Letting go is not complicated. It is simple. Not easy. Simply identify the situation you want to let go of and ask yourself, "Am I willing to waste my energy further on this matter?" If the answer is "no," then that's it! Let go. Telling someone is a bonus. Detachment is only for you, never for another. It promotes healing. Choice is always present when you let go. You do not have to let go and there are consequences.

Letting go of behavioral patterns that no longer serve us often feels as though we are risking our safety and comfort.

Calculated risks taken for the benefit of our own well being are worth taking. This form of movement is safer than standing still. Those who remain stationary become an easy target for misery of their own creation.

The energy we expend by holding on often leaves us drained and with a feeling of hopelessness.

Letting go does not mean you should stop doing whatever it takes to make your relationship work. Let go of your expectations about how you think it might work out and instead focus all your energy on what you want, not what you don't want.

Expectations vs. Needs! We often expect our love partner to make the best choices for themselves and our relationship and when they are not our choices, we often get angry or disappointed. . . or both. Most people call this situation a problem: a problem we create by our expectations. Try this: "no expectations, fewer disappointments." It's that simple. Not easy. Simple. No expectations equals unconditional love.

We all experience the need to have healthy choices exercised and when they don't show up, we either choose to have conversations about them or not. If the choices are abusive and therefore unacceptable, we begin to think about making a responsible choice to leave the relationship. However, always picking our lover apart because their choices are not the ones we would make can only point the relationship in the direction of failure.

If we could accept the notion that everyone is doing the best they can, regardless of whether their choices are our choices, our attitude about our relationship would improve and perhaps the relationship we have would become the relationship we enjoy being in.

We must learn to distinguish between expectations and needs. Everyone has a need to be loved, to be understood, to be accepted and to be forgiven when necessary. For us to have expectations about how those needs get fulfilled can only cause disappointment.

continue story below

Unfulfilled expectations always causes problems. It is important to allow our love partner the freedom to fulfill our needs in their own best way. To do so, can only inspire a love that goes far beyond what we ever could have imagined! What you can be with in life. . . lets you be!

It takes no strength to let go; only courage. Courage is a byproduct of a positive self-image.

When there seems to be a lack of love, it is only that you are keeping it away.

Whenever you feel lonely, deprived or rejected, tell yourself that there is never a lack of love. Love is always available everywhere, especially inside of you. Then stop and realize, you can always open your heart. You can give to others the love you have been longing for. When you do this, not only do you feel better, but love from others soon comes streaming back to you.

Exercise: Look around and see who is right there around you. Find something positive about that. Become aware of your negative judgments of them and let them go. Become aware of the distance that you are creating between the two of you by your own thoughts. Now, find something else positive about them. If you feel you can, tell them. (This step make take awhile to do. It is not absolutely necessary in the beginning, just finding something positive is a great help as well).

This action of finding something positive about another person, and "letting go" of negative, judgmental thoughts about them, is in itself an act of love. It is a way of exercising our love giving-receiving ability, strengthening our muscles and seeing the beauty in everyone.

We are strongest when we are letting go of what doesn't work. That's change in action. When we open our mind to behave in a different way, we create the freedom to love. To open our hearts to love is perhaps the greatest gift we can give to ourselves.

When you finally understand that it is "not" unfashionable to negotiate situations rather than standing firm and allowing the past to rule your present, relationships become relationships you can live with.

When you understand that time spent justifying your position that is not working is futile, you can then move forward with a velocity that frees you to address the issues and deploy solutions that are clearly essential to everyone's well-being.

We use reasons to explain away why we don't want to do something different; reasons why we don't want to change. If we know that doing something different might help the situation, not doing something different is called "stupid." The best reason why has never solved the problem.

Often reasons why are understandable, however what is not understandable is why we feel the need to have our lives dominated by reasons why we didn't do something different instead of results. When we make the decision to go for results in our love relationships. . . that's the real moment we make a decision to grow and prosper.

May all your prayers be "Thank Yous!"

next: No One Can Hurt You

• No Expectations, Fewer Disappointments!
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• No One Can Hurt You
• Forgiveness
• Never Intentionally Say Hurtful Words to Your Partner
• Audioapathy
• Do What Works!
• The Essence of Romance
• It's Time for the 3rd Degree!
• Catch Your Partner Doing Something Right!
• Relationships NEVER End!
• Unfulfilled Expectations
• Relationship Derailment

back to: Celebrate Love Homepage

Left picture, Jed Diamond, author of the bestseller Male Menopause.

