant,effects.,Now, most of the treatments
we have for depression,take six weeks, sometimes
eight weeks to work.,Well, ketamine
works immediately.,What they’ve been
looking at it in,is people who are very
depressed and suicidal.,They’ll get the
ketamine IV infusion.,And almost immediately, the
suicidal ideation resolves.,Their depression lifts.,They’re feeling better.,Unfortunately, the effect seems
to only last a few days, maybe,a week or two at most.,And then it goes away.,And they haven’t yet
been able to find a way,to sustain the effect
without additional infusion.,So it’s not a very practical
treatment at this point.,It’s still pretty experimental.,The actual mechanism
is still in question,,whether this is something that’s
really going to be sustainable.,,But I list it here as
something that’s exciting,,a new inroad into treating
difficult to treat depressions.,,I wanted to end on a
positive note here.,I’ve done some
research in this area.,My mentor, Dr. Ketter, has done
a lot of research in this area.,Bipolar disorder is,
as I’ve mentioned,,a very disabling and
disturbing illness.,But there are some
things about it,that there could be a little
bit of a silver lining,here, that there is a link
between bipolar disorder,and increased creativity.,And we can see here,
many eminent individuals,who have suffered from
bipolar disorder, some of whom,have been public about it.,,This is a study that
was done by Ludwig,who looked at over
1,000 biographies,of eminent individuals and
looked at rates of mood,disorders– so not
just bipolar disorder,,but also unipolar depression–
in these individuals.,You can see clustered at the
top are the more creative arts.,Poetry, fiction, theater, music.,You can see that the
rates of depression,are quite a bit higher up
there than you see down,at the bottom where we
get the military, science,,public office type people.,And then also the
rates of mania seem,to be a little bit more
prevalent as you go up,into these more creative arts.,There’s been a lot of
studies on this topic,,and this is just one example.,But it does seem to be
that bipolar disorder is,over-represented in
creative individuals,,and creativity may be
over-represented amongst people,with bipolar disorder.,And what it seems to be is there
is some kind of an interaction,here where bipolar disorder is
associated with a specific type,of personality or temperament.,And that, in turn, interacts
with the bipolar illness,to fuel greater creativity.,And so if you look at
creative individuals who,have no mental illness and
patients with bipolar disorder,,you can find a lot of
crossover in their personality,and temperamental traits.,It’s just food for thought.,But it’s something to feel
good about, that there might,be some strengths
despite the suffering,of the different illness phases.,,So to summarize,
bipolar disorder,is a chronic and
recurrent illness.,It affects up to 4%
of the population,,is a leading cause of
disability around the world.,Depression really does account
for the majority of the illness,burden of bipolar disorder in
terms of both time spent ill,and amount of
functional impairment.,There’s an unmet need for
effective and well-tolerated,treatments for
bipolar depression.,Creativity and
creative achievements,may be increased in people
with bipolar disorder.,This is potentially mediated
by personality and temperament.,,Wanted to post some of
our current studies,,if you’re interested.,We are doing a study right
now of a medicine called,Suvorexant, a recently
FDA approved treatment,for insomnia that we’re
looking at in bipolar disorder,patients who have insomnia.,And that’s for patients
ages 18 and older,who have bipolar
disorder, are currently,experiencing insomnia.,I’ve listed the
phone number there,you can contact if you’re
interested in that.,Infliximab for
bipolar depression,is another study for
patients ages 18 to 65,diagnosed with Bipolar
I or II disorder,currently experiencing
symptoms of depression.,Please note that’s a
different phone number.,There’s two different phone
numbers for these studies.,,And I’m happy to take any
questions at this point.,,Go ahead.,Me?,Yeah.,Is it fair to say that there
is no quantitative diagnostic,technique for bipolar disorder
as well as other kinds,of mental disorders?,Is it fair to say that?,So the question is,
is it fair to say,there is no quantitative
diagnostic technique,for bipolar disorder as well
as mental disorders in general.,I would say at this point in
time it is fair to say yes,,that we lack that type
of quantitative data.,We’re making great strides
in looking at genetics,,looking at other
types of bio-markers,,neuro-imaging that might help
us at some point in the future,be able to tell
what a person has.,At this point, we
are still, what we,might say, in the “dark ages.”,We’re really relying on what
the patient sits in front of us,and tells us.,We’re relying on what their
family members tell us,about their behavior.,It’s very clinically driven
interview and history based,diagnoses at this point.,And the folks at the National
Institute of Mental Health,are very unhappy
with the situation,and really want to
drive forth research,that looks at more
quantitative ways,to diagnose and understand
these illnesses.,A follow-up question to that
is that if that is the case,,then it makes your job, to
treat bipolar disorder with any,of those medications
and then try to assess,the efficacy of any treatment.,So the point was made, it
makes it very challenging, yes,,to diagnose and
treat the illness.,And as I’ve suggested,
it can be challenging.,We do look for certain
clinical markers,that suggest a risk of bipolar.,Back there.,I’m wondering if
you could comment,on the link between ADHD
and bipolar disorder.,How often do you see it?,Are they related in some way?,And with respect to ADHD in
a person that has bipolar,,can you prescribe Adderall?,Should they be using Adderall?,Good question.,So I was asked about the
link between ADHD and bipolar,disorder and how do you
treat– specifically you’re,asking how do you treat ADHD
in someone who has co-morbid,bipolar disorder.,So this is an issue
that comes up very often,amongst pediatric populations.,There does appear to be
some link and an increased,co-morbidity of
these two illnesses,,particularly in children.,What it seems to be is that
patients with bipolar disorder,have a higher rate of ADHD than
kids without bipolar disorder.,But if you look at
people with ADHD,,there doesn’t seem
to be an increased,rate of bipolar disorder
amongst those patients.,But some people
would beg to differ.,But in general, it
seems to be the case.,So there is a link.,In adults, ADHD tends to not
be as commonly diagnosed.,There is some thought that
it burns out in adulthood.,So it comes up more and it’s
better studied in children.,Can you treat the ADHD?,What is ADHD?,Sorry.,Attention deficit
hyperactivity disorder.,Yeah.,And can you treat it?,From what I’ve seen,
