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.

6.10 What is the interaction between the medications used in treating bipolar illness and alcohol?

Many of the drugs used to treat bipolar disorder have sedative effects; this is true not only of the antipsychotics and benzodiazepines but also the anticonvulsants, particularly carbamazepine. Alcohol tends to enhance these sedative effects and can also exaggerate other CNS side-effects, such as ataxia. There is no direct interaction with lithium unless alcohol is drunk to the level of causing dehydration which can raise lithium levels.

Some antidepressants, particularly trazodone and the sedative tricyclics such as amitriptyline and dosulepin (dothiepin), are also likely to enhance drowsiness when taken with alcohol. SSRIs are generally less sedative and the interaction is likely to be less.

Doctors often feel in a dilemma when discussing alcohol use with people who suffer from manic depression. Patients need to have information about interactions but doctors do not want to be seen to encourage alcohol as so many patients have problems with excessive drinking. Most longer term medications do not prevent drinking modest amounts of alcohol. There is an element of trial and error because individuals vary in their tolerance of alcohol and medicines. Patients will usually find that they can tolerate a moderate amount of alcohol in combination with their medication.

Heavy restrictions on alcohol are difficult to comply with as so much social life revolves around drinking alcohol and most of us like to drink. If patients feel doctors have unrealistic views about alcohol then they probably will not be frank about their alcohol use.

On the other hand, it is easy to collude with excessive drinking and if you can help someone tackle a common problem early then you are doing them a real favour. Discussions that help them to explore non-alcohol-related avenues of social contact, or even experimenting with not drinking, can be useful lines to follow. But one needs to stay realistic as alcohol use is so pervasive in our culture that even when people do get involved with other activities (e.g. playing squash), they find that they are expected to go and have a drink afterwards!

6.11 What is the effect of bipolar illness on work?

Those who are acutely ill with depression or mania will usually be too disabled to work, either because their concentration and attention are not sufficient or their judgement is poor. In the longer run it is disappointing to see that only about a quarter of manic depressives seem to be able to maintain work at a level at which their qualifications and experience would suggest they are capable. The reasons for this include the direct effects of the illness on the ability to work and the attitude of others. The disruptions that acute episodes of illness can cause are the most obvious effect. Manic episodes that involve embarrassing and irresponsible behaviour can prove very disruptive to working relationships that thrive on trust. Even after recovery from an acute episode low level depressive symptoms are common and this can impact on the motivation and innovation that productive work requires. Some people have mild cognitive deficits which prevent them performing at the level that would be expected, even if they have apparently made a good recovery from their mood symptoms. Many patients feel that the medications they are taking are affecting their cognitive ability or their enthusiasm or creativity. These are aspects of medication that are not well described or investigated and it is very difficult to disentangle effects of medications from long-term symptoms.

The attitude of employers makes an enormous difference; those that are sympathetic, often because they have had emotional problems themselves, can be enormously helpful in promoting achievement at work. More commonly employers can prove very negative and obstructive and really prevent people who have made a good recovery from returning to work. Those who will allow patients to test out their abilities by coming back to work on a gradual basis, both in terms of responsibility and time, usually get the best out of those with bipolar illness. However, in jobs that require a high degree of responsibility and independence, including medicine, it is often difficult to put into place the required supervision and monitoring that would enable people to practise effectively and safely.

It is easy for people with bipolar illness to take very low key jobs in an attempt to avoid stress and because their self-esteem is poor. Unfortunately boring jobs can prove just as stressful as more responsible ones. Try to encourage people to find a way of making a reasonable assessment of their abilities, perhaps by asking a colleague who knows them well. Those with bipolar illness should aim to work to the best of their abilities rather than assume that they have to go for a job with lower expectations.

6.12 What are the rules on driving?

Doctors need to make an assessment of the fitness of a patient to drive at that particular time and give consideration to the longer term. Those who are acutely ill with mania or depression should not drive because of judgement and concentration problems and they need to be told this. This assessment can be very obvious when people are severely ill but is much harder to judge at milder levels of illness. Doctors need to consider not only the level of illness at the time the patient is seen, but also their recent behaviour. The account of others such as family and their view of the risk can be very informative. Also consider whether the illness is likely to get worse as judged by the severity of previous episodes and, if the illness is settling, that sufficient time is allowed to be confident that there will not be a relapse.

