Moclobemide (Manerix) has been shown to be effective and to have a low propensity for ‘switch’ into mania compared to the tricyclic antidepressant imipramine (Silverstone 2001) (Fig. 3.1). Moclobemide is a monoamine oxidase inhibitor (MAOI) which often worries prescribers because of concerns about dangerous interactions with foods (the cheese reaction occurs when the amino acid tyramine passes through the gut without being broken down and leads to a rise in blood pressure). However, moclobemide is a specific inhibitor of monoamine oxidase in the brain and does not inhibit the form found in the gut. Tyramine can therefore still be broken down in the gut and so does not get through to cause a hypertensive reaction. Moclobemide is also a reversible inhibitor and is relatively short lived so there is only a short (days) wash-out period before another antidepressant can be started if there is a need to change treatment.

Fig. 3.1 Moclobemide versus imipramine in bipolar depression.

(Based on data from Silverstone 2001.)

3.5 For how long should antidepressants be continued after recovery from depression?

The concern for bipolars who continue antidepressants is that they may be running an increased risk of mania while they are on this treatment. Because of this it would be recommended to discontinue antidepressants at an early stage after recovery from bipolar depression at about 3 months. This is in contrast to the advice for those with unipolar depression which is to continue the antidepressants for at least 6 months after recovery. Unipolar depressives are also often advised to take antidepressants long term as preventive treatment; however this would not usually be appropriate for bipolars.

For bipolars consideration needs to be given to effective long-term preventive treatment such as lithium (see Chapter 4). If they are to continue with antidepressants they must also take an antimanic drug, such as lithium, an antipsychotic or valproate (see Q 3.7).

It is always worth checking the individual’s history–what has been the experience following previous episodes of depression? If this indicates that switching to mania occurred following each depression then the antidepressant should be stopped within a few weeks of recovery from depression.

3.6 Should bipolars continue on their long-term preventive treatment if they become depressed?

Definitely. It is very important that long-term prophylactic treatment (e.g. with lithium) is continued when the patient becomes depressed. This is because the depression is most likely being treated with antidepressants and if the lithium is stopped there is an increased chance of switching into mania (Fig. 3.2). Obviously at some point the patient will need to be reviewed to assess how effective the preventive treatment is, but the usual time to do this is after recovery from the acute episode of depression.

Fig. 3.2 Treatment with lithium in combination with antidepressants reduces antidepressant-induced manic relapse.

(From Prien et al 1984, with permission.)

3.7 Is there a role for long-term antidepressants as a way of preventing depression recurring in bipolars?

Taking an antidepressant on its own as a preventive treatment in bipolar I disorder is definitely not recommended. However, if an antidepressant has proved beneficial in combination with a mood stabiliser and the previous history has been of a preponderance of depression, then continuing antidepressants is likely to be a good strategy. It may also be worth considering other combinations or alternative mood stabilisers in this situation.

Many bipolar II patients are treated successfully in the long term with antidepressants without lithium or other preventive treatments. This usually follows on from a period of treatment with antidepressants that has been successful without a switch into hypomania. As long as an eye is kept on making sure that elated periods are not occurring, then this is a reasonable option. However, there is a need to be wary as many of those who suffer from hypomanias are not good at recognising them or tend to play down the problems that they cause. Ask someone else in the family if the patient is getting on reasonably.

3.8 What is the best medication for depression in someone who has a history of hypomania but has never been manic (bipolar II depression)

The mainstay of treatment for bipolar II depression is antidepressants, one option being the SSRI fluoxetine (Fig. 3.3). However, the initial decision to be made is whether to prescribe a drug that will prevent manic symptoms developing in addition to the antidepressant. This is a matter of judgement–at one end of the scale a patient who has had only short-lived and not disabling hypomania in the past is suitable for antidepressant treatment on its own but with monitoring for the appearance of manic symptoms. At the other end, someone who is currently depressed but with previous prominent, frequent and socially disabling hypomania should certainly be taking treatment to prevent further manic symptoms along with the antidepressant. Judging where a patient is on this spectrum is difficult and prescribing treatment often requires a lot of negotiation as many patients will be keen to relieve the depression but may not be concerned about hypomanic symptoms. It is usually the case that the manic depressive patient is very keen to relieve and prevent depression but the family (and others including doctors) are more concerned about the social disruption of hypomania.

Fig. 3.3 Treatment of depression with fluoxetine in bipolar and unipolar patients.

(From Amsterdam et al 1998, with permission.)

The choice of antidepressant for bipolar II depression is the same as that for bipolar I depression (Case vignette 3.1).

You need to be wary that treatment with an antidepressant on its own in bipolar II patients may be leading to more instability of mood or even rapid cycling.

CASE VIGNETTE 3.1 ANTIDEPRESSANTS MAY DESTABILISE THE COURSE OF BIPOLAR ILLNESS

Melanie has had periods of depression that began in her twenties. At first they were noticeable because she felt very down and couldn’t sleep well but she put these down to the stressful job she was doing which involved a lot of travelling round the country. She had spells like this once or twice a year and they lasted about 6 weeks, and she would often miss a few days’ work when she couldn’t get out of bed. However, she would always bounce back and often after a bad spell she would feel much better and treat herself a bit, particularly buying designer clothes for which she had a penchant.

