We are a psychology teacher with bipolar disorder and a professor of psychiatry from an international research team working to improve lives of people with BD. For World Bipolar Day - Ask us anything!

Will there ever be a way to diagnose Bipolar that doesn’t have to do with a negative and often life-ruining effect of SSRIs prescribed by a general practitioner?

Steven here--I went through an SSRI struggle myself (long story there). It’s tricky. Many people with bipolar disorder have a depressive episode as their first mood episode, so antidepressant prescriptions at that time make some sense from the point of view of the medical practitioner--because the person hasn’t yet met criteria for bipolar disorder (i.e., they have not displayed symptoms of mania or hypomania). The only way I can see out of this situation is better patient profiling prior to the writing of prescriptions. For example, asking the individual whether they have family members with bipolar disorder. Perhaps in the near future, once we know more about the genetic and epigenetic factors that play a role in the emergence of bipolar disorder, we might be in a much better place to write prescriptions (and develop medications) that are better able to treat the symptoms of bipolar disorder with fewer side effects (i.e., personalized medicine).

There is also the issue, which you raise, about general practitioners often being the first person to prescribe for a person with bipolar disorder. Their education on current evidence-based pharmaceutical interventions is critical, since there simply aren’t enough psychiatrists to go around. There are now excellent treatment guidelines for bipolar disorder (e.g., like those produced by CANMAT <https://www.ncbi.nlm.nih.gov/pubmed/29536616>) that can help doctors choose the best possible medication given the particulars of an individual’s diagnosis.

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Man, those SSRIs and other drugs used to rein them in afterwards were so overpowering that I won't fucking touch psychiatric help again. Maybe my bipolar disorder, if I have it, is mild enough to function without any pills. Been pill free for over 5 years now and I'd say my life is flourishing as much as normal people.

It really ruined it for me though. I spent three years in a hellish state that I'll never get back and I've been permanently changed, if not my directly in my brain, then my learning because I have absolutely no trust for Doctors or my family anymore. Only person I open up to is my fiance because of the trust issues since I had to fight on my own to get to my best state while everyone else was trying to convince me to be miserable and continue an overmedicated path, my doctor included. Sometimes I wonder if getting through depressive slumps would be easier on the right balance of medication, but I will never, ever be convinced to try again.

From Erin - I appreciate your POV and your comments. Within CREST.BD, we’ve tried over the years to position ourselves carefully as a network that focuses on a particular condition: bipolar disorder. This approach privileges a biomedical stance, which is entrenched in our belief in the utility of diagnostic systems for accessing treatment and care. And in our belief that psychiatric medications save lives and help optimize quality of life in many people. However, it’s never been our intention to disenfranchise people who don’t align with this view; rather, we embrace diverse worldviews. Figuring out how best to support people who don’t identify with psychiatric/mental health systems -- through helping them to access good evidence on self-management strategies for example -- is something we work hard on. It’s a work in progress for us, but one that we care about.

The town I've lived in for the last several years is flooded with meth. I've known several addicts reasonably well, and with all of them I've seen that they have serious psychiatric disorders - a grab-bag of affective and psychotic symptoms separate from the direct effects of the amphetamines - which are untreated or inadequately treated. Many have at some point, such as in rehab, have been diagnosed with bipolar or a related disorder such as schizoaffective disorder.

Ours is an isolated, rural community. There's no access to mental health care, and the local Rural Health Clinic doctor is quite inadequate when it comes to psychiatric issues. People in the community don't seem to have an understanding of mental health issues, and even most people with diagnoses know nothing about them and have no support in managing their lives with a psychiatric disorder.

Instead, they self-medicate with meth whenever possible. Looking at the actions of methamphetamine in the brain, and comparing it to various psychiatric drugs, it's easy to see how meth would tweak some systems in the brain that are involved in mental illness, providing a brief respite for the user

To what degree do you think that increasing public awareness of mental health issues, destigmatizing them, and increasing access to mental health professionals along with providing more extensive mental health training to GPs would contribute to alleviating the "meth epidemic", which has clearly taken a toll on communities such as ours?

Steven here--I am very sad to hear of this situation. I’m sure that better education surrounding mental illness in general, and surrounding the higher risk of substance abuse in individuals with bipolar disorder in particular, would go a long way to help prevent substance abuse.

Hi! Thanks for doing this AMA. When you create an online tool, what methods do you use to evaluate and validate it as performing the way you intended?

Erin here - a great question to start us off for this AMA, thanks! We’re actually just writing up some data on this, from a study where we compared the psychometric performance of our paper and pencil bipolar quality of life scale http://www.crestbd.ca/research/research-areas/quality-of-life/ with its online counterpart - https://www.bdqol.com/ . We you hope see - and what we did see in this example - is the paper-and-pencil and online versions of the scale ‘behave’ in the same way psychometrically.

For another project we’re doing - ‘Bipolar Bridges’ - we’ll be evaluating ‘user engagement’ with a new app for bipolar disorder. For that project, we’ll be assessing engagement in terms of things like such as focused attention, the app’s aesthetic appeal and how intrinsically rewarding it is.

Any way I can be updated on this app’s release?

Yes! We will be posting updates on our website and social media channels. Website: crestbd.ca / Twitter: @crest_bd / Facebook: facebook.com/crestbd, or, subscribe to our mailing list at www.crestbd.ca/research.

Keep it touch!

Is it common for someone with bipolar (I don’t remember if I or II) to become angry? My bf/ex bf has bipolar and anytime I ask him a question he sees it as an interrogation. Or sometimes he’ll randomly lash out with words for no reason. Hence the reason for our many breakups. How do you tell someone they need help when they don’t want it?

