We are bipolar disorder experts & scientists! In honour of World Bipolar Day, ask us anything!

What resources, if any, exist for those of us who live with and love someone with bipolar disorder? Years ago, there was a woman on the Moth who told the story of her bipolar mother, and for the first time in fifteen years I felt like I wasn't alone... because as much as I don't know what it is to have this disorder, no one, neither my friends nor my family, knows what it is to love a bipolar person.

Andrea Paquette HERE: I truly love this question because I have written SO much on this topic. I have been a blogger on Bipolar Magazine (BpHope.ca) for 6 years and here is the link to my profile: https://www.bphope.com/author/andreapaquette/ I talk about love, my mother who has bipolar like myself, relationships with a partner and more. I feel that this blog will really bring some light for you. Thank you for your question. Also, Julie Fast has a book called “Loving someone with Bipolar Disorder” Here is the link on Amazon: https://www.audible.ca/pd/Loving-Someone-with-Bipolar-Disorder-Audiobook/B071LD2Y84?source_code=GDGGBRF0814170006&ds_rl=1250324&gclid=Cj0KCQjwmIuDBhDXARIsAFITC_57Hesye4Uc7OaPh8GrpM8prd-SGpmcDv2z3q7uu_X4cO7HwJLp_w8aAjVoEALw_wcB&gclsrc=aw.ds

Good luck and well wishes!!

Erin here. There are also some great resources provided by our team member Dr. Lesley Berk in Australia via https://bipolarcaregivers.org/ - you can download a detailed guide for caregivers there.

What is the relationship between bipolar disorder and trauma?

I’ve heard before that traumatic experiences can activate latent bipolar that might otherwise stay a dormant genetic predisposition. Is that true?

I’ve been diagnosed as bipolar for almost a decade, but recently received a diagnosis of (C)PTSD. Are those mutually exclusive? Could my PTSD be mistaken for bipolar? Or did I just get lucky enough to have both?

Hi there - Catriona here. You are absolutely correct that traumatic experiences can be the trigger to a mood episode and a diagnosis of bipolar disorder. Everyone has genetic vulnerability to bipolar disorder (that’s right - everyone! :)), but there is a great deal of variability in terms of how much genetic vulnerability someone has (depending on a variety of things - some of which are somewhat understood; a lot of which are not yet understood at all). People can experience trauma and not develop bipolar disorder. On the other hand, people who have never experienced trauma can develop bipolar disorder - there are many types of life experiences that can act in concert with genetic predisposition to trigger a mood episode and BD diagnosis. I am not a psychiatrist, so I hesitate to speak too strongly about your question regarding whether C-PTSD could have been mistaken for bipolar disorder. As far as I know, there is a bit of an evolution in terms of our understanding of C-PTSD in the field, and it is certainly possible for a diagnosis at one time in history to end up getting re-categorized later on - as our field develops greater understandings of how the brain works and what different pictures of symptoms really represent. It is also definitely possible to have multiple diagnoses (as I’m sure you are aware! :)). For your particular case, it seems like it would be worth a deeper discussion with your psychiatrist - have you tried asking the person who gave you the diagnosis of C-PTSD? I also want to acknowledge your courage in continuing to work with health professionals to get support for your mental health. My understanding is that health professionals don’t always have training to provide trauma-informed care and that interactions with providers and treatment that is sometimes offered can compound the experience of trauma. I hope you are now receiving trauma-informed care that is serving you well.

Interesting that you are not getting any answers there. I hope you will.

Talking to many people, mental health professionals and having read about the topic of trauma and CPTSD and mental health quite a lot it seems obvious that being bipolar, being depressed and most other mental disorders are rooted in trauma or CPTSD and are amplified or mitigated by personal sensitivities. Most these mental health issues are mainly symptoms of unresolved trauma or CPTSD that have spiraled out of control over time, and that if the trauma or CPTSD gets dealt with, the said mental health issues/symptoms will greatly be reduced or even disappear.

But that's not so convenient nor comfortable to consider if you have made a living out of studying and helping people managing the trauma or CPTSD symptoms called bipolar disorder.

If someone has been shot by a gun it isn't that helpful to tell him he is suffering from bleeding and apply a bandage to soak up the blood. You need to remove the bullet and disinfect the wound, inspect the damages caused by the bullet, repair what can be repaired such as possible damaged bones and organs and apply stitches.

Hi thorgal! Research assistant here. Our panelists actually don't see the thread–they all work from a Google doc, which unfortunately means they don't see what's upvoted! Giving 28 people access to one Reddit account would be pretty chaotic :)

Also, since our experts are all around the world, the person with the right expertise to answer this might not be in a good time zone right now.

I'll let the panelists know about the interest in this question, although I can't promise an immediate answer!

Can OCD ever be mistaken for mania? I've been diagnosed bipolar 2 then bipolar 1. But I've read about some types of OCD where you obsess about things over and over in your head and your mind goes very fast full of different thoughts. I seen a video on YouTube where a guy was recreating his OCD and it seemed like what mania was to me. Although not the inflated self esteem and mood. But I've had periods of racing thoughts without feeling good.. Does this count as mania or could it be OCD? Just wondering if there are similarities? I could be wrong any advice is great 😊

Hi Nigila here. Your observation is definitely interesting. True that OCD symptoms are recurrent and there can be the racing which can happen with the pace of thoughts and the repeats and ruminations. But still the individual retains some degree of understanding and awareness about the thoughts and them being not reasonable and there will be a lot of effort resisting them. In Bipolar state, the logic and reasoning may not be working so well and the content of thoughts, the speed of thinking and speaking, and the disinhibition and abandonment with which they get displayed will be very different. Also, the thoughts and actions in Bipolar may be more far-fetched and not so logical as they would be in OCD ruminations.

Trisha here - this is a great question. I would agree with your observation and Nigila’s response that there can be overlap between symptoms of OCD and mania. I’ve heard patients describe becoming hyperfocused on certain projects/ideas, and thinking about them in a way that seems obsessive, when in a manic state. Furthermore, symptoms of OCD over a person’s lifespan may wax and wane, and therefore seem ‘episodic’ in the way that mood episodes in bipolar disorder are.

The important clues that signal someone is experiencing mania rather than OCD is the presence of other hallmark manic symptoms. These would include changes in mood (elated, irritable or both), high amounts of energy and feeling like you need less sleep, inflated self-esteem, impulsive actions (spending more, feeling disinhibited sexually, using drugs/alcohol in uncharacteristic ways), and taking on more projects. The presence of some or all of these, as well as the changes in logic/thought process mentioned in Nigila’s response, would signal a manic episode rather than OCD.

Another thing to consider is that an individual may have OCD and bipolar disorder. In fact, up to 20% of individuals with bipolar disorder also have OCD. When this is the case, it is sometimes difficult to distinguish whether the individual is experiencing symptoms of OCD, experiencing a mood episode or both.

u/VegaSolo u/Jessalynftw u/secretlifeofpuffins

What's the best type of therapy for type 2?

How to handle stigma from my family? My dad told me that it was because of the devil. My mom holds no such beliefs, but she does struggle with understanding it.

Do you ever feel like your emotions are fake? I have that issue when a mood swing hits?

Can it be commonly comorbid with an anxiety disorder?

And finally, can trauma trigger bipolar to manifest earlier in adolescence instead of adulthood?

Hi- Rosemary here. I live with bipolar 2, and was diagnosed when I was 12 years old. I was severely bullied during that time, and now armed with more knowledge about bipolar, I think that could have partially surfaced my bipolar at that very young age. I will try my best to address all the components of your question. I was hospitalized in 2018 for a mixed episode, and after that point began seeing a psychologist who I am still seeing. The kind of therapy I do is dialectical behavioural therapy https://keltymentalhealth.ca/dialectical-behavioural-therapy which I understand doesn’t work for everyone but has worked well for me. I think there are different kinds of therapy that work for different people because we are all so unique and therefore unique in our needs in therapy.

I am Chinese- Canadian, and Buddhist. Leading up to my hospitalization in 2018 there were times where my parents would tell me that I was not chanting Buddhist dharma enough and that was why I was becoming unwell. I don’t hold anger towards them about that because I know they didn’t know better and they were so afraid of what was happening and did not know what to do. I am sorry to hear about what your dad said. For me, educating myself more about bipolar has given me a strong foundational understanding of my illness that is not easily swayed in the face of stigma. This doesn’t mean its any less painful or invalidating when people make comments like the ones you and I’s parents made but I believe it gives us stronger boundaries, protects ourselves and validates our existence and our struggles. I think my biggest piece of support about how to handle stigma from family would be about building those strong emotional boundaries for yourself. Because we cannot change what other people think of our illness, but we can try our best to control how much we let that impact us. I have confidence and hope for a world with less stigma towards mental illness but in the meantime as we are working towards that, I will continue building as strong of an emotional boundary as I can.

Yes, I have at times felt that my emotions are fake. I have felt unsure about whether my happiness was “true” happiness, or if it was hypomania. I think validating yourself and having some healing mantras in your mind can be helpful. Something I will repeat to myself when I am feeling like I am judging myself or am judging the validity of my emotions is “back to center.” “Back to center” as in, I am bringing myself back to the center of myself, and trying to ground myself into the present moment.

I don’t know too much about the comorbidity with an anxiety disorder research but I do know when I get depressed I am almost always also anxious, and that physical manifestation can feel like my forearms are being injected with poison. Thank you for your questions.

Hi – Emma here. I’m really sorry to hear it’s hard for your family to understand what is going on for you. Many people with bipolar disorder find their mood is worse as a result of stressful interactions at home, like the ones you have described. That’s why one of the forms of psychological treatment recommended involves the whole family – it’s called Family Focused Treatment Therapy. The goal is to provide information on the condition so family members can understand that it is real, what causes it, how it is best treated, and how family members can support people living with it. Doctors can help refer you to psychologists with expertise in this area, and there are lots of good resources for family members online. Our colleagues from the UK came up with this online toolkit for relatives: https://reacttoolkit.uk/ However, you know your family best - if you have the sense that talking to them about your mental health might make them angry or act in a way that makes you unsafe, it might be best to get support around ways you can cope with stigmatising beliefs and stressful interactions.