The most common problem associated with male menopause is depression which is closely related to impotence and problems with male sexuality. Approximately 40% of men in their 40s, 50s and 60s will experience some degree of difficulty in attaining and sustaining erections, lethargy, depression, increased irritability, and mood swings that characterize male menopause. The symptoms of depression in men are commonly not recognized for several reasons:

• The symptoms of male depression are different than the classic symptoms we think of as depression
• Men deny they have problems because they are supposed to "be strong"
• Men deny they have a problem with their sexuality and don't understand the relationship with depression
• The symptom cluster of male depression is not well known so family members, physicians, and mental health professionals fail to recognize it.

Male depression is a disease with devastating consequences. To paraphrase from Jed Diamond's book Male Menopause:

• 80% of all suicides in the US are men
• The male suicide rate at midlife is three times higher; for men over 65, seven times higher
• The history of depression makes the risk of suicide seventy-eight times greater (Sweden)
• 20 million American will experience depression sometimes in their lifetime
• 60-80% of depressed adults never get professional help
• It can take up to ten years and three health professionals to properly diagnose this disorder
• 80-90% of people seeking help get relief from their symptoms

Differences between Male and Female depression:

Men are more likely to act out their inner turmoil while women are more likely to turn their feelings inward. The following chart from Jed Diamond's book Male Menopause illustrates these differences.

next: Antidepressants May Cause Premature Delivery
~ depression library articles
~ all articles on depression

David, My Bipolar Story I am 30 years old and live in East Texas. While many people with bipolar disorder have a hard time staying in a relationship, I have been blessed to be able to stay married for 11.5 years now.

I have been diagnosed as bipolar 1 rapid cycling, and while my diagnosis is only a few years old, I have been bipolar for most if not all of my life, exhibiting symptoms that my parents remember as early as four years of age. One interesting thing about my bipolar experience is that I am one of the weird ones who happens to cycle up more than down and under normal circumstances reaches higher than lower. While that sounds like fun to many, there are downsides, such as I tend to have psychotic manias.

I am a photgrapher and digital artist. I love to create and attribute much of my creativity to my illness. I also write poetry and fiction and recently completed my first poetry chapbook, which I am quite proud of, titled ~In Search of Grace.~ I am also working on a novel which has a bipolar main character.

As much as I have had my life torn apart by bipolar disorder and have suffered through horrible psychotic manias and suicidal depressions, I usually feel that having bipolar disorder is a blessing rather than a curse. While I do hope for the right meds to help lift the bottom of the lows and put a ceiling on the highs, I do not hope for a cure. I honestly believe that if a cure was discovered tomorrow, I would refuse it. Too much of the person I am, a person I have struggled for years to accept and love and finally do, is molded and shaped by this illness, that at this point I am afraid of who I would become without it.

David

back to: Juliet: What Hypomania, Mania and Mixed State Feels Like to Me
~ bipolar disorder library
~ all bipolar disorder articles

Acceptance is an attitude I am learning to extend toward other people and myself, and toward certain types of circumstances.

Acceptance toward People
Not everyone needs to be changed, just because I believe they should. "Should" thinking has become a warning sign to me.

In recovery, I have worked to acquire an open-minded willingness to receive people as they are in the present, with the understanding that all people are in the process of becoming. I need to allow other people their process, without any interference from me.

My alternative to accepting people was to reject them. By nature, I tended to reject any person whom I perceived as different from me, more or less gifted than me, would not listen to my unsolicited advice, etc. This was my ego—pure and simple. This was also insanity, because my thinking was based on the belief that others should perfectly match my expectations! When they didn't, I had a justifiable reason for rejecting them.

Now, I am learning how to make allowances for the fact that every person is unique and valuable despite background, ideology, religion, sex, etc. Most importantly, acceptance helps me to remember that each person is "in process" (i.e., at different stages of growth). For example, it is easy to accept that a newborn baby cannot eat a ten ounce steak. Adults allow a baby time and space to grow and mature. And in the meantime, the infant is given suitable baby food. Granted, this is an obvious example, but often adults expect children to behave like adults: "Big boys don't cry" and "You should know better" and "Don't be such a baby about every little thing." As an adult, I sometimes forget that other adults still carry within themselves that precious and vulnerable child. Where they are at this moment in their growth is different from me, and I need to be sensitive and accepting of that fact.