the risk is there,that the stimulant medication
can exacerbate the mood,symptoms and potentially
trigger mood elevation,if you start one of these
medicines in someone,with bipolar disorder.,But there have been
other researchers,who have argued that if you
adequately treat the bipolar,disorder with mood stabilizers,
anti-psychotics, et cetera,,that you can then
safely treat the ADHD,with careful
monitoring to make sure,that they’re not experiencing
destabilization of their mood.,It’s still tricky.,You got to make sure,
because these stimulants can,cause insomnia.,Insomnia is a big problem
in bipolar disorder,,and you don’t want
to make it worse.,But I would say
it’s controversial,,but there’s an argument to be
made that if you adequately,treat the bipolar
disorder first then,you can start going on to
start treating the ADHD.,,Are there any new medications
or treatment strategies,,maybe with less
medication, that you’re,aware of that look promising?,So the question is are there
new treatment strategies,that maybe are non-medication
oriented that look promising.,So some of the ones
that I brought up here,,I don’t know how promising they
are because that the data just,isn’t there in bipolar disorder.,For rTMS, for example.,But this might be a treatment
that can be helpful.,It’s a non-medication
treatment for people,who have failed to
respond to medications.,Ketamine, I know there was a
study in bipolar depression,that looked good.,But again, this has
its own limitations.,So there’s other advances
being made in TMS,looking at specific parts
of the brain to target,,looking at different
modalities of TMS.,That’s the new horizon of
what people are looking at.,But right now, I
think we’re really,dealing with medications.,And most of the
development has been,in anti-psychotics,
which unfortunately,do carry a lot of side effects.,So we do have a great need for
more discovery in this area.,The answer to this
question is yes, please.,Is there any hope for food,
nutrition, foods or supplements,and exercise going with
the person’s strengths,and lessening the medication?,So the question is can food,
dietary changes, or exercise,,more natural approaches, be
effective in bipolar disorder.,,So there are some what we
call nutraceuticals that,have gained some attention.,These are things like
inositol, deplin–,which is involved in
folic acid, processing it,,somewhere along the
pathway of serotonin.,,There’s been some
excitement about these.,They haven’t really
gone that far,or proven themselves that well.,But there are some doctors
out there who prescribe these.,And patients will say they
have maybe a mild or moderate,effect.,Food, I’m not as familiar with.,I know that maintaining
a healthy diet,and healthy exercise regimen
is always a good thing.,And exercise, in particular,
can be a mood lifter,,can be very helpful
in depression.,If you’re dealing with bipolar
depression, unless it’s mild,I would say that you’re not
going to get much mileage out,of just doing these
natural things.,You are going to need
something more intensive.,But if you’re on good
medicine and you’re,getting a little bit of mild
depression, then certainly,I always recommend that my
patients get more active.,They start doing more social
things, being more involved.,And exercise, of course,
to maybe get themselves out,of it without having to
increase or add more medicine.,So there’s some room for that.,It’s not going to be really that
helpful in a very severe case,of depression.,But yes, good question,
thanks, In the back.,Has there been any history of
treating bipolar depression,with EMDR?,So the question is has there
been experience treating,bipolar depression with EMDR?,EMDR is a form of
psychotherapy that,has gained a lot of momentum in
the treatment of particularly,trauma related mental
illnesses like PTSD.,And I am not aware
of any studies,looking at this particular
modality in bipolar disorder.,Just speaking
anecdotally, I have,a number of patients who do
pursue that type of therapy.,They find it helpful
and therapeutic.,What we do know about
psychotherapy in general,is that the key
factor supporting,the success of the
therapy is the alliance,between the patient
and their therapist.,So there are these
evidence-based treatments,like CBT.,They are very good
for clinical trials,because they’re manual based.,They’re very regimented.,So you can study them in
these controlled fashions.,But I would say that if
you feel a good connection,with your therapist
and you’re responding,well to whatever
their approach is,,it’s probably going to help you.,,Yes?,Once of your slides mentioned
interpersonal and social rhythm,therapy.,What is that?,What is that?,And what is the role?,In what phase of the
illness is it useful?,,So I mentioned interpersonal
and social rhythm psychotherapy.,And what is that?,Where does it help?,So this was developed
out of Pittsburgh.,There is already a type
of psychotherapy called,interpersonal
psychotherapy that’s,widely used in manual based.,Interpersonal
psychotherapy focuses,in on an interpersonal problem
in one’s life and really hones,in on that as the source
of a person’s distress,and tries to break that
down and work on it,over a number of sessions.,Interpersonal and
social rhythms therapy,is building on that model.,They’re adding
into it a component,that was felt to be
particularly relevant,for bipolar disorder,
which is social rhythms.,The idea that your social
rhythm, your social routine,,your interpersonal patterns are
very important in maintaining,your mood stability.,So they will focus on aspects of
routine, medication adherence,,sleep, hygiene.,Things like that
are very important.,And what phase of illness?,Again, as I mentioned,
these therapies,have mostly proven to be
effective in the maintenance,phase, in delaying the
recurrence of mood episodes,when somebody’s
achieved stability,rather than getting someone
out of an acute episode.,,Yes?,What are options are there for
insomnia in bipolar disorder?,Well, one of them,
we’re looking at here,in our study, Suvorexant.,But that aside.,So the question is what are the
treatment options for insomnia,in bipolar disorder?,,The same treatment
options that you,would see for
anyone with insomnia,are often used in
bipolar disorder.,So the benzodiazepine,
sometimes we use.,The benzodiazepine-like
hypnotics, like zolpidem.,Or trazodone is commonly used.,Now, with bipolar disorder, we
often give very sedating mood,stabilizing medications anyway.,So sometimes we will
leverage that to try,to help someone sleep.,So quetiapine, for
example, if we’re giving it,for a mood stabilizing
medication,,will often help treat
insomnia as well.,If somebody can’t handle the
high enough dose of quetiapine,to get the mood
benefit out of it,,sometimes we’ll use a low
dose of quetiapine just,to get sleep better on track.,Dr. Ketter likes to
use clozapine for sleep,in patients with very