Erin here, this is a great two-part question, thanks for asking. Yes, it’s very common for symptoms of irritability/anger (and impulsivity too) to be experienced by people with BD. These symptoms can be extremely distressing for both the person with BD, and those who are at the receiving end of it.

Your question about ‘insight’ in BD is a frequent one we hear from family and loves ones - it’s also very distressing to know that someone you love needs help, but to see that they’re not in a position - at that point in time - to know that they need help. This is particularly common during episodes of mania.

Here are some resources that you may find helpful:

• https://bipolarcaregivers.org/taking-care-of-yourself/maintaining-or-rebuilding-your-relationship-with-the-person
• http://www.care2.com/greenliving/how-to-work-through-mental-illness-as-a-couple.htm
• On bipolar anger: https://www.bphope.com/bipolar-stories-video-blog/video-bipolar-anger/

We have also compiled a list of articles on managing relationships with loved ones with BD here: http://www.bdwellness.com/Support-Tools/Resource-By-Area/Relationships

Should people with Bipolar Disorder, either 1 or 2, plan tentatively to get Alzheimer’s or Dementia when they grow older just based on the health effects that mania induces on the brain after a long period of time?

Erin here - wow, great question, and one that we could spend the whole AMA trying to answer. There is an amazing body of science emerging in this area - for a deeper dive, I’d suggest starting with the work of the International Society for Bipolar Disorders (ISBD) Targeting Cognition Task Force - this group includes the opinions of key scientists working on this topic currently. In this paper, for example, the taskforce addresses the best methods for assessing and addressing cognitive impairment in people with bipolar disorder: https://www.ncbi.nlm.nih.gov/pubmed/29345040

At a lighter level, many of us - whether or not we live with BD - should be ‘planning tentatively’ to experience significant cognitive decline as we age! We and we should all be doing what we can proactively as we age to protect brain health.

Steven here--Just a quick note that one of the most common medications used for the treatment of bipolar disorder, lithium, seems to be neuroprotective. There are even some suggestions in the research literature that lithium might be a potential prophylactic for Alzheimer’s disease or even help reduce the cognitive symptoms associated with Alzheimer’s disease (e.g., see https://www.ncbi.nlm.nih.gov/pubmed/26402004).

Are there any other medications for BD (say something like lamotrigine) that may also do the same as lithium or is lithium the only one that is known to be neuroprotective?

Steven here--There is some evidence that lamotrigine and sodium valproate (aka Epival) are neuroprotective in certain animal models of epilepsy. Most of the studies on the neuroprotective effects of those two drugs have been conducted in animal models of epilepsy because both were anticonvulsant medications before they were adopted as mood stabilizers for BD. Whether such neuroprotective effects are also present when treating humans with epilepsy or bipolar disorder remains to be seen. (I don’t know of other mood stabilizers with neuroprotective effects.)

Hi, Thank you both for doing this today and eharby4 for raising this issue. This is my first time on reddit. I have lived with the symptoms and diagnosis of Bipolar Disorder 2 for more than 30 years. Almost 3 years ago, I was diagnosed with mild-moderate cognitive impairment. I would like to know more about the intersection of these conditions. Over the years, I learned to manage bpd in many ways and felt like I was living well. I am trying to do the same with dementia. Any suggestions? sources? or ideas to share?

It’s our first time on Reddit too, so you’re in good company, lol! We’ve spent several years in our team at CREST.BD developing a Bipolar Wellness Centre to support people with the condition, there’s a section in there specifically on cognition and BD: http://www.bdwellness.com/Quality-of-Life-Areas/Cognition

A section on evidence-informed tools: http://www.bdwellness.com/Support-Tools/Resource-By-Area/Cognition

And a webinar on the intersections between cognition and BD from one of our team members, Dr. Ivan Torres: http://www.bdwellness.com/Support-Tools/Webinars

Hope these help! Erin.

What would you most like to tell us that no one ever asks about?

Good question. Not sure where to start actually, as that is a big space. Maybe one of: (1) how I have dealt with self-stigma; (2) what I am learning about how teaching environments affect postsecondary student mental health (but that is not really directly related to bipolar disorder…); or (3) what living well with bipolar disorder means in practice from my perspective. That’s just off the top of my head, though I am happy to chat about anything really. - Dr. Steven Barnes

Since bipolar disorder seems to have a societal/environmental component, what would you suggest as preventive steps to avoid developing it? Is prevention even possible?

Steven here - That’s a tough one. I would say that virtually all forms of mental illness have an environmental/experiential component, but whether that component is a causal factor in an illness like bipolar disorder is far from clear. There is some research in adolescents at risk for bipolar disorder (e.g., they have a first-degree relative with bipolar disorder) that suggests (with a big emphasis on ‘suggests’) that early interventions targeted at diminishing the impact of, or onset of, depression might help prevent subsequent hypomanic or manic episodes.

Erin here - there is some exciting - but still nascent - research underway looking at how best to predict which youth with bipolar disorder (BD) will progress on to develop the condition. Arming people who are known to be at risk (e.g., have a family history of the condition) with psychosocial tools to help maintain resilience is logical starting point. There’s now solid evidence to indicate that supporting self-management strategies and coping skills in people with BD can improve health and quality of life - this should be the first step in terms of preventing potential progression from milder manifestations of the condition into full blown BD.

How do you handle relationships when the other person does not have nor understand Bipolar?