Driving can be such an important part of life, particularly for those who live in more rural areas where public transport is limited, that doctors are loath to prevent driving. However, this needs to be balanced by the risks that driving entails. Patients are far more likely to injure themselves or someone else in the course of their driving than they are because of direct violence.

The author’s usual rule is to consider people fit, even if they have had a severe episode, if they have made a good recovery, which has been sustained for 3 months, and as long as the medication they are taking is not interfering with their ability to drive. This judgement is usually made on the basis of observations and the report of the patient, and again making use of a relative if this is possible.

All patients with manic depression should be encouraged to contact the licensing authorities. In the UK the way to do this is set out on the driving licence documents. Patients should give the authorities the names of doctors who can provide evidence about their fitness to drive. Tell patients that this is a legal requirement and that their licence is not valid, and neither is their insurance, if they have not informed the authorities of any serious illness which includes manic depression. This has the advantage of not only being true but putting some independent decision making into the process rather than you being the sole arbiter.

Doctors also have to make judgements along with patients on the effects of medication and most of the medications used in bipolar illness can impair attention and concentration and so driving ability. This is often particularly true when the treatment is started. Particular care should be taken about benzodiazepines which are commonly found in the blood of those involved in car accidents. Many patients think that taking the medicine is what is stopping them driving whereas it is usually the opposite: it is regular compliance with treatment that is necessary for them to be fit to drive regularly again.

6.13 Are manic depressives more creative than other people?

Both mania and depression do lead to people thinking about themselves and their situation in different ways from those of us who have never experienced these extremes of mood. This insight can certainly be used creatively but the usual barrier to this is the difficulty in concentration and motivation which is so much a part of acute manic depressive illnesses. The increased energy of hypomania can improve productivity and the combination of fast thinking and distractibility can lead to innovations in thinking and ideas. Several famous poets, novelists and artists have suffered extremes of mood, particularly depression, which some think is linked to their creativity (Jamison 1994). Schubert is the composer who is often cited as a classic example of a manic depressive whose levels of productivity and creativity varied dramatically from year to year according to his mood state.

On the other hand, the sad truth is that most people who suffer from manic depression have their creativity badly stifled by the illness so that productive work and family life are curtailed because of the disruption of the illness. Creative people come in all different shapes, sizes and temperaments and it is doubtful that there is anything inherent in manic depression that makes people more creative than others. There is some evidence suggesting that those who are close relatives of someone with manic depression tend to be more successful in their careers than the average. However, it is always difficult to interpret these studies because they can be very selective in which families are investigated.

6.14 What are the issues around manic depression and contraception?

6.15 What advice should be given to a woman with manic depression who wants to have a baby?

There are two main aspects to this advice:

the risk of illness during pregnancy and after childbirth

the potential effects of medication on the growing foetus.

Women remain at risk of suffering acute episodes of mania or depression during pregnancy though the risk may be slightly reduced when compared to other times. However, the reduction in risk is small and it should not be assumed that pregnancy is protective against manic depression. On the other hand, the risk of relapse (particularly of manic relapse after childbirth) is very high, perhaps eight times the risk of any other month. Most women with manic depressive illness will need to take some preventive medication during pregnancy. Only those who have infrequent episodes are likely to get through pregnancy without a relapse and without medication.

The risks to the foetus from the medication do need to be balanced against the risks to the foetus and the mother if she relapses. Acute mania or depression will almost always require medication, often at higher doses and with more than one medication. Thus the aim of preventing exposure of the foetus to medication can actually lead to higher levels of treatment than if the preventive medication had been continued. This is coupled with the effect on the physical health of the mother through poor self-care during an acute episode.

The discussions with a woman who wishes to get pregnant (or who presents already pregnant) are never easy and only a mother can weigh up the risks of taking or not taking medication.

The safest tactic is to try to reduce and stop the medication prior to pregnancy. This is not always easy and the situation often arises of trying to take a woman slowly off preventive medication in order for her to become pregnant only to find that she relapses each time and has to restart treatment.

6.16 What special measures need to be taken when a pregnant woman is continuing to take medication?

If the mother has decided to continue preventive treatment during pregnancy despite the risks to the foetus because the chance of relapse without treatment is high, then you need to ensure that the obstetric team is aware of the medication and the reason for it. It is likely that the degree of monitoring of the foetus will be increased to detect any defects at an early stage.