refractory insomnia who,have taken boatloads
of other medicines,and aren’t responding.,So clozapine’s an
anti-psychotic that,requires a lot of monitoring
with blood levels.,And you check your
white count once a week.,But it’s a very
sedating medicine.,It can help people with
refractory insomnia.,So I would say using
the standard sleep,medicines that are out there.,And if those fail,
then trying to go,to the anti-psychotics
which have sedating effects,is a common strategy.,,Yes?,Is there any
information out there,regarding the use
of medical marijuana,in treating bipolar at all?,So the question was raised
as to any data or information,on medical marijuana
for bipolar disorder.,To my knowledge, there aren’t
any really big studies on this.,I tend to think if
someone’s using it,,it’s probably
going to help them,,if anything, with sleep, maybe
a little bit with anxiety.,It’s probably not
going to do anything,for depression or mania.,And so that’s just based
on clinical experience.,Studies need to be done.,I haven’t seen any
big studies on that.,Yes?,You didn’t mention this,
but what is rapid cycling?,What is rapid cycling,
is the question.,Rapid cycling is defined
as having four or more mood,episodes within a
12 month period.,I didn’t talk about
it specifically.,It’s kind of a whole
other area of discussion.,It does affect what
sort of treatment,you may want to choose.,If you have rapid
cycling depression,,you may be having lots
of episodes of depression,in the same year or
you may have depression,alternating with mania or
hypomania throughout the year.,We tend to think that
anti-convulsants like Depakote,or lamotrigine might be better
for rapid cycling bipolar,disorder.,But you can still try lithium.,You can still try
the anti-psychotics.,There aren’t a lot of
great studies on treatments,for rapid cycling.,But the common
thinking is that you’d,want to switch to an
anti-convulsant to try,to get that under control.,You want to avoid
antidepressants,in rapid cycling.,That’s another thing, because
they might exacerbate it.,,Are there any injectables
medications for bipolar?,The question is are there
any injectable medications,for bipolar disorder.,Yes.,Particularly for the
maintenance phase of treatment.,Risperidone
long-acting injectable,is FDA approved
for the maintenance,treatment of bipolar disorder.,Injectable medicines, much more
commonly used in schizophrenia.,But they can be very helpful for
patients who are having trouble,sticking with their meds,
who go off their meds,,but they have good family
support and good provider,support and they’re able to
get into their doctor’s office,once every month or every two
weeks to get the injection.,So risperidone is
the only one that,is approved for
bipolar specifically.,But any of the other ones–
aripiprazole or paliperidone–,could also potentially be used.,,Yes?,How do you distinguish between
schizoaffective disorder,and a psychosis
associated with mania?,Those are two separate
things, I think,,and how do you
distinguish those?,The question was
asked how do you,distinguish between
schizoaffective disorder,and psychotic mania.,That’s a good question.,And if you’re in the hospital
with a psychotic episode,where you’re also manic, it’s
hard to know at that moment,whether there is
a schizoaffective,or a bipolar disorder.,And the difference being
schizoaffective disorder,is a much more predominately
psychotic illness,where the patients would
be psychotic even when,they’re not in a mood episode.,Whereas bipolar disorder, if
you’re going to be psychotic,it has to be limited to
the actual mood episode.,And the psychosis
won’t occur outside,of the depression or the mania.,So it’s a tough one to call
if you’re in the hospital,and you just see a
snapshot of that patient,in a moment in time.,You really need the
longitudinal follow-up,to understand if the
psychosis persists even when,the mood episode resolves.,And that would lean towards
a schizoaffective diagnosis.,,Yeah.,Does the intensity of
an individual’s bipolar,change over their lifetime,
or does it stay steady,,or is there a lot of
individual variation,when you look at one
individual over time.,I’m sorry, what was the
first part of your question?,Does the what?,The intensity of–,The intensity.,–bipolar or the degree
of the bipolar condition,,does it change over
time on one individual,,or is there a lot of
variation on that?,Is that a predictable path?,Does the intensity
of the illness,change over time
within individuals,in a predictable way?,So there are
theories about this.,There is an argument
of something,called kindling theory.,Robert Post came up
with this theory,,that it’s like a
seizure disorder,where one seizure
begets more seizures.,And epilepsy kind of
progresses in that manner.,So he likened bipolar
disorder to epilepsy,,saying episodes
beget more episodes.,So as the illness wears on,
episodes come more frequently,,they’re more spontaneous,
less related to stressors.,So that’s a model of illness
progression suggesting,the illness gets more
intense over time.,What we have seen in reality,
actuality, doesn’t necessarily,support that.,We do see a lot of variability
across individuals,,that some will do
better over time,,will get the memo that they
need to take their meds,,and they’ll stay
on them and they’ll,function better and be OK.,Other people, you do see
the progressive pattern,where they’ll get
worse over time,despite how much you treat them.,So I think there isn’t really
an easy answer to that.,There’s a lot of heterogeneity.,And now even with
introducing these subtypes,of bipolar disorder,
Bipolar I and II,,you’re going to see even more
variability in how the illness,course proceeds.,,We have enough time,
one more question.,Someone I haven’t heard from.,You.,Good.,Say a little bit more
about the heritability.,I have trouble interpreting
the 85% statistic you quotes.,Yeah.,OK.,So do you want me to
go back to that slide?,Not necessarily.,All right.,So the question was asked
as far as heritability,,how do you interpret the
85% heritability of bipolar,disorder.,Those heritability
estimates come,from family and twin
studies, looking,at how much the illness hangs
together within a family,,for example.,And you guesstimate from
that how much of the illness,is due to genetics.,So the 85% heritability is a
way of saying that about 85%,of your risk of the illness
is due to genetic factors,rather than other factors such
as environmental stressors,,geography, things like that.,So the 85% suggests
that bipolar disorder,is a very heritable illness.,And we could see
that in family trees.,You could see it with
this increased risk,with first degree relatives.,That’s really the
take home message,,that bipolar
disorder is something,that runs in families.,There are genetic aspects of it.,We haven’t yet
discovered the gene.,There’s no gene,
apparently, that,causes bipolar disorder,
which has been disappointing.,But we can’t really
