A Guide To Maintaining Mood Stability

Mary Ellen Copeland experienced episodes of severe mania and depression for most of her life. She interviewed numerous people to find out how people who experience psychiatric symptoms relieve these symptoms and get on with their lives.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts, the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Living Without Depression and Manic Depression: A Guide To Maintaining Mood Stability". Our guest is author and researcher, Mary Ellen Copeland. Besides writing about it, Mary Ellen experienced episodes of severe mania and depression for most of her life. She underwent numerous hospitalizations and medication trials that weren't helpful.

For the last ten years, or so, she's been studying how people who experience psychiatric symptoms, relieve these symptoms and get on with their lives. She's incorporated those self-help methods into her own life and tonight she's here to share with us the tools to maintaining mood stability. You can read more about Mary Ellen Copeland here.

Good Evening, Mary Ellen, and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Before we get into some of the self-help methods, I mentioned that you tried psychiatric medications, antidepressants, along with the hospitalizations and therapy. Why, in your estimation, where those things not as effective or helpful as I'm sure you hoped they would be?

Mary Ellen Copeland: It's really nice to be here, David!

I think the therapies that were suggested by the doctors were not helpful because my life was so chaotic. I had no idea how to take care of myself. I sabotaged my own efforts at wellness.

David: Can you elaborate on that a bit?

Mary Ellen Copeland: Yes, I would be glad too. I didn't get enough rest. I ate lots of junk food. I didn't exercise. I had no idea how to relax. I didn't know how to say no to the requests of others. I sometimes abused substances. You can't get well when you live like that.

David: How many years have you suffered with mania and depression?

Mary Ellen Copeland: I think most of my life. I remember being very depressed for long periods of time when I was a child. I wish I had gotten help then. It wasn't until I was in my thirties that I finally reached out for help.

David: And why did it take so long?

Mary Ellen Copeland: I thought I could control it myself. But I was never able to. I didn't know how. That's why it has become so important to me to reach out to others and find out how they have helped themselves relieve these horrible symptoms.

David: I'm assuming, since you titled your book A Guide To Maintaining Mood Stability, that the goal here isn't really to cure depression and manic depression (bipolar disorder), but to really stabilize your moods so that you don't experience these huge mood swings. Is that correct?

Mary Ellen Copeland: That's correct. I work on managing my moods every day. But now I know a lot of ways to help myself feel better, so the moods no longer overwhelm me and my life. I still have symptoms, but they are much milder and of shorter duration. I used to spend months in the hospital, but now I have either a bad day, or several days, or sometimes just a bad afternoon.

David: That is a huge improvement.

I want to mention here that Mary Ellen is not a medical doctor, but she is a therapist, and now is involved primarily in educating others about mental health. The information she has to share with us tonight is based on interviews she did with others and her own experiences.

Please tell us, Mary Ellen, who you interviewed and what they were suffering with?

Mary Ellen Copeland: I have, in the last twelve years interviewed thousands of people from all over the country, who experience psychiatric symptoms or mental health problems.

David: And what have you found out in terms of self-help methods that worked?

Mary Ellen Copeland: I have found many things that are helpful to people. I have found so many things, that now I have ten books based on my findings. One of the first things I learned for myself, was that I, myself, had to do things that I enjoy. I had forgotten how to play and how to have a good time. So I began sewing, playing the piano, painting pictures, getting together with friends, and it made a huge difference in how I felt. I learned about the effects of diet, light and exercise on my moods and how to use them as ways to get my moods back under control. I could go on and on about this. There is so much to tell.

David: So one thing is, do things you enjoy doing. Put some joy in your life. What about diet?

Mary Ellen Copeland: I have found that junk food (food that is highly processed or loaded with sugar or fat) makes me feel much worse. If my diet focuses on healthy foods, like fresh vegetables, fruit, whole grain foods, some chicken and fish, I do much better. I have found that there are certain foods that make me feel worse including foods that I think should be OK. I have learned a lot through trial and error. Working with a good nutritionist and educating myself through self-help books and internet options. My diet is much different now than it was just a few years ago.

David: We will continue on with more of these self-help methods. But we have a lot of audience questions, Mary Ellen. So let's address some of those:

BreezeeBC: Why do I still have manic-depressive episodes, even though I am on medication?