In the case of valproate and carbamazepine you must ensure that the woman is taking folate before becoming pregnant, as this can reduce the incidence of neural tube defects.

Monitoring of mental state and medication needs to continue but at a higher level of vigilance. The levels of lithium can vary with pregnancy and often decrease with changes in body fluid and renal excretion. This may mean that a higher dose needs to be given to preserve the prophylactic effect. This should be borne in mind after delivery as the levels can rise as these effects reverse.

You need to ensure that you record your discussion in your records as this is an area that commonly leads to litigation.

6.17 What is the risk of relapse after childbirth?

6.18 What is puerperal psychosis?

The puerperium is defined as the first 3 months after childbirth. This is the time in a woman’s life when she is most likely to suffer a relapse of manic depression. Mania is more common than depression though both occur as do mixed states. For about a third of all women who suffer from manic depression, the puerperium is the time when they first experience a serious episode of mania or depression.

A puerperal illness can be somewhat unusual in that the symptoms vary markedly throughout a single day. For example, when seeing a mother at one time in the day she can appear fairly rational and her symptoms not be prominent, but when seeing her a few hours later she can be clearly psychotic and disturbed (Case vignette 6.2). The other common feature of a puerperal psychosis is confusion so that mothers can have difficulty saying what day or what time it is, have trouble recognising people or places and getting lost in familiar surroundings.

The recognition and treatment of puerperal psychosis is vital for the health of both mother and baby and it is for this reason that there are specific mother-and-baby psychiatric beds in many (but unfortunately as yet not all) parts of the country. Successful treatment of a newly delivered psychotic mother can also prove exceptionally rewarding as she will usually make a good recovery.

The treatment of puerperal psychosis is essentially the same as treatment of mania or depression at other times, antipsychotics usually being the basis of medication treatment because manic and psychotic symptoms are so common. Some psychiatrists say that electroconvulsive therapy is particularly indicated at this time as it is a treatment of rapid onset and effectiveness, enabling the mother to recover as quickly as possible.

6.19 Can women breast feed if they are taking medications for bipolar disorder?

6.20 What is different about treating adolescents with bipolar disorder?

Diagnosis can be a difficult issue in this age group. There are a lot of other changes going on for teenagers and irritability is commonly seen. There is a natural reluctance to give a mental illness diagnosis and pursue a line of medication use unless you are sure that this is correct. Adolescents have the same symptoms as adults although adolescents may be more likely to have psychotic ideas and mixed affective states (see Q 1.11).

Treating adolescents with almost any medical condition can be stormy. This is often related to feeling angry and resentful at having a serious illness when their peers are all fit and healthy. Teenagers are usually keen to show their independence, make their own decisions and take care of themselves. Giving advice to them about treatment and lifestyle can often lead to resistance! It is usually difficult for them to fully recognise the nature of their illness and how little control they can have over their emotional state. People who suffer from bipolar illness need to take much better care of themselves than their peers do, which can be another source of resentment. Sticking to treatment regimens is difficult for everyone but teenagers can find it particularly arduous.

Illicit drug use is common among those in their teens and twenties and more common among those who have a mental illness. This can not only affect the course of the illness but also lead to other health and sometimes legal problems (Case vignette 6.3).

On the other hand, adolescents can also prove very robust and often manage to make up for lost time when they do recover. There is no reason to think that treatments that are effective for adults should not be used for adolescents, but as in the rest of medicine there are few treatment studies in this age group to guide the choice of drugs.

6.21 How should anxiety be treated in someone with a bipolar illness?

Anxiety is a common problem for those suffering from manic depression and at least a quarter of manic depressives report this. The first line of assessment and treatment is to look at whether there are prominent symptoms of depression. Anxiety is a common part of depression and if there is a full depressive syndrome then treatment would proceed as usual for bipolar depression.

However, others experience marked anxiety but do not have prominent depressive symptoms and the anxiety needs to be treated in its own right. A first step is to look at lifestyle factors, particularly the use of alcohol and caffeine. On the medication front antidepressants are usually the treatments of choice for anxiety disorders but the risk of precipitating mania should always be borne in mind (see Q 3.15). Benzodiazepines are effective anxiolytics in the short term but the risks of tolerance and dependence mean that these treatments should be used for a few weeks at the most.