It was also important for me to distinguish the difference between acceptance and approval. I allow myself to feel approval or disapproval of other people's actions and choices. I am also free to express my feelings in healthy ways. When necessary, I can take steps to protect myself if another person's actions put me in danger. My boundary is: if another person's choices and actions do not affect me, then their choices and actions are none of my business.

Acceptance toward Myself
When I began my recovery, I was too hard on myself. I inflicted guilt on myself for all my problems. I blamed myself for my life circumstance. I berated and hated myself for being in the condition where I found myself. By choosing acceptance, I am learning to be gentle with myself. I am also learning to extend patience toward myself. Like others, I too am in the process of becoming. If I am accepting of others, I can extend the same courtesy toward myself. I can be patient and loving to my own inner child. Regarding guilt, it was necessary for me to accept responsibility for the actions and choices I'd made in the past. But the past is past, and I must accept the past. There is no reason to go on living in guilt, forever re-living the past in the present.

Acceptance toward Circumstances
Through recovery, I am also learning how to willingly suspend and set aside my preconceived ideas, desired outcomes, expectations, and personal agendas in the face of circumstances I previously would have sought to control or change.

I am learning to make a conscious and deliberate choice to receive circumstances as they are, with the belief that the eventual result will be beneficial. Acceptance is beneficial for me, because I am relieved of anxiety, controlling, "helping", and other unhealthy behavior. Acceptance is beneficial for my Higher Power, because it allows God to order circumstances for the best possible timing, again, without my interference.

Choosing the attitude of acceptance is a powerful and beneficial recovery tool.

next: Patience

Recently I have meditated on the power of forgiveness available to those of us in recovery. My thinking was sparked by a letter I received through the alt.recovery.codependency newsgroup. In particular, these words struck deep in my heart:

"Forgiveness is a natural process that occurs when you have reached a certain stage of acceptance about another person's limitations, character flaws, and their incapacity to behave in a way you had hoped and expected. When you get some glimmer that it was impossible for that person to respect and honor you in the way you wanted, you can forgive them for not having that ability."

For so long, I was bitter toward my ex-wife and her family for the way they treated me during our separation and divorce. I resented them taking away the privilege of seeing my children on a daily basis. I detested them for taking the stance that they were so right and I was so wrong. I despised them for the one-sided and narrow-minded myopia they displayed when I asked to be forgiven. I resented how they turned their back on me and have ignored me for the past five years—though they claim to be Christians. No matter what I did, I could not earn their forgiveness.

Yet, I was unable and unwilling to forgive them as well.

Oh, yes, I thought I had forgiven them—until I caught myself the other day—actually grinding my teeth at the mere thought of how my ex-wife used to treat me.

I still have much recovery work to do!

But I also realized that my wife and her family have a basic incapacity to behave in the way I expect them to behave. I used to think they were unwilling. But now, I see their incapacity to truly forgive, to really love, and to be honestly open-minded.

And it's not their fault. They are just products of their environment and training and their choices.

They can't do any better, because they don't know any better.

Oh, they may have intellectual knowledge of what forgiveness and love are about—but they can't live it when the opportunity arises.

I, on the other hand, am also incapable of understanding deep in my heart and soul, how hurt they were by my behavior. How much they are still hurting - whether by choice or not. I cannot live up to their expectations, either.

But recovery has taught me that I can (and must) forgive them for their incapacity to forgive. That is very powerful stuff. So powerful that it has raised me to a totally new level of awareness and perspective on life and relationships.

I can also forgive myself for my incapacity to forget how I was treated. I can forgive myself for expecting too much of them.

So, what I am now impelled to develop is my capacity to forgive my ex-wife and her family—to overlook what appeared to me as simple-minded, intransigent, stubbornness.

I must develop this same power in all my relationships. The capacity to forgive others for not living up to my expectations. And, the capacity to forgive myself for expecting others to live up to my expectations.

Thank You, God for the power of forgiveness. Thank You for the power You have given me to forgive and be forgiven. Thank You for bringing me a few steps closer to heartfelt forgiveness of myself, as well as others. Amen.

next: Morning Meditation

Bipolar disorder in geriatric populations and which bipolar medications are effective for treating seniors with bipolar.

"With respect to bipolar disorder in geriatric populations, we, in fact, do not have published guidelines," began Martha Sajatovic, MD, in her address at the 17th Annual Meeting of the American Association for Geriatric Psychiatry. While there are guidelines for the treatment of bipolar disorder in general populations, these guidelines are "certainly not cookbooks for clinicians but really offer us some guideposts and helpful recommendations for a very complex condition in our patients," she acknowledged.