A bad spell of depression then hit her and she was off work for a month and started treatment with an antidepressant. This seemed to get her right within a couple of weeks but she went a bit more over the top and to her embarrassment ended up sleeping with one of her salesman who was 10 years her junior. This led to another spell of depression but an increase in the antidepressant again led to improvement. However, by the end of the year she was feeling ‘all over the place’, never knowing how her mood was going to be week to week. Her work was going badly as she was now regarded as a liability when previously reliability was her middle name.

A trial of lithium without an antidepressant is indicated.

3.9 What if the depression is not improving with antidepressant treatment?

The following questions should be considered before contemplating a change in medication:

Have you given the treatment long enough?: At least 4 weeks with no response, or 6 weeks with only minor response. It can be difficult to stick with the treatment when there is little improvement; a realistic time scale for improvement should be discussed with the patient from the beginning–it may well take up to 4 weeks to start to see a difference. It is also worth discussing at this point the balance between the time needed to give this treatment a good try against the time it will take to make a changeover to another medicine. Focusing on other ways that the patient can help to make a difference to the level of depression is also useful (see Qs 3.29 and 3.36).

Have you tried a high dose?: If the patient is not improving, doses should be increased to the maximum, provided that the treatment is reasonably tolerated before turning to an alternative antidepressant.

Have you assessed concordance/compliance?: Is the patient really in agreement with this treatment and taking it (see also Q 5.43)? Are they forgetting because they are feeling so tired, lethargic and can’t remember to do anything including taking the tablets? Is there some way of improving this–linking it with some more routine or habitual aspect of their life (e.g. brushing their teeth)?

Are they physically ill? (see Q 3.27): Specifically, are they hypothyroid or anaemic?

Are they drinking alcohol to excess or taking illicit drugs?

Is there another medication that they are taking that might be affecting their depression (e.g. steroids)?

Is there a social or relationship problem that could be addressed?

3.10 What are the next lines of treatment in bipolar depression that has not responded to the first antidepressant treatment?

If the patient is taking lithium in combination with the antidepressant, first increase the dose of lithium up to a level of about 1.0 mmol/l.

If this is not successful, continue the lithium but change the antidepressant to a different class of drug. It would be worth reviewing what treatments the patient has been on previously to see if it is possible to identify another drug that has been helpful in the past. If no clear treatment option is apparent the usual rule of thumb is that if the patient has been on an SSRI, change to a tricyclic and vice versa.

If the patient is not on lithium then this can be added as an augmenting agent as lithium in combination with antidepressants can lead to more improvement than the antidepressant on its own. (If these options are not successful, this is the stage where most experts are starting to scratch their heads too!)

Other options that are available include other groups of antidepressants, thyroid hormone (at above replacement levels), lamotrigine, tryptophan or electroconvulsive therapy (ECT) (see Q 3.22) (Fig. 3.4) and psychotherapeutic talking treatments (see Qs 3.20 and 5.46).

Fig. 3.4 Acute treatment of bipolar depression.

3.11 Is lithium an effective antidepressant?

Lithium can be an effective treatment for bipolar depression either on its own or in combination with an antidepressant. The first step in treating depression in a manic depressive who is currently on lithium is to check compliance, then the serum lithium level. If there is room to increase the dose of lithium, bearing in mind the blood level and the side-effects, then this should be tried initially unless the illness severity is very high and immediate antidepressant treatment is needed. If the patient is not on lithium, then again this can be a sensible first line treatment as it is likely to be required to prevent a manic swing if the patient is going to be taking an antidepressant.

3.12 Is the treatment for depression in the elderly different?

The same lines of medical treatment are useful for the elderly as for other adults. There is a paradox for the elderly that they are more sensitive to medications in terms of side-effects (probably because of reduced metabolism of drugs, and reduced excretion of lithium) but they also seem to be less responsive to medications and may actually require higher doses.

Physical illness is more likely to complicate treatment in older people which may limit the dose of medicines–for example cardiac disease may limit the dose, or even the prescription of tricyclic antidepressants. ECT is more commonly required in the elderly as they are more likely to experience psychotic symptoms, retardation and poor food and fluid intake.

3.13 Is the treatment for depression in adolescents different?

There are very few trials of treatment of bipolar depression but there are virtually no data on the treatment of bipolar depression in adolescents. There have been concerns that unipolar depression in this age group does not show a good response to antidepressant medication. This is difficult to reconcile with the data for adults which show a clear benefit in improving depression–is there some basic change in depression and its response to treatment at 18 (or 17)? There are also concerns that some antidepressants (SSRIs) can cause agitation and an increase in suicidal thoughts and behaviour, and that this effect is more marked in adolescents.

Psychological treatment is often recommended for non-bipolar depression in this age group, but unfortunately it is often not available. In bipolar depression there is little evidence to recommend psychotherapeutic approaches on their own.

