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When Feeling Down Gets to Be a Habit

Bipolar disorder, or manic depressive illness, is like an action film with an unhappy ending. While in a manic phase, which lasts for weeks at a time, an individual is bursting with energy, barely sleeping and talking nearly non-stop. For the gifted few-such as Van Gogh, Napoleon or Robert Schumann-this can be a time of impressive accomplishments. For the average person, it's a time of hyperactive, risk taking, disruptive, promiscuous or even criminal behavior. In many cases, the person alienates friends and coworkers with extreme over confidence and an inflated ego. Afterward there is often a phase of deep despair. While a period of normal mood may intervene for a while, the person with Bipolar Disorder is plagued by numerous mood swings.

Less common than other forms of depression, Bipolar Disorder strikes only one to two percent of the population, but the impact of the illness is more substantial than that. A significant number of patients are never treated, and for those who enter treatment, a firm diagnosis may initially be illusive. Without treatment, a person is likely to have 10 or more major mood swings over a lifetime. More than half of these individuals develop a substance abuse problem; 15 percent commit suicide. Unlike other forms of depression, which may involve only one episode, Bipolar Disorder usually lasts a lifetime. Medication and psychotherapy can help control moods and symptoms, but the potential for future episodes is always there.

New Medications Emerge

In 1949, Australian John Cade, looking for a cure for gout, noted that lithium had a calming effect on laboratory guinea pigs. After determining the safety of the substance by taking it himself, he then used lithium to successfully treat 10 manic patients. As later studies demonstrated, the substance not only has a calming effect during acute mania, but can be used over the long term to reduce mood swings and prevent recurrence. It was years later before lithium became accepted and widely used. As a treatment for manic depressive illness, it was approved by the FDA in 1971 and is still a mainstay of treatment, either by itself or in combination with other medications.

Lithium usually helps manage depression as well as mania, but most patients need an antidepressant as well. Doctors have to exercise care, however, since an antidepressant can bring on or exaggerate an episode of mania.

Some subtypes of Bipolar Disorder have never responded very well to lithium, and side effects can be troubling. Taken as an overdose, the drug can cause death or permanent nerve or kidney damage. At normal doses, side effects include thirst, frequent urination, trembling hands and weight gain. Patients must be monitored for evidence of long term kidney and thyroid problems.

In June, 1995, Valproate (Depakote), an anti seizure medication since the early 1960s, was approved by the FDA for manic depression. It is listed along with lithium as first line treatment in the Expert Consensus Guidelines for Bipolar Disorders published in the Journal of Clinical Psychiatry [November, 1996]. Another anti seizure medication, carbamazepine (Tegretol) has also been found effective as a mood stabilizer and is being prescribed for many cases of Bipolar Disorder. Valproate and carbamazepine have been found similar to lithium for stabilizing moods...and better for some patients. Side effects are different so patients who don't tolerate one drug can be tried on another or on a combination.

Now being studied are two newer anti seizure drugs, lamotrigine and gabapenin. Early reports indicate these drugs may be useful in treating cases that are resistant to other medications and with fewer side effects.

The anti psychotic medication clozapine (Clozaril) has also been used as a mood stabilizer. Other antipsychotic drugs under investigation include olanzapine, zyprexa and quetiapine (Seroquel).

Combination therapy is often preferred so that the patient can be given a lower dose of each drug. Most bipolar patients have to take medications for an indefinite period, often for the rest of their lives.Adjuncts to Medication.

During a manic phase, a patient is unlikely to be helped by talk, but once the mood is stabilized a supportive therapist can help a patient understand the illness and its symptoms, learn to deal with every day situations and relationship problems, and stay compliant with treatment over the long haul.

Electroconvulsive therapy (ECT) is another treatment option. It is usually reserved for patients who do not respond well to medication, have trouble with side effects, or prefer ECT to long term drug therapy. It works by using an electrical stimulus to induce a seizure, thereby altering the patient's response to neurotransmitters in the central nervous system. Muscle relaxants and anesthetic agents are used so that convulsions and muscle spasms are barely noticeable, but the procedure may cause transient short term memory loss. ECT has a good safety record, however, and proponents say negative side effects are usually minimal. Particularly for those bothered by recurrent mood swings, maintenance ECT on an outpatient basis can be a preventive measure.

Bipolar Disorder must be thought of as a chronic disease, such as diabetes or hypertension, with a toll at least as great. With early detection and a good treatment plan, most patients can lead satisfying, productive lives.


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