Psychological approaches to managing anxiety can be effective though they are probably less so in those with manic depression than in those with uncomplicated anxiety disorders. However, everyone suffering from an anxiety disorder should be familiar with a relaxation technique that they find effective and the basics of anxiety management which can be found in a self-help book (see Further reading and Turner 2004).

6.22 Do people with manic depression have evidence of brain damage?

Studies that have compared patients with psychotic illnesses including schizophrenia and manic depression with normal controls have consistently shown that there is a statistical increase in the amount of fluid in the ventricles of the brain and surrounding it. This indicates that there is, on average, some loss of brain matter in those with psychosis compared with controls. This is more markedly so in those suffering from schizophrenia than with manic depression.

The differences between bipolars and normal controls are statistical rather than categorical; in other words it is not possible to tell from any brain scan whether the person is in the bipolar or the control group. There is often a difficulty in finding appropriate controls for comparison and some studies have tended to compare patients to ‘super normal’ people who have been heavily screened to exclude any possible factor that might affect the brain, rather than just the guy who lives next door!

Magnetic resonance imaging (MRI) studies have also tended to show an increase in abnormalities in the brain. These show up as intense white spots on the scans. These hyperintensities occur in the white matter of the brain and are often present even in the early stages of bipolar illness in those who have made a good recovery from the acute episode. We do not know what these abnormalities mean or why they occur. It has been thought that these may relate to vascular changes in the brain, though they can be present in those bipolars who do not appear to be particularly liable to vascular disease. It would be easy to assume that these lesions would be related to cognitive impairment but so far this has not been shown to be the case (Monkul et al 2003).

It is not apparent that there is a particular area of the brain which is abnormal that might be considered as the ‘seat’ of manic depression.

Many people with manic depression and their families ask that their brain be scanned to see if there is any abnormality. Many psychiatrists will perform brain scans particularly of new patients with manic depression to make sure that there is no organic abnormality but the pick-up of identifiable lesions is low and that of remediable lesions is even lower.

6.23 What is the treatment for rapid cycling?

Taking antidepressants is strongly associated with rapid cycling (Fig. 6.1) and the best line of treatment is to stop the antidepressant. There is also a connection associated with thyroid dysfunction and this should be checked as well.

Fig. 6.1 Illustration of the course of rapid cycling, in this case induced by antidepressants.

It is very unusual for a patient to start the illness in a rapid cycling phase, so those who go into rapid cycling will usually have already been treated with lithium. If not, then lithium should be considered. Valproate is generally thought to be a more effective treatment than lithium for rapid cycling, though this may be partly a selection bias in the studies in that the rapid cyclers are already lithium non-responders. It may require a combination of the two mood stabilisers to bring about a resolution. Carbamazepine is the other option in trying to find a long-term treatment for the illness.

The good news about rapid cycling is that it is not a state that manic depressives stay in long term and that even if the treatment doesn’t change it, rapid cycling does seem to resolve though it may transform into chronic depression. Rapid cycling is comparatively rare: at any one time less than 5% of manic depressives will be in a rapid cycling phase. It also seems to be associated with bipolar II illness so that patients are moving between depression and hypomanic states rather than the more severe manic states.

6.24 How common are substance misuse problems among manic depressives?

It is likely that the illness leads to increased use of psychoactive drugs rather than the drugs causing the illness, as there is a rise in the rate of drug misuse following the onset of the illness. However, there is also an effect of drugs and alcohol on the course of the illness, exacerbating both mania and depression.

Those who have problems with alcohol or drugs are less likely to be compliant with their treatment and are at higher risk of suicide. It is such a common problem in this group of patients and the consequences are so serious that it needs to be routinely enquired about in all bipolars. However, it is also not uncommon to see reductions in alcohol use in the depressive phase of bipolar disorder, either as part of a general withdrawal from social situations or sometimes because patients recognise that alcohol makes them feel worse and more ‘out of control’.

6.25 How should alcohol problems in bipolars be treated?

The principles of treatment for alcohol misuse and dependence are the same as for anyone else. The particular issue for most manic depressives is that they experience a predominance of dysphoric mood and so want to relieve or escape from this in any way that they can; alcohol offers a considerably more rapid relief than any of the medications we offer. However, chronic heavy alcohol use leads to more depression and withdrawal symptoms usually include anxiety. These depressive and anxiety symptoms tend to be attributed to the manic depression and alcohol seen as the only route to release. At the other end of the mood spectrum, mania causes disinhibition and drunkenness is a common consequence of this. Alcohol can then lead to escalating disruptive or aggressive behaviour.