Steven here--My personal feeling has always been that you should let the person get to know you a bit before telling them that you have bipolar disorder. The reason for this suggestion comes from my own experiences: If a person knows you as a person first, rather than someone with a diagnosis, then when they learn of your diagnosis it is more difficult for them to see you as someone who is defined by their illness (i.e., the label will not define you for them). It is also important for you to educate that person about bipolar disorder once you have disclosed to them.

how can those with BD with seasonality prepare for the changes in seasons?

Erin here - a great question, and one that’s close to my heart (my PhD focused on Seasonal Affective Disorder, or SAD). Changing seasons are a known risk factor in BD - particularly in the Spring. One thing I would recommend here would be to do a ‘life chart’ - life charts are basically a way of mapping out your prior episodes of hypomania/mania and depression, and examining any patterns between them and factors such as the changing seasons. Knowing whether Spring is a potential trigger for you for elevated mood (or depression in the Fall) is the first step. After getting a ‘helicopter view’ of your patterns of mood episodes over your lifetime, ongoing, more ‘fine grained’ mood monitoring is key, that is, measuring your mood on a daily basis in a mood diary or by an assessment scale. This can empower you know when intervention is needed. You can also proactively prepare for clock changes, by ensuring your sleep hygiene routines are extra vigilant at these times. Find research, tips and tools for sleep and BD at: http://www.bdwellness.com/Quality-of-Life-Areas/Sleep

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Great AMA thank you so much!
I wanted to ask, what are the early warning signs? How do you know if someone you love might be starting to deal with Bipolar Disorder and how you would approach them to talk about it?

Erin here - it really is our pleasure, and what a great, far ranging conversation so far! The answer to your question depends on whether you’re talking about early warning signs for an impending episode - there are called ‘prodromes’ in the scientific or clinical literature, or early warning signs that someone might be experiencing BD more broadly, I think you’re referring to the latter? Some of the symptoms of BD can appear very similar to those of depression - this is one of the things that makes it difficult to for people to get the ‘right’ diagnosis of BD. A diagnosis of BD can’t be made accurately until someone has a clear episode of hypomania or mania. To complicate things further, many people don’t seek help when they’re initially experiencing hypomanic episodes - they’re sometimes a welcome relief from depression. But there are some ‘cardinal’ symptoms of BD to watch for - lack of need for sleep, rather than the ‘hypersomnia’ more frequently seen in depression, an increase in energy, talkativeness, big or ‘grandiose’ ideas… My advice on talking to someone who you love about your concerns would be come at the conversation from a place of compassion (which it sounds like you are) and to start the conversation by talking about what you’re noticing in concrete, behavioural terms -- “You know I care about you, and I’ve been noticing lately that things have been different <for example, A, B> - I wanted to reach out and see if I can help in any way, and to touch base to see if you have any concerns about this?

Hi doctors! Thanks for doing an AMA.

If there were one common misunderstanding about bipolar disorder you could disavow, what would it be and how would you address it?

What, if any, ethical concerns exist around creating a network directly connecting people with bipolar disorder, researchers, and healthcare providers?

Finally, what was something you thought you knew but later found out you were wrong about?

Thanks!

Steven here--regarding your first question: As a person living with bipolar disorder, the misunderstanding I would most like to see done away with is the notion that persons with bipolar disorder are violent/dangerous. The opposite is true: Individuals with bipolar disorder (and just about any other mental illness) are more likely to be the victims of violent crime than the perpetrators.

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The second misunderstanding that I would like to see dispelled is the idea that bipolar disorder involves noticeable/visible rapid changes in mood. Such ‘rapid switching’ is very rare in bipolar disorder. For example, the definition of ‘rapid cycling bipolar disorder’ is having 4 or more mood episodes in one year; given that rapid cycling is not very common, this illustrates that the mood episodes in most cases of bipolar disorder are long and that the switch between mood states (e.g., between depression and mania) is often slow and even undetectable by most.

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Regarding your second question: I am actually going to seek some clarification on what sort of ‘network’ you are talking about. Could you clarify? For example, there are certainly different ethical issues associated with creating an online social network vs. an in-person one. Personally, I see more potential issues with the former than the latter (in the first instance, mostly related to data privacy).

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Regarding your third question: When I was first diagnosed with bipolar disorder, I lived under the false belief for many years that this meant that I would be unable to achieve the goals I had for my life. The opposite has turned out to be true. I don’t believe there is any reason to think that one cannot live a satisfying life once one is diagnosed with bipolar disorder. With appropriate interventions, people with bipolar disorder can live well.

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Hi, thank you for this AMA!

I've been trying different medications for about 2 years for my bipolar II disorder and nothing really seems to work. The hypomania is gone (RIP my fun side) but the depression seems treatment resistant.

What medications do you recommend for bipolar depression, so that I can bring them up with my doctor next week?

Also, two people have recommended that I use ADHD meds for the lows. Would you recommend that I try ADHD meds to treat my lows?

Steven here--Sorry to hear you have been struggling with the medications. There are actually some solid evidence-based guidelines for the treatment of bipolar disorder--including when depression predominates. For example, see the following paper:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5947163/

I’m hesitant to recommend any specific medication since I don’t know all the details of your condition (and I am not a physician), but bringing the above research paper to your doctor might be a good step to take.

Hope that helps a bit.

What are some effective ways to reduce stigma from health care providers?

