Special circumstances and considerations

6.1 How can families come to terms with the illness?

There is no doubt that manic depression is a very serious, long-term illness that has a major impact on both the sufferer and the family. It puts enormous strain on close relationships and many families have been permanently ruptured by its effects. Each family finds its own way of coming to terms with the illness although there are some themes that often emerge.

Bipolar illness is usually outside of most people’s experience and it is easy to mistake the signs of the illness for other problems, such as delinquency or drunkenness or just plain stupidity. It is often only much later that these behaviours can be recognised as symptoms of manic depression. Reacting to an illness is different to reacting to other problems because of the issue of responsibility. Most of us would consider our partner or adult children to be responsible for their behaviour if they are getting into arguments, losing their job or getting drunk. However, if this is because they are manic then we would think that they are less responsible for their behaviour and we would give them more leeway, tend to ignore it but focus instead on getting appropriate help and treatment. Shifting from blaming the person to blaming the illness is a major shift in attitude.

However, the next step that is often reached is how much is the person who has the bipolar illness responsible for keeping themselves well and how much falls to the family? These issues usually revolve around the patient taking medication appropriately and taking care of themselves in terms of alcohol or illicit drugs and other aspects of lifestyle.

The other tension is that the patient will generally resent everything about the way they behave being put down to their illness, so that effectively anything they say or do which is at all out of the ordinary is dismissed as a symptom of their illness.

These issues are very similar to those that occur in adolescence as parents grapple with giving their children independence to do what they want, whether it is the right thing or not!

The accusation that ‘you’re treating me like a child’ is commonly heard. Finding the right balance at the right time is never perfectly achieved but can only be approached if both sides are able to be honest about what they think and feel. The right approach in one circumstance and in one stage of the illness may be entirely wrong in another, but finding this flexibility is very difficult. It is also easy to react with anger (on both sides) and want to walk away but this rarely works well, though occasionally is exactly right!

There are other aspects of the illness that families have to grapple with including the loss of hopes and dreams for the patient and for themselves and others in the family. Taking a realistic look at the illness and how much it will affect everyone’s lives is hard as there is a lot of uncertainty, particularly in the early years. Some will tend to go down a path of denial, and this is an aspect of thinking that most families go through at some point. They may either ignore what has happened or just hope that it will not happen again. Alternatively, they may move to the other extreme and assume that normal life is now entirely over. Keeping a realistic view of the future is important, and revising it as events unfold is part of that.

6.2 What is the best way to present information to parents about the cause of bipolar disorder?

Most parents will feel guilty if their child develops a mental illness. This is partly because we all feel responsible for how our children turn out and worry about whether we have brought them up properly. In bipolar illness it is more complicated because there are strong genetic factors. Understanding the genetics of the illness can be very painful and provokes thoughts such as: ‘It’s all my fault, he’s got this from me because I’ve been depressed’.

Try to put this into perspective for the parents. There are risks for all of us that our children may develop manic depression (about 1%). If a parent suffers from manic depression then there is about a 10% risk of any child having a bipolar illness. The risk of depression in the general population is about 5% but nearer 25% for the children of bipolars. Depression and bipolar illness are also very variable illnesses in their severity. These are substantial figures but on average if a manic patient had four children only one is likely to have a serious affective disorder, and there are of course many other possible illnesses for which they may be at risk (see Fig. 2.2).

6.3 Do manic depressives have cognitive or intellectual deficits?

When Kraepelin made the distinction between manic depression and schizophrenia a hundred years ago, he did it partly on the basis that there was cognitive impairment among the schizophrenic group. In fact the name he gave to the illness we now call schizophrenia was dementia praecox. This comes from the Latin, meaning a precocious or premature dementia. It is certainly true that a major disability for those who suffer from schizophrenia is an impairment of their intellectual function. The situation for bipolars is less clear.

Before the symptoms of the illness start it is commonly found, among those with schizophrenia, that their school performance has been below average. This does not seem to apply to bipolars and in fact they are likely to be somewhat above average.

It is easy to recognise the intellectual impairments of severe depression, particularly when it is accompanied by retardation where even the most basic of mental tasks (e.g. getting a few words out) is difficult. The distractibility of mania also precludes clear and effective thinking. However, when there has been a good recovery from mania and depression, is there any cognitive impairment still present? At first sight there is not, but when detailed tests of intellectual function are undertaken then abnormalities emerge. Bipolars as a group do not have the severe impairments that those with schizophrenia show but they still do not equate to normal controls. It may be that this is part of the explanation for why those with manic depression often do not seem to be doing as well at work as would be expected even though they have made a good recovery in terms of being free of manic or depressive symptoms.

There are no particular tests that bipolars are especially likely to perform poorly on that can be easily tested in the surgery and in fact the differences between bipolars and normal controls tend to be matters of degree rather than categorical differences. It is also worth remembering that even minor levels of symptoms can have a substantial effect on intellectual function and this needs to be borne in mind when considering treatment.

6.4 Are there chemical changes that occur in bipolar disorder?

The most commonly reported chemical change is an increase in cortisol in the blood during periods of depression or mania. The daily rhythm of cortisol is normally at its lowest at midnight and highest in the morning, but in severe affective states this rhythm tends to be lost with persistent high levels at night. This overproduction of cortisol is not suppressed by giving dexamethasone.