But what do the guidelines, such as those published by the American Psychiatric Association, the Veterans Administration (VA), and the British Association for Psychopharmacology, say about treatment for late-life bipolar disorder? Dr. Sajatovic cautioned that this sizable patient population has unique issues, since older individuals who develop bipolar disorder may have a new-onset form of the illness. "We can estimate, based on existing data, that the prevalence rate is 10% in individuals older than 50. And that surprises a lot of people who have the idea it is a rare bird."

No Data, Just the Facts

While treatment for older patients may follow the same principles as for other patient groups, there is a severe scarcity of data specific to late-life bipolar disorder, explained Dr. Sajatovic, who is Associate Professor in the Department of Psychiatry at Case Western Reserve University School of Medicine, Cleveland. "In fact, if you look at treatment guidelines, they really only address the care of older people with bipolar disorder in very general ways. A lot is speculation. What we do not have are clear and specifically focused treatment guidelines for bipolar disorder in later life."

What happens in the absence of clear, evidence-based guidelines? She cited a study by Shulman et al in which his team analyzed community prescription trends in individuals older than 66 from an Ontario, Canada, drug benefit program from 1993 to 2001. "Very interestingly, during that time period, the number of new lithium prescriptions fell from 653 to 281. The number of new valproate users went from 183 to over 1,000 in 2001.

"The number of new valproate users surpassed the number of new lithium users in 1997, so while the curve from the lithium was going down, the curve for the valproate was going up, and crossed in 1997. This trend was seen even when patients with dementia were excluded from the analysis, so really, it was for late-life bipolar disorder. Clearly, clinicians and patients are talking with their feet here. We do not have data that say this is what you should do, but this is what's happening."

VA vs Community

Dr. Sajatovic also reviewed a study of a VA psychosis registry, looking at bipolar disorder in the VA system and age-related modifiers of clinical care. Interestingly, she reported, there are more than 65,000 individuals in the VA database with bipolar disorder, and more than a quarter are older than 65. "You don't have to be a statistician to figure out where we're going with this. There are a large number of individuals who are progressing into a later-life diagnosis of bipolar disorder."

Once the bipolar disorder group was identified, Dr. Sajatovic focused on their drug treatment patterns, which contrasted with those of Shulman et al's findings. Individuals were stratified into three age-groups: 30 and younger, 31 to 59, and 60 and older. She found that 70% of patients who had been prescribed a mood stabilizer were receiving lithium. "In the VA system, lithium was the mood stabilizer of choice, by a long shot. Very different from what's happening in the community," she noted. Dr. Sajatovic allowed that it was not clear if these were patients already being treated with lithium, or if the findings were a reflection of the VA population, which is followed for a longer time than a fragmented community sample.

The use of valproate was seen in 14% to 20% of the VA population, which is quite a bit lower than the use of lithium; carbamazepine use was similar to valproate. "There were a small number who were on two or more agents—again, different from a community sample where you see a lot more polypharmacy," she observed.

It is an interesting story, as well, with the use of antipsychotic medications, as Dr. Sajatovic reported that 40% of patients were prescribed oral antipsychotics. Olanzapine was the most commonly prescribed atypical antipsychotic in the VA system, across age-groups, followed by risperidone, although risperidone did not yet have an FDA indication for bipolar disorder.

The Pros and Cons of Lithium

Lithium is the most extensively studied medication for bipolar disorder in the elderly. It is an effective mood stabilizer in older adults and has an antidepressant effect with some patients, said Dr. Sajatovic. The frequency of acute toxicity with lithium in geriatric patients is reported to range from 11% to 23%, and in medically ill patients the rate can be as high as 75%.

Based on her experiences, Dr. Sajatovic made the following recommendations to clinicians: When prescribing lithium for the elderly, reduce the dose by one third to half of that given to younger patients; the dose should not exceed 900 mg/day. A baseline screening for renal function, electrolytes, and fasting blood glucose, as well as an EKG, should be conducted. "There is some controversy about target serum concentrations. What we know from the geriatric data is that patients who are at higher blood levels have better control of their bipolar disorder symptoms but are more likely to get toxic. So they are likely to tolerate lower blood levels and need to maintain their treatment with lower blood levels." Lithium can be a problem, especially at the higher blood levels, she said.