Steven here - I have experienced such stigma on multiple occasions. The one sort of experience that is most salient for me (simply because it has happened so frequently) has been certain interactions with pharmacists. With some pharmacists, when I hand them my prescription for Lithium or another mood stabilizer (i.e., treatments that are primarily used for bipolar disorder), I am suddenly treated differently by them (e.g., they start talking more slowly to me; their conversational tone ceases and turns into something colder).

I would say the best intervention for most forms of social stigma (such as that displayed by some health care providers) is education about bipolar disorder ,as there are many misconceptions about bipolar disorder present in some health care providers. Incorporating more in-depth education about mental health and mental illness in the health-care education system might go a long way to help solve such issues.

Erin here - concurring with Steven’s thoughts here, but I’ll also add that addressing ‘structural’ forms of stigma in healthcare systems is vital. People seeking treatment for mental illnesses must be afforded the same rights and opportunities as people accessing treatments for non mental health-related conditions.

Do you think that currently, BD is over diagnosed and over medicated? And if so, what are your suggestions for dealing with both.

Steven here--as someone who has lived well with bipolar disorder for many years now, I do have a bias towards the use of medications in bipolar disorder. That being said, we still have a long way to go before we can prescribe medications with confidence. The current movement towards personalized medicine might help address this issue. For example, I am currently taking 5 different medications for my bipolar disorder--each drug treating a different symptom rather than the condition as a whole. Also, medications are only the beginning when treating bipolar disorder--once stabilized and safe, there are many psychosocial interventions that one must incorporate into one’s life. Short story here is that, from my perspective, drugs are a tool towards getting better, but they are not the final solution.

Regarding the overdiagnosis question, there is some discussion that Bipolar Disorder Type II (which includes depressive episodes and hypomanic episodes, but no manic episodes) is showing an increase in the number of new diagnoses. What that means exactly is unclear. It might be that ‘hypomania’ is ill-defined (which many people think is the case) or it might be that we had been overdiagnosing people with major depressive disorder, when many of them should really be receiving a diagnosis of bipolar disorder type II. There are many other possible reasons for the increase in diagnoses of bipolar disorder type II

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Erin - The potential risk of BD should not be downplayed. Suicide rates in people with the condition are disturbingly high - up to 15% of people with BD will end their own lives. Pharmacological treatments are vital for many people to stabilize mood, and to reduce risk from suicide. And in many of the interviews we’ve done with people with BD, getting the correct diagnosis is described as a relief, and a potential gateway to accessing the most effective treatments - both medications and talk therapy. Having said all this, there are interesting country and system specific patterns in diagnostic rates and treatment approaches to BD. What is needed - and happening internationally - is the continued refinement of international evidence-driven treatment guidelines. Also needed are more effective ways for sharing data on, say, prescribing patterns and outcomes, across countries and regions. In this way we can work internationally to deliver the most effective forms of treatment for the condition with the aim of optimising health and quality of life

I'm at a career transition point and am trying to find a field that BP won't interfere with. Are there certain fields that folks with BP find themselved drawn to and / or excel at?

I am in the middle of a depressive episode that's been going on for 3 weeks now, not sure any employer will ever understand.

Steven here--I believe that one’s choice of jobs or careers can have significant ramifications for an individual living with BD. Personally, I have had much more success in situations where I have flexibility in my work hours and/or am self employed. I have worked both inside and outside academic settings. Academia has been a particularly fruitful environment for me to be in because of the flexibility in my work hours. Outside of academia, I had more success in situations where I was self-employed as opposed to jobs where I had to show up every day 5 days a week.

All that being said, one key aspect of managing bipolar disorder for many people is maintaining a regular schedule. So, I can envision that for many people living with BD, a job with a regular schedule might be better for them.

Ultimately, I think one has to try a few careers (which is of course the norm these days) before one can figure out what works best for them in the context of their living with BD.

Do you have any recommendations for books or movies with realistic depictions of bipolar disorder, especially featuring psychosis?

Do you think there's any potential in ketamine or MDMA therapy for bipolar disorder?

Regarding the books and movies question:

We blogged at CREST.BD last year on some of our preferred movies that did a good job of portraying mental illness - http://www.crestbd.ca/top-mental-health-movies

There are two groups internationally we also really like who are dedicated to supporting safe media reporting on mental health, suicide and substance misuse - https://mindframe.org.au/ in Australia and Mindset in Canada http://www.mindset-mediaguide.ca/

The BBC documentary series with Stephen Fry is also great: ‘The secret life of the manic-depressive’ is the title. One of our favourite animated depictions of bipolar disorder is here: https://animatedminds.com/the-light-bulb-thing. Animated minds is a project where audio-recorded interviews were conducted with individuals with different diagnoses and then those individuals worked with an animator to transform their story into a short animated film. Wonderful idea in our opinion…

Regarding the ketamine therapy question: There is a lot of work underway in this area. Ketamine seems to have utility in treating major depression and acute depression in bipolar disorder (see https://www.ncbi.nlm.nih.gov/pubmed/29955493)

Regarding the MDMA therapy question: I don’t know of any clinical trials with MDMA for bipolar disorder at the moment. Most clinical trials are listed at https://clinicaltrials.gov, so it is a good place to check where things are at with particular novel therapies. It could be an MDMA-based therapy for bipolar disorder might emerge at some point in the future as there are so many clinical trials currently using MDMA for other conditions.

What do you think of the abuse that happens within mental health hospitals?

Erin - such an important topic for dialogue. Protecting the rights of people in the mental health system is pivotal, and a big part of this is ensuring that people being treated in hospital for mental illness fully understand their rights. A 2011 survey commissioned by the Ministry of Health in British Columbia in Canada found that 43% of respondents who had been ‘certified’ as involuntary patients reported that they had not been told their rights in a way they could understand.

