March 2003, speaker meeting of NAMI PA, Main Line
Our speaker, Dr. Laszlo Gyulai, Director of the Bipolar Disorders Program at the University of Pennsylvania, provided a wealth of information on bipolar disorder. He began by describing some of the different forms of bipolar disorder. For example, bipolar disorder 1 includes manic episodes, whereas bipolar disorder 2 includes hypomanic episodes, but often more depression and suicide attempts than in bipolar disorder 1. Both types of bipolar disorder can cause impairment in work, relationships, and quality of life, but with good treatment individuals with bipolar disorder can generally get much better and function well.
Many individuals with bipolar disorder have a comorbidity, such as:
(1) substance abuse (especially cocaine, amphetamine or other type of drug abuse with bipolar disorder 1 and alcohol abuse with bipolar disorder 2)
(2) anxiety disorders such as panic disorder, obsessive-compulsive disorder, or generalized anxiety disorder.
When present, these comorbidities make it more challenging to design effective treatment.
Bipolar disorder begins at different points in the life span for different individuals. For example, bipolar disorder can affect children and may be difficult to diagnose in children under 10; in this age range it is important to assess whether the child has bipolar disorder, attention deficit disorder, or conduct disorder, or possibly some combination of these conditions. (An audience member mentioned that information on bipolar disorder in children can be found at www.bpkids.org.) Although bipolar disorder often has a young adult onset, onset of bipolar disorder can occur as late as 60-80 years old. Late onset bipolar disorder may be triggered by a mini-stroke, so it is important to test for this (e.g. with an MRI).
Effective medications for bipolar disorder include:
(1) lithium (although not for patients who have rapid cycling and/or mixed mania/depression)
(2) mood stabilizers/anticonvulsants (e.g. Depacote, Tegretal, Trileptal, Lamictal)
(3) atypical antipsychotics (e.g. Zyprexa, Respiradol, Seroquel, Abilify).
Each of these medications has somewhat different effectiveness and side effects, and it requires a combination of a well-informed doctor and some trial and error to find the right medication for a given individual. Often, one or more of these medications will be prescribed in combination with another medication such as Neurontin for anxiety or an SSRI (e.g. Prozac, Paxil) for depression, although antidepressants should be used with caution since they can trigger a manic episode in genetically predisposed individuals. When medications are too expensive for an individual’s budget, he or she should contact the company which produces the medication to inquire about their patient assistance programs. (We will have more information about medications and how to obtain help in paying for medications at our May 12 meeting when Larry DiBello will present Update on New Medications.)
The other important component of treatment for bipolar disorder is cognitive therapy and/or supportive interpersonal therapy. (Psychoanalysis and other insight therapies are not recommended.) Cognitive therapy can include:
(1) education of the patient and of the family
(2) helping the individual patient to identify symptoms of the early stages of mania and developing strategies to avoid the development of mania (e.g. agreeing to consult with your partner before carrying out impulses related to money)*
(3) strategies to improve compliance with medication
(4) and additional types of cognitive therapy used for major depression.
This type of therapy is available at the Bipolar Disorders Program of the University of Pennsylvania in Philadelphia and at the Beck Institute in Bala-Cynwyd. Combined medication and structured cognitive therapy can also be provided by some psychiatrists or by a team of a psychiatrist and a psychologist who cooperate to provide coordinated care.
Dr. Gyulai also described ongoing research concerning changes in the brain in people with bipolar disorder, as well as multiple studies he is involved in to understand and improve treatment and prognosis for individuals with bipolar disorder. He generously answered many, many questions from the large audience who attended his presentation. Among the interesting responses he provided are the following.
Use of LSD, hallucinogenic mushrooms, or cocaine can trigger a manic episode in a genetically predisposed individual; this is especially likely with repeated drug use. This kindling effect can result in long-term bipolar disorder. Ephedra (found in quite a number of herbal remedies) also can induce a manic episode.
Consumption of a small amount of caffeine is okay for many people with bipolar disorder, but no caffeine should be taken after 2 PM because it is very important not to disturb the daily rhythm or interfere with sleep.
Physical activity is helpful for individuals with bipolar disorder.
For some people with bipolar disorder, early fall and early spring are a time of special risk with more rapid cycling and more suicide risk.
Changes in women’s hormones may affect their bipolar disorder. Women seem to do better during pregnancy and many women can safely be taken off their medications during pregnancy.
If you are close to someone who has bipolar disorder but denies their illness, Dr. Gyulai encourages persistence in kind discussions which provide consistent feedback and set limits. Denial of illness can be a very difficult problem and in some cases individuals will resist treatment until they have to be committed to the hospital.
Individuals who may be interested in participating in studies at the Bipolar Disorders Program or in seeking treatment can call Dr. Guylai’s office, 215-746-6414.
*Another useful strategy suggested by Ruth Deming of New Directions is to have an ongoing partnership between two individuals with bipolar disorder who help each other to recognize signs of incipient mania and take steps to prevent the development of a manic episode.