Overall, even more care needs to be taken when considering the treatment for bipolar depression in adolescents. However, the same lines of treatment as for adults should be followed. Keeping a long-term perspective and focusing on appropriate longer term preventive treatment is a good basic principle, though severe depressive episodes will require antidepressant treatment despite the current uncertainties.

3.14 Should low level depressive symptoms be treated?

As indicated in Chapter 2, chronic depressive symptoms are the most frequent long-term problem for bipolars (Fig. 3.5) and we are probably too reticent about treating these. This is partly because it is the manic symptoms that tend to be much more obvious to health professionals and family. Patients may be suffering with low level depressive symptoms but the fact that they are not actually getting into the trouble that occurs in mania can lead one to think that this situation is all right. There is also concern about using antidepressants because of the risk of making the illness worse (see Qs 3.15 and 6.23). However, long-term but low-level depressive symptoms do need to be searched for and considered.

The first line of treatment is to optimise current medication. If the patient is on long-term treatment such as lithium, there may be leeway to increase this further, provided that side-effects are tolerable and blood levels are not excessive.

If the patient is not on an antidepressant and long-term preventive treatment has been maximised, then look at the effects of previous antidepressants. If they have led to a worsening of the illness through rapid cycling or quick switches into mania then antidepressants should only be used with great caution or not at all. Some antidepressants have a lower propensity for inducing mania and so one of these may be more appropriate (see Table 3.2).

If the patient is taking an antidepressant ensure that this is at a therapeutic dose–just because the symptoms are of a lowish level doesn’t mean the antidepressant should also be at a lowish level. It is worth trying to reach the highest dose tolerated with one antidepressant before considering changing to another.

Combinations of longer term preventive treatments (e.g. lithium with carbamazepine or valproate) should also be considered.

Finally, consider an alternative such as lamotrigine (see Q 3.4) which is less likely to lead to the complications of switching and rapid cycling.

Fig. 3.5 Bipolar disorder dominated by depression.

3.15 Do antidepressants trigger mania?

Antidepressants can trigger a manic illness in those who have previously been manic, but only rarely in those who have not previously been manic (see Table 3.2). Antidepressants should not be prescribed to someone who has had a previous episode of mania (even if it was a long time ago) without an additional treatment to prevent mania.

Tricyclic antidepressants are more likely to trigger mania than SSRIs. The use of antidepressants of all types is also associated with rapid cycling (several episodes of mania and depression in quick succession). Patients who have a rapid cycling pattern should not continue to take antidepressants and stopping these drugs can lead to a considerable improvement in the stability of their mood.

Whether it is reasonable to give antidepressants to someone who has only suffered hypomania but not mania in the past is much more uncertain. It is not clear whether antidepressants can lead to mania in someone who has only been hypomanic previously. One trial in this group of patients found that some did become hypomanic again, but did not find that patients became manic for the first time (Amsterdam et al 1998) (see Fig. 3.3)

The safest line of treatment would be the combination of an antidepressant with lithium but patients who have experienced hypomanias but not manias are often reluctant to take antimanic medications.

3.16 What treatment is needed for depression with psychotic symptoms?

It is usually only the most severe depressions that are accompanied by psychotic symptoms. Psychotic depression is a high risk state and the propensity to suicide is very high in this group, and they are more unpredictable. They often need treatment in hospital and a high degree of nursing care, not just for their safety but also because they have difficulty looking after their basic needs, including feeding and washing.

These more extreme depressive states will frequently warrant treatment with ECT (see Q 3.22).

Psychotic depression requires treatment with both antidepressants and antipsychotics. There is also a substantial risk of shifting into mania from the psychotic depressed state and so the antipsychotic drug needs to be continued at least as long as the antidepressant.

3.17 What is the best treatment for anxiety symptoms in bipolar depression?

Anxiety symptoms occur commonly and often prominently in bipolar depression. They may appear on their own but are more usually part of the depression. The first line of treatment would be to treat the anxiety symptoms as if they are an aspect of depression (see Q 1.14). However, the anxiety symptoms may persist despite antidepressant treatment at a full dose in combination with a mood stabiliser. If there are still prominent depressive symptoms then follow the usual further lines for treating depression (see Qs 3.10 and 6.21). It is worth giving some consideration to the antidepressant being prescribed as MAOIs are thought to be more effective in depression with anxiety.

Pragmatically, many doctors treat prominent anxiety symptoms with antipsychotics and these certainly can produce a calming effect for many patients. The dilemma when doing this is leaving the patient relatively free of anxiety but sedated because of the antipsychotics, particularly when using the older antipsychotics such as chlorpromazine. The risk of tardive dyskinesia in the long-term use of antipsychotics should also be borne in mind.

Benzodiazepines are commonly prescribed for bipolar patients with prominent anxiety but their use must always be balanced with the likelihood of tolerance and dependence developing. They should only be used for intractable anxiety and only for short periods if possible; however they remain an option. Buspirone is a non-benzodiazepine antianxiety medication. There have been no trials of this medication in bipolar patients but it may be worth considering and some patients have responded well to this in combination with an antidepressant.

There are effective psychological techniques and treatments that are beneficial for anxiety symptoms:

Has the patient read a book about managing anxiety effectively? (see Further reading).

