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Bipolar disorder treatment and depression treatment

Depression, mania and bipolar disorder.

Treatment of depression

Depression is a serious illness and cannot be compared to ordinary reactions of grief or sadness. It is normal for most people to experience grief or crises in the course of a long life without having it turn into a period of depression. Serious crises can, however, mark the beginning of a depression in persons with a predisposition for it.

It is estimated that in Denmark about 4% have a depression at any given time. About 125,000 people in Denmark have a moderate to serious depression requiring medical treatment. Another 1.5%, or 75,000 persons in Denmark, have mild depressions. Mild to moderate depression can often be effectively treated with cognitive therapy and antidepressant medicine. Serious depressions require first and foremost a medicinal treatment, after which a psychological treatment may be initiated.

Depressions are characterized by the following symptoms:

Feelings of sadness
Reduced energy
Reduced desire
Prone to crying
Negative view of one’s self and the future
Thoughts of death or possibly of suicide
Poor sleep at night

Difficulty falling asleep
A 24-hour rhythm in which the condition is often worst in the morning
Reduced appetite and weight loss
Reduced memory and ability to concentrate
Reduced libido
Symptoms of anxiety

The illness can become so serious that psychotic symptoms develop, typically in the form of delusions that one’s financial situation is in ruins, that one’s inner organs have become rotten, or that one is responsible for all sorts of misfortunes such as natural disasters.

Mania

Mania is in some ways the opposite of being depressive. A manic phase can last for days, weeks or months. The following symptoms may be observed:

Exaggerated joy (cheerful mania)
Excessive anger (angry mania)
Increased energy
A high level of activity
A swarm of thoughts
Increased libido

Increased creativity
Sleep disturbances
Disjointed thinking
An infectious mood
Megalomanic notions
Risky behavior

Bipolar disorder treatment

A diagnosis of bipolar affective disorder (manic-depressive disorder) is made if a person has had at least two affective phases, one of which must be a mania, a hypomania or a combined condition. Hypomania is characterized by the same symptoms as mania but in a milder form. Typically, the person does not feel ill and therefore does not seek bipolar disorder treatment.

In a combined condition there are both depressive and manic symptoms in the same illness phase. Previously it was thought that the lifetime risk of bipolar affective disorder was about 1% (which means that about 55,000 Danes develop this illness). However, new studies indicate that the frequency of previous hypomanic phases in those who are depressive is significantly higher than previously assumed. Furthermore, some people with recurring depressions develop manic symptoms.

It is therefore reasonable to assume that about 50% of those who have a depression should be placed within the bipolar spectrum. The diagnosis is difficult, because people often see their earlier hypomanic phases as a period of their life in which they were well-functioning and productive and did not feel ill.

Early diagnosis of bipolar affective disorder

The bipolar illness is characterized by an unstable mood and may be accompanied by varying degrees of sleep problems and anxiety. The illness is basically about periods with depressive symptoms, periods with hypomanic and manic symptoms or combined conditions in which there are both increases and reductions in energy, mood and cognitive function. These are the symptoms that have traditionally been watched for in order to make the bipolar affective disorder diagnosis, and many refuse to make the diagnosis until there are positive signs of both depression and mania.

The problem with this strategy is that depression and mania are often the last symptoms of the bipolar illness to appear. Symptoms such as sleep disturbances, anxiety, eating disorders or a high tolerance for alcohol are more frequently being viewed as the first signs of illness. Combined with high creativity, a need for or benefit from structure and exercise, and the existence of other family members with mental disorders all serve to increase the suspicion of a possible bipolar illness with development of depressive and hypomanic/manic symptoms in later life.

During the past 10-20 years there has therefore been an increased focus on what we call the bipolar spectrum. Instead of waiting to see the degree of depression or mania that has traditionally been required in order to make the diagnosis, a diagnosis within the bipolar spectrum is used to initiate an earlier bipolar disorder treatment and to work with prevention. Treatment for a patient who is suspected of being within the bipolar spectrum can very well differ from the treatment for a bipolar disorder.