STAGES OF MANAGEMENT

The first stage of management is recognition; it is easy to overlook alcohol problems when you are focused on serious mood disturbance but this should be borne in mind with all bipolars because excessive drinking is so common.

Though some dependent drinkers will deny problems it is not usually difficult to recognise those with dependent alcohol problems who have the features of craving alcohol, tolerance to its effects and withdrawal symptoms when they don’t drink. Management of dependence will usually need to include using benzodiazepines (e.g. diazepam and chlordiazepoxide) when they stop drinking to minimise withdrawal symptoms.

Looking for lower levels of problem drinking needs to be a routine enquiry in the ongoing care of someone with manic depression. Try to find out specifically what they are drinking and how often:

Do they drink every day?

What is the longest they have gone without a drink?

Why do they drink–is it to relieve anxiety or promote sleep or just ‘an escape’?

Have they considered drinking less?

What have they tried to do already?

TREATMENT

Discuss the fact that it is a common problem for bipolars and that you want to make sure that their alcohol intake doesn’t slowly creep up as a preventive strategy. Many people minimise the problems and it is only by coming back to the subject over the longer term will you be able to get them to accept that a change is needed.

The specific issues related to manic depression also need consideration. Drinking alcohol to excess is a common feature of the acute phase of both mania and depression. It may be that alcohol use between episodes is at a reasonable level. In that case the priority in treatment will be to manage the acute symptoms and if the patient can be persuaded to do this then the alcohol excess will come back under control as they recover.

More commonly the alcohol misuse will be an important factor in preventing recovery from the depression, and so reducing alcohol use is the priority. This involves two main approaches:

Encourage a trial of abstinence to see how this affects the mood. This only requires patients to commit to a short-term change and there is a fair chance that, contrary to their expectations, their mood actually improves and they gain more stability. This will hopefully show that the alcohol is actually worsening their mood in the longer term, even though they find it gives relief in the hours after they take it. Alternatively, the medication may prove more effective when the effect of alcohol is removed. It is often also said that alcohol prevents antidepressants working properly. It is certainly true that giving up alcohol in itself has a beneficial effect on depression.

Maximise the benefits that can be obtained from the treatments for the bipolar illness, particularly the longer term preventive treatments, but commonly also treating low grade depressive symptoms. This is an appealing strategy, especially if it means that the patient does not need to reduce their drinking; however it is rarely successful unless attempts to reduce the drinking are also made.

Finally, be aware that alcoholism accompanying bipolar illness puts the patient at particularly high risk for suicide.

6.26 How should drug misuse in a bipolar patient be managed?

The same principles apply to drug misuse as to alcohol misuse: give the appropriate treatments and help that would be offered for the individual problems. In practice, however, this is usually difficult, the main reason being that drug misuse and manic depression make each other worse.

Substance misuse worsens the prognosis of bipolar illness because episodes of illness and psychotic symptoms can be induced by the pharmacological effect of the drug. It is also much less likely that the patient will take the medicines regularly if they are frequently intoxicated.

STAGES OF MANAGEMENT

The first stage of management is recognition; it is easy to overlook these problems when you are focused on serious mood disturbance, particularly mania. The symptoms of mania and of stimulant use are often indistinguishable and it is possible to feel confident of the diagnosis but not be sufficiently aware of the drug misuse. This should be borne in mind because drug misuse is common, particularly in young people. Some patients who have not used drugs for several years revert to them when they become manic but deny it, minimise it or forget to mention it. They may still be rather ashamed of using drugs even when they are manic and be evasive of testing. It is relatively easy nowadays to test urine for drugs in the surgery with dipsticks. Many doctors find it difficult to ask patients to give a urine sample. One approach is: ‘I know that youapos;d previously had a problem with drugs when you were ill before/earlier in this spell, and it would be reassuring for me to know that they are entirely out of your system.’ However, it is a common experience never to reach an entirely frank exchange about drug use.

Next, assess the severity of the substance misuse:

What are they taking, how often and in what circumstances?

Are they addicted–is there craving, tolerance and withdrawal symptoms?

Was this a problem that was apparent before the manic depression developed or is it closely related to dysphoric or elevated mood states?