Is there a local psychologist or cognitive therapist who could help to teach these techniques? (see also Q 3.21).

3.18 How is the risk of suicide judged?

This is a challenge for everyone who looks after manic depressives, and the statistics on suicide–that between 10 and 25% of those suffering from manic depression die through suicide–are very sobering and confirm our limited capacity to judge suicide risk and to prevent it.

It is important to focus on the more immediate basis for judgement of risk by considering what the patient is saying at the time they are seen. However, to get a full picture, several background factors should be taken into account:

All those suffering from manic depression are at least at moderate risk for suicide–this serious mental illness substantially inflates the risk. It is not justifiable to regard anyone with this diagnosis as at low risk for suicide.

The quality of the patient’s life is usually based on having close relationships, employment, financial security and physical health. These aspects of life are adversely affected in those who do commit suicide but are very difficult to change.

Older age is a risk factor for suicide in the general population but is less important among manic depressives where suicide occurs across the age range.

Personality factors–including impulsiveness (which can be indicated by previous self-harm, drug and alcohol misuse)–and erratic relationships are also worth considering.

The more immediate factors are usually those that are more susceptible to change–for example what is the current level of depression? Both acute and chronic depressives are at high risk and there may be treatment options that could reduce the level of depression and so the risk of suicide. Recent adverse events also increase the likelihood of suicide but with time the impact of even the worst event (e.g. a close bereavement) tends to abate.

Most people who commit suicide do so when they are intoxicated with alcohol–often because they use it for Dutch courage to carry out a frightening act or to dull the pain of it. Others do not intend suicide when they start to drink but then become more impulsive and reckless when they are drunk. Prediction of risk of suicide in the intoxicated is particularly difficult, though it is invariably higher than when sober.

3.19 How can suicidal ideas be elicited?

Discussing suicidal ideas is never easy, but it does get easier the more you do it. Try to normalise the discussion by making it clear you anticipate that people who are depressed do think about dying and suicide:

‘Almost everyone who is depressed feels suicidal at times–I was wondering to what extent this has been affecting you?’, followed up by:

‘What had you thought you might do?’ (Try to find out if the patient has actually made any plans or done any preparatory acts, e.g. putting a noose in the boot of the car.)

What does the patient think would be the effect of their suicide on others–from ‘I know I couldn’t, it would kill my mother’ to ‘They would all be better off without me, even my baby–then someone would take proper care of her’.

What has prevented them from taking their own life? Sometimes the reasons will be a surprise: ‘I couldn’t stand my ex-wife finally getting the house!’

The usual block is either consideration of others or not having the courage to go through with it. Has the patient actually done something already that could have been fatal, or was intended to be fatal? Be wary of dismissing those who have committed multiple previous suicidal-type acts such as frequent overdoses–these people are at higher not lower risk and are more likely to finally kill themselves.

The presence of psychotic ideas or experiences makes successful suicidal acts more likely. Using the usual judgements about their ideas on psychotic depressives is very risky as these are the patients that are most likely to surprise you as it is not possible to use logic on those for whom logic has gone out of the window.

The other side of the balance in judging suicide risk is: Are there good lines of treatment and care that are likely to make a major difference to the patient’s mental illness? It is likely that you would take more extreme action (including detention and enforced treatment if absolutely necessary) in a young person early on in their illness history with an acute severe depression who is very likely to respond to treatment than someone with a history of chronic treatment-resistant depression even if the risk of suicide is similar. It can be easy to concentrate on taking action to prevent suicide–having the family watch the person carefully or admission to hospital–instead of focusing on treatments that are likely to beneficial.

It is worth bearing in mind that a majority of manic depressives who do kill themselves are not on optimal treatment, although this is often because of poor compliance. Lithium does reduce the rate of suicide, some have claimed even to the level of the general population. Has this patient had the best treatment available, or at least a trial of treatments (including lithium) that are known to be beneficial?

It is very unusual for people who are manic to commit suicide. They can, however, hurt themselves through the risks that they take or by overestimating their physical prowess–for example thinking they can run as fast as a train and putting this to the test with tragic results.

3.20 Is psychological treatment for depression useful for bipolars?

The symptoms of bipolar depression can be so disabling with retardation and overwhelming negativity that it is difficult for psychological treatment to penetrate these barriers. However, this line of treatment is worth considering, particularly in the longer term. Several psychological approaches can be helpful and it is usually a combination of approaches, tailored to the individual patient, that is the most successful.

Cognitive behaviour therapy: This is the mainstay of psychological treatment for depression and the principles of this can be applied in bipolar depression in a manner similar to the way it is used in unipolar depression (see Q 3.21). The main differences lie in the fact that the symptoms of mania (e.g. optimistic thinking) may be a bad sign rather than a good one.

Past experiences and relationships: Other psychological approaches focus more on past experiences and relationships. The aim of this is to help patients to understand the patterns of their relationships, what difficulties have emerged and how their attitudes and feelings have contributed to this. A better understanding can lead to an improvement in relationships.

Marital therapy: For those who are currently in a relationship, particularly one that is under strain, a good approach to psychological treatment is one that involves the partner as well. Couple or marital therapy can be a very effective way of mobilising the resources of the couple to improve their relationship and making use of the major asset that comprises a good relationship.