Much of the treatment that is initiated in cases where there is only a suspicion of bipolar affective disorder is non-pharmacological and can in many cases stand alone as a preventive measure against further progression of the illness. This involves a focus on sleep, structure, exercise and caution with respect to alcohol and drugs.

Often the ”reward” for using the bipolar spectrum is that incorrect treatment may be avoided. This is especially true of patients who receive antidepressants as treatment for depression. It seems logical enough: the patient has not previously been manic, there are no immediate signs of hypomania, and the patient is clearly suffering because of the depressive symptoms.

The problem with antidepressants – and the reason why they must be handled with care – is that in patients with bipolar affective disorder it can result in mania. At an early stage of the disease progression, it is very likely that there have not yet been any clear signs of mania or hypomania, so how does one separate patients with a single depression from those who have the first depression of a bipolar disorder?

There are two different pharmacological treatments (antidepressants and mood-stabilizing medicine such as lithium). The non-pharmacological treatment is much the same, although it is probably most important for the bipolar patient, because it is to a high degree used to stabilize the mood and thereby prevent later fluctuations. It therefore makes a great deal of sense to focus on the non-pharmacological treatment and exercise caution regarding the use of antidepressants, because a sudden mania can be extremely unpleasant.

Antidepressants may not only be harmful when given to bipolar patients, it may also be difficult to phase out the treatment without causing unpleasant side effects (withdrawal symptoms). Lithium, on the other hand, does not have the same consequences when given to a person not suffering from bipolar disorder.

It may sound frightening to speak of bipolar disorder if one does not identify oneself as having depression and mania, but the diagnosis is important to the treatment. It may therefore be appropriate to speak of the bipolar spectrum at an early treatment stage, even though manias or depressions may not yet present themselves clearly, and even though the initiation of a pharmacological treatment may not yet be relevant. The bipolar spectrum is a more nuanced way of looking at the mental suffering, and can be of help if medicine must be considered as a treatment at some later point in time.

What is “the bipolar spectrum”?

In contrast to bipolar affective disorder, where there are certain criteria that must be met in order to make the diagnosis (such as the duration of the depressive and manic periods and the number of fluctuations), the bipolar spectrum represents the idea that bipolar disorder develops gradually, with ups and downs and neutral areas during a lifetime. Depression and mania cay be understood in a more nuanced way than by saying that one either has it or one doesn’t. The energy, mood, concentration, cognition, etc. can all fluctuate, and it is not necessarily the classic symptoms of depression or mania that are the first to appear.

In addition, attention is paid to the genetics of the illness, where the existence of relatives with bipolar disorder points towards this diagnosis; mental symptoms at a young age also increase its likelihood. The bipolar spectrum includes patients that have not yet developed the “full-blown bipolar disorder”, and there is hope that an early intervention with non-pharmacological and in some cases also pharmacological treatment may improve the patient’s prognosis more than waiting for the array of symptoms corresponding to a “full-blown bipolar disorder” with a serious depressive or manic condition.

Here in the clinic, we see many patients who are currently suffering from anxiety disorders (e.g. panic anxiety and ODC) or eating disorders, but who have previously had unstable moods or energy. This detail is important with regard to medical treatment, because anxiety illnesses are often treated with antidepressants, while this treatment for someone whose anxiety is secondary to bipolar disorder can cause the illness to worsen. Anxiety in connection with bipolar disorder is usually treated via the bipolar disorder treatment, which often consists of both pharmacological and non-pharmacological intervention plus cognitive behavior therapy.

So it is important to watch for signs of bipolar disorder in patients who perhaps only show small signs, because the treatment prognosis often depends on which illness is being treated (as it so often does). The small signs, which typically seem quite natural because patients have usually lived their entire lives with them and experience them as being unique to themselves (e.g. high energy and robustness at work, a creative mind, “life of the party”, etc.), can be difficult to accept as being signs of illness. It can therefore be difficult to accept the bipolar diagnosis if the patient experiences it as being exaggerated or “made too quickly”.