TREATMENT

The initial line of treatment is to find out how serious a problem the patient perceives it to be and have a discussion about the consequences that are already apparent and what may be ahead. Many bipolars will recognise that others see drug misuse as a problem but feel they cannot tackle it because it is one of the few ways they have of gaining relief. This can be particularly true of cannabis use, which is rarely perceived as deleterious. Unless you can be agreed on the nature of the problem it is very difficult to make further progress and treatment suggestions will tend to fall on deaf ears. If this is the stage patients are at, you will need to continue to focus on the problems and consequences along with looking at any efforts they have made to tackle it. Ask about periods when they have not used drugs:–how did they get on, what other ways did they use to deal with unpleasant emotions?

If there is a clear addiction to opiates then substitution and detoxification are likely to be required if they are to stop using the drug. Opiate withdrawal is usually managed by specialists, either psychiatrists or specialist general practitioners, because of both the clinical and the legal issues involved. Stimulant and cannabis withdrawal are not usually treated with medication.

Managing the interaction between the manic depression and the substance misuse involves two main approaches:

Encourage a trial of abstinence to see how this affects the mood. There is a fair chance that, contrary to patients’ expectations, abstinence actually improves mood and they gain more stability. This may be because the drug is actually worsening the mood in the longer term, even though they find it gives relief in the hours after they take it. Alternatively, the medication may prove more effective when the effect of the drugs is removed.

Maximise the benefits that can be obtained from the treatments for the bipolar illness, particularly the longer term preventive treatments, but commonly also treating low grade depressive symptoms. However, as with alcohol, response to treatment is often poor when the drug misuse continues.

PQ PATIENT QUESTIONS

6.27 Is it safe for me to have a baby?

The most basic question to ask about this is: ‘Are you well enough to manage to take good care of yourself throughout pregnancy and yourself and your baby afterwards?’ This will depend on how severe your illness is, how long you have been well for and what help and support you have from family and friends.

Pregnancy does not protect you from suffering a relapse of your bipolar illness, though the chance of this may be a bit lower. This means that most women with manic depressive illness need to take some preventive medication during pregnancy if they are going to stay well. There are some risks to the baby from you taking medicines, particularly in the first few months of pregnancy. In fact the highest risk time is the first few weeks when you may not even know that you are pregnant. That is why it is important to plan this before you get pregnant, and also when you are taking treatments that you take good contraceptive measures (see Q. 6.14).

6.28 What effect will the drugs I am taking have on the baby?

The great majority of babies born to women who have bipolar illness are entirely normal and only a very small proportion is affected by the type of medicine you take. However, you will need to weigh up before you get pregnant what the risks are and whether you can accept them. This is a very difficult decision to make and unfortunately many women get pregnant and then think about it, which means that they have missed the boat.

All three of the most commonly used long-term treatments (lithium, valproate and carbamazepine) can affect a baby growing inside you. Valproate and carbamazepine are particularly associated with problems in the development of the nervous system, including spina bifida, but it is likely that if you take a vitamin called folate that the risk of this occurring can be reduced. The specific risk with lithium is likely to be a heart abnormality.

It is difficult to be sure what the risk is of your baby being born with a recognisable defect. It depends on many other factors (your age, health, diet, family history) as well as the effects of any drugs. Probably the best estimate we have is that there is a 10% chance of some problems being recognised (including very minor problems) and about 1% of a severe, life-threatening problem. However, you must talk over with your doctor what the risk is in your particular case, even if in the end the doctor is not able to give you a more accurate figure.

Older antidepressant and antipsychotic drugs seem to be safer during pregnancy and some women opt to try this route of treatment.

The other side of the balance is the risk of suffering depression or mania when you are pregnant and the effect of this on your health and the medicines that you would need to take if this occurred.

6.29 Am I likely to get ill soon after I have had a baby?

You are more likely to get ill in the first few weeks after having a baby than at any other time in your life. The chance is about one in three. You should make plans to recognise this early and either take preventive treatment or have some treatment accessible to take at the first sign of illness. The chance of developing mania and psychotic symptoms (delusions and hallucinations) is particularly high.

You must tell people about this risk, including your midwife, health visitor and obstetrician, and of course your close family.

When you are pregnant you must discuss with both your general practitioner and the mental health team what you and your family should be looking out for and what medicine you should be taking. If you are not taking any medicine to prevent a recurrence of the manic depression when you are pregnant you should seriously consider starting it as soon as you have the baby, even if this does mean that you cannot breast feed.