Other Agents - Valproate and Carbamazepine

Valproate is increasingly used for bipolar disorder by many clinicians as a first-line agent, "but again, we don't have controlled data. There are no randomized controlled trials in bipolar disorder that have been published." Though there are no controlled data for the use of valproate in secondary mania, Dr. Sajatovic recommended—after an EKG and screening for liver enzymes and blood platelets—a typical starting dose of 125 to 250 mg/day with a gradual dose titration. For patients with bipolar disorder, the usual dose range should be 500 to 1,000 mg/ day; patients with dementia may require lower doses.

Valproate is not without its dangers, she warned, especially at higher serum levels. A therapeutic range of 65 to 90 mg/day has been recommended in the literature. Carbamazepine is used with moderate frequency; although its side effects may be more problematic than those of valproate, it may be preferable to lithium in secondary manias, she explained. The screening is quite similar to that for valproate, and the appropriate dose is 100 mg once or twice daily and may be increased to 400 to 800 mg/day. "A little kicker about carbamazepine is that auto-induction may occur during the first three to six weeks and you may require an increased dosage during this timeframe. Check serum levels prior to doing that," Dr. Sajatovic advised.

What About Atypical Antipsychotics?

The VA database indicates that 40% of older patients are treated with antipsychotics; unfortunately, most reports are open label and retrospective, Dr. Sajatovic said. Clozapine, risperidone, olanzapine, and quetiapine have all been reported to be of benefit to elderly patients with bipolar disorder. All except for clozapine, she pointed out, have FDA approval for the treatment of bipolar disorder. Clozapine is used for treatment of refractory illness, primarily with mania. "We actually underutilize clozapine in refractory mania. And that's certainly true in the VA," she opined.

The use of lamotrigine is increasingly becoming an issue, and again, there are no data specific to lamotrigine, Dr. Sajatovic pointed out. According to data she presented at the American Psychiatric Association's 2004 annual meeting, it appears that older adults may tolerate lamotrigine better than lithium, which was not an unexpected finding, given the existing toxicity data. "The downside of lamotrigine is that you're not going to be able to titrate it quickly. You need a month to get people up to therapeutic doses." Accordingly, she does not recommend it as a first-line agent for mania, and studies do not support this use. "But particularly for people with recurrent bipolar depression, this could be a very nice compound," she allowed, and there are case studies published supporting its use in the elderly.

Should clinicians change patient medications based on concerns about side effects? "The party line of the British guidelines is to go with lithium unless there's a reason not to, such as side effects. US psychiatry appears to be a little more open to other agents, atypicals in particular, although some of this could be due to marketing forces. The point that there is no guarantee that a patient will respond to an atypical is valid."

Source: Neuropsychiatry Reviews, Vol. 5, No. 4, June 2004

next: Management of Mania in the Elderly
~ bipolar disorder library
~ all bipolar disorder articles

Comprehensive list of questions and answers about signs, symptoms and treatment of bipolar disorder and other related mood disorders.

1. What is bipolar disorder?
2. What are the differences between bipolar I and bipolar II disorders?
3. What is rapid cycling?
4. At what age does bipolar disorder appear?
5. Is bipolar disorder genetic?
6. How is bipolar disorder treated?
7. What medications are used to treat bipolar disorder?
8. What is a manic episode?
9. What is hypomania?
10. What is dysthymia?
11. What is major depression?
12. What is atypical depression?
13. What is meant by a mixed state?
14. What is seasonal affective disorder?
15. What is postpartum depression?
16. What is schizoaffective disorder?
17. What resources are available for people suffering from bipolar disorder?
18. How can family members assist the bipolar patient?
19. What are the challenges of bipolar disorder?

1. What is bipolar disorder?

Bipolar disorder is a common, recurrent, severe psychiatric illness that affects an individual's mood, behavior and ability to think clearly. It occurs in 1% to 2% of the population in the United States. A variant, called bipolar II disorder, is probably even more common and occurs in up to 3% of the general population in this country.

2. What are the differences between bipolar I and bipolar II disorders?

Bipolar I disorder is characterized by episodes of mania that alternate with periods of depression or periods in which individuals have simultaneously occurring manic and depressive symptoms called mixed states. In contrast, bipolar II disorder is characterized by recurrent episodes of depression and milder symptoms of mania, called hypomania. Hypomanic episodes typically do not impair an individual's ability to function to the extent that full-blown manic episodes do Additionally, hypomanic episodes are not complicated by psychotic symptoms.