Mary Ellen Copeland: Medications are never the whole answer. Take a look at your life. Are you spending time with people who treat you well? Do you eat healthy foods? Do you know how to relax? Do you take good care of yourself? Take a look at your lifestyle, and make changes where you need to.

dhill: I have been informed, by many sources, that ADD/ADHD, depression, etc. are caused by beta-carbolines created in our systems by the poisons in the prepared food that we eat. I have even been told that my son's anxiety and depression are not a psychological disorder, but results of these poisons. Can you comment on this, please?

Mary Ellen Copeland: I suggest you learn a lot more about this, by checking out websites and books that deal with healthy diet. Then decide what feels right to you. You may notice that your son feels worse when he eats certain foods. That will give you good clues about what is really going on.

scooby: What part of my depression is biochemical, and thus can yield to medication therapy. Furthermore, what part is going to yield to your type of therapy? Do I have to be in two ports to find out where my ship is going to arrive and when?

Mary Ellen Copeland: I think you should do everything you can to take good care of yourself. Then, if you still have symptoms that are hard for you to manage, you can use medications, if you choose to. It is important to remember that medications are just one tool to use to maintain mood stability. You will find many other things that are helpful to you as well.

David:One of the other tools you mentioned is light. How is that helpful? And what kind of light are you referring to?

Mary Ellen Copeland: Many people notice that they get more and more depressed when the days get shorter in the fall or when there is a series of cloudy days. This is referred to as seasonal affective disorder. They may also notice it when they spend a lot of time indoors. Sunlight helps relieve depression for many people. Getting outdoors, even on cloudy days, can help you feel better.

David: Here are some more questions:

buttercup: Are you saying medications are not always the way to go?

Mary Ellen Copeland: I am saying that there are choices to be made. I think it is very important not to expect medications to take care of problems in your life that need to be addressed in other ways, such as: taking good care of yourself and spending time with nice people. Many people find that when they have become very good at taking care of themselves, they need less medications, or no longer need them. But it takes time to learn the skills needed, to take really good care of yourself. It is important not to stop your medications but, first, to work on your wellness.

David: From the questions coming in, one of the things I'm finding is that many people, whether it's because their doctors have led them to believe this or not, think medications alone will be the cure. And they are disappointed, now that they've tried them, to find out they are not the cure-all.

Mary Ellen Copeland: I found out the same thing. Medications cannot fix an unhealthy lifestyle. And I found the side-effects of many of the medications, like extreme weight gain, lethargy, and lack of sex drive, to be intolerable.

specie55: Have you had any in-depth therapy to better understand the origins of your depression symptoms?

Mary Ellen Copeland: I have been in therapy with a wonderful woman therapist for many years. She helps me sort out current problems in my life. We have also worked together on issues related to trauma when I was a child. I think these traumatic events were a key factor in my mood instability. Current research is supporting the link between traumatic experiences and psychiatric symptoms.

David: I noticed that several of your books are geared towards women. Is that because you are a woman, or is it something else?

Mary Ellen Copeland: The book I wrote with Maxine Harris, Healing from Abuse. This is the only book I have written that is for women. I do not feel qualified to write a book on that topic for men. However, I do feel that many of the ideas in that book will be useful to men. It is based on a research project with women only.

David: You also mentioned exercise, as a self-help tool. And I know that some people may wince at that. How has that helped you, and what kind of exercise are you referring to?

Mary Ellen Copeland: Any kind of exercise is helpful. Movement of any sort, even walking up and down the stairs or doing simple stretching will help. Depression gets worse if you just sit around, and it gets much worse if you sleep too much. It may be very hard to exercise and you have to push yourself to do it. Do some kind of exercise you enjoy.

Joelle: What are the first steps to take, if one is at the place of a "no exercise, junk food, no relaxation experience" type lifestyle?

Mary Ellen Copeland: I was working with a group of people who developed a really good planning and action process for restoring wellness. It is called a Wellness Recovery Action Plan. I have written about it in several of my books and it has become popular across the country. I developed such a plan for myself and use it all the time. It has made a huge difference in my life.

David: From all the interviews you did, can someone achieve mood stability without a healthy diet, exercise, light, etc.?

Mary Ellen Copeland: I haven't met anyone yet.

photogirl624: My son has just been diagnosed Bipolar at age thirteen after being labeled and treated for ADHD his whole life. What are your thoughts on diagnosing children with Bipolar Disorder and the controversies that surround that?