Counselling: This is aimed at resolving current practical and emotional problems. Time is given to looking at ways of managing practical problems–for example a young mother looking at what possibilities there might be for childcare to allow some time away from looking after children. However, it is very difficult for those who are more than mildly depressed to make use of this approach because their negative view of themselves and their situation strongly colours their perception of the problems.

Education: The most basic form of psychotherapy is education, both about the illness in general and about the particular pattern of illness in that patient. It is only when people are able to recognise how the illness manifests itself in their case that they can really take on productive approaches to taking care of themselves and finding which treatments are helpful. This is vital for everyone who suffers from manic depression.

The approaches outlined above can all prove useful for those with bipolar depression; however there has been relatively little research into what specific treatments are most effective for those with manic depression. Hopefully this will become clearer in the next few years, but it is likely that the non-specific factors in psychotherapy are equally as important, including an accepting, understanding, empathic relationship with a therapist who can instil a sense of hope and build on the strengths of the person.

3.21 What is cognitive behaviour therapy?

Cognitive behaviour therapy (CBT) aims to help people to recognise and alter the patterns of behaviour and thinking that occur in depression. There are a variety of approaches used to look at the way people who are depressed talk to themselves inside their heads.

RECOGNISING AND MANAGING NEGATIVE THINKING

This is one of the basic techniques of cognitive therapy. It involves identifying those negative thoughts which spring into the mind easily–for example ‘I’m useless’ is a classic idea that occurs to a depressive in response to any difficulty. This can lead on to ruminations about how others would be ‘better off if I wasn’t around’ and then to suicidal thoughts. This run of thinking inevitably further depresses the mood and half an hour going round this theme will make anyone feel a lot worse.

Step 1: Recognising this pattern is the first step in intervening–even a simple self-acknowledgement of what is happening can help to stop the rumination. These thoughts are likely to emerge again as they become so automatic, but if active rumination can be changed to an attempt to interrupt, this can be very helpful. There are usually a number of similar ‘mental grooves’ that make up depressive thinking.

Step 2: The next step after recognition is examining the truth of the self-talk. What does ‘I’m useless’ mean? Does this mean that the person can’t do anything at all–not even make someone a cup of tea? Usually the automatic depressive thinking is very extreme and it is not difficult for a therapist to challenge it in this way, and usually patients feel better when this is done in an interview.

Step 3: The third step for patients to learn is to challenge their own thinking; psychotherapy techniques aim to get patients to take this on for themselves. Cognitive therapists have a wide variety of techniques to help people manage their thinking more effectively, but it can also be useful for doctors to use this type of approach in discussions with the depressed (see Further reading).

PROMOTING PRODUCTIVE BEHAVIOURS

It is common for those who are depressed to restrict their life to minimal activities, which is often just the essentials–‘the grind’. Even when it is difficult to penetrate the negativity of thinking it can be worth trying to encourage patients to look at what they are doing day by day. Looking at getting back into routines, but starting at a low level, is a first step. Even small changes–having a shower each morning, taking a short walk –can help self-esteem and break into the pattern of inactivity.

Consider also pleasurable activities in which patients had previously been involved and which could be tried out again. Starting with low level activities–a walk in the park with a friend rather than a wild night out on the town–is a sensible place to begin (see also Q 3.36).

3.22 Does ECT have a place in the treatment of manic depression?

A few patients who have had ECT in the past and found it to be the most effective treatment will come and ask for this treatment first line if they become depressed. This would be completely outside some guidelines (e.g. National Institute for Clinical Excellence, see Appendix 1), but it is a request that should be seriously considered as ECT is the quickest and most effective antidepressant treatment.

Usually, however, ECT is reserved for more extreme situations. The commonest of these would be the treatment of psychotic depression which is life-threatening, either because of suicide risk or where the patient is not eating or drinking sufficiently.

Often those patients in such extreme states lack the capacity to consent to treatment with ECT and occasionally they will agree because they see it as a punishment and this fits with their desire to be punished. Therefore this treatment will often need to be done in a legal context which protects both patients and doctors. In England and Wales this would be with the patient detained under the Mental Health Act 1983 and a second-opinion psychiatrist appointed by the Mental Health Act Commission having agreed with this line of treatment.

Occasionally ECT can be used in the treatment of mania or mixed affective states (see Q 4.12).

3.23 What is ECT?

Electroconvulsive therapy (ECT) is the quickest and most effective treatment for depression. However, it is often seen as a barbaric treatment, mainly because the idea of having an electric current applied to your brain is a very worrying one. It is certainly true that unmodified (no anaesthetic and no muscle relaxant) ECT did lead to very serious side-effects including broken bones and has been vividly depicted in the movies. Unmodified ECT is no longer given. The reality of ECT for most patients is that they report it to be only mildly unpleasant and are usually very relieved that their depression is improving.

ECT involves stimulating the brain so that an epileptic convulsion is induced. This is done with a high frequency electrical pulse delivered between two electrodes placed on the scalp. In bilateral ECT the electrodes are placed on opposite sides of the head; in unilateral ECT one electrode is on the side of the head and the other on the top of the head. The non-dominant hemisphere (usually the right side) is stimulated in unilateral ECT.