say where that risk,is coming from in terms
of specific genes.,But we do know there’s a
large, large genetic component,to the illness.,Thank you, Dr. Miller.,You’re welcome.,[APPLAUSE]

Chatting with a Person with Bipolar Disorder

Hey, I’m Andrew Hales and this video is brought to you by better help.,In this video we discuss,bipolar disorder and the effects it has on all aspects of life many of you might relate to my guest today whether with,depression or anxiety or any mental illness,and you might find it difficult to get help,,,,,,,Depression or anxiety or any mental illness and might find it difficult to get help. I myself have dealt with depression. It can definitely be,Tricky finding help let alone getting out of bed,,,,,,,,,,,,so that’s why I partnered with better help for this video finding a therapist making an appointment and leaving your home to meet a,,,,,,,Stranger, it’s not easy. It’s also very expensive running,,,$150 to,,,,,,$300 a session better help makes getting therapy easy by allowing you to connect with a professional therapist anywhere and anytime you need it you,Can use messaging video chat or phone calls modern therapy. That’s built around your schedule,you can even switch therapists anytime to match with the right therapist and,Best of all, it only cost an average of 65 dollars per week,So if you think better help can be a benefit to you,Please click on my link in the description box and get started today. Okay. Thank you. Here’s the video,Hi, I’m Andrew Hales. Welcome to another edition of chatting with I’m here with,Paloma,You,You have bipolar disorder,Yes, okay. When were you diagnosed?,um,I was diagnosed February of,2016 which was about a year and a half after I started showing symptoms of mania and depression and,I was diagnosed at that time with bipolar one,PTSD and anxiety with OCD and intrusive thoughts. It’s kind of just,However you um I was oh my gosh, how old I was I,21 no, I must be twenty-two. What what triggered it like, why did you do were just feeling shitty? I went to the doctor,I’m sick. Um, no, so I,Well, it started kind of happening around,19 I started feeling really depressed,but I wasn’t,Really taking it. Seriously. I guess I feel like a lot of us can feel,Sad and like we can’t get out of bed, but I think that you know society kind of tells us,Oh, you’re just lazy. You’re just being sad. Very gray,Yeah, and so it’s one of those things that you can really do mean it within your own self and be like, okay,You know, I shouldn’t tell anyone. I’ll just act like I’m fine,and so yeah, so I started feeling really depressed when I was 19 and,basically,bipolar disorder can be triggered by,Certain events. And so it’s like if you experience something traumatic at that time when you’re in at all,It usually comes up between late teens and early to mid-20s. Mm-hmm,so you can experience something traumatic or it can be some trauma from childhood that is triggered as an adult and,or it can just be like just randomly start it can just from stress or,Not sleeping. So it’s like up and down,Like really extreme moods. Yes,No, yeah,So basically there’s different kinds so bipolar one is when you have that extremity in both realms of mania and depression,And it’s just it’s a mood disorder. So you feel really high and they feel really low, right?,Yeah, and then there’s bipolar too which is where you have,Depression and it can be extreme depression and hypomania, which is a milder form of mania,So that’s kind of like the euphoric feeling that people experience. What kind you have bipolar one?,Okay, and I have that with rapid cycling which basically means that,you will for me personally I,Had it where you know, I had a few weeks mean man,And then I had a few weeks depressed and then it got into the realms of a few days,Manic a few days depressed and then even within a day,I would feel mania and depression so it can get it can you know be a few months here and there or,It can be every day you feel that so and you’re on medication now. Yes, and that make that controls it,Yes, so you don’t having too many ups and downs,No, I actually I haven’t had an episode for a year and a half,So that’s been really nice an episode of depressive or mania you mean either? Okay, yeah or correction,Yeah. Yeah, sometimes I wonder if I have that a lot of people probably do everyone like ups and down to normal,so,What why do you think yours were more severe than others?,Definitely. Um, well, yeah, I feel like a lot of people can relate to,Depression and kind of understand that like loss of interest in activities,You know, you can’t get out of bed. You can’t go to work stuff like that,And obviously it goes to the realms of self-harm and suicidal thoughts and so for me,I was very much going to the extremes in both realms where I did have suicidal thoughts and,at the same time, you know, I’d have that for a few weeks and then for another few weeks, I’d feel manic and,it’s interesting because in both realms of hypomania, which is mild mania and then in,what they call full-blown mania,You’re feeling definitely different than normal,How I I mean, I definitely didn’t diagnose myself,I went into the doctors and explained everything and and he gave the diagnosis. But basically I went into full-blown mania which is,such a,No one is a interesting thing but kind of wild thing. Well, yeah, I hear it feels good Oh,- Oh Mia, which is the euphoric feeling you haven’t felt that oh I did at first and then it went into,Oh, yeah, I loved it. I sure,Yeah, you feel like you can conquer the world. Yeah. I know it’s that’s that’s what’s so interesting. Is that some people,Don’t even kind of want to or they may not even know something’s wrong because they just may be feeling and it feels so natural,To you at the time like I’m just feeling great. I’m on top of the world and life through the party,I just got a good night’s sleep or something. Yeah,And so I feel like with full-blown anemia the difference in that is that you,just,It’s like oh well, I guess how I can describe it,I mean, I obviously I don’t know if everyone’s taking drugs, but basically, you know how they explain it,Is that hypomania and mild mania is very much you take like the perfect drug, you know,That just makes you feel great,And then how I can describe full-blown mania for myself is?,As if someone’s just like force feeding you a handful of drugs and you have no idea how you’re gonna feel,Because I would feel I mean my heart would be racing. I would actually like pass out like faint because it was so intense,um, you just feel I would basically,Be pacing back and forth my room and I would think it’s 20 minutes and I’ve been like three hours,you’re just it’s,My mind would race so fast that I wouldn’t even be able to talk properly because it would just be too intense,so it’s just such a wild feeling and it’s very hard to explain but the fact that it really,Makes you so you’re not able to do