In terms of your other questions – yes, people with bipolar disorder often experience anxiety at the same time – one study found over half of people with bipolar disorder experienced anxiety too (https://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.161.12.2222).

Hi. A lot of times people with borderline personality disorder are mistaken to have bipolar disorder. One of the main differences I know of is that bipolar has periods of highs and lows that last for periods of time, and borderlines have extreme mood swings. I can see how these would be easily mistaken for the other by the unknowing eye. What are the big identifying factors of bipolar that separates it from other disorders?

Tom here. Just to add as well, Bipolar disorder is the only mental health problem I’ve encountered where part of it (i.e. mania) can be enjoyable at times (sometimes, for some people, usually for short periods). One study found that ¼ of people with Bipolar didn’t want to get rid of it completely and less than half wanted complete control over their moods. The main reason for this was people saying that they have enhanced abilities and fun when they are manic. I’ve never met someone with Borderline Personality Disorder who wants to keep part of their problem. But see thread above: Trying to ‘go with’ the mania because it’s fun is a risky game to play!

Hi – Emma here. You’re right to pick up that there are a lot of symptoms that look similar between bipolar disorder and what is called borderline personality disorder. Large shifts in emotional state, irritability, impulsivity, and suicidal or self-injurious behaviour can occur in both these conditions. It is important to tell these conditions apart because different treatments are better suited for bipolar disorder as compared to borderline personality disorder. For example, we know a lot about what medications can be helpful for bipolar disorder, but the question of whether pharmacological treatment helps with borderline personality disorder is still hotly debated, and for such people psychological treatment would be considered the ‘first-line’ treatment option.

The major way clinicians tell these conditions apart is the duration and frequency of mood shifts. In bipolar disorder, changes in mood typically last longer and occur less frequently, whereas people with borderline personality disorder tend to have mood that fluctuates throughout the day (their mood shifts are also more commonly triggered by interpersonal events). There’s also other key markers that we might be looking for that are specific to bipolar disorder, like a family history of the condition, mood instability that is triggered by sleep loss, and limited need for sleep when manic. People with borderline personality disorder tend to experience a fractured or unstable sense of self that is less common in bipolar disorder.

However, it’s important to also acknowledge the limitations of our diagnostic system – there’s no laboratory test or marker we can see on a slide that says ‘yes, this is bipolar disorder’. Increasingly, psychological science is looking to understand the traits that might underpin numerous disorders.

Tom here. For me the psychological profile of Bipolar Disorder is fairly unique, though it does overlap with other problems. Research shows those with Bipolar disorder tend to have very high standards for themselves, big ideas around achievement and reaching goals. For example beliefs such as “My life is wasted unless I am a success”, “If I fail partly, It is as bad as being a complete failure” and “If I don’t set the highest standards for myself, I am likely to end up a second rate person” have been shown to be more common in Bipolar disorder than those with depression. I discuss this more in this video here: https://www.youtube.com/watch?v=qGclYO60ays

Okay so sorry if this is a stupid question but what are some of the lesser known symptoms of bipolar disorder (maybe even specifically type 2)?

When I was diagnosed it all went so fast and my doctor didn't give me that much info. I know all the DSM 5 things, but I'd like to know more. It helps me so much when I read things I can relate to, it makes me feel so much less crazy. For example when I found out mixed states existed or hypomania...I suddenly understood myself better. So yeah, sorry if my question is a bit vague. I'm just looking for typical symptoms that are a bit lesser known or not talked about that often.

Ivan here: This is actually a really good question. One of the symptoms that can be common, yet is not reflected in diagnostic criteria, is the presence of changes in cognitive functioning such as attention, memory, concentration, and complex problem solving (sometimes referred to as executive functioning). If present, these difficulties can contribute to problems in daily functions such as managing finances, work, school, and other areas that require these skills. The presence or severity of cognitive difficulties can vary widely across individuals with bipolar disorder, so it can impact different people in different ways.

u/Sea_Salt_1453 u/jhorry u/assezconfus

Why am I the way I am?

Andrea Paquette HERE: I totally get what you mean! I have bipolar disorder and I actually did not LIKE who I was, but things changed after some time. I used to live in the place of “poor me!” Questioning why I had bipolar and asking whose fault is it? I know now that I am unique and it is totally ok that I have bipolar disorder. I have done a lot of things with it like start a charity, write blogs and books about my experience and also found a new love for myself. I know that I have bipolar and I am NOT bipolar. Head up and know that being you is ok and acceptance is key to freedom.

Could somebody speak to medication burnout? I've seen lots of remarks about that being an issue, where efficacy just drops over time. How can one tell if that is starting to happen?

Kaj- Recently i have been going through a medication change. I noticed that my sleep was becoming more erratic and I felt I was not rested. I also found that I couldn't concentrate, my mood was changing. My best friend first noticed I was not the same way. At first I thought this might be due to the stress about the pandemic but it was more and in talking to others they suggested maybe I should contact my psychiatrist.In our meeting we found that I had not changed my in a few years. We decided to change up the medication and in like a month I felt much better. My recommendation is to see your psychiatrist, list your symptoms and discuss the possibility of changing your treatment protocol.

If you don’t mind me asking, what kind of change did you make? Does it change if you swap one med for another in the same class, or did you need to switch to a different strategy entirely?

Kaj - in my case I have been on seroquel , quetiapine and at first it was great for sleep and what I call “glued together” but over time it was not working. I instinctively knew I needed to change something because I tried all kinds of things including diet, exercise but it wasnt enough. So talking with my clinician we decided maybe for energy and to help the quetapine we added abilify - however I must qualify this - medication changes are between yourself and your doctor. We always say in our group do not just make your own changes with medication. So in my case the strategy was to add something and we are still seeing how this will work out.

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Hi Victoria here - I live with BD 1 (rapid cycling with mixed states with occasional psychosis). I’m speaking from my lived experience and not a clinician perspective. I have not experienced benefits from smoking marijuana. In fact the extreme opposite. It has triggered psychosis for me.

I never was a regular smoker and only tried it a handful of times. But most times when I did try it, it propelled me into a varying degrees of psychosis. Once when I needed to go into the hospital.

I haven’t smoked any for decades now because of that. For many people who I have heard from who have BD 1 pot is not helpful at all. Though I am sure there are exceptions to the rule.

I know anxiety sometimes can be decreased with it, but from my layman’s understanding that’s when someone doesn’t have bipolar disorder. I would recommend avoiding it. I use other tools to manage my illness that have more evidence behind it that helps to balance mood: good sleep, exercising, eating well, managing and addressing stress, address interpersonal issues as they come up, creating a safe and stable home environment, ensuring some financial security, therapy, spirituality, medication, mindfulness are some of the management tools I use. I hope this helps.

very helpful thank you! I recently made the decision to start moving away from it, so far so good. Shoutout to /r/leaves for inspiration and support.

I have a pretty good setup for my home life and job for a while now, but I've always struggled with consistent exercise. Any recommendations / what works for you?

Victoria again - So glad my experience can be helpful. Well, you’re not alone in struggling with consistent exercise. People without bipolar disorder struggle with that!! With depression added in there it makes it even more challenging. Here are some tips that help me:

The first for me is finding some kind of exercise I actually like and find fun, but that is also easy to integrate into my life and week. I may like swimming, but getting to the ocean or the pool takes too much time for me.

Running though works – I really like it because I get outside into the fresh air and into the trails around my house and I can double duty it by running my dog. So I get that dopamine hit of achievement on a couple levels. It’s also really easy for me to incorporate into my day (I aim for 3 times a week for 25 – 30 minutes). I just need my shoes and get out the door.

So, something fun and low barrier or easy to do.

I also need to be able to feel the effects of the exercise on my mood to feel like it’s worth doing. For some it could be a team sport like soccer where the social aspect really boost/balances their mood.

For me it's needing that vigorous intense exercise that increases my heart rate, where I sweat and feel like my mind clears for a bit and my energy feels boosted. It’s kind of like an immediate gratification kind of thing.

Then to the nitty gritty: how to actually get to doing it!

Some days it's super easy. Often though my mind gets in the way and my motivation is down along with my energy. I play a game with myself.

And I often need to start really really (and I mean really) to stay consistent. My motto is small is big. I needed to watch out for my perfectionistic thinking and unrealistic thinking.

I tell myself I just need to get dressed into my running clothes and going for 10 minutes. I don’t even need to run. And I can turn back if I want to. Usually this gets me over the inertia and I go for longer and begin to enjoy it.

I also throw three times a week when I’m struggling. I aim for something doable but still slightly challenging – maybe it’s twice a week for 15 minutes. I use positive self-talk too and evidence reminders – that is I remind myself how good I feel afterwards, that usually I don’t want to go for a run but it usually always helps. And I remind myself how good I feel not just physically but how proud of myself I feel when I do it even if it’s only for a few minutes. I hope this gives you a few ideas. It was a long answer to a short question, but exercise has been so powerful for me and it’s so empowering because I can do it and it helps me so much.

Hi, Steven here: Like Victoria, I live with BD 1. There is evidence that mood episodes can be triggered by marijuana use. I haven’t experienced that personally, but I have become heavily addicted to marijuana at various points in my life (addiction is often comorbid with BD). That being said, there does seem to be benefits (e.g., anxiety reduction; help with sleep) to high CBD/low THC marijuana strains or CBD capsules/oils. I have experienced such benefits personally. However, I do want to underscore that the research evidence for such benefits is limited. So, I would recommend against the use of THC, but maybe consider (carefully, in consultation with your physician) CBD for anxiety symptoms and sleep issues that commonly accompany BD.