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Iva Cheung, a PhD candidate at SFU in Vancouver, has been working to change this and has developed a suite of materials to help patients better understand their rights and to encourage clinicians to foster a culture where patients feel safe to talk about their rights. You can find them - translated into multiple languages - here: https://www.bcmentalhealthrights.ca/

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Link to MOH report: http://www.health.gov.bc.ca/library/publications/year/2011/BCMHSU-DescriptiveReport-2011.pdf

Thanks for doing this!

Could you explain about the different types of bipolar?

I've been diagnosed with bipolar after I was hospitalised because of a severe manic episode. I thought I had bipolar 1, but my mania was caused by being put on antidepressants and benzos. I've subsequently read that you can't be diagnosed with bipolar 1 if your mania was caused by drugs so I'm a bit confused by all the different things I've been reading to try and educate myself about my illness.

Thanks again for taking the time to do this :)

Steven here--There is actually considerable disagreement over whether a manic episode that occurs following treatment with an antidepressant is the result of a ‘direct’ effect of the antidepressant or is the result of the antidepressant ‘unmasking’ a pre-existing bipolar disorder in the individual. Really, the best approach following the sort of episode you have had is to be closely monitored for future hypomanic or manic episodes before landing on a diagnosis of bipolar disorder.

As a side note, many mood stabilizers (e.g., lamotrigine) have fewer adverse side effects than antidepressant medications (at least SSRIs and SNRIs)--that has been my experience (and I am pretty sure the literature would back up that assertion).

Has there been any progress in finding out why lamictal and lithium are so helpful? Last I heard it was kind of a mystery

Steven here--Lamictal (aka Lamotrigine) has been studied extensively in animal models of epilepsy and it’s anticonvulsant mechanisms are fairly well understood. The reasons for why it is also effective in bipolar disorder are less clear. Here is a review article on the subject if you are interested: https://www.ncbi.nlm.nih.gov/pubmed/30523725

Lithium has been studied extensively for its mechanisms of action in the treatment of bipolar disorder, but there is still no general consensus on which of its many effects might be what is helping individuals with BD (e.g., https://www.ncbi.nlm.nih.gov/pubmed/27638546).

An interesting effect of lithium is that it helps regulate circadian rhythms (i.e., it is a chronobiotic like melatonin): interesting because in many individuals with BD there are alterations in circadian rhythms.

What are your opinions on lithium for bd, given the heavy risks? Same question for antipsychotics. I’ve read that they shrink the brain over time. Are we getting closer to any new treatments?

Steven here--Lithium certainly does have risks if administration and frequent blood tests (to check for lithium levels) aren’t done regularly; that is, there is a risk of toxicity if lithium levels are too high. However, there is no evidence that i know of to suggest that Lithium reduces brain volume. In fact, brain volume is greater in individuals with bipolar disorder who are treated with Lithium versus those who are not (e.g., see https://www.ncbi.nlm.nih.gov/pubmed/28886501). Antipsychotics on the other hand do show some evidence of reducing brain volume, albeit slightly--most of this evidence comes from studies involving individuals with schizophrenia as opposed to bipolar disorder (e.g., https://www.ncbi.nlm.nih.gov/pubmed/28370309).

My mom was diagnosed with BD about 15 years ago, after being incorrectly diagnosed with (and therefore incorrectly medicated for) depression for the previous 10 years. Post BD diagnosis, my parents divorced, and I’ve had a lot of trouble coping with what I perceive as personality changes in my mom. According to her, she’s now on a medication cocktail that works. Do you have any suggestions or coping mechanisms for family members dealing with a loved one’s diagnosis?

There is a great website out of Australia spearheaded by one of our team members - Dr. Lesley Berk - which focuses specifically on supporting family members of people with BD, this would be a great place to start: https://bipolarcaregivers.org/taking-care-of-yourself/maintaining-or-rebuilding-your-relationship-with-the-person

What are your opinions on the effect of marijuana use for someone with Bipolar? Personally, I have found alcohol causes manic episode and leaves behind a depressive episode, but I have a harder time pinpointing the effect/affect of marijuana use.

Hi cokocart and u/liquid_entropy,
Thanks for the question. Erin here. I just shared my thoughts on Marijuana and BD here: https://www.reddit.com/r/bipolar/comments/b70k55/we_are_a_psychology_teacher_with_bipolar_disorder/ejwvzxd/

What are your experiences with Bipolar and pregnancy?

I’ve had 4 pregnancies, 2 of which ended in loss and I was diagnosed Bipolar II at age 18, well before the pregnancies. I took medication through each pregnancy, but I felt the hormonal change combined with my disorder, was incredibly hard to balance, especially after the births.

Erin here, I’m really so very sorry to hear about the losses you experienced. There’s a lot of active research happening in this area, see for example this recent qualitative (interview-based) study titled "What if I get ill?" perinatal concerns and preparations in primi- and multiparous women with bipolar disorder. - https://www.ncbi.nlm.nih.gov/pubmed/26781551

And this recent systematic review which takes a deeper dive into risks of recurrence of mood disorders during pregnancy and the impact of medications: https://www.ncbi.nlm.nih.gov/pubmed/30769297

Erin here, I’m really so very sorry to hear about the losses you experienced. There’s a lot of active research happening in this area, see for example this recent qualitative (interview-based) study titled "What if I get ill?" perinatal concerns and preparations in primi- and multiparous women with bipolar disorder.

https://www.ncbi.nlm.nih.gov/pubmed/26781551

And this recent systematic review which takes a deeper dive into risks of recurrence of mood disorders during pregnancy and the impact of medications:

https://www.ncbi.nlm.nih.gov/pubmed/30769297

I was recently diagnosed with bipolar disorder in the last few months. I am afraid to mention to friends or family because they view mental illness in very negative ways.