3. What is rapid cycling?

The term rapid cycling was originally coined by David Dunner, M.D., and Ron Fieve, M.D., in the 1970s when they identified a group of individuals who did not respond well to lithium. These patients typically had four or more episodes of mania or depression in the 12-month interval prior to lithium treatment. This definition has been adopted formally by DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.) and specifically means the occurrence of four or more mood episodes within the preceding year. In severe cases, rapid cycling can occur even within a one-day period.

4. At what age does bipolar disorder appear?

Bipolar disorder most commonly presents in the late teens and early 20s. Unfortunately, for most individuals, lifelong treatment may be required to prevent recurrent manic and depressive episodes. Equally unfortunate is evidence that the illness often goes undiagnosed and untreated for many years; the longer the illness progresses without treatment, the greater the impairment in an individual's psychological, educational and vocational development. Additionally, untreated bipolar disorder carries a high risk of suicide.

5. Is bipolar disorder genetic?

Bipolar disorder, among all psychiatric illnesses, may have the greatest genetic contribution. For instance, if an individual has a parent with bipolar disorder, the chance that the individual's child will have bipolar disorder is about nine-fold greater than in the general population, with the risk rising from about 1% to about 10%. The inheritability of this illness is estimated to be anywhere from 50% to 80%. On the other hand, if a person with bipolar disorder is thinking about having children, there are still good odds that the child will not have bipolar illness. So the genetic determinants of the illness are complicated.

6. How is bipolar disorder treated?

The cornerstone of treatment is medications that treat acute manic, depressive or mixed episodes, and which, in the long run, attempt to prevent the recurrence of these episodes. Such medications include lithium, divalproex (Depakote) and, more recently, some of the atypical antipsychotics as well as antidepressants.

Psychotherapy plays an important role in improving the course and outcome of this illness in people. In particular, those with bipolar disorder often have strained relationships with loved ones because of their experiences during manic or depressive episodes; psychotherapy can help repair these torn relationships. In addition, psychotherapy can educate people about the signs and symptoms of their illness, how to pay attention to warning signs and how to nip emerging episodes in the bud. Psychotherapy can also help individuals cope with the stress that can sometimes precipitate manic or depressive episodes.

7. What medications are used to treat bipolar disorder?

There are a number of medications for the treatment of people with bipolar disorder, among them a group of medications called mood stabilizers. These include lithium and divalproex and possibly some other anticonvulsants and atypical antipsychotic drugs. The therapeutic strategy is to treat acute manic episodes and then continue long-term administration to prevent episode recurrence. These medications seem to be somewhat less effective than antidepressants in treating acute depressive episodes.

Antidepressants may be used in conjunction with a mood-stabilizing drug to pull someone out of a depressive episode. Such antidepressants include the older tricyclic antidepressants, the monoamine oxidase inhibitors and the newer selective serotonin reuptake inhibitors, venlafaxine (Effexor) and buproprion (Wellbutrin). There is some evidence that these new medications are better tolerated than the older antidepressants and may have less risk of precipitating hypomanic or manic episodes.

8. What is a manic episode?

A manic episode is a discrete, recognizable psychiatric state that is often a medical emergency. It is characterized by severe alterations in mood consisting of euphoria, expansiveness, irritability and, sometimes, severe depression. In addition, people who are manic may have racing thoughts and speak very quickly in an uninterrupted fashion. Their behavior is characterized by increased activity, diminished sleep, a tendency to be distracted, engaging in many activities at once and disorganization.

Mania can occasionally become so severe that it is accompanied by psychotic symptoms such as delusions, hallucinations and very disorganized thinking, similar to schizophrenia. In addition, people in manic episodes can be very impulsive and occasionally violent. Often, unfortunately, they have little insight into their behavior during the throes of an actual manic episode.

9. What is hypomania?

Hypomania is a milder form of mania. Someone who is hypomanic typically is more active and energetic than usual. They may have accelerated thinking and speak very quickly but, overall, their functioning is not substantially impaired. The symptoms are not so severe as to hinder their ability to interpret reality or function in most areas of life.

10. What is dysthymia?

Dysthymia is a state of chronic depression severe enough that people are plagued by some symptoms of depression, but not so severe that the number of depressive symptoms meet criteria for a full-blown major depressive episode. It is a chronic, mild depression rather than a frank, severe depressive episode. There is evidence, however, that people who have dysthymia suffer from as much or more disability over the long run, as compared to those who have severe depressive episodes but recover in between. Like major depression, dysthymia is an illness that can be successfully treated with antidepressant medications.

11. What is major depression?

Major depression is a well-characterized medical illness that consists of a number of discrete symptoms. These include a persistently depressed mood for several weeks or longer and an inability to experience pleasure or enjoy normal activities.

