Sunday, 2 October 2016

Does He or She Have Bipolar?

One of the most frequently asked questions about bipolar disorder goes along the lines of, “I suspect my (name/relationship) has bipolar, what should I do?” The question may appear simple but it’s actually loaded with assumptions and potentially different ways it might be answered. In this post I attempt to unpack just some of reasons why answering such a question is actually quite difficult. In so doing I’ll be leapfrogging around a few ideas.

Anyone with an internet connection knows how easy it is to access medical advice and information. Access to health information via the internet represents an acceleration of what was already recognized as a booming industry by television, books, newspapers and magazines.

The movement for self-knowledge and self-empowerment via the internet has both merits and disadvantages. In terms of advantages, people are more aware than ever of their health and its intricacies. In terms of the disadvantages, I’m more aware than ever before of the tendency for people to medicalize sensations, emotions and behaviors even though, to my mind, they fall within the bounds of normality. Awareness and sensitivity to health issues is great, but when it extends to the willingness of people to make lay-diagnoses, I think we move into murky territory. Self-diagnosis can be problematic but at least only one person is affected. Diagnosing others can have all sorts of upsetting consequences.

At least the, ‘I suspect’ question suggests the person has an element of doubt about what they are asking. Increasingly the, ‘I’m absolutely convinced’ question is making its mark. Is there really a difference between the two? Well, that’s yet to be determined, but it perhaps says something about the nature of research via the internet and the type of information most commonly found via search engines for certain types of question. Some of this is well intended, if inaccurate, some is good, some should be trashed.

So, we return to the question. “I suspect my husband/boyfriend has bipolar”, how might we answer? Well, there’s the, ‘see if you can get them to see a doctor’ response; it’s safe and potentially very useful advice. But, very briefly, let me play devil’s advocate with the question. Even if we accept the very real possibility that another person has bipolar, we can’t actually assume anything about that person in terms of their willingness to seek help or treatment. After all, some people with bipolar may never have been diagnosed. Some have, but go through their lives without treatment. Some turn to alternative therapies. Some, of course, sign up to conventional medical treatments and stick with it because in weighing up the costs and benefits they perceive more benefits. It’s not my intention to cause confusion where help is genuinely being sought but I think it is useful to illustrate some different perspectives.

If your partner recognizes their moods or behavior are causing them or others distress and they see some pattern in this, your support in helping them with proper medical diagnosis and treatment options is likely to be one of the most positive and significant things you can do.

Wednesday, 25 May 2016

Depression, Children & Adolescents

Low mood, unhappiness, tearfulness and irritability are common features of teen depression, particularly when not related to anything specific. Extreme reactions are also a sign. For example, if someone dies it is common for everyone to feel upset, but if the grief seems more extreme or lasts much longer it could indicate depression.

Teen depression is important as it can indicate the start of further and deeper symptoms. The fact that depression is both persistent and long-lasting has encouraged greater focus on the provision of effective interventions at a young age. The initial onset of depression is typically around adolescence or early adulthood (16-20).

Various preventative approaches have been used. These have been categorized as Selective, Indicative or Universal prevention measures. Selective prevention refers to measures used in people who are vulnerable or have high risk of depression. An example would be the children of a depressed mother. Indicative prevention targets people who have already showed some signs of depression, perhaps in a fairly minor way. Universal prevention makes none of the previous assumptions. Here, a group of people in a particular area, group, class or age range are targeted. The disadvantage of the universal approach is that whilst it embraces everyone in a particular category, help is being offered to many people who would generally be considered as low risk for depression.

Some studies have found selective and indicative prevention to be more effective, although relatively few studies have followed up volunteers beyond 6 months. There is also a question of what really constitutes a prevention effect? To this end only a handful of studies claim that intervention has truly prevented depression. That is, where a control group showed an increase in depressive symptoms compared with a group in which some form of active intervention was shown to decrease, or at least prevent increase, in depressive symptoms.

One interesting example is The Penn Resiliency Program (PRP)  which uses a school-based program that teaches adaptive coping skills to children at high risk of depression. Over 2,000 children have been studied in at least 13 different controlled studies. What emerges is an indication that PRP seems to be long-lasting and effective when compared with no-treatment control groups. However, in one study of rural schoolchildren in Australia, no benefits of using PRP were reported (Roberts et al, 2003).

According to the World Health Organization, depression affects 121 million people worldwide. It is amongst the leading causes of disability and by 2020 is estimated to become the second leading contributor to the global burden of disease. It stands to reason that anything that reduces the burden on individuals and society has merit. If programs such as PRP can demonstrate an ability to prevent depression, then such programs should surely be rolled out more extensively and controlled evaluations undertaken.