Is there a better way I can understand my diagnosis where I feel less negatively about myself? I am currently on medication, talk therapy, and full time student. I feel as though I am making very positive strides in getting the help I need, but on the other hand with the way I view things after others talking so negatively about it, it’s hard to stay positive.

Steven here--I am sorry to hear that you have been struggling so. I was in a similar space when I was first diagnosed with bipolar disorder in the late 1990s. I would suggest that what you are dealing with, in part, is ‘self stigma’: The internalization of the stigmatizing views of bipolar disorder held by individuals and institutions in our society.

My experience with self-stigma is that it had more of a negative impact on my wellbeing than the bipolar disorder did. For example, I became hypervigilant of the slightest indication that another person knew of my diagnosis or thought differently about my diagnosis. That hypervigilance led to unfortunate consequences for me: I ended several friendships based on my perception of stigma in others for which I had very little evidence. There are several ways of dealing with self-stigma. One is self-disclosure (I would recommend a safe environment as a starting point, rather than posting on Reddit per se :), the other is educating others about bipolar disorder; that is, if they know more about bipolar disorder then you are mitigating stigma both against yourself and others living with bipolar disorder.

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Hi there! This is really great and highly appreciated. I was diagnosed with BP when I was 16 (35 now). I have BP II, PTSD from a trauma and also ADHD. Recently I have been diagnosed with being medically resistant to BP medications. The most recent combo I have been trying is 100 MG Lamictal and 20MG Prozac. I also take Ativan as needed for panic attacks which regularly occur. My doctor does not want me on ADHD medication, but I feel like the ADHD is exacerbating the BP II. I have had to recently apply to disability due to this and have been homebound the past few months. I've gained weight and have been battling reoccurring SI.

It has been really difficult for me to accept after having hope for so many years that I just need to find the correct combo.

For people like me who are medically resistant, what advice can you offer? Is there anything more that can be done for us?

Erin here - “treatment resistance” - it’s such a hope-inspiring phrase isn’t it? (not). Tell me, what you tried in terms of psychological interventions at this point?

Hi, thanks for doing this! I go to UBC and have just recently realised I need therapy because right now I'm only on medication. I was wondering, where would be a good place to look for one? I can't afford much at all being an out of province student at and live quite far away from campus. I'm worried about having a bad experience with another one and walking away again like I did in my hometown but I know I need the help. I know UBC has resources for this but I've heard many bad stories about it, especially with wait times. Would you suggest looking anywhere else or know of a good place/person to look into?

Steven here--my department has recently put together a comprehensive list of resources both on and off campus for mental-health-related issues: https://psych.ubc.ca/undergraduate-wellbeing/

If you are looking for a peer-run support group, which can be very helpful in my personal experience, then you should look at attending meetings of the kaleidoscope on campus: http://the-kaleidoscope.com.

What do you think are some really great movies/shows/books/plays that accurately depict bipolar disorder and do you think for the most part the media and TV gets it wrong?

We know that this is a very real issue - see for example this 2019 review paper looking at the impact of media reports of severe mental illness on stigma and discrimination, and interventions to mitigate adverse impacts.

https://www.ncbi.nlm.nih.gov/pubmed/30349962

We blogged at CREST.BD last year on some of our preferred movies that did a good job of portraying mental illness - http://www.crestbd.ca/top-mental-health-movies

There are two groups internationally we also really like who are dedicated to supporting safe media reporting on mental health, suicide and substance misuse -

https://mindframe.org.au/ in Australia and Mindset in Canada http://www.mindset-mediaguide.ca/

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Steven here--there are quite a few out there. The BBC documentary series with Stephen Fry is great: ‘The secret life of the manic-depressive’ is the title I believe. My favourite animated depiction of bipolar disorder is here: https://animatedminds.com/the-light-bulb-thing

Animated minds is a project where audio-recorded interviews were conducted with individuals with different diagnoses and then those individuals worked with an animator to transform their story into a short animated film. Wonderful idea in my opinion…

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Suggestions for coping with the loss of my old life (been extremely high functioning, sociable, high achievement, great job) now completely thrown away?

Erin here - sense of self and identity - or more precisely, identity loss - is a common issue in people with BD. We tackle this issue a bit in the ‘identity’ section of our Bipolar Wellness Centre: http://www.bdwellness.com/Quality-of-Life-Areas/Identity

There, we talk about how some people with BD describe the onset of the condition as a disruption in their life story and identity. For these people, being diagnosed with BD altered their life course and required them to take time to think about and re-evaluate their sense of self. However, other people report positive changes, seeing their BD as a transformative or life-altering process. One particular challenge is role engulfment, a state in which your identity becomes entirely based on one aspect of yourself or one role that you fill, undervaluing or ignoring other aspects and roles. There are some tools and resources too that might be useful to you: http://www.bdwellness.com/Support-Tools/Resource-By-Area/Identity

Thank you for taking the time to do this! It's great that you're reaching out and educating others, especially when I'm sure you're very busy. I've got a few questions for you.