anything,You know kind of similar to depression how you can’t do anything you had friends witness this,Yeah, they would they would tell you like you’re being really weird or now,Yeah, I mean at the time I didn’t I didn’t have many friends,but,But I did have my girlfriend my current girlfriend,she,Saw me and usually I would just like knowing that,That there was something wrong with me not in Oceania was mania,I would just lock myself in my room and be like I can’t interact with anyone socially, but she saw me one time when?,Was manic and she’s just like are you okay because I would be talking super fast. I wouldn’t be making sense,I told her you know, my heart’s beating so fast, like I think I mean II might need to go to the hospital,Which can actually happen in mania where you have to be hospitalized. Mm,so so yeah, so definitely but after she noticed I was like,Okay, never never being around her again like that because I don’t want her to think there’s anything wrong with me. Yes often something,We’re scared of people being like there’s something wrong with you and not wanting to be close to you in any way. Yeah. Yeah. Yeah,You said?,Have you been hospitalized? No, okay,I haven’t kind of had a choice like because because I just I definitely felt like I needed to on several occasions,With depression in with the mania, but it’s very much,You know, I was working full-time going to school full-time and I was very worried,You know,if I go to the hospital if they put me in the mental hospital and then,If I’m gonna get let go from work or you know,It’s just it’s very scary or and I can make money which I need to make so,it’s one of those things around is like, you know, tough it through just get through it, but,You came to the doctor and you’re like I’m having these weird episodes these whatever and he’s just like yeah you,Did he have you take a quiz or how did the diagnosis happen? Yeah, definitely with him. It was really great,He’s a really great psychiatrist,Unfortunately, some aren’t so some for example,we’ll have you in for a few minutes and,say and you just say,Oh,I I feel this this and that and then they mark you as like six different things and give you six or prescriptions,Which is so unhealthy?,For mine, I was very lucky and he really took the time I explained to him like, you know,past trauma and stuff like that and he really tried to,understand what it was and obviously he does have a degree in it and everything and so it was very much a few sessions and,Yeah, what was the past trauma?,You don’t want to share,Yeah might be too long of a story but it’s fine,No, um, yes, so well basically in my case it was we stem from childhood trauma,Which was brought up as an adult and so it was very much like ongoing abuse from when I was like a toddler to like,13 and then from 14 to 18 I very much,Tried to zone it out and disassociate and then when I was 19,I got into an abusive relationship with one of my first girlfriends and,That was like physically emotionally,Abusive and it was the same as when I was a child and it felt the helplessness,I felt so so much helplessness and that triggered that started triggering the depression and then the mania so it was very much, you know,What’s the what medication are you on?,I’m on risperidone, which is actually an anti-psychotic. It sounds so bad,I hate nights like such a you know to me respect I do say risperidone what you say risperdal risperidone risperidone,Okay,And that’s specifically for bipolar. Um,Well, it’s interesting. A lot of people with bipolar. Actually, don’t take that,It’s kind of more specific so to schizophrenic or people who are diagnosed as schizophrenic,basically will take I don’t know not sure the exact milligram but they take a higher milligram than I take and,And basically under I’m pretty sure it’s under one milligram people,Diagnosed bipolar will take it and for me personally,It’s because when I was in the manic mode,I would experience like hallucinations as in hearing things and seen shadows,It wasn’t too much visual hallucinations and also since I experienced intrusive thoughts, which is very much, you know,Like when you see a scary movie and you have a scary scene in your head and you can’t stop replaying it,It’s very much that was with intrusive thoughts. You just can’t stop it,No matter what you do, so that can happen with past trauma that they can keep her plane. So specifically for me,but I think that’s something that,That depending on the person,Then lamictal is being mood stabilizer, which is very common for people to use you take,So yeah, that one’s kind of more like lithium a little bit exactly. Okay. Yeah,Or is it lithium? Or I don’t even know no, I,Always think of Nirvana when I say with him. Yeah. Yeah,So my doctor actually prefers lamictal lithium has been something that’s been around for a long time,But it it can have negative side effects. And also you do have to have blood blood work done,I think like every month or every few weeks and so,We decided on lumic dole and it’s been really great,And I think that’s the newer one that a lot of people that’s so it’s just those two for now. Yes,Okay, you said you mentioned self-harm?,What was that about you you were suicidal? Yes,It’s not really funny no, I know,It’s such a it’s something where I’ve gotten to the point where I can talk about obviously like not joke, I guess no,You’re good. It’s great. Yeah. Yeah, and I think there’s comfortability with,With kind of accepting how things were and so you can not necessarily laugh about it,But you know, I mean, it’s a good story. Yeah,So this is before the diagnosis or during or after what when did that happen,Yeah, it was definitely before it was a depressive episode. Yes,So basically as the mania got higher the depression got lower as in you know higher depression,so basically when I was on my highest and mania that’s when I,started self-harming,Something but I would actually do a lot it was like bruising. I,Kind of creates a certain type of pain that I did that since I was younger,Since I was a kid, and I think that’s something where when you’re a kid,bruising like,Bruising like just hitting something just hitting your arm. Yeah,Yeah, usually with like ah, yeah,so that’s I think it’s because I did it as a child that it was very much something ingrained into me and like almost,reflex and that’s the interesting thing about self-harm is that maybe people don’t realize that sometimes that even comes as a,Reflex when you’re feeling worthless when you’re feeling depressed. It can almost be something that just to take the pain away,It’s like anything hurting yourself felt good,um, yeah, it’s it’s such an interesting thing to,To talk about because I feel that I’m sure a lot of people can understand,I think a lot of people may not get it but it’s basically when you’re filled with so much emotional pain,To be able to take that away by some type of physical,pain