The process of modified ECT involves a general anaesthetic, followed by a paralysing muscle relaxant and then the application of the electric current. Many patients do not realise that they are going to be unconscious and relaxed when they are having the treatment. The treatments are usually given twice a week and a typical course is of between 6 and 12 treatments.

3.24 What are the side-effects of ECT?

Bilateral ECT is more effective than unilateral ECT but also has more side-effects. The most common side-effect is headache and most patients would experience a mild headache after ECT. The commonest troublesome side-effect is memory loss: this is usually for some of the time around the ECT but can be more extensive. Some patients find this very distressing and all patients should be warned of this possibility. It is difficult to disentangle this side-effect from the effect of depression on memory which is also substantial.

3.25 What are the risks of ECT?

The risks are mainly those of having a general anaesthetic and there are rare deaths associated with ECT, usually when a very debilitated, poorly nourished and dehydrated depressed patient is being treated. This needs to be balanced by the effectiveness of the treatment and the need to provide rapid relief to patients in mental and physical extremis.

3.26 Is transcranial magnetic stimulation a useful treatment for bipolar depression?

Transcranial magnetic stimulation (TMS) involves placing a strong electromagnet next to the skull in order to affect the nerve cells underneath. There have been reports that this can be helpful in treating depression among those with both unipolar and bipolar depression, but the effect is only small and probably temporary. As with many studies of antidepressant effects, the main thrust of research has been on unipolar depression and there is still too little evidence to recommend this treatment in bipolar depression.

Intriguingly, it has been suggested that stimulation over the left prefrontal cortex may improve depression and over the right prefrontal area may alleviate mania. This tallies with other studies of patients who have had a cerebrovascular accident that has led to affective disorder, which also suggests that the illness may lateralise in this way.

The effect of TMS does not appear to be very strong and it seems unlikely that TMS is going to be a commonly used treatment in the near future. In addition, the availability of machines for this purpose is still very limited (Boniface & Ziemann 2003).

3.27 Are there any blood tests or other investigations that should be done when someone is depressed?

Usually bipolar depression comes within a longer course of bipolar disorder. If the patient is taking longer term prophylactic treatment, it is likely that some investigations will have been done, particularly thyroid function tests, as part of monitoring this treatment. However, it is worth bearing in mind that depression can be associated with a variety of physical illnesses. The most important investigation would be a simple review of physical systems to elicit any symptoms indicative of a physical illness. Thyroid function should certainly be checked in any episode of depression. Prominent physical symptoms such as tiredness may prompt investigations to ensure that anaemia is not present. One of the major complications of depression is alcohol misuse and review of liver function may be indicated. It is likely that an estimation of renal function has already been obtained if prophylactic treatment such as lithium is being considered.

3.28 What is the best way to talk to someone who is depressed?

There is no best way but there are aspects of the interview that are worth considering. The depressed often need more time than we usually put aside for consultations, they may be retarded and have poor concentration which means that getting them to provide the relevant information can be slow. They are, however, often easy to deal with briefly because their low self-esteem and hopelessness means that they do not want to take up any time as they don’t believe they will be able to get help. The hopelessness of depression can be infectious and there is a need to guard against falling in with this and not following a line of treatment that may be beneficial.

The patient will only be able to take in a small amount of information, so advice needs to be kept simple and should probably be written down as well. It is often helpful to have a friend or relative along as they will be able to recall more from this interview. They can also help to keep a more balanced picture of the meeting than the negative bias that the patient will tend to recall of what has been discussed. Keeping a balance between optimism and realism is difficult, as encouragement should be provided, but unrealistic promises about the benefits of treatment or overoptimistic prognoses for the speed and extent of improvement can backfire later and lead to patients losing confidence in their treatment. Focusing on what someone can do to improve their own symptoms and situation and not just relying on the medication is important (see Q 3.36), particularly in helping to improve self-esteem:

Focusing on the efforts that they have already made and trying to get patients to spell this out can help to get a more realistic view of the current position.

Looking at what happened during previous periods of depression and how recovery occurred is useful and realistic in terms of prognosis.

Making plans on an achievable and gradual basis even from a small start–for example having a walk to the post box each day as a beginning on which to build–can discourage unrealistic goals (e.g. walking 5 miles a day, when the post box has not yet been achieved).

Helping to recognise the circular patterns of thinking and trying to put aside worries even for a short while is helpful.

Letting patients discuss at length the way they are feeling and the thoughts that they are getting can prove counterproductive and many depressed people complain that counselling makes them feel worse if all they do is talk about their feelings and problems and reinforce their own negativity.

Being listened to is valued by most people who are depressed and it is worth giving some time to this in most interviews–sometimes it can be the major intervention. However, usually there are several assessment and management goals in the interview and there is a need to guard against spending all the time listening and not achieve any of these goals. Getting this balance right is not easy in any consultation, especially when under pressure from time.

