Bipolar Blues B Bipolar disorder (BD) is a very serious and under-recognized disorder that affects two-to-six percent of the population 1. Along with schizophrenia and other psychotic conditions, it is one of the few psychiatric disorders (at least its manic side) that puts the “crazy” into craziness for much of the lay population unaware of our diagnostic language. BD is characterized by periods of depression that alternate with periods of mania, hypomania, mixed states or normal mood. Mania is characterized by racing thoughts, euphoria, inability to sleep, driving fast, walking/talking fast, spending sprees, hyper-sexuality, and increased religiosity (usually of a bizarre nature) that can last several days or weeks. Hypomania is a less intense expression of manic symptoms that typically lasts a few days at a time. Mixed states (a.k.a.—dysphoric mania) include a mixture of depression, severe irritability, and the high energy and agitation of mania. Bipolar patients are sick with mood problems nearly half of their lives with nearly 80 percent of that time in some sort of depression 2. BD is a major cause of depression, suicide, substance abuse, sexual acting-out, and financial and marital destruction. It is often confused with depression and historically treated inappropriately with antidepressants that can worsen their symptoms. Many are sick for years and see multiple doctors before finally receiving appropriate treatment. This is unfortunate, as there are a wide variety of treatments that can positively impact this disease state 3. Thus, one would expect that the offer of appropriate treatment would be welcomed and complied with by patients. However, this is not the case, as patient non-compliance with medication treatment being the most common obstacle to the successful treatment of bipolar disorder 4. The following details some of the common reasons for non-compliance in bipolar patients (and others also) and some practical strategies for increasing compliance.
Hopelessness As noted above, many patients are sick for years and have a long track record of failed treatments before the proper diagnosis is made and treatment initiated. Thus they are not eager to have faith and hope in any treatment regimen and will rightfully assume that it will not work. They lost hope a long time ago and will need a good reason to believe that things could be different. Educational resources must be used to teach the patient and their families and friends about the illness so that a sense of hope can be based on facts, not promises. O T I require my patients to read several books and become familiar with the Depression and Bipolar Support Alliance website at www.DBSAlliance.org. I encourage patients to have a healthy sense of doubt that has been earned by their past failures. However, I ask that they do their own research on the diagnosis before reaching final conclusions. The more patients can learn about their illness, the less helpless and hopeless their attitude will be.
Lack of Control The nature of this disease can quickly make a sufferer feel like a victim who is at the mercy of the disease. Is it very much a genetic-based disorder with a cyclical and spontaneous onset that often involves severe mood swings. This lack of perceived control reinforces the hopelessness I talked about above and encourages a pattern of passivity that is unwanted. Most bipolar episodes, depressed or manic, can be traced to identifiable triggers (stress, insomnia) or predictable patterns (premenstrual, medication triggers such as steroids). Using mood charts will help patients learn what makes their disease “tick,” diffuse the seeming chaos, and give a sense of behavioral mastery.
But the Mania is ‘Sooo Good’ One of my patients told me that if he could bottle the manic feelings and sell them, he would be rich. Early mania feels good—very euphoric, empowering, enlightening. However, most patients experience four depressions for every mania—with the depressions lasting longer. Thus the depression becomes a severe “tax” to pay for the relatively brief periods of mania. Also, mania is not always good—it usually ends badly. It starts as euphoric bliss, but then progresses to paranoid agitation and potentially to frank psychosis. Without treatment, mania can produce a fully schizophrenic-appearing clinical state with hallucinations and delusions. One can develop delusional spiritual beliefs that can regrettably affect one’s spiritual confidence and assurance even after the episode is over. The financial and sexual impulsivity can leave medical (STD’s, pregnancy), relationship (affairs) and credit/legal problems that persist long after the high has crashed. For example, one of my patients inherited a large sum of money when his mother died. His mother designated this money for his children’s college fund. He spent the entire college fund on two sports cars and visits to strip clubs over a three-week period of time. I encourage my patients to respect this disease. The manias are seductive, but have a very bitter after-taste that lasts a long time. The depressions are guaranteed, as the higher you get, the lower you fall. Mood charts are helpful in documenting this as they have areas for documenting the kinds of symptoms that accompany each maniac and depressive episode. Thus, the patient has a “journal” as a reminder that mania is not all that it appears to be from a superficial perspective. Imagine my patient above trying to explain to his wife and children the zero balance in the college fund (she divorced him).
I Hate Taking Medication The objections here include side effects, costs, complexity of dosing schedule and a general distaste for taking chronic medications. The last is important because bipolar disorder is a chronic disease and requires ongoing treatment. Many patients resent this and “forget” to take their medication on a regular basis. In the past, I told patients that they didn’t have to like their medications, but just “pinch your nose and take them.” I now “preach” a different sermon. For years, bipolar patients had few choices for coaching for treatment. It was either lithium carbonate or nothing—and lithium only worked for 50-60 percent of patients without significant side effects or efficacy problems. We now have treatments that have better side effect profiles and simpler dosing schedules 5. Patients now have choices, some of which are generic, that are cost effective. So I now tell my patients to have an “attitude of gratitude” about their medication possibilities, as we can actually help them most of the time—if they let us. It is an ongoing challenge—a lifelong and, literally, a life-changing challenge— to yield to the necessity of the bipolar medication regimen.
Summary: Take Active Responsibility The man by the pool of Bethesda was sick (Matthew 5:1-11), knew that he was sick, had been sick for a long time, but had a list of excuses for why he could not get well. It was always because of circumstances beyond his control or the failures of others. He was resigned to staying sick, though he was talking to the Great Physician. Many patients with psychiatric disease states have become complacent and too accepting of their diseases. The words of Jesus ring true; “Take up your bed and walk.” Take responsibility and get active in your healing. Do not wait for someone to do it all for you. Become an active partner in your care and participate. Don’t get too cozy with your illness. Get off the bed of passive resignation and start living a different life—a life free of the spiritual, physical, psychological and financial paralysis. Thank God for His protection against the full consequences of this illness. Many patients experience irreversible consequences with suicide, substance abuse, or sexual acting-out. Several of my patients have developed sexual addictions that began while manic and continued despite achieving mood control. Another patient was exposed to HIV while acting out in a manic high. Still another sold a new “paid for” Cadillac for $300 and spent the money on marijuana before returning home to her family three weeks later with three sexually transmitted diseases. She had stopped her medication as an “act of faith” and because it caused weight gain. Now she is grateful for treatment choices that previous generations begged and prayed for, though she lost her family in the process. The opportunity to comply with a well thought-out treatment plan is a blessing. It is not given to all and should not be ignored and delayed, but instead embraced. Otherwise non-compliance and non-participation will amount to sitting by the pool, pinching your nose and letting the illness have its way.
References 1 Lyles MR.“Bipolar Disorder.” Christian Counseling Today 2003:11:64. 2 Kupfer DJ, et al. “Demographic and Clinical Characteristics of Individuals in a Bipolar Disorder Case Registry.” Journal Clinical Psychiatry 2002:63: 120-125. 3 Hirschfeld R. et al. “Practice Guideline for the Treatment of Patients with Bipolar Disorder.” American Journal of Psychiatry 2002:159: 4, April (supplement). 3 Jamison KR, Gerner RH, Goodwin FK: “Patient and physician attitudes toward lithium: relationship to compliance.” Archives General Psychiatry. 1979: 36:866-869. 4 Lyles MR. ”Managing Bipolar Disorder.” Christian Counseling Today 2004:12:78.
Michael R. Lyles, M.D., is an AACC Executive Board Member and is in private practice with Lyles & Crawford Clinical Consulting in Roswell, Georgia.