Tom here. There is research from the Netherlands following up large group of people from the general population which showed that cannabis use can increased manic symptoms in this group. There is also evidence that in those with Bipolar disorder, cannabis use can increase how long manic episodes can go on for. So I would say be cautious as it can lead to relapse.

Erin here: This question came up a lot in our 2020 Reddit AMA - here’s a little blog we did covering our previous responses :-) https://www.crestbd.ca/2020/04/20/bipolar-cannabis/

Thank you for doing this, awareness is key and I was pleasantly surprised to find out there was a day for this.

That said I was diagnosed with bipolar type 1 in my early twenties. I consider myself very high functioning and like many I find a lot of the medication (on my fourth med swap) to be debilitating to my productivity. Off medication (currently) I’m able to maintain a high GPA, focus on a successful entrepreneurial endeavor and enjoy several hobbies until I inevitably hit that point where I forget to sleep, eat and become wildly not fun to be around.

I know that currently it’s nigh impossible to maintain without medication but could that change in the future? Any new alternatives on the horizon that could make life a little easier without feeling like I’ve been chemically lobotomized?

Have any of you ever seen someone in a clinical setting that did well without medication? Is there any documentation on just how progressive the damage to the brain is after an episode? Thank you for any insight you can provide.

Natasha here -- I was diagnosed with bipolar 1 when I was 20 and struggled for many years with this problem. I'm now getting close to 30 and through the years I have gone from a cocktail of antipsychotics to now I only take a couple meds that don't give me any side effects. However, there's a trade off. I take less harsh meds, but I have to work really hard to manage my stress levels and take care of myself in all ways (and I mean REALLY take care of me). I spent many years building my skills and knowledge to get to this point. There highs and lows are still there, but not as prominent. And there are still times when I have to take more meds short term to manage my symptoms. It has not been an easy journey, but like yourself I identify as high functioning and really wanted to finish school (and I did). There’s no easy answer to this, but I wanted to provide some hope that you can find your way to where you want to be. I was extremely lucky to find a psychiatrist who helped me achieve this goal of the least meds possible.

How do you help a suicidal bipolar person? What are the odds of actually changing this way of thinking? I (bipolar type 2) lost my bipolar son to suicide. For obvious reasons, I’m monitored closely now. Every one keeps telling me “he wasn’t an if but when” kind of diagnosis. Is that really true? Was there no hope to save him?

Hi, Emma here. I am so, so sorry to hear about your loss. It would be completely natural for you to be struggling with the question of what, if anything, could be done. While it is true that people with bipolar disorder are more likely to struggle with suicidal thoughts and behaviours, there is no “suicide gene”, and the disorder is not a death sentence.

The part of your question that I’m going to focus on is the question of whether anything could have been done. It is true that there are warning signs that somebody may be thinking about suicide, and strategies that can be put in place to try to help them manage that feeling or keep them safe from potential means of suicide. However, this does not imply that the ultimate responsibility of preventing suicide rests with loved ones. Thoughts of “if only I had…”, “I should have known…” may be placing additional suffering on your shoulders. Yes, as a society we should be doing what we can to pick up on these signs, to be present and loving, and to offer support and resources. But ascribing blame for missing a sign or not doing enough makes the road to healing rockier and more difficult to traverse.

It can be really challenging to process these feelings, even with other people who have dealt with the death of a child. Bereavement as a result of suicide may bring up feelings of not only sadness, but also anger, abandonment, shame, guilt, and worries about the implications of your shared diagnosis. That’s normal, but can be difficult to talk about, and stigma unfortunately means that friends and family may be less likely to reach out. Seeking psychological support can help, especially as people with relatives who died by suicide may also be at elevated risk of complicated and persistent grief, PTSD, and their own suicidal thoughts. Depending on where you live, peer support groups like the Compassionate Friends can offer advice, reassurance, and validation.

It sounds like you have some supports in place, and my thoughts go out to you. If you or other readers have concerns about yourself or others, please consider contacting emergency or crisis services in your country (see https://unsuicide.org/ for a worldwide directory of resources).

Hi! What are your thoughts on using psilocybin in conjunction with lamotrigine (for BP2)?

Erin here. Surprise surprise, there’s not a published literature on this that I can find yet (though I can see some prior discussions on Reddit and Shroomery). We’ll continue to weigh in on this question as we get some of our psychedelic treatment experts on the line – hold tight for more input!

Josh here. I agree with Erin. There are no published studies on this question. However, there are some published case reports of serious adverse interactions between psychedelics and lithium including seizures and death. There is a preprint of a study that looked at online reports on websites like reddit that supports this https://psyarxiv.com/r726d/. Few interactions were found with lamotrigine. This work is not definitive obviously so extreme caution is warranted. Also, so little work has been done, we can’t say if there are different patterns for different psychedelics at this time.

I have epilepsy (although I haven’t had a seizure in several years. I was diagnosed later with bipolar. What is the relationship between epilepsy and bipolar? I take lamictal which is also an anti-convulsant. Does the fact that it’s an anti-convulsant mean anything in the relationship between the two disorders?

Chris Gorman Yes, A. In the past, before anticonvulsants existed or medications for psychiatric conditions, the common approach for both was to place a person in a mental hospital. Thankfully now, there are medical treatments for these conditions.

B. The original medication alternative to Lithium was a medication called Carbamazepine, an anticonvulsant that seemed to prevent seizures in an area of the brain close to areas that influenced mood. Since then, every anticonvulsant is tried as a mood stabilizer. Lamotrigine prevents bipolar depression and does not provoke mania, cause more symptoms of depression, or destabilize mood like antidepressants frequently do.

Hi! I was wondering if bipolar depression is the same as clinical depression, or if they are distinct from each other? Both in terms of symptoms and what is happening neurologically.

Erin here: Great question to get us going!

A partial answer to your question is that *clinical depression is clinical depression*. Bipolar Disorder is a type of mood disorder that typically (but not always) goes hand-in-hand with clinical depression. And this is the case whether someone is experiencing BD type I or BD type II. A diagnosis of BD type II actually requires the individual to have experienced at least one major depressive episode or “clinical depression”. There’s been ongoing research to look at how non-bipolar depression (“unipolar depression”) might differ in terms of how it’s experienced by people compared to bipolar depression. Studies have suggested that a range of symptoms profiles might be experienced more often in bipolar depression (for example, experiencing psychosis when depressed, more pronounced mood variation across the day, and over-sleeping instead of under-sleeping, or insomnia).

Tom here, just to add to Erin’s thoughts, one difference is that those with Bipolar disorder may have ‘mixed’ episodes where they have both some symptoms of depression (e.g. feeling sad and hopeless) but also some symptoms of mania (e.g. racing thoughts and agitation- finding it hard to sit still)..

Miklowitz: It is very common for bipolar depression to be misdiagnosed as major depressive disorder- depression in the two disorders can look very similar, unless the clinician is on the lookout for some tell-tale bipolar signs. Family history of BD is one sign; having quick onset and offset depressions (ie, that come on quickly and leave quickly), many mood shifts while depressed, including some upward mood swings; a highly lethargic form of depression with motor slowing or a highly agitated, anxious form an earlier age at onset (e.g., having your first depressive episode at age 13), or having psychotic symptoms (delusions or hallucinations) all may suggest a bipolar course of illness. Of course, there is considerable variability from one person to the other. The clinical implication is that if you have bipolar (rather than unipolar) depression, you want to be careful about taking antidepressants alone- you may be able to take them in conjunction with a mood stabilizer (eg lithium) or an antipsychotic (eg Abilify) but it may be risky to take them alone.

Is there a way to reduce depression while keeping some level of mania?

Erin here. This is such a common question to get in clinical settings. Depression - even low levels of depression or residual symptoms - suck, and they erode quality of life. And low levels of hypomania (i.e., lower-level symptoms of mania) can for some people be a pleasant state; many people with BD will say that their utopian ‘sweet spot’ for mood would be no depression but just a touch of hypomania. In reality, that’s a really hard sweet spot to maintain clinically, and there are inherent risks in that approach, as Andrea alludes to.

Tom here. I have had lots of my patients say they do not want to lose the mania, and as someone who has experienced it myself I get it: it can feel amazing at times. Unfortunately, keeping yourself stable means having to work on reducing the risk of both depression and mania. After mania can often come a crash with regret or shame about what happened when you were manic, this then fuels the depression. So I’m afraid I don’t think it’s possible to keep mania and not depression. It is worth saying as well to beware that the temptation to go with a high in the early stages can lead to you doing things which increase your mood further (e.g. not taking medication, going out more, spending more money) and further until you became unwell and the mania really causes you problems. The metaphor I use with my patients is the early stages of mania is like being on a skateboard on the top of a really steep hill. It’s exciting at first, but if you don’t get off early it will just keep getting faster and faster until it's not safe anymore and you might get hurt.

Andrea Paquette HERE: I have bipolar disorder and I understand how tempting it can be to “want” some level of mania. Mania is not fun and can be dangerous if it is entertained. I feel that it is not the level of mania many need to focus on, but maintaining a “balance” which is hard to do, and it is possible with the right medical support from a team, medications, therapy and much more. Depression reduces quite often and then many can enjoy a semblance of balance.

What are your thoughts on the user of psychadelics in treatment, and how can I get involved?

Erin here. As you probably know, there’s so much exciting new research being undertaken internationally looking at the potential for psychedelics as a treatment option for people with mental health conditions. Historically though, all of this research has excluded people with BD because of concerns about risks, like risk of inducing psychotic or manic episodes. We’ve been partnering at CREST.BD over the last year with the BAND Lab at University of California, San Francisco to support their work to study psilocybin (the primary psychoactive compound in magic mushrooms) for the treatment of depression in adults with BD type II. As an initial stepping stone, we just wrapped up a survey of people with BD who have been using magic mushrooms when living with the condition, you can see blogs on some of work here: https://www.crestbd.ca/2021/02/25/bipsi-phase-2/

I’ll let our other panelists weigh in on ways to keep up to date with psychedelic research study opportunities.

