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Interview: Bipolar Affective Disorder – Text
Dr. Sagar Parikh


Dr Sagar Parikh
Head, Bipolar Clinic
Centre for Addiction and Mental Health, Clarke Division
Director of Continuing Education
Assistant Professor of Psychiatry
University of Toronto.

 
q At what age is bipolar affective disorder most likely to occur?
a Bipolar disorder starts young. Unfortunately, usually it begins sometime in adolescence, at a time when teenagers are already going through a lot of different challenges as a result of adolescence and may be experiencing moodiness that is a normal part of adolescence.
   
q Does that make it difficult to diagnose than in the teenage population?

a Yes, it is very difficult to diagnose in that situation, in that if the symptoms are mild, they are often interpreted as being part of the normal adolescent turmoil, when in fact, true adolescent turmoil is not really a reality, but more of a myth. When it is more severe, however, it is unmistakable if someone is willing to look.
   
q What are the things that physicians should be looking for then if they are to pick up bipolar affective disorder on first presentation?

a Depression seems to be slightly more common than mania in the initial presentation of bipolar disorder. In an adolescent in particular, changes in functioning, that is, a loss of interest in usual activities, excessive sleep, a lot of absenteeism in school, an unwillingness to go with their friends - these may be important clues to the fact that depression may be occurring. Conversely, if there is a bit of excess - excess in terms of too much running around, too much energy, too much partying - then there may well be suggestions that a hypomanic or a manic episode is happening.
   
q How would you tease out the depressive phase of bipolar illness in a patient who presents for the first time with bipolar illness in the depressive state?

a The signs and symptoms of depression are fairly universal. So there's always the cardinal abnormality in either mood or loss of interest in the usual activities and usually a host of other symptoms. In bipolar depression, however, certain symptoms are more common. Rather than decreased sleep, that is, initial insomnia and the early morning awakening of unipolar depression, we often see oversleeping - people reporting up to 15 hours a day; overeating rather than undereating, and extreme fatigue.
   
q Similarly, if a person is hypomanic so they are not in full blown mania, is it difficult to pick up more subtle signs of hypomania?

a Mild hypomania is an extremely elusive situation, in many cases, it just resembles someone having a good time. Here it is important to get a sense of how much disruption a person is creating for others, and also to look again at the physical signs. Is there a clear decrease in the amount of sleep the person is getting? And secondly, is the amount of physical energy elevated?
   
q Are patients themselves possibly not aware that they are not even remotely mentally ill? They have this surge of energy and they like it?
a It is almost universal, particularly in the first episode, that people would not recognize this as an illness at all. If you are hypomanic, it is perhaps one of the best experiences of your life, and if you are a teenager or young adult and this is your first episode, it is only natural that you might look at this as a time of heightened excitement rather than anything truly or potentially abnormal.
   
q So do you have a difficult time convincing patients that they do have an illness that requires treatment. If you do, how do you persuade them to take the illness seriously?

a The lack of acceptance of the diagnosis of bipolar disorder is probably the single biggest problem in treating it. A useful strategy that I've found in helping convince people that they may have an illness is simply to carefully record their symptoms in their own words. So for instance, rather than reporting that someone has a diminished sleep and excessive pursuit of reckless behaviors, I go directly to what the person tells me and they typically would say, "Well, I'm only sleeping 4 hours a night, and I'm chasing women who I shouldn't chase," or "I was spending recklessly". I use their own terminology, I write it down on a piece paper, and I then ask the person again, "When you look at this list of symptoms or changes that you have described, is this you? Is this the normal you? Or is this something that's different". And quite often they are willing to accept that "No, this isn't me, I'm not usually like this." Then I say, "Well, one hypothesis is that perhaps it was a bipolar disorder with a hypomanic episode. Is that a possibility?" And we go on to talk about that. Then I go on to say, "Let's say, as you are suggesting, that it is not. What is your theory? How could you explain this? Could there be another explanation?" In this way, it is done in a tone of collaborative scientific inquiry and we are both detectives trying to explain the facts.
   
q Do women with bipolar affective disorder present any differently than males or are the symptoms fairly common to both sexes?

a Bipolar affective disorder is an equal opportunity offender. Both sexes are equally affected, and although in the long-term, women may have more depressive episodes, in general they experience much the same types of symptoms.
   
q I've read that there is often a significant time lag between the time treatment for bipolar disorder is initiated and really the onset of illness. Any suggestion as to how we could perhaps shorten that interval so that patients perhaps receive treatment more appropriately at an early stage?

a Well some public education about what mood disorders are and how they show up would help. Secondly, some education of people like high school guidance counsellors, teachers and family physicians would also help in terms of being able to recognize that there are some abnormalities.
   
q Looking specifically at women who might require treatment, these are young women, they are often in their reproductive years, how should physicians handle female bipolar patients who want to get pregnant or in fact who do become pregnant on therapy?

a There issue of handling pregnancy in someone who has a confirmed bipolar disorder and who is on medications, that issue needs to be individualized. Briefly what needs to be done is the risk of continuing treatment versus the risks of stopping treatment have to be evaluated for the affected woman. It is now understood that lithium - which was formerly thought to be a terrible drug in pregnancy - is actually probably safe. The other major mood stabilizers such as carbamazepine and valproic acid, however, are NOT safe in pregnancy. As a result, the question boils down to: Can this woman or should this woman continue on lithium during part if not all of the pregnancy, and two, if they are not on lithium, should they be switched to lithium?
   
q And how do you determine that, Dr Parikh?
a I think it is an individual decision based on the number of episodes of illness in a particular woman, and their own tolerance for potential risk.
   