it,Distracts you completely it distracts you and also when you feel worthless the big thing for me was when I felt so much self-hatred,I would just be like I deserve this. I deserve to self-harm I deserve to be harmed and,So yes, it’s definitely a mix of those things so bipolar and what else?,So bipolar PTSD and then anxiety. How often do you go to counseling?,Or therapy, yeah, it’s all the same I,Go to my psychiatrist every few months before it was every three weeks,when I was first getting started for about the first year and now,yeah, now I only have to go every few months because I do have,the medication that I feel is best for me, and at first it was very much kind of trying out different medication, so,How many did you try out um about?,five Wow,Yeah, that was,Well, it was interesting because they were each for different things. So I took prazosin which is for PTSD nightmares,That like makes you like sleep hella good or,It’s supposed to,So basically, it stops your body from having adrenaline rushes, which is what you experienced during nightmares,And so that was really helpful at the time. I feel like that would give me a nightmare. I’m like – comatose or something,No, it’s very interesting,For me it was worth it because I was deliberately not sleeping because my nightmares were so bad,And so it did help me but in the morning, I would feel so groggy and I would stand up and almost pass out,for weird nightmares as well,uhm very much just trauma from my past and kind of it’s so interesting because you know,,If you’ve had a nightmare where it feels so real it can be very damaging in the way of you,It’s it’s in a way reliving the trauma,So yeah, that’s why I wouldn’t want to sleep because I just be I would try to sleep two hours a night before I got,The medication just because I was like, I really don’t want to don’t want to fall asleep and dream about that,Do you think you’ll ever be off medication that’s an interesting question,Well, I did you know, I’m one looks a pro. Yeah. Yeah. I’ve been on lexapro over two years just for I,Mean social anxiety depression. Yeah, yeah,No, I understand that. I have really bad social anxiety. Yeah, so it’s like so nervous to be here,I mean, yeah, I’m always a little nervous before these two. Yeah,Well, it’s interesting my my doctor says a goal is to,Eventually have patients either get off their medication or at least lessen the dose and so for me personally,it’s interesting because since I you know have only been on them for,You know,Year and a half two years or something. I,Feel that. I’m so comfortable that I wouldn’t really want to mess with it as of now, but,I guess it’s just something where I’d have to see but it’s just so hard to think of kind of going back to,Knowing or also. I’ve had withdrawals when I haven’t been able to get my medication on time and they are so painful,Still pain. Yeah, like brains – yeah, so so I’m just kind of like I’m good,I know that’s how I feel. Like I’m like, I’m fine where I am,And I it’s not too much of a hassle just like everyone’s like oh, it’s hard to take a pill every day,It’s like it. Well, you take food every day. It’s like it’s like it’s just one more thing. It’s not that big of a deal,Takes like literally half a second,But,Yeah, so you experience some stigma people are just like Oh or like have your parents been like you don’t have bipolar or I don’t,Know Oh completely,That’s what’s really sad is when people do mean it and say oh you don’t have depression,You don’t bipolar you don’t have you know any type of mental health issue you’re dealing with,so yeah when I actually,First kind of accepted that I may have mania and depression,I wasn’t trying to diagnose myself, but it was more. Just okay,I’m reading about this in researching and it does kind of fit of it,And so I was trying to accept it which is really hard to accept things like that,But yeah feel out of control. You don’t know what and you don’t want to be weak,Completely. Yeah, that’s definitely part of the stigma and what not with mental illness,So yes, so the first person I told they actually were like, oh, no, you’re just sad,I know the hard part was I thought I could trust them and then when they said that it was like yikes,I’m not telling anyone, you know, because the one person I trust can even validate it then it’s like who would yeah,And then with the stigmas around it, I think bipolar I mean people,Misuse it all the time whether in a trying to be professional manner or not,It’s definitely one of those things where I think it’s very much associated with just being crazy and a lot of people think,That you can kind of implode at anytime and just have like an episode at any time and go crazy,And also something that I’ve gotten which is very sad is that you’re unsafe,It’s like unsafe to be around you because you kind of explode at any time,And so that’s that’s obviously,You know can be very hurtful to people. Have you ever wondered if you’re a narcissist. Oh,If I did not yet am I yeah, but when I was a kid actually I was very you’re a bra,No,No, I actually,definitely exhibited signs of a,sociopath to be honest,I think I was very cut off I think because of the abuse I had to very much just you’re like emo. Oh,No, I was actually one of those people who seemed like perfectly fine and then inside had no empathy,Which would I I think it was just you know,When when you’re experiencing that pain it’s kind of like you have to pretend as if you is if you don’t feel pain well,It’s like this ongoing thing. And so so I think I just,It was it was a very interesting thing,But then when I got older, I think I became like too empathetic to the point where I would just you know,just I felt like I,do I don’t want to say that you can even feel too much but maybe in a way and then you know the depression and,Mania start happening. So you feel a lot within that especially within the depression,What kind of abuse are we talking about?,It’s it’s really up to you oh, I just don’t know,I don’t think so. I mean well, maybe I don’t know. It’s I mean it’s not live so no no,I mean, yeah some podcasts do that like h3, I think does alive and yeah. Yeah, that would be scary,I know anything live are like terrifying about. Yeah, I’ve been on TV a few times. It’s pretty scary. Yeah,Well like back when I did the breaks. Yeah. Wait, I actually I saw the one where you danced,Oh my gosh, it’s so cringe. I,Know like the the producer before was the second,Alright, you have to be way more pumped up than how I I’m seeing you now like got me all freaked out,I was man. Oh,Yeah the doctors,Okay, what were you talking about oh, yeah,Yeah, if you’re I think that’s well, yeah, I don’t know I’m just curious yeah, um, so basically,From when I was like a toddler to like 13, I was actually like used in child pornography,So yeah, so that’s why it’s it’s very much. Holy shit,Interesting from who like your parents, um