If you can manage to get through the first 2 months without a relapse then the risk of relapse goes down to how it was before you got pregnant.

6.30 Can I still have a few beers?

The basic answer to this is yes. You do need to be cautious because alcohol can interact with medications. Many medications used to treat bipolar disorder have sedative effects and alcohol will usually exaggerate this sedation or drowsiness. A good rule of thumb is that you are likely to find that each drink is worth two compared to how it would usually affect you if you were not on the treatment. However, most longer term medications would not prevent you drinking moderate amounts of alcohol. There is an element of trial and error because individuals vary in their tolerance of alcohol and medicines. Most people manage to find whether they can tolerate reasonably a small amount of alcohol in combination with their medication. Drinking and driving is dangerous for everyone but if you are also taking medication then you are at much higher risk of having an accident and you are breaking the law if you are not capable of driving because of the combined effects of alcohol and drugs.

Alcohol and manic depression interact in other ways apart from the medication issue. About a quarter of manic depressives report serious problems with alcohol use. This may be because they are trying to ‘self-medicate’, i.e. they are trying to reduce their symptoms by drinking. This can be to reduce anxiety, dull depression or sedate mania. Chronic high use of alcohol runs the risk of addiction and the well-known physical and mental complications of alcoholism.

The main difficulty that people find with drinking less is that so much social life revolves around drinking alcohol and most of us like to drink as it makes social situations easier and more enjoyable. However, it is worth thinking about whether you can have some social life that does not include alcohol. Exercise and sport tend not to include alcohol (at least beforehand!) but finding good avenues to socialise that don’t include alcohol can be good for your mood all round, not just because you are drinking less.

6.31 What should I tell my employer or put on a job application form?

This depends on the employer! The general advice about filling in application forms is not to write manic depression on the initial form. These forms are generally only seen by lay people who have very little understanding of the illness and so the stigma of the illness is likely to lead rapidly to rejection rather than a reasonable assessment of your abilities. On the other hand it is important to let employers know that you have been ill and what the possibility is that you might become ill again. One suggestion is to put on an initial form that you have suffered from depression and are taking medication and only go into further details when you are dealing with a doctor or nurse who is assessing your occupational fitness. Obviously with small firms there is not the same occupational health back-up and so you need to have a discussion at some point with your potential employer about your illness. In the end honesty is usually the best policy, though being cautious about how much you reveal may prove more useful in the beginning! Talking to others who have been in the same position (e.g. in groups like the Manic Depression Fellowship, see Appendix 1) is often the best way of generating ideas for dealing with this difficult area.

6.32 Why can’t I think as well as I used to before I developed manic depression?

Several studies have shown that people with manic depression tend to do less well on tests of ‘cognitive function’, i.e. thinking skills (e.g. IQ type tests). Although on average manic depressives do less well than the general population there is a wide range (as there is in the whole population) so that many with the illness are still doing better than average.

We do not know the cause of this problem. It is possible that whatever the brain change is that causes the manic depression also causes the cognitive changes. Brain scans of people with manic depression tend on average to show more minor problems than those of other people–for example on the most sensitive magnetic scans more small areas tend to ‘light up’. We do not know the meaning of this, although possibly there is a blood flow problem. However, you could not look at a scan and say ‘that person has manic depression and that one does not’ and there is no particular area of the brain of manic depressives on which everyone has a bright spot. Some of these differences may explain why a number of people with bipolar illness have problems with memory and concentration, even when they are not depressed or manic.

The other obvious possibility is that the medicines may affect the brain. Certainly if you get a toxic level of lithium you will be generally physically ill and you can damage the brain. This is why it is so important to monitor the levels carefully so that you never have toxic levels. On the other hand, there are some interesting studies suggesting that lithium may help to protect brain cells if they are damaged by a stroke, or even protect against Alzheimer’s dementia.

The other medicines–particularly the older antipsychotics–can have effects on the brain which cause sluggish thinking which is why most patients and doctors prefer the newer antipsychotics.

What can you do about this? Probably the more episodes of illness that you have the more likely you are to suffer the ‘brain’ problems and so doing all you can to avoid relapse is important. Also on the general principle of ‘use it or lose it’, keeping your mind interested, involved and active must be worthwhile for all of us.