Mary Ellen Copeland: I do not believe in diagnosing children. I believe it can be a stigma that keeps them from doing the things they want to do with their lives and it changes people's expectation of them. I believe we should work with our children, to help them learn how to relieve symptoms that are troubling to them and others, and leave labels out of it. I know this is often not a popular view.

jeckylhyde: I have been suffering with Bipolar Disorder all my life, but was diagnosed in 1986. After my second big crash, my therapist suggested that I buy your book The Depression Workbook. I was skeptical, but reluctantly picked it up. When I got to certain sections, I got even more depressed because I couldn't relate to so much of it. Especially the support sections. I have no family and only a few close friends scattered across the States. How do I build a support system without scaring off any new friends?

Mary Ellen Copeland: Building a support system is very important. You deserve to have people in your life who treat you well and support you through hard times. I have learned from others, that the best way to do this, is by joining a support group. Find one that feels right to you, and attend.

David: Here are a few audience comments on what's been said tonight:

recov10: I am not familiar with your new book, however, The Depression Workbook, has helped me for many years. It is a source right at my fingertips, and I thank you for helping me understand so much more about bipolar disorder, manic depression.

rick1: Mary, you know it's not about foods. It is really about tenseness.

Helen: Mary Ellen, I really appreciate your self-help books. I strongly believe that there are many things we can do to help manage our moods, and I think that often people with mental health disorders don't hear this, so they feel helpless and hopeless because of the disorder. So thanks for sharing what helps.

Reb: Both my mother and I have been diagnosed with Bipolar Disorder. Me, since 1971, and I agree with everything you mention. My mother is 88 now and is a convalescent. Her doctors do not keep her on medications for Bipolar and she is doing the best I ever seen.

Alley2: The Doctor has me on so much medication, but it doesn't really work. Instead, it just drugs me up. Furthermore, when I feel I need counseling, I don't get it, and I have to practically beg for it.

Sandra: I have been on Prozac for ten years, and find that I just as soon stay in my apartment rather than go out. Some days, not often, I need to get out but other days I get so down and want to stay in.

scooby: Isn't it wonderful to see people as warm, humorous, wacky rather than Axis I=Axis II=...I like you already :o)

David: Many of the things you referred to tonight, a healthy diet, exercise, even light, have to do with metabolism. Is that a key to maintaining mood stability ... speeding up your metabolism in a healthy way?

Mary Ellen Copeland: I think speeding up your metabolism in a healthy way, when you are starting to feel depressed, really works. I also have found techniques to slow me down when I am experiencing early warning signs of mania. It works both ways, and through consistent trial and error. Each person can find what works best for them in their life.

David: And we really haven't talked about mania (manic depression, bipolar disorder) too much yet. What self-help tools have you found to be effective for curtailing or containing the manic episodes?

Mary Ellen Copeland: The tool I use most to curtail mania is deep breathing relaxation exercises. When I realize I am starting to get really speeded up, I take a break and do one of these exercises. I have some of them on tape. Others, I have memorized. Sometimes I will spend a whole day involved in a very quiet activity with the radio, TV and music off, just to cool myself down and avoid mania. I used to have severe mania but have not had it in many years.

gremmy: Has it become more common for people to be put on more that one mood stabilizer? I feel like my options are running out. I'm a rapid cycler. My doctor just put me on another mood stabilizer and that makes two now.

Mary Ellen Copeland: Many people are on more than one medication. I am not an expert on medication. I am an expert on self-help. I have found that I can best manage my own moods by using many different self-help tools. I am allergic to most medications, so that has not been an option for me. And I manage my moods very well these days. I have been able to work, and do the things I want to do with my life. I have recently remarried and I am enjoying a wonderful relationship. This is something I couldn't do in the past.

dekam20: Do you believe that people with mental health problems are at high risk of abusing drugs and alcohol?

Mary Ellen Copeland: I believe they are. Mental health problems are very painful. Alcohol and other substances, will make you feel better at first. They relive the pain, but then, it is so easy to become dependent on them. They often cause depression and other severe side-effects. I believe using these substances are not worth it.

Joelle: Do you have suggestions for networking with other manic depressive people who have worked through lifestyle changes and no longer take medication (or take a lower dose than medically recommended)?