Changes in basic functions include sleep and appetite disturbances, diminished interest in sex, and difficulty in making day-to-day decisions. Sufferers may also feel physically or cognitively anxious, agitated or very slow. Most conspicuously, they may sometimes have suicidal thoughts or even attempt suicide.

12. What is atypical depression?

Atypical depression distinguishes people who seem to have many of the symptoms of major depression, but have difficulty staying asleep or seem to sleep too much. Additionally, instead of having a diminished appetite, they have a marked increase in appetite, a sensitivity to interpersonal rejection and leaden paralysis-a feeling of being so depressed that it is major effort to do even basic tasks. Atypical depression resembles hibernation in that metabolism is slowed and sufferers sleep great lengths and eat excessively.

13. What is meant by a mixed state?

A mixed state is a combination of manic and depressive symptoms. While common, mixed states are underrecognized, with an estimated 40% of people who present with manic symptoms having a sufficient number of depressive symptoms to be diagnosed as being in a mixed manic and depressive state. Some studies have shown that suicidal thoughts are greatly increased in people in the midst of a mixed state. Treatment has been poorly studied, but recent evidence indicates that some of the newer medications, such as divalproex and olanzapine (Zyprexa), may be more beneficial than older drugs like lithium.

14. What is seasonal affective disorder?

Seasonal affective disorder (SAD) is a mood disorder occurring at a specific time of the year. The most common seasonal pattern is recurrent depression in late fall and early winter or sometimes in the late spring or early summer around the time of the solstices. There clearly seems to be some biologic component to this, perhaps having to do with ambient light and its duration and intensity. There has been a great deal of study in using bright-light therapy as a treatment intervention for mood disorder. In addition, standard treatments such as antidepressant medicines are also effective for treating people with a seasonal pattern to their mood disorder.

15. What is postpartum depression?

Postpartum depression is a major depressive episode following the delivery of a child. The length of the postpartum period for risk of depression varies, but the greatest risk is within the first one to three months after delivery. This is an especially vulnerable period, and obstetricians and pediatricians need to be especially vigilant during this time. Recognizing postpartum depression not only alleviates illness and suffering in the mother, but also prevents secondary effects on the growth and development of the infant.

16. What is schizoaffective disorder?

Schizoaffective disorder is really two different illnesses: schizoaffective disorder bipolar type, and schizoaffective disorder depressive type. The bipolar type resembles bipolar disorder with recurrent manic and depressive episodes over time, but has psychotic symptoms outside the manic or depressive episodes. The psychosis is more chronic punctuated by manic and depressive episodes. The depressive subtype resembles schizophrenia with chronic psychotic symptoms, but has recurrent depressive episodes.

17. What resources are available for people suffering from bipolar disorder?

There has never been a time of greater hope for people with this illness. There have been substantial advances in treatment in the last 10 years. Twenty years ago there was really only one medication, lithium, that was widely regarded to be effective. There are now a number of alternative mood stabilizers; there is a whole new generation of antidepressants for depression and another group of medications that may, over time, improve upon older mood stabilizers. There have also been advances in psychotherapy, including group therapy to improve functioning, cognitive therapy to reduce stress and improve functioning, and substantial support from consumer advocacy groups like the National Depressive and Manic Depressive Association (NDMDA).

18. How can family members assist the bipolar patient?

The first step for any family member is to educate themselves as well as the family member who has the illness about bipolar disorder. They should try to identify the features of the illness that are distinct to that individual, including the warning signs of recurrent manic or depressive episodes, so that someone in treatment can get immediate help to ward off those symptoms.

In addition, education helps people understand what is and is not within the control of an individual who has this illness. Family members can also assist with medication compliance and should be supportive in a health-supporting way for the family member with the illness. This will also prevent their own burnout and exhaustion.

19. What are the challenges of bipolar disorder?

There are still people who do not respond well to available medication. Compliance with treatment still remains a problem, as does access to treatment for many patients. People with serious psychiatric illnesses sometimes have problems obtaining appropriate mental health insurance coverage.

Furthermore, bipolar disorder is still underrecognized and underappreciated in the general population. People with bipolar disorder require individualized treatment. Many people do well with pharmacology-based treatment, but others need in-depth psychotherapy and support from community services, including rehabilitation and long-term treatment.

Source: Answers provided by Paul Keck, M.D., professor of psychiatry at the University of Cincinnati College of Medicine.