I've been diagnosed with bipolar and typically have manic states that last less than 8 hours. Long manias are VERY rare for me. I thought for a minute I might actually have BPD but confirmed I don't. How common is this situation for those with bipolar? Is there anything else that might be going on to cause it?

Also on a separate note, I want my career to be researching and solving chemical imbalances so I can do what I can to find cures (or better solutions) for bipolar, depression, Parkinsons, and such. What job role comes to mind when you hear that?

Erin here, I’ll answer your first question first. Within our understanding of presentations of BD, there is ‘rapid-cycling’, which refers to the presence of at least 4 mood episodes in the previous 12 months that meet the criteria for manic, hypomanic, or major depressive episode. https://www.ncbi.nlm.nih.gov/pubmed/25004199

Kramlinger and Post coined the terms “ultra-rapid cycling” and “ultra-ultra-rapid cycling” (also called “ultradian cycling”) to describe mood episodes that occur monthly (ultra-rapid cycling) or over the course of as little a day (ultradian cycling) - but I believe these terms are still a little controversial in the literature. Here’s a link to brief overview doc that you might find helpful (the author is well-regarded in the field): mdedge.com/psychiatry/article/66291/bipolar-disorder/ultra-rapid-cycling-bipolar-disorder-critical-look#bib1

I’m sorry if this has already been asked, but what do you do if your patient has gone through numerous meds and still nothing works? Do you just keep trying? Is there something that works for everyone?

Dr. Rob: There is no silver bullet that works for everyone, unfortunately. If treatment success has been elusive after multiple trials, at that point, it is worth getting the opinion of a mood disorder specialist to see what options remain or what steps may have been missed in the workup and treatment plan. Mood disorder specialists are highly specialized psychiatrists who are able to offer consultation to General psychiatrists and their patients.

Will you post a picture so we know you’re not one professor with multiple personality?

Our proof! :-) https://twitter.com/CREST_BD/status/1106589623159934977

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Besides chamomile tea and humidifer with oils. What are some inexpensive natural remedies besides our meds to help calm us down from a manic episode?

Erin here - a caveat first, any suggestions I make in response to this question are positioned as a complement to pharmacological approaches for managing hypomania and mania, not as a replacement.

As with all chronic health conditions, self-care or ‘self-management’ strategies play a crucial role in staying well with BD. At a basic level, self-management in BD refers to the routine activities the person undertakes to maintain wellness and stability. Research illustrates that many BD self-management strategies are akin to the healthy lifestyle behaviors many of us aspire to, regardless of whether we live with a mental health condition or not: balanced diet, regular exercise, sound sleep, and so on.

Research also demonstrates, however, that effective self-management in BD, for many people, goes well beyond just attention to healthy lifestyle behaviors. In a recent study we used community-based research methods to ask people with BD and expert treatment providers to assess the importance of diverse self-management strategies for their effectiveness in ‘maintaining balance in mood’ and ‘stopping progression into hypomania or mania’. Core approaches included strategies such as medical management, calming activities, physical activity, planning ahead, intervening early and decreasing use of stimulants.

In addition to reading our publications in the links provided, you can view the self-management strategies we found to be most effective via these interactive visualizations produced by the one-and-only Steven Barnes.

The ones related to ‘Stopping Progression into Hypomania and Mania’ are here: http://www.stevenjbarnes.com/sketches/stoppingProgressionV7/

The ones related to ‘Maintaining Balance in Mood’ are here: http://www.stevenjbarnes.com/sketches/maintainingBalanceV1/

A range of ‘calming’ strategies to help keep stability in mood are described in the link above, good luck!

What can family members do to help patients with BD?

Erin here. There is a great website out of Australia spearheaded by one of our team members - Dr. Lesley Berk - which focuses specifically on supporting family members of people with BD, this would be a great place to start: https://bipolarcaregivers.org/taking-care-of-yourself/maintaining-or-rebuilding-your-relationship-with-the-person

I'm a bit late but I really do hop you answer this.

I was first diagnosed with depression after I was heavily smoking weed. I later made the mistake of smoking weed while on antidepressants which lead me into a manic phase. I have now pretty much recovered several years later, and have been on the same treatment of Sertraline and Lamotrigine for over a year. I don't want to keep taking these as I do not enjoy the side effects, and to me it seems as if I should be able to stop taking them since it has been over a year since I have been depressed and I have had nothing resembling mania? Also I think that the only reason why I was manic in the first place was due to my combining weed and antidepressants.

My psychiatrist has told me that I'll need to take Lamotrigine for the rest of my life, but that we could talk about taking me off Sertraline after two years' observed successful treatment?

Thank you

P.S. I know not to take/ask for medical advice online, I'm just curious.

Dr. Rob: First, it’s good that you’re having an ongoing discussion with your psychiatrist about whether your manic episode was substance-induced or reflects a primary disorder which you would have developed in any case. If you do have a primary disorder, then it is important to stay on maintenance medication. If your disorder was substance-induced, then, as you suggest, careful titration off your medications becomes a possibility. There is, unfortunately, no straightforward way to tell. Some options to discuss with your psychiatrist include getting a second opinion, trying a reduced dose of your medication, or rotating to a mood stabilizer which has a better side effect profile for you. Perhaps even the proposed plan of gradually coming off of sertraline will lead to improved acceptability of the side effect profile.

As someone with BP, I am intrigued by the mention of "prodromes" in an earlier reply that wasn't elaborated upon further. I didn't know there was a word for that/those weird feeling(s) before either a manic/depressive episode, and I'm wondering if you could explain a bit more about the biological origins of these warning signs? What can we do to prepare ourselves and others?