Patients will gain confidence if they perceive that their depression is understood–for example by asking about common symptoms that they will have and also understanding that they are likely to be feeling worthless, hopeless and desperate. Accepting that they are likely to have thoughts about death and suicide makes a discussion of these issues much more productive than if they think that you are going to be shocked by these ideas. There are limits to what can be offered but letting patients have a means of contact if they are getting worse–and knowing how quickly they will get a response–can be very helpful.

3.29 What general advice can be given to someone who is depressed?

The suggestions below have a reasonably firm foundation for unipolar depression but there are precious few studies in bipolar depression. However, extrapolation of these ideas to manic depressives with some reservations is worth considering.

DIURNAL RHYTHMS

Most people who are depressed lose the basic rhythm of life, they are sleeping badly and are often up at night whereas in the daytime they are resting, sleeping or doing little. Endocrine studies (e.g. cortisol levels) reflect this as they tend to show that the depressed lose their diurnal rhythm with a constant high level of corticosteroids. Are there small changes that they can make to try to re-entrain themselves so that they are active in the day and thereby give themselves a better chance of sleeping at night?

EXERCISE

Exercise can improve mood–those that exercise regularly have better mental health and trials of exercise in depression have shown the benefit. Those who give up exercise run a higher risk of experiencing depression. No specific trials have been done in bipolar depression but many people report that this is helpful.

To most people exercise implies running or other high exertion sports. Suggesting this to a depressed patient is likely to be ignored when they feel they can hardly get out of bed. Find out what they had been doing before they were depressed or what they used to do earlier in their lives. People are more likely to take up exercise in which they had previously been active rather than try something new. Look initially at low level exercise: doing some walking or going for a swim can be both useful and acceptable. If patients can then build on this to take some exercise regularly at a more substantial level it is likely to be of considerable benefit to their mental and physical health in both the short and the long term.

ENJOYABLE ACTIVITY

Many people who are depressed have brought their range of activities down to the bare minimum–‘just the grind’–and have stopped doing the things that brought pleasure to their lives. Asking ‘What do you do for fun?’ usually elicits the response that they ‘don’t do fun’ nowadays but can lead on to a discussion of what they had previously done for interest. Again start low and build up rather than have expectations that are unlikely to be achieved.

LIGHT AND SUNLIGHT

Winter depression can be specifically treated with bright light, but many people find the dark winters depressing (see also Q 3.34). It is surprising how much light there is outside on even a dull winter’s day. Encouraging the depressed to get some fresh air and sunlight, even in the winter, may sound very traditional advice but works for some!

3.30 What advice can be given to someone who is sleeping badly?

It is worthwhile for those suffering from manic depression to have as good a sleep pattern as they can and a variety of techniques to hand that promote sleep. A regular sleeping habit is a good starting point, always going to bed and getting up at the same time. Encouraging people to get up in the morning even if they have not slept well is a good foundation. Sleeping in the daytime tends to make the night’s sleep worse but can be very tempting!

Taking some exercise, such as having a walk in the early evening, can improve the chances of getting off to sleep later. Although alcohol can help people get off to sleep it tends to wake them up in the middle of the night as the alcohol levels are coming down. Stimulants such as caffeine in coffee or tea should be avoided in the evening.

There are a variety of techniques that people can use to help to get themselves off to sleep, or at least to relax. Virtually everyone who suffers from manic depression will benefit from having one of these strategies available to them. Relaxation techniques (e.g. breathing exercises) are the most basic methods. These can give both physical and mental relaxation; however it can also be helpful to have a specific mental technique to quieten down the thoughts that are crowding round the mind (see Q 3.38). It is generally much easier to learn these techniques when reasonably well rather than when in the grips of depression.

In acute depression with serious sleep problems there are several pharmacological options. If the patient is already on a sedative medication it may be appropriate to increase this–for example raising the dose of carbamazepine at night. If an antipsychotic is being taken the dose of this could be increased or this treatment could be given on a temporary basis–for example olanzapine (usually 5-10 mg) or chlorpromazine (up to 100 mg).

Prescribing a hypnotic is another option, though many are reluctant to use benzodiazepines because for every 10 patients started on them one is likely to continue long term. However, if this is a short-term prescription only then temazepam 10-20 mg is appropriate. The newer sleeping pills such as zopiclone (7.5 mg) are thought to be less likely to lead to dependence but still need to be used with caution.

3.31 How long does an episode of depression usually last?

Even severe episodes of depression do usually remit. If this is the first episode of depression, it is possible to predict with confidence that the patient will recover. Even without treatment the depression will come to a spontaneous end, and prior to modern treatments it was unusual to stay depressed for more than a few months. Looking at how long episodes have lasted previously is a good indicator of how long this one will last.

With the appropriate treatment some improvement should be seen within a month. If there is no improvement on the current treatment after 6 weeks then it is unlikely that this treatment at this dose is going to work. It is, however, worth persevering with each treatment (though not usually each dose) for at least 6 weeks to judge whether the medication is useful. It is very easy to change treatments after a couple of weeks because the symptoms are not improving only to find after three changes that the options are running out and you don’t know whether to go back to an earlier treatment!