A large number of other tests, particularly of abnormalities in the amine systems of the brain (serotonin, noradrenaline (norepinephrine) and dopamine), have been looked at in both bipolar illness and more commonly in depression which suggest that there may be underlying changes in these systems. However, this work is very difficult to do because of the urgency of treating patients in severe affective states and the effects of medications on these systems. It is for these reasons that a coherent and consistent account of brain chemical abnormalities has yet to emerge. It is common to hear that manic depression is caused by a chemical imbalance in the brain but rare to hear exactly what this imbalance is. We tend to assume that because a lot of the drugs we use affect the amine systems that manic depression is a problem in these systems and that the drugs correct this. Lithium is a very basic challenge to this idea, and we still do not know with any certainty how this treatment works.

6.5 Do complementary treatments have a place?

Where the line between mainstream and complementary treatment is drawn is uncertain. We are still not sure what forms of ‘talking’ therapies are effective (see Qs 3.20 and 5.46) and many people find less specialist forms of talking useful, from non-directive counselling to assertiveness training and anger management.

Alternative medicines: There are really no good data to guide advice on alternative drugs or foods in bipolar illness, but it is inevitable that some patients are taking them as the market is huge. Often the treatments that are used in depression such as St John’s wort are tried in manic depression. St John’s wort has been shown to be of benefit in mild depression and so it seems likely that it would also help bipolar depression, but like other antidepressants it may also have the propensity to destabilise bipolar disorder (see Table 3.2). There are also concerns that there can be interactions with other drugs, and so if St John’s wort is being taken it should probably not be mixed with mainstream drugs. It is difficult to give advice on other herbs apart from exercising caution.

Vitamins and minerals: Vitamins and other mineral supplements are also popular but should not be seen as a substitute for a healthy diet. However, some bipolar patients with a severe and chronic illness can become malnourished and taking multivitamins would seem sensible. Those who also have complicating alcohol problems may well benefit from B vitamins.

Omega 3 fatty acids: Omega 3 fatty acids, usually found in fish oil, are popular for both rheumatological and psychiatric disorders and there have been some encouraging trials in manic depression (Stoll et al 1999). The doses recommended in the clinical trials have been high and most readily available preparations will not provide these high levels. These may well become mainstream treatments in the future.

Relaxation therapy: Being able to relax is a great advantage to anyone who has problems with anxiety which includes most bipolars. Many complementary therapies, including aromatherapy, yoga, tai chi and massage have a strong relaxation element to them which can make them very helpful.

Homeopathy: Some alternative practitioners recommend that all medicines are stopped but this can be very counterproductive. There does not appear to be any evidence that homeopathy is effective in bipolar disorder.

6.6 How does the stigmatisation of mental illness affect manic depressives?

Stigma means a mark of social disgrace. It is a form of prejudice that means making negative assumptions about people. It has a major impact on those who experience mental illness including those with manic depression. The common views are that they have brought the illness on themselves and that they are likely to be dangerous and violent.

There are also some rather paradoxical ideas–for example thinking that depression is a sign of weakness and that people should just ‘pull themselves together’ while at the same time thinking that nothing can be done to improve mental illnesses and therefore it will permanent. These views are so common and pervasive that many people with the illness will also share those ideas and so not think that it is worth bothering trying to get some help or treatment (see also Q 5.44).

The other view that people who have bipolar illness commonly hear is–‘You don’t seem like the type of person to suffer from depression’–which chimes with the idea that only certain people can experience mental illness (see Q 1.18).

The practical effect of stigma is that people are not given a chance to show what they can or cannot do–it’s just assumed that they are incapable. It is also very corrosive to someone’s self-esteem to be dismissed on the basis of assumptions about their illness.

Obviously manic depression does have a disabling effect on everyone that experiences it and it can lead to extreme, bizarre and unpredictable behaviour. This is part of the illness and needs to be faced and tackled head on, although stigma does exaggerate the disability.

Education about the illness and getting to know people who suffer from manic depression seem to be the only ways to reduce stigma. Learning about the reality of bipolar disorder and the ordinariness of those who experience it can change attitudes. One of the most powerful ways that stigma can be tackled is by prominent people letting it be known that they suffer from manic depression. In the United States, Ted Turner, who founded CNN (the news network), made it public that he suffered from the illness. In the UK, Spike Milligan was not only open about his illness (Case vignette 6.1) but also became patron of the Manic Depression Fellowship.

6.7 Should patients be given drug holidays?

6.8 What is the future direction for treatments for manic depression?

We have the same hopes for the treatment of manic depression that we do for most other illnesses. Molecular biology offers the possibility of a more profound understanding of the condition and the potential to create more specific treatments.

One line that may prove fruitful in the near future is choosing treatments according to genotype. Not all treatments are as effective in one person as in another and if we can discover the genetic associations of this, then we may be able to give more specific advice about what medications are likely to be useful for a specific individual.

The sad truth is that we are not using the treatments that we have at the moment to best effect. This is most apparent in the research that has looked at suicide in bipolar patients (Isometsa et al 1994, Schou 1998). Most bipolars who kill themselves have either not been prescribed appropriate long-term treatment or have not been taking it.

We need to improve our general skills as doctors so that we are better at recognising the condition, teaching our patients to understand their illness and finding the best ways of minimising their disability. Research on psychotherapeutic approaches may also tell us what specific areas we should be focusing on and techniques we should be using.

6.9 What is self-management?

Everyone with a serious chronic illness needs to find a way to understand and manage that illness so that the disabling effect on their life is minimised.

The term ‘self-management’ has been used by the Manic Depression Fellowship (MDF, see Appendix 1) for this process of gaining more control over the condition. The MDF is a national self-help organisation in the UK. They promote this process of taking more responsibility for one’s own condition through literature, self-help groups and a national training course.

There are a number of elements in self-management:

Being an informed and insightful patient is undoubtedly one of the best routes to long-term mental stability for those with bipolar illness.