Stress Over Time

One way of monitoring the effects of particular lifestyle issues on health is to track them over a period of time. What complicates the issue is the fact that our lives don’t stand still. Massive changes in the way we work, our own expectations and the expectations of others, can all occur within the space of a few years.

I was pleased to see these very issues acknowledged in a report from the University of Gothenburg. Researchers from the Sahlgrenska Academy have been following the progress of 1500 women since the late 1960s, monitoring the association between stress and psychosomatic symptoms (bodily symptoms caused or aggravated by stress). Psychosomatic symptoms such as headaches or migraines are well known associates of stress, but the extent and nature of psychosomatic symptoms in relation to stress is less well known.

The Gothenburg study reveals some interesting if not altogether unsurprising results. We learn that once their results were adjusted for smoking, body mass index and physical activity, a clear link emerges between the experience of stress and increased levels of psychosomatic symptoms. Specifically, the incidence of stress was highest in the 40 to 60 age range with single women more likely to feel stress and more likely to smoke. Muscular and joint aches and pains were most commonly reported (40% of the sample) and gastrointestinal complaints, headaches and migraines made up a further 28% of reported symptoms.

As Dominique Hange, one of the researchers points out, a great deal has changed since the late 1960s, so the problem here is whether the meaning of stress has also changed over time. Asking volunteers exactly the same questions does not guarantee a consistent interpretation. Plus of course our scientific understanding and interpretations of stress have also moved forward, so are we really in a position to compare like with like?

I think it’s reasonable to point out a couple of significant changes over time. The first is that our understanding of the effects of stress is far more advanced and far more accepted today than it was just 40 years ago. Secondly, as Hange rightly observes, women’s lifestyles and work patterns have changed greatly, so the experience of stress may have changed accordingly.

Like me, anyone who was born pre-internet and mobile devices will appreciate how different the world is today. Actually, I can remember using a Gestetner copying machine in the 1970s because the new photocopy machine was about three miles away in another building. Now, like many others, I have mobile devices and a combined scanner and copying machine on my own desk. I suppose the point is, like other observers have commented, our ‘switch off’ time is increasingly being intruded upon. Precious few of us, I suspect, can honestly say we aren’t exposed to some form of stimulation during our waking hours, whether this is the TV, the internet, music or text messages.  

Tuesday, 24 May 2016

ECT for Bipolar

Despite seven years of medication and doing what you’re supposed to do, Mary. feels no relief from symptoms. Mary. says it affects every aspect of life but she also has concerns about changing meds because of previous bad effects. ‘How bad do I have to be to qualify for electroconvulsive therapy?’ Mary asked, ‘

Electroconvulsive therapy (ECT) isn’t considered a first-line treatment but it can be effective for severe bipolar episodes. When Mary asked ‘how bad do I have to be?’ the answer it seems depends on where you live and your severity of symptoms (as perceived by your psychiatrist). One of the major concerns over the use of ECT is whether it causes damage to the structure and function of the brain. For this reason its use is subject to fairly stringent restrictions. However, one of the reasons that ECT is still available as a treatment is that it can be extremely effective.

When I say that ECT isn’t thought of as a first-line treatment, I mean that it only tends to be considered when other treatments have not been effective. It may be considered if the person is perceived as high risk for suicide, where there are prominent psychotic features of depression, or where very severe depression is not responding to other forms of treatment.

If ECT is prescribed a typical course may be anywhere between 6 to 9 treatments around 2 or 3 times per week. Sedatives are first given, followed by muscle relaxants. When the patient is fully anesthetized an electrical current is passed into the brain. Evidence suggests that ECT delivered to both hemispheres of the brain (bilateral) is more effective than to one hemisphere (unilateral). However, high dose right unilateral appears as effective but without the side effects, such as memory loss, that frequently accompanies bilateral ECT.

So when Mary says ‘I want to zap it out. Plain and simple,’ what are we to answer? I guess the first thing is to sympathize with her frustration and the need to have something done. More pragmatically perhaps I have to point towards what is actually known about the effectiveness of ECT. It is well known that ECT can provide fairly speedy and effective relief, but it does have limitations. The main limitation is that it has a very high relapse rate. Numerous studies also point to loss of memory. Memory seems to improve during the months after treatment but amnesia for events immediately before ECT often remains. Around the time of treatment it is quite common for people to experience confusion and some memory loss.