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A short essay on how to offer support, encouragement, and inspiration.

Life Letters

I'm sorry that you're hurting so desperately right now. I know how painful the seconds, and minutes, and days can be, how long the nights are. I understand how very hard hanging on is, and how much courage it takes.

I ask though that you hold onto one day at a time. Just one day, and slowly this despair will pass. The feelings you fear you're trapped in will serve their purpose, and then fade away. Difficult to imagine isn't it? Almost impossible to believe when every cell in your body it seems cries out in agony, desperately in need of comfort. When it feels like the only thing in the whole world that can touch your pain and banish it is beyond your grasp. And after all this time, the assurance that you will heal has become an empty, broken promise.

Just let one tiny cell in your body continue to believe in the promise of healing. Just one. You can surrender every other cell to your despair. Just that one little cell of faith that you can heal and be whole again is enough to keep you going, is enough to lead you through the darkness. Although it can't banish your suffering, it can sustain you until the time comes for you to let your pain go. And the letting go can only occur in it's own time, as much as we would like to push the pain away forever.

Hold on. Hold on to appreciate the beauty of the earth, to feel the songs of the birds in your heart, to learn and to teach, to laugh a genuine laugh, to dance on the beach, to rest peacefully, to experience contentment, to want to be no other place but in the here and now, to trust in yourself, and to trust your life.

Hold on because it's worth the terrible waiting. Hold on because you are worthy. Hold on because the wisdom that will follow you out of this darkness will be a tremendous gift. Hold on because you have so much love and joy waiting to be experienced. Hold on because life is precious, even though it can bring terrible losses. Hold on because there is so much that you can't now imagine waiting ahead on your journey - a destiny that only you can fulfill. Hold on although your exhausted and your grasp is shaky, and you want more than anything to let go sometimes, hold on even though. Please hold on.

So much in life can be difficult, even impossible to understand. I know, I know... So many of us have cried in despair, "why?" "why?" "why?," and still the answers and the comfort failed to show. Survival can be a long and lonely road, in spite of all those who've stumbled down the path before you. And it can be a treacherous, torturous journey - so easy to get lost, and yet impossible to avoid even one painful step.

And the light, the light at the end of the dark tunnel for so long cannot be seen, although eventually you'll begin to feel its' warmth as you move forward. And forward you must move in order to get through the hell of remembering, of despair, of rage, of grief. Keep looking forward please. Rest if you must, doubt your ability to survive the journey if you have to, but never let go of the guide ropes, although when you close your fingers around them, your hands feel empty, they are there. Please trust me, they are there...

When you're exhausted, when all you have to count on is a weakened, weary faith, hold on. When you think you want to die, hold on until you recognize that it's not death you seek, but for the pain to go away. Hold on, because this darkness will surely fade away. Hold on...Please hold on.

next: Life Letters: You Can Do It, Can I?

1. Men need to grow up. Mama doesn't live here anymore. Make notes to yourself. Remind yourself to take out the garbage and other things that will keep harmony in your relationship.

2. Go to bed by 9 p.m. at least one night each week. You won't miss anything. AND you can spend some quality time with your partner and be more rested and ready to face the world again the following day.

3. Simplify your life by getting rid of relationships in your life that drain your energy. Develop some new relationships with people who help build you up, not bring you down.

4. Even though you are in a relationship, you must make time for you. Often people forget about taking care of themselves. They become so involved in the relationship they forget about #1. You owe it to yourself and life.

5. Be courageous. Be who YOU are. Stop trying to be someone you think someone else wants you to be. Stand up for who you are.

6. Learn to move past the "small stuff" fast. Don't linger in the past with something that happened that you cannot change. Forgive if necessary and move on. Hanging on to anger, resentment, etc., is an energy drain. Life is too short. Take time to tell those you love how much you care each and everyday.

7. Stop complaining about things your partner does that annoy you. Instead catch them doing something right and offer a sincere compliment with a dash of love and perhaps a hug thrown in.

8. When things become stressful in your relationship, stop and take a deep breath. Pause. Relax. Ask yourself, "Will becoming more upset about this push me closer to what I want or further away?" Create something constructive to do to instead of becoming stuck in your negativity about the situation.

9. Let your partner catch you with a smile on your face. Be happy. Happiness is a wise choice. Happiness is contagious.

10. Design a quiet place to do some serious soul searching. Spend time alone. Think about what you can do to bring more quality to your relationships. Self connect. Who would you have to become and how would you have to do things differently for your life and your relationships to be a 10?

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