Josh here. I agree with Erin. There is a lot of enthusiasm especially about psilocybin’s potential as an antidepressant. However, people with BD have been excluded from all clinical trials to date. In fact, most studies have excluded people if they had a close relative with BD. Previous researchers did this because of concerns about possibly inducing a manic or psychotic episode as these have been described both anecdotally and in the published case report literature. We recently completed a systematic review of these case reports and found that while this has been reported, it seems to be rare. What the actual risks are in controlled clinical and research settings (for example with professional therapists, known quality and quantity of psilocybin, absence of other drugs, and close follow-up) is currently unknown. Many antidepressants carry some risk of inducing mania. Therefore, the balance between risk and benefit needs to be considered in all treatment decisions. We are working towards conducting the first small trial of psilocybin in people with BD type 2 as a first step to understanding if this treatment is safe and potentially effective for BD. If successful, we plan to conduct more studies to more fully understand what role, if any, psychedelics can have in the treatment of BD. We will announce the start of the trial on our twitter account and other media outlets hopefully later this year.

What is the role of circadian rhythm disturbances in bipolar? Light and dark therapy has had huge effects on my mood. Is there any new research on the neurological differences in bipolar?

Erin here. We have several panelists in this AMA with expertise in circadian rhythms and BD, they’ll weigh in on this question! One of our gurus is Dr. Greg Murray but we need to let him wake up, it’s only 6am still in Melbourne lol. More soon.

What are your thoughts about the amount of overlap/co-morbidity seen between lots of psychiatric disorders (eg. bipolar, ADHD, schizophrenia, schizo-affective, depression, anxiety, autism, OCD, tourette's, etc)?

How effective do you think psychiatry currently is at treating those of us with dual- and multi-diagnoses? What changes in this area do you hope to see in the future?

Which journals would y'all recommend to someone wanting to stay informed on current bipolar/psychiatric/neuro research?

Steven here. Speaking as a non-clinician and person with BD who has also at one point been (mis?) diagnosed with one or more of schizoaffective disorder, major depressive disorder, and anxiety disorder, I am certain there is significant overlap between the conditions you list. This is in part because of the way we diagnose psychiatric disorders. We use the Diagnostic and Statistical Manual of the American Psychiatric Association in the US and Canada--now in its fifth edition (DSM-5) (FYI: Most other countries use the World Health Organization’s International Classification of Diseases (ICD) version 11 for that purpose--there is much overlap between the DSM-5 and the ICD-11). The DSM-5 (and its predecessors) define each diagnose (be it BD, depression, schizophenia, etc.) based on a cluster of symptoms. Many of the symptoms in each cluster overlap are the same as those in other clusters. What distinguishes one condition from another, according to the DSM-5, is the particular constellation of symptoms. Thus, one can expect that there will always be overlap using such a diagnostic methodology, and there will always be the chance of misdiagnosis.

There are alternative diagnostic systems (to the DSM-5 and ICD-11) that have been proposed. For example, the National Institute for Mental Health in the US has developed the RDoC (https://www.nimh.nih.gov/research/research-funded-by-nimh/rdoc/index.shtml) as an alternative based on researchers frustration not only with the vague boundaries between conditions in the DSM-5, but also because with each edition change the diagnostic categories change. For example, my grandmother had manic depressive disorder according to the DSM-2, depression according to the DSM-3 and bipolar disorder according to the DSM-4. I saw nothing change in her behaviour as soon as the next edition was published! This underscores an important point about psychiatric diagnoses, they are in some ways ‘moving targets.’

I personally think that if the psychiatrist or physician focuses on the symptoms (e.g., mood switching, psychoses, flat affect) rather than the diagnostic category, then treatment can be more effective for people with comorbid conditions.

Some journals: Bipolar Disorder, Journal of Affective Disorders. There are many others...but those are a start that are most specific to BD.

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Eric here. This is a great question! And I need to be clear that I am not an MD, so I don’t prescribe medications, and I hope that others weigh in. As someone who works with youths, reads the literature a lot as a researcher, here’s a quick “Spark Notes”:

ADHD researchers and long term studies don’t see a risk of mania in their treatment studies or long term follow-up (look at the Multimodal Treatment of ADHD [MTA] study, or 10 and 20 year followup studies by Stephen Hinshaw, Rachel Klein, or others).

Practicing clinicians see people who get hypomanic or manic after taking a stimulant. The problem is that they have no control group to see what would have happened if they hadn’t given the med. (Imagine going to a doctor and them flipping a coin, and saying “tails, and I give you placebo” and they flip it and don’t show it to us! Can we please go see someone else???)

The trouble is, mood disorders are episodic; they come and go (like catching a cold or flu), which makes it really hard to figure out triggers and treatments. Would the person have gotten hypomanic *anyway*, even without the medication?

Research studies can help answer that exact question, and the best studies (random, concealed assignment -- like flipping that coin and not showing us) find no significant difference in how often people “switch” on stimulant or placebo. That’s not saying that “switch” does not happen; it does, but at roughly the same rate in placebo as stimulant. There are older reviews by Licht et al., Joseph et al. (<-- which was our group), and Gaye Carlson (the current president of the American Academy of Child and Adolescent Psychiatry!) wrote a paper called “The Bottom Line” making that point in 2003. Since then, studies by Russ Scheffer and others looking at treatment of mood disorder found not increased risk of switch adding a stimulant.

The bottom line, still: If treating ADHD, adding a stimulant doesn’t look like it increases risk on for later bipolar. If treating bipolar, then adding a stimulant doesn’t increase risk of hypomania or mania on average. It can (and sometimes does) happen, but not at a higher risk.

Adding the names and sources is to help the curious who want to fact check or read more in their DIY searching!

I am interested in becoming a researcher as it seems to suit my personality and abilities well. My partner is working on a doctorate, but when she's done it may be my turn to work on some higher ed, or just straight to a research and development role. How have you all, especially those living with BP (and ADHD) made it, and is it a satisfying career path for you?

Tom here. I’m a clinical psychologist so I work clinically but do bits of research as well. I have a diagnosis of Bipolar Disorder and found my career and mood are very strongly related to another, for example getting manic about my dissertation about hypomania (no really!). I spoke more about this more in this video here: https://www.youtube.com/watch?v=CvfkZsduXW4

Certainly my own experiences helps me think about research ideas, and lived experience can be an asset. But you also need to be careful and look after yourself. Academia can be very competitive, and it is very easy to quantify your performance compared to others (e.g. looking at citation rates), this can be triggering for those with Bipolar disorder who often have high standards and self-critical tendencies. For me, I love research, I have used therapy to help me focus on why I love doing research (scientific geekiness, rationality, it helping people), rather than focusing on how much I have achieved (e.g. number of papers published etc), this makes me more resilient when stuff doesn’t go my way. Focus on your passion for the research, try to be kind to yourself and keep high standards in check and I hope you will love it as much as I do!

Georgina here: I am a research psychologist, and I love my job mainly because I feel like improving our understanding of bipolar disorder through research makes a huge difference in terms of treatment, prevention and reducing stigma, as well as educating the next generation of psychologists (I teach psychology students). That said it is a challenging career path and I agree with Tom it is really important to focus on ‘why’ you decided on this career option. I have found that a crucial element for my job satisfaction and progress is having good collaborators and mentors who you can bounce ideas off of, learn from but who can also buoy you up when things are tough. Good luck with it all.

Is there a clinical difference with late onset bipolar disorder and do individuals who develop bipolar disorder later in life require different forms of treatment (such as different medications) than those who develop it earlier?

Erin here: Here’s a great starting point for you from the International Society for Bipolar Disorders (ISBD) Older Adults with Bipolar Disorder Taskforce

Can severe PTSD present like bipolar? Like if someone is experiencing extreme frustration/entrapment, gaslighting, etc. for extended periods of time (leading to C-PTSD), can that manifest in a sort of mania or psychosis? And how can that person get appropriate treatment? Edit: meaning — if it looks like bipolar but actually isn’t, would the treatment be the same regardless? (Or can someone actually develop bipolar from extreme stress?) And/or how does a patient try to explain that difference when they’re constantly dealing with under-qualified professionals, say in public health systems...

Catriona here. It sounds like you have been frustrated by the professionals you’ve encountered on your mental health journey, and that perhaps you don’t have a care provider that you trust? Unfortunately, this is all too often the case. Further, not enough professionals are trained in trauma-informed care, and some treatments can trigger re-traumatization, especially when the treatments aren’t provided in the context of trauma-informed care. In terms of whether the treatment would be the same regardless, some treatment options are common to both - like CBT, as Tom says - but some are unique to bipolar disorder, and some more often used in C-PTSD (as far as I understand - I am not a psychiatrist). Understanding whether someone has bipolar disorder or C-PTSD or both would definitely impact treatment approach. For example, while EMDR is increasing its reach, it started as a treatment for PTSD and isn’t a common approach to treating bipolar disorder. Doctors might suggest CBT for bipolar disorder, but without a trauma-informed approach, it could risk re-traumatizing someone with C-PTSD. Antidepressants are often recommended for PTSD (and C-PTSD), but mood stabilizing medications are the appropriate pharmacological treatment for bipolar disorder. With respect to your sub-question, yes - someone can absolutely develop bipolar disorder from extreme stress. Bipolar disorder (and all mental illnesses) are caused by a combination of genetic vulnerability and life stress. Someone with extreme stress could develop bipolar disorder even if they don’t have a lot of genetic vulnerability for it. It sounds like you need to find a healthcare professional that you trust, with training in trauma-informed care, that can sort through this with you and support you in accessing treatment that serves you well… which I know isn’t easy! I want to acknowledge your courage in continuing to try to advocate for yourself in the face of such frustration.

u/Wonderminter u/Naerwyn

One of the things I struggle with is relationship building and it’s partly due to not knowing how to explain my shifts in moods from time to time. I could meet someone one day and be very bubbly and social but other times I’m extremely depressed and reclusive and it can get confusing and off putting to people who try to get to know me. I’ve been asked about it before and I never really know what to say because I feel my bipolar disorder will run people off. Plus it’s not really something to bring up casually. And I’m running out of excuses. How do I navigate dealing with mood swings while trying to form relationships?