Here it is important to understand that all doctors regard a diagnosis as a hypothesis which they use to choose the most appropriate treatment, and you as a patient are never forced to follow the treatment regime. But diagnoses are usually based on experience, and here at the clinic we have a great deal of experience in spotting early symptoms of bipolar disorder and helping stop its progression. But this requires an expanded understanding of the illness and seeing the small signs, typical characteristics and particular behaviors which we over the years have often found to be caused by bipolar disorder and are not, for example, the recurring depression, social phobia, excessive alcohol consumption or eating disorders that are often the symptoms for which our patients initially seek treatment. These symptoms can be caused by an underlying bipolar disorder which must be treated first in order for the above-mentioned symptoms to disappear.

Bipolar disorder is in many ways poorly understood, but it is certain that it is more nuanced than the traditional categorization of depression and mania. The bipolar spectrum is a way of viewing the illness in a more appropriate way, so that more patients can be included in the bipolar disorder and receive appropriate treatment, instead of waiting for the manic fluctuation.

The following should cause consideration as to whether a depression is related to bipolar disorder:

Early depression debut (childhood or as a teenager)
Psychotic symptoms
Serious suicide attempts
A need for electroshock therapy
Hospitalization in a psychiatric ward
Alcohol or drug abuse
Eating disorders, bulimia in particular
Lack of response to antidepressant medicine

Extremely fast effect of antidepressant medicine (hours, days)
Manic symptoms after antidepressant medication
Mood fluctuations as a part of one’s “personality”
Mental illness in the family (including alcohol and drug abuse)
High creativity and artistic talent
Highly gifted

Treatment of bipolar affective disorder

Left untreated, many will experience a disease progression that becomes increasingly characterized by depressive phases of increasing length and severity. Fortunately, good treatment results can be achieved if early treatment is initiated.

Medicine

It is our opinion that antidepressants should be avoided and mood-stabilizing medications used instead. If there have been clear manic phases, lithium would be the first choice, but in cases of hypomanic phases, lamotrigine is often preferable, as this medication has a mild side effect profile. Anti-psychotics may also be used, for example Abilify, Seroquel, Zyprexa or Risperdal.

Psycho-education

It is very important to educate the patient about what it means to have bipolar affective disorder, because a variety of interventions can prevent a mild mood fluctuation from becoming a true depression or mania.

Exercise

Exercise is extremely important for a person with bipolar disorder. Some can do without medication altogether if they engage in a lot of sports. For those unaccustomed to exercise, caution should be shown to begin with in order to avoid injuries, but as a rule it is safe to say that the more frequent and intense the exercise, the better.

Structure

With regard to prevention/curing depressive and manic phases, it is a great advantage if meals, working hours, exercise, sleep, housework and social activities can take place within reasonably well-defined boundaries.

Sleep

It is of utmost importance to ensure a good night’s sleep. Sometimes it is enough to have regular bedtimes, at other times sleep medication may be necessary for a while. Persons who have trouble sleeping should avoid midday naps.

Alcohol and drugs

It is normally an advantage to avoid alcohol and narcotics. If alcohol or hashish are used as sleeping aids, a sleeping medication is much to be preferred.

Links

On the bipolar spectrum

Famous people with bipolar disorder

Kim Engelbrechtsen has written a new book, Mania and Depression. The book was released on 27 September 2013 by the publishing company Siesta. The book focuses on what it is like to have bipolar disorder, and is based on 15 interviews with people who have bipolar disorder and their families. It is an open and honest discussion of what it’s like to live with this illness. About 40,000 Danes have bipolar affective disorder. In the book, the well-known Danish pastor Johannes Møllehave talks about his own experiences with mood fluctuations.

Call us at 38 28 88 72 or send us a message on pboks.dk and learn more about depression treatment and bipolar disorder treatment.

We have patients from Copenhagen, Greater Copenhagen and northern Zealand.