3.32 When should someone who is depressed be in hospital?

ADVANTAGES

The main advantage of being in hospital is that nursing care is readily available. This gives a good opportunity for assessment of the severity of the depression and its complications including nutrition, hydration and suicide risk. In the most severe cases nursing care includes helping the patient to maintain basic self-care–for example bathing, changing clothes and help with eating and drinking. Nursing staff can also encourage a simple daily routine to try to reinstate a more normal rhythm of activity in the day and sleep at night. Taking away some of the day-to-day responsibilities from those incapable of dealing with them is helpful in the short term.

The usual reason for admission is a combination of how disabled the patient is balanced by the presence of what help is available at home. The lonely isolated depressed man is likely to require admission at a lower severity than the woman with a close family who is able to give the considerable time and sympathetic assistance that is needed by the severely depressed.

DISADVANTAGES

Treatment in hospital can undermine patients who have taken pride in managing despite their depression and can lead to further loss of self-esteem. Life in hospital is rarely calm and peaceful–everyone admitted is in an extreme mental state and being surrounded by disturbed patients can be very disturbing! It can be very hard to get a night’s sleep in a ward with even one manic patient who does not want anyone else to be asleep. Some patients can be very disruptive to recovery and encourage others to behave more extremely (e.g. by self-harm such as cutting themselves) or to undermine outside relationships. Remember that being depressed leaves people very vulnerable to others. Illicit drugs are commonly available in and around hospitals; drug dealers often target such patients knowing of their vulnerability.

Coming into hospital and so avoiding dealing with serious problems at home is a double-edged sword. It can be useful to be protected from the difficulties in the real world but it can also lead to those problems escalating–for example as the bills mount up and the electricity is cut off or the flat is vandalised because it is unoccupied. The same is true of relationships that are under strain and a hospital admission can be the final straw that leads to break up.

TO HOSPITALISE OR NOT?

If it is possible to provide extra help at home through the local mental health and social services then this would usually be preferable, unless there is a very high suicide risk or it would put an unreasonable burden on the family. The presence of psychosis in depression is a very ominous sign and it is very likely that admission will be needed unless there is an equivalent level of support outside hospital. There is always a substantial suicide risk among the severely or chronically depressed and judging when this is so high as to require monitoring by nursing staff in hospital is a challenge for us all (see Q 3.18). The fact that there is a substantial number of patients who commit suicide during their admission or soon after discharge is testimony to this.

3.33 What advice can be given to relatives of someone who is depressed?

The main advice that can be given to family or friends who are caring for someone with bipolar depression is similar to that given to patients (see Q 3.36). It is very helpful to have a family member in the interview when giving advice to a depressed patient because they have such difficulty concentrating and remembering what has been discussed. The discussion will often turn to the balance between trying to encourage the depressed person but not feeling that you are bullying or nagging them. This is a difficult but important balance to strike. Sometimes it is possible to get the patient to tell their carer what they find most helpful and what they want the family to do when they are finding it difficult to motivate themselves. It is more likely to be acceptable when they have initiated the idea rather than when they are being pushed by the relative.

The other worry of carers is suicide risk and this should be discussed as frankly as possible, recognising that suicidal ideas are very common in depression but trying to help carers to identify when this might be becoming too extreme or dangerous for them to manage safely at home (see Q 3.19).

Family members need to take care of themselves too–simply asking them how they are getting on can help to acknowledge the major task in which they are involved. Acknowledge the difficulties they face and the range of emotions (including feeling angry) that they are likely to be experiencing–this can help to reduce the guilt they usually feel. Encourage them to find time for themselves away from caring. This can be particularly difficult if they are worried that the depressed person might do something suicidal–help them to look at these risks realistically and to understand that they cannot watch someone every moment.

3.34 What is seasonal affective disorder?

Seasonal affective disorder (SAD) is winter depression often associated with summer hypomania. It is quite a common pattern of bipolar illness, particularly at the milder end of the spectrum. Most of us find some change in our mood and energy between summer and winter–seasonal affective disorder seems to be a magnification of this effect. It may be more common in more northerly climes where the winter night is longer and daylight is in short supply. Like many bipolar depressions it is associated with an increase in appetite and sleep. Some people think it may be related to hibernation in other animals but there is no evidence that any of our animal ancestors hibernated so this is unlikely.

If seasonal affective disorder is related to lack of sunlight then it makes sense to replace this with artificial light (see also Q 2.34). There are several types of artificial light boxes available. However, the principle is for the depressed patient to sit next to a very bright light, usually for an hour in the morning and an hour in the evening. They can read a book or be watching television but need to look at the light frequently while they are doing this. This is actually very restrictive and compliance with the treatment is often poor; however some people particularly like this approach. There are now some ‘light hats’ available which are essentially baseball caps with bulbs in the peak; however, the efficacy of this has not been well proven compared to the light box. The other alternative for getting more light is to have a walk outside as even dull days produce a lot of light and the exercise can also be helpful for depression.

Certainly some patients find light treatment very beneficial and in the UK some will start using it when the clocks go back an hour at the end of British summertime to prevent the onset of their depression. Boxes usually cost about £200 which can be prohibitive for some patients and few clinics hire them out.