Andrea Paquette HERE - I have found that being upfront with people about my bipolar is important for my own mental wellbeing and to eliminate the stigma that I once had inside - self-stigma and shame. I also tell myself that I go through my ups and downs and that is ok. Good and real friends will understand and when you are feeling more active and energized, then that may be the time to form new relationships. Don’t worry about bipolar running people off because the good people stick around no matter what. I always say, “If they cannot accept me...for ALL of me, then that is just ok.” I also keep my friend circle small with like 2-3 close friends and build on those friendships.

How can you balance a busy lifestyle and still keep your BP in check? I’m a student with BP1 and I find that I can get caught up in deadlines and send myself into a depressive spiral, while on the other hand while manic studying myself to burnout.

What strategies can you use to manage BP symptoms like having trouble concentrating, focusing, and memory problems? Before I was diagnosed I had no trouble with schoolwork, and now it feels like I’m in a fog, unless Im manic.

Thanks for the AMA guys, happy world bipolar day to you all! May we lead happy and healthy lives :)

Erin here, great questions, thank you. Happily, we’ve got some tools and resources that might help you! Our CREST.BD Bipolar Wellness Centre (www.bdwellness.com) has specific sections in it dedicated to supporting education/school life and cognition: https://bdwellness.com/life-areas/study/ and https://bdwellness.com/life-areas/cognition/. And you can also find tools and resources for those life areas, as well as a link to our BD-specific Quality of Life Tool, that helps your measure and track how you’re doing in those domains over time here: https://bdwellness.com/tools - good on you, you’ll get there!

Tom here. I find mindfulness personally very helpful and often recommend it to my patients. We have developed some free mindfulness exercises here so help yourself: https://www.youtube.com/watch?v=PSmz-086JDQ&list=PLFbeQlTqQPGTLAmNgKs0srX9Vau7mctFf

I think from the sounds of things trying to balance studying/work and relaxation/enjoyable activities is really important. Taking on too much can lead do ‘burning the candle at both ends’ which is bad for your mental health. Trying to plan ahead so that you are not having to stay up late working might help, as well as making sure that you plan in enjoyable activities, down time and seeing people so it’s not just studying! All the best.

It's often brought up that psychiatry is one of the few medical fields where the organs that the practice is centered on treating are not actually examined and measured. What, if any, advancements can we be expecting in the near future to correct this? What's holding us back?

Jill here- thanks for this great question. You’re right that psychiatry is different from other fields in that there’s no quick test to diagnose mental disorders - although research on the brain is growing all the time. We do have ways to systematically measure important aspects of mental illness like symptom occurrence and severity, side effects from medications and quality of life factors. One way to do this is through ‘measurement-based care’ (MBC) which is an evidence-based practice that can be used by clinicians in partnership with patients. Using standardized outcome measures to assess occurrence or changes in these factors on a regular basis can help to identify improvements or worsening symptoms and can help to guide treatment decision making. Engaging patients in MBC can be very empowering as it allows patients to track and monitor their own symptoms and to discuss these changes with their clinicians. We are doing a study in China now that uses technology like apps to enhance MBC and to make it easier for patients to engage in this process. Unfortunately even though MBC is evidence based it’s not widely used by clinicians- as in much of medicine there’s a research to action gap. Our current research is trying to understand what factors influence clinician and patient willingness to use MBC and how to put in place strategies that promote its use. Stay tuned for more from us on that!

How do you guys deal with brain fog from medication? Am on epilim and seroquel- great combo for me but i feel I am slower than when i wasn't medicated. Also, any nootropics good for that? Thanks for doing this AMA!!

Hi Ivan here: You bring up a good question which is relevant to many people diagnosed with bipolar disorder and taking medications. Cognitive difficulties can be associated with bipolar disorder itself, but can also be influenced by side effects from medications. The strategy with any medical treatment is to try to maximize the benefits derived from the treatment and to minimize unwanted side effects. In your case it sounds like you are deriving benefits with regard to symptoms, but that cognitive side effects are problematic. One approach may be to consult with your treating doctor and to collaboratively determine if indeed the cognitive difficulties are caused by the medications. If so, there may be things that could be tried to help reduce the side effect profile (reducing doses, modifying medications, etc.). It can be somewhat of a trial and error process, especially since people are affected differently and respond differently to treatments; however, it could be a worthwhile effort. The question of whether there are any nootropics or cognitive enhancers is one that is currently receiving a lot of attention in the research arena; however, as of yet there are no established medical treatments that have been clinically approved for this purpose (although there are some promising preliminary research findings with some agents). Another behavioural therapeutic treatment that has been developed is called cognitive remediation therapy (CRT), and this could be worth pursuing if it is available in your area.

Do mixed episodes (racing thoughts/high energy, irritability/ low mood) mean that a person has bipolar disorder or can they appear in individuals with clinical depression as well? Also, if diagnosis and treatment for mental health issues depend on the individual's self reporting symptoms how can we be sure that we understand and describe what we experience accurately and as objectively as possible?

Hi there – Emma here. The DSM (the psychiatric handbook for diagnoses) used to say that mixed episodes were only present in people with bipolar disorder, because patients had to meet full criteria for both a manic and a depressive episode. However, slow changes are being introduced to recognise that these conditions (unipolar depression and bipolar disorder) likely overlap and intersect much more than we thought. The qualifier “with mixed features” can now be added to a diagnosis of an episode of major depressive disorder if there are an adequate number of hypomanic symptoms present.

Keto diet - are there any studies being done on if the keto diet helps with maintaining stability? Personally (BP1 here) I feel like the keto diet helps me maintain stability. If I fall off the wagon I tend to have a depressive episode almost immediately following. I've read that a strict keto diet helps those with seizure disorders and the fact that some common mood stabilizers are anti-seziure medications, I was curious if there are any correlations. Might be far fetched, but it piqued my curiosity: )

Hi – Emma here. I’m not an expert on this by any means, but it is an area of emerging interest. There’s more and more research to show how we eat can impact the way we think and feel. Some colleagues over in Australia focus on this topic (https://foodandmoodcentre.com.au/) – in fact, I think they are the only research centre to study nutrition and mental health exclusively - and they have done some thinking about ways the ketogenic diet might be helpful for BD and psychotic disorders (https://pubmed.ncbi.nlm.nih.gov/32034911/). There is unfortunately too little research to say conclusively whether it helps, but you may find it interesting to follow their work for updates.

Diagnosed BP1 here. Do you feel bipolar disorder is overdiagnosed and is in danger of becoming a 'trendy' mental illness?

Do you feel that antipsychotics are over prescribed in bipolar disorder?

Is there any evidence of bipolar remission, given time?

Miklowitz: Bipolar I is still overdiagnosed in kids, because clinicians do not always agree on what constitutes a manic episode in a child. In adults, when bipolar is overdiagnosed it’s usually bipolar II rather than bipolar I. If you’ve had a clearcut manic or mixed episode, according the DSM-5 that’s all you need for a bipolar I diagnosis.

Docs do tend to choose antipsychotics if the person is highly agitated and a danger to self or others, but they may be warranted in such acute situations. The real problem (IMHO) is that antipsychotics should usually be discontinued after the person reaches remission, assuming that the person is also taking a mood stabilizer like lithium, lamotrigine or valproate. But many docs recommend staying on antipsychotics if they think that’s the best way for you to stay stable. It’s worth a discussion with your doctor. Yes, there is plenty of evidence for long-term remission in BP - about 30% go episode-free for a year or longer if they stay on meds, or they may have minor episodes that don’t disrupt their functioning as much.

Tom here. I wouldn’t say trendy, but I do think there is more awareness which has led to more people seeking help. I anecdotally noticed this after media highlighting Bipolar disorder, for example a documentary by Stephen Fry and a soap with a story line about it in the UK. More awareness is a good thing, so long as people try and seek out professional help and not try to self-diagnose when they might have other issues, not Bipolar Disorder.

Is anyone reporting on a relationship between vitamin D and mania? I've noticed over years that whenever I start a vitamin D supplement, my mood spikes.

Erin here. Huh. In this recent review “vitamin D supplementation was associated with a reduction in both depressive and manic symptoms” https://pubmed.ncbi.nlm.nih.gov/32971313/

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Hi! Steven here. Lithium was the first mood stabilizer discovered (and in fact, was the first effective drug discovered for the treatment of a psychiatric disorder), but is still considered to be the ‘gold standard’ against which other putative mood stabilizers are compared. It is also the only ‘anti-suicidal’ drug (that I know of). Lamotrigine was discovered more recently to have mood stabilizing effects (in the late 90s; prior to that it was used exclusively as an anticonvulsant), is particularly effective against bipolar depression, and has relatively few side effects. Both lithium and lamotrigine have some of the best evidence supporting their use as mood stabilizers. More recent research on mood stabilizers has focused on the use of antipsychotics, such as aripiprazole (aka ‘Abilify’), olanzapine, and others.

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Hi Victoria here - chiming in. I have bipolar 1 (mixed state, rapid cycling with some psychosis). I started with Lithium. It wasn't good for me. The side effects were too great. My doc and I finally found a dosage of valproic acid (apo-valproic) that really works well for me. It’s another antiepileptic / mood stabilizer. Maybe one of the clinicians can speak about it. I’ve been on it for years (a couple decades) and it hasn’t stopped working and my bloods levels are good. Hope this helps.

How are bipolar and borderline personality disorder related, if at all? I have BPD and have read that it can be like bipolar except instead of cycling every two weeks its every day. Here I am reading about rapid cycling bipolar and wondering what your thoughts are on BPD.

I understand you guys aren't experts on BPD but I would still be happy to hear any thoughts.

EDIT: I just noticed a similar question has already been asked and answered.