q Speaking of treatment, are their obvious first-line choices for the treatment of bipolar patients or does it again come down to the constellation of symptoms that you are treating?

a The treatment of bipolar disorder always begins with a mood stabilizer. There are two mood stabilizers that are, roughly speaking, equivalent as first-choice agents, these two being lithium and valproic acid. The differences that exist between these agents include the specific type of symptoms [they are treating] and the side effect profile and there are some other characteristics, but by and large, either lithium or valproic acid will be the first-line agent regardless of whether the person is depressed or manic. Now if their symptoms are moderate to extreme, the mood stabilizer will be supplemented either by a calming agent such as a benzodiazepine or an antipsychotic in the case of mania, or by an antidepressant in the case of moderate to severe depression.
   
q How do you convince your patients to take what is likely to be lifelong therapy? Have you found any ways to enhance patient adherence?

a We believe that psychoeducation is helpful in convincing people to stay on treatment. But what is usually termed "psychoeducation" is different from what we do. What is usually meant by psychoeducation is spending a single session or even just a few minutes explaining what the disorder is and how it is treated. Our approach to psychoeducation is to recognize that first of all there has to be information about disease management, but also about episode prevention. Secondly, there has to be some education on how to convey the news of the disorder to family members and to other places where the person is going - to the workplace, to the school, as appropriate. And third, education about the disorder has to thoroughly include family members so that they may understand and support the person properly. Finally, we know that psychoeducation, like any learning, requires repetition and reinforcement. So it's often our practice to schedule several psychoeducation sessions - up to 5 or 6 in the first month or two after the diagnosis is first made and to supplement the education by the use of both brochures and videotapes.
   
q If any of the mood stabilizers needs to be discontinued, is there a way to do it correctly so that patients don't undergo withdrawal?
a We are fortunate in that we have excellent data now on the fact that abrupt discontinuation of mood stabilizers is the worst thing to do to a patient. As such, it is prudent to reduce mood stabilizers over a 2-month to 3-month period, if possible. For instance, if someone is on lithium, 1200 mg/day, it would be prudent to cut back by 300 mg per day every two or possibly three weeks until the person is off the lithium.
   
q Is there any role for either the benzodiazepines or antidepressants in the treatment of bipolar disorder?

a Benzodiazepines are often very useful for a few weeks at a time during hypomanic or manic episodes. In depressive episodes, benzodiazepines may also be useful to deal with initial insomnia. The use of antidepressants in bipolar depression is complicated by the fact that these agents can cause breakthrough mania and perhaps even rapid cycling. As such, antidepressants should be reserved for moderate and particularly severe episodes of bipolar depression.
   
q In patients where the phase of the illness is exacerbated and patients are really quite ill, are there ways to augment therapies that are perhaps more effective than others?

a There are many ways to help patients with bipolar disorder. They always start with a mood stabilizer, and then they include the addition of other agents such as antipsychotics, antidepressants and benzodiazepines, as indicated. But there are also combination strategies where two or perhaps even three mood stabilizers are combined. Finally, there are numerous, novel anticonvulsants that have either just been released or are about to be released on the market. And these novel anticonvulsants are very useful in the management of refractory patients. Two agents in particular are in use now: gabapentin and lamotrigine, and of these two agent, it appears that lamotrigine will be helpful in all stages of bipolar illness, but usually as an add-on, not as a sole agent.
   
q Is there a role for electroconvulsive therapy at all in the treatment of the manic phase?
a ECT is still the single best treatment in all of psychiatry and one of the best treatments in all of medicine. That said, it is generally limited now to severe bipolar depression, it is still effective - with good scientific data to back this up - in mania, in particular it is the treatment of choice in pregnant women who are no longer on mood stabilizing medications and who become manic during pregnancy.
   
q Should patients be on treatment prophylactically or indefinitely or how do we look at maintenance therapy for bipolar patients?

a The CANMAT Guidelines (See: "Treatment of Bipolar Affective Disorder") go into some detail about how to judge whether someone needs prophylactic or maintenance treatment. Briefly, if someone has had only one episode and it was mild, then it is worth at least considering whether treatment beyond one year is necessary. Anyone who has had two or more episodes or one episode with severe consequences likely will have to be on medications indefinitely.
   
q Have you found that there is anything you can do as a clinician who treats a lot of these bipolar patients that helps patients remain well in the global context?

a Certain aspects of lifestyle change can help. Number one: sleep patterns are the single most important triggering factor, particularly for mania but possibly also for depression, and I advise my bipolar patients to avoid shiftwork and wherever possible, to maintain fairly regular hours of going to bed and awakening. Secondly, it's clear that certain stimulant drugs and commonly prescribed medications such as prednisone can also tip people into mania. These drugs may still be necessary for other medical conditions but it just calls for closer monitoring when these medications or street drugs are being used.
   
q Is an illness like bipolar affective disorder even more difficult in terms of its impact on a person's life than major depression?

a I think that there is no doubt that bipolar disorder is more disabling than major depression. And this has been borne out by a number of research studies which have looked at the extent of disability in bipolar disorder. It's also true that the completed suicide rate in bipolar disorder is somewhat higher than that for major depression.
   
q And are patients also at risk for suicide in their manic phase?
a Patients are usually at risk for suicide mainly in their depressed phase, but during their manic phase there are a few other things that can happen. Accidental deaths are far more common and they often result from poor judgement - for instance, driving at excessive speeds or trying unusual athletic activities which the person is not actually that equipped to handle, for instance, going rock climbing when they are not really fit to do that. Secondly, in patients who are older and who lead sedentary lifestyles, a manic episode may trigger an outburst of physical activity, which in turn may trigger a heart attack and death.
   

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Over one million Canadians suffer from some form of depressive illness.