from some people very close to my family,Like huncles it on some whatnot,Oh my gosh,And up until 13, how did you like,What like what happened was there someone found out and you got out of it and um, no,he was very much that it just stopped and,I don’t like the sounds so sick, but maybe I like aged out of it in a way because a lot of,lives in California,Couldn’t you get them or did you get them arrested?,No, because they like threatened if I said anything so it’s very like they threaten your life,They threaten a lot of things so it’s basically and especially as a kid, you know,You feel so helpless,so even though you know like,this is,so much pain and all this stuff and that’s why I felt very like suicidal as a kid because I was just like I don’t,Want to experience that you know, oh my gosh,That’s crazy, but that intern eyes or whatever,These people are still out there and you’re and you still haven’t told on them or whatever,That you that you were raised, it’s man. That’s crazy,Yeah, it is quite the way that it was like video or pictures. Yeah Wow,yeah, so it’s it’s very much something that I,Didn’t even accept until recently,It’s very much something that you try to,just put on just,Disassociate completely. Yeah, I can’t even comprehend that,yeah, so that that’s why I like the PTSD nightmares and everything were so rough and then,yeah, so but it’s really something that I have just been accepting within the past year to be honest because obviously it came up and,That’s how you know, I knew obviously I had to accept it because of the mania and depression,I knew that I had something to do with that,But I really haven’t accepted it until this past year and I’m still in that process,Because it can be very difficult to go back to that and try to I feel from that,Yeah, well you seem you seem perfectly normal,Holy shit, well, I guess I just met you but no,Are you vegan or anything?,Well, all these documentaries coming out or claiming, you know,You go plant-based and all a lot of all these symptoms and diseases will disappear, you know,So that’s one thing I want to try out. Oh really like for me yet. Like maybe hopefully get off lexapro. Yeah,yeah, I don’t eat too much meat or,or dairy products and whatnot in general,And I try to have a healthy diet because that’s definitely yeah,The exercise? Yes. Yeah, not not as much as I should,but,But yeah, definitely that really helps and then obviously just sleeping really helps when I don’t get a good night’s sleep,It’s my psychiatrist says that your emotions can just be anywhere like yeah, so it’s really important to sleep,So I try to at least follow that yeah, you’re youtuber. Um,Not full-time. I do I do make youtube videos, but they’re pretty,Silly and stuff like that. It’s like a hobby now ish. Yeah. Yeah. It’s very much a hobby,And then for full-time, I work in television production, and then I’m a writer,I just published my first book so that’s been pretty cool. Oh, yeah the poems. Yeah. Yeah. I haven’t,There’s no link on your Instagram. I couldn’t so,Is it on it’s on Amazon? Yes. Okay, I just type in. Oh,Yeah, yeah and I can put it on this video too, when did it come out, um, it just came out last week,No,basically,I was doing it. It’s kind of with undercover because I wanted to get some reviews by people,And they say like that’s good to have reviews the Cornish public. So yeah. Alright any last words?,I think I covered everything that I wanted to ask. No. Yeah,Um, well thank you for watching if you would like to,Purchase my book,Or if you don’t have the means to you can DM me and I’d love to give you a special code for it to get,It for free. It’ll be in the link in my bio and maybe the link. Yeah, definitely. Yeah,Yeah, if you want to subscribe to my youtube channel, I make silly videos or to my Instagram,Your pro. Oh,You didn’t you did it all for me. I usually do that part,Oh, I mean no, I just say thanks for watching good

Understanding Bipolar Disorder

understanding bipolar disorder,bipolar disorder encompasses a wide,spectrum of symptoms and is classified,according to the types of mood episodes,exhibited including manic hypomanic,major depressive and mixed episodes,bipolar one disorder involves a manic or,mixed episode in contrast to bipolar two,disorder which involves at least one,major depressive episode and at least,one hypomanic episode but no full manic,or mixed episodes bipolar disorder,should be differentiated from major,depressive disorder or MDD which is,diagnosed when a patient experiences one,or more major depressive episodes,without any lifetime episodes of,hypomania or mania depicted here is a,life chart or mood chart which follows,the patient’s lifetime history of mood,episodes this permits the identification,of mood episodes that are the most,prevalent and important to prevent in,this patient as with many patients with,bipolar disorder,depressive episodes become the more,prominent aspect of the illness as the,person ages several morphometric,differences have been observed in the,brains of bipolar disorder patients,relative to healthy subjects white,matter hyperintensity x’ and reduction,in gray matter volume identified with,MRI have been described in patients with,BPD,increased ventricular size and decreased,frontal cortical area volumes may also,be observed in BPD patients,the pathophysiology of bipolar disorder,encompasses environmental behavioral,neuronal cellular and molecular levels,at the molecular level aberrant,signaling Cascades alter synaptic,plasticity strong evidence supporting,the importance of second messenger,signaling has come from studying the,targets of mood-stabilizing drugs such,as lithium GSK 3 and IP 3 signaling,Cascades are known to mediate axon Oh,Genesis synaptogenesis neuronal growth,and cone spreading other downstream,effects may also be involved the,heritability of bipolar disorder is,around 80% monozygotic twins are,reported to have a higher incidence of,developing bipolar disorder,approximately 40% whereas the incidence,is only 10% in dizygotic twins although,the process of developing bipolar,disorder likely arises from complex,interactions between genes and,environmental factors the specific genes,that contribute to this risk are not,known with certainty variations of,several genes have been identified as,potential contributors to the,pathophysiology of bipolar disorder,among the identified genes are those,associated with serotonin signaling SLC,6a for T P h2 dopamine signaling SLC 6a,3 drd4,glutamate transmission Dao a DT NB p1,and cell maintenance and growth NRG one,BDNF di SC one the most significant,environmental triggers of mood episodes,among patients with bipolar disorder,include use of drugs with mood altering,properties changes in circadian rhythm,and life stressors successful management,of bipolar disorder requires particular,attention to minimizing the effects of,these influences

What is Bipolar Disorder ?