Erin here, thanks for the further question. Prodromes are just a less accessible term for early warning signs. So not so much a weird feeling before the onset of depression or mania, but rather lower grade or more subtle symptoms or signs that tell you an episode might be on it’s way. I’ve worked with quite a few people clinically though who have described their specific prodromes as just that - a weird feeling or observation. I remember working with one person who cycled extremely rapidly between mood episodes. He could tell he was heading for mania when colours started to shift slightly - they became more vibrant and vivid. The important thing to know is that many people with BD will have fairly consistent ‘relapse signatures’ - so time examining your own particular early warning signs and monitoring for them - especially during times of stress, can be time well spent.

if your significant other with BD seem to not really care about their health and just not as active as before, how would you approach them without being pushy to become more active. What would really help someone to not self-stigmatize themselves? and to be more involved and engaged with one's life?

There is a great website out of Australia spearheaded by one of our team members - Dr. Lesley Berk - which focuses specifically on supporting family members of people with BD, this would be a great place to start: https://bipolarcaregivers.org/taking-care-of-yourself/maintaining-or-rebuilding-your-relationship-with-the-person

We’ve published quite a bit on self-stigma and BD specifically, you can find more details of that work, and the work of others, here: http://www.bdwellness.com/Quality-of-Life-Areas/Self-esteem

How curable is the condition, a verified BD case, with the best treatment available today? Is it treatable or curable by psychotherapy or does it just help the management, not that that isnt important. I am interested because I am working in the mental health profession and going to psychotherapist training.

Steven here--I can’t say that I know of anyone personally who has been cured of BD, but my psychiatrist has told me that he has encountered a few situations where there seemed to be complete remission of symptoms in a small number of his clients with BD. (I can’t locate a literature on remission in BD--perhaps I have been looking in the wrong places.) He claimed that this was through a combination of psychotherapy and medication.

There is an important place for psychotherapy in the treatment and/or management of BD--it has certainly played an important role for me, and the research backs me on that. For me, it was particularly helpful in the development of insight into my BD; for example, knowing when one is symptomatic and knowing when to reach out for help. It was also helpful in symptom management and in dealing with thought distortions (e.g., distorted views about my self-efficacy).

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Should i be concerned about having children? I would never want them to suffer like this as a result of my disorder...but i have always wanted children.

Erin here, such an important question, and one that has been at the heart of the work of one of our team members, Dr. Jehannine Austin http://www.crestbd.ca/about/team/jehannine-austin/. She’s a psychiatric genetic counsellor. Psychiatric genetic counsellors are trained to talk to people about understanding risk information relating to different types of mental illness. You can learn more about this field by accessing Dr. Austin’s AMA on this topic (link), visiting the website of the National Society of Genetic Counselors https://www.nsgc.org/ or there is excellent information provided by Dr. Austin’s group at: http://www.bcchildrens.ca/our-services/mental-health-services/genetic-counselling

Can people with Bipolar and BPD have a healthy relationship?

Steven here--I know of no evidence that would indicate that a healthy relationship isn’t possible with BD or BPD (that isn’t to say the BD or BPD don’t affect relationships). Like any relationship, there needs to be understanding from both parties. As someone living with BD, I have been with my current partner for about 20 years and I would say we have an excellent relationship; likewise, i have excellent relationships with other people (e.g., Erin...who is typing as I type this...). The person with BD (i.e., me ) or BPD needs to understand that their active symptoms not only affect them but also affect the other. For example, it was important for me to realize that my mood episodes not only took a toll on me, but that they also took a toll on my partner; I needed to respect my partner’s means of coping with my symptoms. Likewise, the other person in the relationship has to appreciate that the person with BD or BPD can’t always manage their symptoms effectively and that they might either need their support or some space depending on the particular symptoms.

Hi there, I see you're from Vancouver, tell me, how do you feel about the specific diagnosis: 'St. Paul's bipolar'?

I imagine you've come across it but, for the uninitiated, it's when you're talking to a physician at Vancouver General Hospital and say:

"For years I was diagnosed as type II bipolar by outpatient psychiatry at St. Paul's hospital, I didn't fit the DSM criteria but they keep insisting I had it."

And he rolls his eyes and tells you about a thing they call 'St.Pauls bipolar' and makes an incredible and uncannily accurate guess that you were initially diagnosed by a certain doctor B****?

I'm curious, what do make of that? And what sort of effect might the stigma and the medication resulting from that diagnosis have on someone's life?

Especially when the considered response to 'failing to respond to bipolar medication' is to just keep upping the dose?

I wouldn't mind so much if this was some bunch of podunk headshrinkers, but we're talking 'center of excellence' here. It just seems like everyone knows what's going on, but no one's taking the keys away from grandpa.

Erin here, actually, I have to say in all honesty that that’s a new one for me in terms of diagnostic categories :-)

How fast can rapid cycling occur? Is it possible to rapid cycle over 24 hours?

Steven here - rapid cycling is defined as 4 or more mood episodes per year. Rapid cycling is not that common, and cycling within a 24-hour period is quite rare to see though it is certainly possible. Rapid cycling is more commonly seen in bipolar disorder that has been left untreated for an extended period of time (though it is not an inevitable consequence of non-treatment).

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How are mixed states and rapid cycling different?

Steven here--mixed states refers to a state that usually occurs during the transition from mania to depression or vice versa (wherein there are symptoms of both depression and mania present); whereas rapid cycling refers to the rate of change between mood states: for bipolar disorder, rapid cycling is defined as 4 or more mood episodes per year.

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