Hi! Yes, as you noticed we answered a similar question here: https://www.reddit.com/r/IAmA/comments/mgkm9g/we_are_bipolar_disorder_experts_scientists_in/gstjbhb?utm_source=share&utm_medium=web2x&context=3 :)

What are almost sure indications that someone has bipolar disorder?

How does a person manage those symptoms productively?

What are some struggles that people with bipolar disorder face that a lot of people don't realize?

Hi – Emma here. Unfortunately, there’s no one marker that can tell us for sure if someone has bipolar disorder. Unlike diagnostic tests for other medical conditions (like a blood test or the presence of a specific bacteria), when it comes to making a psychiatric diagnosis clinicians look for symptoms that tend to cluster together. However, there are certain symptoms that are more specific to bipolar disorder that would ping my attention as a clinician. In particular, when people have experience of mania they tend to have a disrupted need for sleep – they don’t even feel tired – and may be sleeping only a few hours, if at all. If somebody reported that in an appointment, I would be very alert to the possibility of bipolar disorder.

While I don’t want to downplay the struggles that a lot of people experience while managing their bipolar disorder, we do know that it’s possible to live well with bipolar disorder, and there are even strengths that people report emerging from experiencing the condition, like creativity and resilience.

The representation of bipolar disorder in the media tends to focus on the extreme highs and lows of mood. However, the impact of bipolar disorder to functioning (a person’s ability to perform their usual role at work, school, or socially) is potentially more disruptive, but less well understood. Even when people aren’t experiencing bipolar symptoms, they can still have problems with thinking and memory that can impact their daily lives. This is something that needs a lot more attention. Fortunately, research has started to look into treatments that might help people recover in terms of their functioning.

Tom here. I think some of the struggles people with Bipolar disorder face that many people don’t realise are: a. Low self-esteem, b. Self-critical tendencies and c. anxiety.

Can bipolar disorder become schizoaffective disorder? If yes what are the possibilities?

Hi, Steven here: My understanding is that it can be hard to differentiate between Bipolar Disorder Type I and schizoaffective disorder. For example, speaking from personal experience, I have been diagnosed with schizoaffective disorder by one psychiatrist and diagnosed by (most) other psychiatrists with bipolar I. So, my thought here is that, rather than BD developing into schizoaffective disorder, there might be a migration from one diagnosis to the other as a function of the diagnostician.

Hi Ivan here: There can be a great deal of overlap between bipolar disorder and schizoaffective disorder, as both conditions can involve the presence of mood symptoms and psychotic symptoms. The key distinction, however, is in the timing of these two types of clinical features. If psychosis only occurs during a mood episode (mania or depression), this is more characteristic of bipolar disorder; however, in schizoaffective disorder an individual will experience psychosis for a period of time in the absence of mood symptoms. Because these patterns of presence of mood and psychosis can change or emerge over time, it is possible that an initial diagnosis with bipolar disorder can change to schizoaffective disorder. I think it would be important to bring up any changes with your treating psychiatrist as this could influence the course of treatment.

Thank you all for your time. Could you touch on BD and pregnancy? Stopping medications while pregnant and breast feeding. The likelihood of postpartum symptoms and how to navigate these concerns? Again thank you.

Hi - Catriona here. The first thing to say is that it is absolutely possible to go through pregnancy and postpartum with bipolar disorder without having a mood episode. The key is to work closely with your care team (including partner/family/friends/healthcare providers) on a plan for your mental health, including what will happen if anyone notices signs of a mood episode. There is a high chance of a mood episode if someone stops their medication abruptly when they find out they are pregnant, so this is not recommended. The risks to baby of most mood stabilizers/antidepressants/new antipsychotics in pregnancy and breastfeeding are honestly fairly low, and the risks to baby of a mother experiencing a mood episode during pregnancy or postpartum are higher - in most cases - than the risks associated with the medications. So - in general, the prevailing wisdom in the medical community is to continue taking your medication. There are a few exceptions. It is ideal to avoid valproic acid in pregnancy and to avoid lithium and carbamazepine in the first trimester of pregnancy. These are due to small increases in risk for heart defects (lithium) and neural tube defects (valproic acid/carbamazepine). Ideally, individuals who are taking any of these medications prior to pregnancy should discuss their use during pregnancy with their psychiatrist and consider switching to alternate medications. A consultation with a reproductive psychiatrist is also ideal if possible. You’ll note my repetitive use of the word “ideal” - this is because I am very aware that life doesn’t always cooperate with our best intentions and plans. If you get pregnant unexpectedly, please don’t stop taking medications before discussing that with your care team. There is a great deal of pressure in society not to take medications in pregnancy and the implication that taking medications in pregnancy makes you a “bad” mother, but it is honestly better for the baby in most cases to continue taking the medication. I took my antidepressant throughout both of my pregnancies, and I am very glad that I did. Gradually tapering and discontinuing your medication before trying to get pregnant, in close collaboration with your care team, is an option for individuals who have been stable for a while and want to give that a try. With respect to breastfeeding, the amount of medication that the baby gets is much less compared to the amount they get during pregnancy, so the risks are lower. Further resources on medications during pregnancy: https://play.google.com/store/apps/details?id=com.infantrisk.mommymeds.paid&hl=en&gl=US; https://mothertobaby.org/

Your second question is obviously connected to your first. The risk of postpartum symptoms is higher with abrupt discontinuation of medications. Postpartum depression is very common - 10-15% of women experience it. Postpartum psychosis is more rare, at 1/1000. Both postpartum depression and postpartum psychosis are treatable illnesses, and moms and babies do very well with appropriate supports. For individuals with bipolar disorder, the chances of postpartum depression and psychosis are higher - approximately 25-50% chance for postpartum depression (which means 50-75% chance NOT to develop postpartum depression) and ~30% chance of postpartum psychosis (or ~70% chance NOT to develop postpartum psychosis). These are average risk figures, and if you’d like to discuss a risk figure tailored to your own family and situation, I encourage you to get in touch with a genetic counsellor. Factors that affect these numbers include your specific diagnosis (BDI or BDII or BDNOS) and experiences of mental illness for other family members (amongst other things). There are many options for managing these risks, which ideally would be discussed with a reproductive psychiatrist, but include medication, psychotherapies, social support, and hospitalization (for severe experiences of postpartum depression and any instance of postpartum psychosis). An acronym which I really like that captures factors to promote mental wellness for everyone, but that are particularly important in the perinatal period is NEST-S: N = nutrition, E = exercise, S = sleep (or rest), T = time for yourself, S = social support. These can obviously be tricky to implement in the perinatal period (sleeping while the baby sleeps isn’t as simple as it sounds ;)), and some are particularly tough during this pandemic, but setting small, achievable goals for each of these mental health supports can make a big difference. Additional resources: https://reproductivementalhealth.ca/bipolar -

Thank you for being here for us. 1. Is there research on the effects of isolation on manic episodes? I was on Short Term Disability last fall (without realizing I was manic) and was quarantining in my apartment. I had two panic attacks in one week that resulted in me calling 911 because I couldn't be alone (I live alone). 2. Does bipolar medication strain the liver? Is there any increased risk for liver disease or fatty liver disease? I am stable now, taking a new batch of medicine, but I have gained 35 pounds since December despite going to the gym. It is hard to lose weight now. I take Lithium, Lamictal, Invega, and Trazodone.

Jill here- I’m really sorry to hear you had such a hard time during isolation. The research on the impact of COVID-19 restrictions and mental health is growing, and we know that the huge life impacts of the pandemic are having an impact on mental health worldwide. The risk of worsening mental health can be especially high for people living with existing mental health conditions, and anxiety symptoms often co-occur with bipolar disorder. Most existing research seems to focus on the relationship between bipolar depression and isolation, but we will probably see increased research in this area because of the pandemic- so please stay tuned. If other panelists know of research I’m not aware of on this I hope they weigh in!

Though you didn’t ask specifically for advice on this I hope this is somewhat helpful- while it sounds like a contradiction, it’s important to stay connected while in isolation. If online connections are fulfilling to you, try seeking them out. There are also a host of telehealth and online mental health support options depending on where you’re located. If you’re not in official quarantine getting out for regular exercise and/or fresh air can really help. We also know that there’s a relationship between reading lots of news related to the pandemic and worsening mental health symptoms. Tearing myself away from the news, not “doom scrolling” etc. is something I struggle with myself but it’s important to try to limit exposure to excessive information that may just cause stress and trigger symptoms of anxiety, for example. Hope this helps!

Are there any apps that you would recommend for tracking moods? Is that of value?

Hi – Emma here. Tracking mood can be really useful when you live with bipolar disorder. It can help people detect when potentially problematic mood changes are occurring and prompt them to intervene early, and it can also help people develop awareness of how stress and lifestyle can impact their mood. Many people are interested in the idea of using apps as they are a lot more portable, convenient, and discrete compared to a worksheet. However, there is a need to be cautious about what apps you download – some of them can compromise your privacy, have inaccurate information, or are stigmatising. My colleague Dr. John Torous does a lot of work in this space evaluating apps, and his team maintains an online library where you can sort apps according to their supported conditions, features, safety, evidence and privacy protections: https://apps.digitalpsych.org/Apps

The CREST.BD team recently ran a large study asking people with bipolar disorder what apps they are currently using to manage their mood. One bipolar disorder specific app people in our survey reported using is eMoods bipolar tracker (although it has some limitations, as you can only track your mood once per day). Some people also worry that having a bipolar specific app reminds them too much that they are living with a chronic illness, and prefer mood apps designed for the general public. Apps like Daylio were also really popular in our survey, but some people found these were limited as the happy-to-sad rating scale doesn’t necessarily capture what it’s like to live with bipolar disorder. It can require some experimentation to find the app that is right for your unique needs.