maybe you’ve heard the term bipolar used,to describe someone who’s moody or who,has mood swings but this colloquial use,of the term is really different from,bipolar disorder bipolar disorder which,used to be called manic depression is a,serious mental illness that causes a,person to have dramatic shifts in,emotions mood and energy levels moving,from extreme lows to extreme highs but,these shifts don’t happen moment to,moment they usually happen over several,days or weeks there are a few different,types of bipolar disorders but there are,some common features first the low moods,are identical to those in a related,disorder major depressive disorder also,known as unipolar depression individuals,with this can feel hopeless and,discouraged lack energy and mental focus,and can have physical symptoms like,eating and sleeping too much or too,little but along with these lows the,thing that sets bipolar disorders apart,from unipolar depression is that,individuals can have periods of high,moods which are called manic episodes or,hypomanic episodes depending on their,level of severity in a manic state,people can feel energetic overly happy,or optimistic even euphoric with really,high self esteem and on the surface,these might seem like really positive,characteristics but when someone’s in a,full manic episode these symptoms can,reach a dangerous extreme a person,experiencing mania might invest all,their money in a risky business venture,or they might behave recklessly,individuals might have pressured speech,where they talk constantly at a,rapid-fire pace or they might have,racing thoughts and might feel wired as,if they don’t need sleep manic episodes,can also include delusions of grandeur,like for example they might believe that,they’re on a personal mission from God,or that they have some supernatural,power and finally they might make poor,decisions without any regard for later,consequences,one way to understand these swings is by,charting them on a graph so let’s hit,the y axis is mood with mania and,depression being on the far ends of the,axis and the x axis is time the average,healthy individual might have normal ups,and downs throughout their life and they,might even have some pretty serious lows,once in a while maybe after losing a job,or moving to a new place and feeling,lonely an individual with the unipolar,depression though might have normal,highs but they’ll probably also have,some crushing lows that last for a long,period of time and might not even have,an obvious trigger now for the bipolar,disorders the first one is called,bipolar one and these are people that,have some major lows that lasts at least,two weeks and then some major highs that,lasts at least a week or require,hospitalization that said untreated,manic episodes can last as long as 3 to,6 months and even though depression is,seen in most cases it’s not actually,required for a diagnosis the second one,is called bipolar 2 and this is when a,person experiences similar lows and has,additional heís called hypo mania which,are less severe manic episodes than we,see in bipolar 1 to qualify for a,diagnosis these hypomanic states need to,last for at least four days once again,though these symptoms generally last a,few weeks to a few months alright the,third one’s called cyclothymia or,sometimes cyclothymic disorder and these,people have milder lows as well as,milder highs or hypomania like you see,in bipolar 2 and they cycle back and,forth between these two over a period,lasting at least two years sometimes,people with bipolar disorder can show,other less common symptoms as well for,example having what I refer to as mixed,episodes experiencing symptoms of both,depression and mania at the same time,another symptom they might have is rapid,cycling which describes a situation,where a person has four or more episodes,of depression or mania within a given,year like most mental health conditions,the exact underlying cause of bipolar,disorder isn’t known and there’s no,single bipolar gene that’s been,identified but it saw that there are,genetic,and environmental factors that play a,part for example one interesting clue is,that people with family members who have,bipolar disorders are 10 times more,likely to have it themselves another,clue is that some drugs and medications,can trigger manic episodes like,selective serotonin reuptake inhibitors,or SSRIs it’s also worth mentioning that,people with bipolar disorder often have,other disorders like anxiety disorders,substance abuse disorders ADHD and,personality disorders as well making,diagnosis and treatment a real challenge,even though there’s no cure for bipolar,disorder identifying and treating,individuals is really important since,there’s a real danger that the person,could harm themselves or even commit,suicide one of the oldest treatments is,also one of the most effective,treatments and that’s lithium salts,lithium acts as a mood stabilizer it’s,moving out the highs and the lows that,they experience that said it’s much,better at treating manic rather than,depressive episodes and so individuals,who take it often have to take other,medications as well which can be,problematic since some antidepressants,like SSRIs can trigger manic episodes in,people that are predisposed to them,other treatment options include,antipsychotics anticonvulsant and,benzodiazepines but many of these,including lithium have side effects that,can be severe and lead to non-adherence,which can be dangerous for the person,now unlike certain disorders like,unipolar depression psychological,interventions like talk therapy or,cognitive behavioral therapy are not,particularly effective in treating the,manic episodes of bipolar disorder,having said that they can still be very,helpful tools to help someone with,bipolar disorder in general especially,after a manic episode is ended they can,also help the person handle stressful,situations that might otherwise lead to,a manic episode thereby helping to,prevent a potential manic episode in the,first place alright so super fast recap,bipolar disorder is a mental disorder,characterized by depression periods of,lowered mood as well as mania periods of,a heightened mood,thanks for watching you can up support,us by donating on patreon or subscribing,to our channel or telling your friends,about us on social media,you