I'm interested in hearing your opinions on the prescription of antipsychotics as first line treatment for bipolar depression & maintenance. I've heard countless stories of bipolar patients being prescribed APs over mood stabilisers, but the literature still seems to suggest that monotherapy with mood stabilisers should be the first point of call. Why do you think that antipsychotics are so popular despite evidence that they should only be prescribed after drugs like lithium and lamotrigine have failed?

MIKLOWITZ: It depends on whether the person is in an acute episode of mania or depression. There is clear evidence for the efficacy of second-generation antipsychotics like risperidone, olanzapine, aripiprazole, and quetiapine for mania and they often work faster than mood stabilizers. So if there is a need for speed, the mania is very severe, and there is a prior history of response to SGAs, most docs will start with them during the acute phase of mania. If the patient is acutely depressed, the choices are less definitive, but even here, certain SGAs have antidepressant properties, including quetiapine and the combination treatment Symbyax. In longer term maintenance, many physicians will taper the regimen to monotherapy with a mood stabilizer, but of course it depends on how the patient has done with monotherapy - some prefer to stay on SGAs if they’ve become stable and can stay with a job, and don’t feel unduly sedated. All of these meds have side effects, and what is most troublesome to one person may be different than for someone else.

Can bipolar disorder be triggered or caused by a traumatic experience?

Chris Gorman Yes, almost all conditions have a stressful event. For example, if you are not used to doing arduous exercise and you have a genetic or other predisposition to heart disease, this could produce your first or other heart attacks. I’m not sure I’ve ever met anyone with a psychiatric condition that was not responding to a stressor.

Georgina here: Although the evidence shows that genetic factors play an important role in the development of bipolar disorder, research consistently shows that stressful and traumatic experiences are also linked to this illness (and many other physical and mental conditions as Chris has said). These experiences may have occurred at any point (e.g., childhood or adulthood).

Hi! My boyfriend was recently diagnosed with bipolar disorder and is having a hard time accepting the diagnosis. His manic episodes are usually marked by paranoia, anger, and agitation instead of happiness and excitement, so he feels like he doesn’t fit the mold of what bipolar is. Is this kind of behavior common in manic episodes, and if so, how can I help him to come to terms with his diagnosis?

Hi, Emma here. While there’s a classic depiction of bipolar disorder in the media, it’s important to note that two people could receive the same diagnosis of bipolar disorder, and report very different symptom presentations and experiences with treatment. Manic episodes can be characterised by euphoric, elevated moods, but they can also involve extreme irritability, excessive energy and restlessness, and psychotic symptoms (such as persecutory beliefs). People can also experience mixed states, where the high energy, racing thoughts, and impulsivity of mania occurs at the same time as the low mood of depression. This can be a really unpleasant, tense feeling, and used to be called “dysphoric mania” or even “black mania” to distinguish it from the type of elated, grandiose mania your boyfriend has described. Anger is a particularly challenging experience in these mood states – those unpleasant feelings, coupled with the impulsivity of mania, can result in people saying or doing things they regret. Coming up with boundaries and agreed upon ways to manage anger before things get too heated is important – see more tips here: https://www.bphope.com/bipolar-anger-unravel-your-wrath/ - anger management strategies can also be discussed without making specific reference to bipolar disorder, if your partner is having a hard time right now talking about their diagnosis.

It can be very challenging to raise your concerns about mental health with a partner, particularly when it comes to bipolar disorder as this diagnostic label is still met with a lot of stigma. Our partners in Australia describe some helpful strategies for having those conversations here: https://bipolarcaregivers.org

bipolar II

I have an adult child who in the past 10 months went off his medications and went into Mania.

The experience has been horrifying. During this phase he/she lost perspective on reality, and this person who was once a loving person towards me and others, now will have nothing to do with me.

I called mobile crisis at a time that was really scary and he/she met criteria for being taken against his/her will to the hospital.

He/she will not forgive me. As he/she have eventually gotten better and got back on meds, their opinion is still the same of me, and wants nothing to do with me. They also want nothing to do with the other family members nor his/her closest childhood friends.

This, while I continue to support him/her as they are unable to work due to the illness.

Can anyone suggest resources that I may not have encountered? I have read the book "I'm not sick" from Dr. Amador.

Looking for answers...

​

Thank you

Victoria here - I am so sorry for what you and your adult child and your family is going through. It’s devastating. I can recommend a few things. Julie Fast is an expert in helping loved ones cope and help when their adult child is suffering and has little insight. She has a facebook page: Julie Fast’s website https://www.juliefast.com/and her Stable Table Facebook group ( https://www.facebook.com/groups/StableTable/) is excellent. She is dedicated to helping those who love someone with bipolar disorder or schizoaffective disorder. I highly recommend her books as well.

Additionally Dr. Lloyd Sederer’s TEDxAlbany talk ‘When Mental Illness Enters the Family’. I highly recommend it. This TEDx talk offers excellent tips for parents, loved ones and others when supporting someone who is struggling with mental health issues but isn't able to see they need help. He also talks about how to get info to health professionals when they can’t divulge private info. https://www.youtube.com/watch?v=NRO0-JXuFMY

And as you mentioned Dr. Xavier Amador’s book and website– specifically about how to communicate with a loved one who has mental health issues who refuses help. I'm not sure if Xavier Amador does private consultations, but know many of his trainers do. Search for one on his website that is near your area or who does phone coaching. His book “I’m not sick. I don’t need help!” may be of interest. https://lfrp.org/

All these are listed in my e-guide along with others that might help: https://drive.google.com/file/d/1vrdr4VCkHBRhf7fP5_1rvwZse4pNoIJ0/view?usp=sharing I hope this helps. Please take care and make sure you get support for your mental health as well!

Hi There! I have been unclear on this: At what point in life does one develop bipolar disorder? Is bipolar disorder present from birth? Does it explain my shy, anxious childhood? My use of antidepressants for 10 years? Could it explain the risky, uncharacteristic actions of my early 20’s? Or did my bipolar disorder begin last year when I was hospitalized due to my first-ever episode of mania and psychosis, and received my diagnosis?

Thank-you to all the panelists and organizers of this forum.

Hi – Emma here. It’s very common for people to be initially misdiagnosed with depression – as bipolar disorder is a rare condition, doctors don’t always ask about periods of mood elevation. In fact, they can sometimes be interpreted positively – as a sign that someone is coming out of a depressed period – and not recognised as a potential indicator of bipolar disorder. It’s been estimate that it can take up to ten years for a person to receive the correct diagnosis. Clinically speaking, one might look back on your earlier experiences of impulsive, out of character behaviour in light of the full-threshold manic episode you described, and say those were potentially early signs of hypomania. Your earlier periods of depression could also be interpreted as mood episodes associated with bipolar disorder.

Some risk factors are probably present from birth, as there is research to show that a family history elevates the likelihood that someone will go on to be diagnosed with bipolar disorder. However, not everybody with bipolar disorder has a clear family history of the condition, and not everyone with a family history develops bipolar disorder. Other risk factors like coping style can also be present early on in life. Environmental factors such as stress, lifestyle disruption (especially changes to sleep), and substance use can trigger mood episodes in people with a pre-existing vulnerability to bipolar disorder. Thanks for your question!

How do you feel about micro dosing hallucinogenics to treat depression? You think it works or is it snake oil?

Josh here. Oops. I failed to see the “microdosing” part. My answer above was for “macro” dosing. We know even less about micro dosing as there have been very few studies. Anecdotally, people report that it helps them but very few controlled studies have been completed. A recent study that used a clever design and recruited “citizen scientists” suggested that a lot of the benefits came from people simply believing they were taking microdoses of a psychedelic. Kaertner, L. S., et al. "Positive expectations predict improved mental-health outcomes linked to psychedelic microdosing." Scientific reports 11.1 (2021): 1-11. We will have to wait and see what the research finds!

Josh here. There certainly is a lot of excitement around the potential to use psychedelics to treat depression and many other mental health disorders. So far most of the studies have been small and poorly controlled. On the other hand, these studies have reported large and sustained benefits from one or two doses of a psychedelic. Therefore, I would say that I am excited about the potential of psychedelics as a treatment but more work needs to be done to determine if and in whom these powerful drugs can be helpful. We and others are actively working to conduct the studies needed to help answer these questions!

What's the best way to differentiate between bipolar II with psychotic features during depression and schizoaffective disorder? How can you tell if the depressive mood is caused by a mood episode or if you're just depressed because you're experiencing psychotic features that are unpleasant?

Additionally, how common are psychotic features during depressive episodes with bipolar II?

Thank you very much in advance!

Hi – Emma here. Symptoms of psychosis appear to be more common in manic episodes compared to depressive episodes, and more common in depressive episodes for those who have BDI as compared to BDII (https://pubmed.ncbi.nlm.nih.gov/18076541/).

As mood and psychotic symptoms can occur at the same time for both people with bipolar disorder and people with schizoaffective disorder, they can be difficult to tell apart. Diagnostically, the way we distinguish these conditions is to look at which set of symptoms appear to be primary. If a person experiences psychotic symptoms (e.g., hallucinations or delusions) in the absence of mood symptoms, we would be more likely to opt for a diagnosis of schizoaffective disorder than BD with psychotic features.

You are right to note that experiencing distressing psychotic symptoms might also trigger a depressed mood or trauma response. Anecdotally, when working with people with schizophrenia-spectrum diagnoses it was sometimes tricky to tell apart low mood from negative symptoms of psychosis (apathy, low motivation and poor concentration). If a psychological treatment strategy for depression didn’t seem to be working for somebody with psychosis, I would consult with a psychiatrist to get a second opinion as negative symptoms may require different treatment approaches.

Hi guys, I have Bi-Polar Type 1 and take 900 mg of Lithium extended release nightly, which has kept me at my most stable mental state in life, so far, for the past 3 years. My only gripe is that my memory is terrible compared to what it once was. Any tips on how I might be able to mitigate this?

Hi - Emma here. This is a really common and unfortunate experience for people with bipolar disorder. It’s hard to know if difficulties are related to your medication or your BD, or both. Research is starting to look at how brain training and similar therapies might be able to help people restore their cognitive abilities – there’s some promising findings, but there isn’t enough evidence just yet. It can be helpful to experiment to see if there are memory supports that work for you – whether that’s mnemonics (like rhyming lists), or putting visual reminders at key locations (like a note about taking medications on the bathroom mirror). I also recently ran an online survey about what kinds of apps people are using to manage the impacts of bipolar disorder – people seemed to like Elevate and Lumosity for brain training (although I can’t speak to how effective these might be), and using the calendar and reminder apps on their phone to give them prompts.

My colleagues Dr. Trisha Chakrabarty and Dr. Ivan Torres might be able to follow up with more specific suggestions. They recently did a webinar on how thinking and memory can be disrupted in bipolar disorder, and tips on managing it: https://youtu.be/OqMV-Fwidxo. We also have some resources available here: https://bdwellness.com/life-areas/cognition/.

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Andrea Paquette here - I take both plus a few more in low doses. Lithium helps balance me out and halts the mania. Lamictal decreases my depression and it is not a fact or one or the other to be honest about it.

I've heard that bipolar is degenerative and gets worse with age. I myself have noticed more symptoms and severity increasing as the years go by. Is this true for everyone and is there a way to manage this?

Ivan here: The question of whether bipolar disorder is a neurodegenerative disorder is a hotly debated topic in current bipolar disorder research. On the one hand, studies that follow participants over time have largely failed to demonstrate that cognitive functions (memory, attention, problem solving) get preferentially worse in patients with BD compared to those without BD. On the other hand, there is some data that suggests a possible relationship between having more mood episodes and poorer cognitive functioning. It may be that there could be subsets of people with bipolar disorder who show stability across time, and other subsets of people with the illness who may be at higher risk for some decline. However, this is clearly a topic that is not fully understood at this time.

Another point worth mentioning is that the experience of noticing changes in symptom patterns across time does not necessarily imply degeneration, but it could reflect changes in the course of the illness, changes in response to medication, influence from other medical conditions that may emerge with age, or other factors. Any changes in symptom patterns should be discussed with your treating clinician so that changes in treatment approaches can be considered

Sorry if this was already asked, I tried scrolling through everything and didn’t think I saw it. I am interested in better understanding the “brain fog” that comes with medication. I have felt this on multiple meds but the ones I’m referring to is lamictal. I feel like it’s helping me stay stable but I’ve lost my edge at work and with numbers. I think in loops to get where I’m going, almost like synonyms of the word I want. How can I get stability without the brain fog?

Hi there! Thanks for asking a question. Yeah, there are a lot of questions to navigate here! Ivan answered a similar question to yours here: https://www.reddit.com/r/IAmA/comments/mgkm9g/we_are_bipolar_disorder_experts_scientists_in/gstwyx6?utm_source=share&utm_medium=web2x&context=3

Can mood stabilizers produce an effect of "disconnection" with reality?

I'm asking for personal reasons. I have been diagnosed with bipolar 2 (had hypomania episodes, but not mania nor psychosis. I did have a mixed episode with paranoia couple years ago). I take 25mg quetiapine as a sleep aid and 150mg lamotrigine. I also use weed for mild anxiety (I think it helps with my mood too). I don't have symptoms anymore and my doctor says I'm "in remission".

However, after taking the meds for just over a year I have now this feeling that I can't connect to anything anymore. I don't have "feelings", I feel like I'm incapable of love. I just live in the present and can't really relate to the past or make plans for the future. I'm on therapy currently (psychoanalysis) and trying to figure this out. But I'm wondering if it could be a side effect of the meds, or if it's a psychological thing.

Thanks in advance!

Victoria here:I sooo relate to this. Though I have BD 1 with psychosis I’ve experience this dulling of emotions and lack of connection to life so to speak.

First and foremost, I realized that what doctors call remission doesn’t mean recovery. Deb Serani has a great article on this: https://www.psychologytoday.com/ca/blog/two-takes-depression/201103/depression-do-you-know-all-your-rs

Lack of symptoms doesn’t mean I was living a full life with a good quality of life. When I was on lithium, I didn’t have any symptoms, but also what is called flat affect. I couldn’t feel anything. I felt like a walking piece of chalk. Just going around living life, but more like a robot on automatic pilot.

I discovered it was an effect of the meds. I hope a clinician chimes in on this, but my suggestion is that if you feel this way then the meds you are on may not be the best meds for you or perhaps not the correct dosage or combination.

My dad and I advocated with my psychiatrist to find another medication that didn’t dull my senses yet still managed my mood. I needed to change to a different mood stabilizer and experiment (under the supervision of my doctor) with the dosage. Eventually I found something that not only reduce symptoms but also helped me worked toward recovery and gaining my quality of life back. I don’t believe that medication should detract from quality of life, but add to it. That’s not always possible with some severe cases of mental illness. But it’s worth aiming for.

I encourage you to talk with your doctor and talking with your therapist about it. Maybe refer to Deb Serani’s article to understand the difference between remission a recovery. Aim high, work in collaboration and stay hopeful! I wish you well! PS: I also think it’s worth talking with your therapist about possible psychological connections to the way you are feeling. For me my psychological challenges always influenced my mood and how I managed my condition. How I feel is always a combination of varying factors.

Are there ever times that it is really difficult for you to distinguish between bipolar I and GAD+depression? A relative of mine had initially been diagnosed with Bipolar I but very late for their age. Later, another psychiatrist diagnosed it as GAD without depressive mood. I have witnessed one manic state in this relative (I am a psychologist by training, but not a clinician). It was during my wedding, so I had a lot of time to observe the person. I could see it leading up to the actual wedding date, because we stayed at the hotel together for pre-wedding activities. I just think that there have been major incidences of impulsivity and depressive state that seem more exclusive to bipolar throughout her life that may not be addressed if therapists continue to work with her under the current diagnosis.

Hi - Emma here. Misdiagnosis is really common for people with bipolar disorder – it has been estimated that it can take up to ten years for people to receive the correct diagnosis, with major depression being the most common misdiagnosis. This is more common for people who have BD-II (where manic symptoms are more mild) as sometimes hypomania can be misinterepreted as ‘getting better’ from a depressive period, and if periods of mild elevation don’t cause serious problems people are unlikely to seek help. Bipolar disorder is also a less common condition, and doctors may miss asking about experiences of mood elevation when taking a clinical history.

It’s challenging to comment on your friend’s situation and what diagnosis might be right for them. You may be in a position to gently encourage them to ask for a second opinion. If they are willing, it’s sometimes useful to have a friend or family member present at an appointment, as they can describe times when a person behaved in a way that was out of character for them. If you do want to bring up this possibility, it’s important to do it in a way that doesn’t sound accusatory or stigmatising - this conversation may be difficult, especially if the label of bipolar disorder seems scary to your friend. A diagnosis of depression and anxiety might feel easier to cope with. Offering reassurance, care and acceptance, regardless of the diagnostic label, might help your friend feel more comfortable with the process of seeking support for their mental health.

Parent has ADHD + BP1 + two kids: 11/yo has no diagnosis but major signs of bipolar, such as sleep, mood, and impulse issues, plus other stuff like clothing sensitivity, battles over nail clipping, and social challenges. Doc has him on prozac for depression. How best to support him at this point? Treatment/meds? Education? Extracurriculars to focus on?

Hi – Emma here. Diagnosis of bipolar disorder in children and young people is pretty challenging, especially as there are other conditions which can look really similar like ADHD, autism, anxiety, or even conduct problems. While it’s important to detect bipolar disorder as early as possible so people can get on the right treatment for them, it’s also important to be careful to avoid misdiagnosis so people aren’t exposed to potentially harmful treatments or a stigmatizing label. To manage these risks in both directions a clinician would ideally be engaging in ‘watchful waiting’ - getting as much information as possible in terms of family history, parent/teacher reports on behaviour, and screening measures (and periodically following these up to see what has changed). In the meantime, the family can be referred to non-specific psychological interventions that can be helpful for any kid, like sleep hygiene and stress management.

I have noticed my depression stems directly from blood sugar related issues. Is this a thing, and if so, would that be considered true depression?

Hi, Steven here: My (somewhat limited) understanding is that diabetes can present with symptoms that are reminiscent of depression. Accordingly, when one first receives a diagnosis of depression, it would be important to speak with your physician about the possibility that your depression might be a manifestation of underlying diabetes (hypothyroidism is another condition that can look a lot like depression, and it should also be ruled out).

Can psychosis symptoms be a a result of bipolar disorder?

Hi – Emma here. Psychosis can occur in both manic and depressive episodes in bipolar disorder, although it is more common in mania. Estimates vary, but it’s thought that up to 50% of people with bipolar disorder have experienced psychotic symptoms. There is some evidence to suggest that people with bipolar disorder more often experience delusions (in particular, grandiose delusions such as beliefs that one is more special or talented than others) than hallucinations (seeing or hearing things that other people can’t), and that delusions are often aligned with their mood (for example, somebody in a depressed phase with psychotic symptoms might believe that they are responsible for a tragic event, as compared to believing they have been chosen by god for a higher purpose).

When it comes to the question of what causes these symptoms, it’s important to note that there is substantial overlap between bipolar disorder and other psychotic conditions. More and more research is being conducted into the genetic and neurological similarities and differences between these syndromes in the hopes that this might enable us to better refine diagnosis and treatment approaches.

Is it possible for me to ever get off my medication (Lamictal) or do I have to basically take it for life in order to keep my mood stable?

Andrea Paquette HERE - Such a tough question. I used to ask that and then finally accepted that I do better on medication and actually require it because of the psychosis that is ongoing and my crushing lows and dangerous manias. I am on 5 meds. A cocktail of low doses that work so wonderfully but it took years to find the right mix. We are all unique. All different. I always say to try meds for a long while and if they help, that does not mean we should get off of them. If they work well then I just stay on them.Of course, work with your doctor. You are not weak for taking meds and it is OK.