Mary Ellen Copeland: Being in touch with people through internet groups and groups in your community are very good ways. A few ways to connect with a group in your community is to call your county mental health department, a local psychiatric hospital, or look for therapists who work with depression and manic depression. They may be able to refer you to a group. Please call around.

PennyP: I am struggling with depression. Medications prescribed have no benefit. What can you suggest? I am upset with my therapist after 5+ years. She is recently writing my prescriptions. I don't trust her anymore, but I really feel lost without her. ANY ADVISE?

Mary Ellen Copeland: I suggest you develop for yourself a Wellness Recovery Action Plan. It involves:

1. Discovering the things you need to do for yourself every day to keep yourself feeling well;
2. Which triggers and early warning signs to watch for;
3. What to do when these things come up, to help yourself feel better;
4. How to know when things are getting really bad and what to do to help yourself then; and
5. A crisis plan that tells others how they can help you, when your symptoms are very severe.

It is the best way I know to manage. And many people are doing this.

lithless: What sort of diet should a person with manic depression, bipolar disorder be on? Should caffeine intake be limited or totally taken out of the diet?

Mary Ellen Copeland: I think each person needs to find out for themselves, what foods make them feel better and what foods to avoid. For instance, I have found that dairy foods make me feel worse. But many people find them to be helpful. Most people say that sugar makes them feel much worse.

I suggest a diet that consists of at least five servings a day of vegetables and fruit, six or seven servings of whole grain foods (i.e. cereal, bread or pasta) along with a bit of chicken or fish. That's what I try to do, but it is hard sometimes. Also avoid caffeine as much as possible. It causes anxiety.

PoohBearHugz: What are your thought's on electric shock therapy (ECT)?

Mary Ellen Copeland: If you are considering electric shock therapy, learn all you can about it before you consent. I personally do not want it. I think there are many simple, safe, and effective ways to relieve symptoms without resorting to this treatment.

David: By the way, we are arranging a chat conference on ECT in October. We are going to have some people on, who have undergone ECT to talk about their experiences. One was not positive, the other is very happy with the result. So stay tuned for that.

scooby: If you could imagine a pie, and divide that pie into pieces, I wonder what size, and thus importance, you would place medication, exercise, diet, support groups, therapy as pieces? Is it okay to take one piece and the next in excess? Just playing with your concepts in my thinker-ticker.

Mary Ellen Copeland: I think this is the kind of thing you have to sort out for yourself. It is different for each of us. However, I personally believe in working with the less invasive kinds of remedies as much as possible. Figure out what works for you, and then do it.

David: Here's the link to the HealthyPlace.com Depression Community and the Bipolar Community. Click on the links to sign up for the mail list at the top of the pages.

For Mary Ellen's website at HealthyPlace.com click here or go to www.mentalhealthrecovery.com. You can view and purchase Mary Ellen Copeland's books about dealing with different aspects of depression and manic depression.

Mary Ellen, thank you for coming tonight and being our guest. It was very enlightening and informative.

Mary Ellen Copeland: It has been a pleasure to be here. Thanks for inviting me.

David: And thank you to everyone in the audience for coming and participating.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Dr. Kathleen DesMaisons, a nutrition expert, joined us to talk about how sugar addiction can affect your mood, causing you to be depressed as well as overweight. She also discusses ways to cure your addiction to sugar through a high carbohydrate diet.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. I'm glad you had the opportunity to join us and I hope your day went well. Our topic tonight is "Food and Your Moods." Our guest is Dr. Kathleen DesMaisons, an expert in addictive nutrition and the author of Potatoes Not Prozac.

Dr. DesMaisons maintains that the same brain chemicals that are altered by antidepressant drugs are also affected by the foods we eat. According to her, many people, including those who are depressed, are "sugar sensitive." Eating sweets gives them a temporary emotional boost, which leads to a craving for still more sweets. The best way to keep these brain chemicals in the right balance and keep blood-sugar levels steady, she says, is through the dietary plan she describes in Potatoes Not Prozac.

Good evening, Dr. DesMaisons and welcome to HealthyPlace.com. We appreciate you being our guest tonight. On your site, you describe yourself as a former sugarholic who was chronically overweight. Can you tell us a little more about yourself, please?

Dr. DesMaisons: I was the child of an alcoholic who was depressed, overweight, and moody. I was smart and committed to my health, but it seemed that no matter what I did, I still felt so bad. I had no idea that my eating was contributing to the problem - sometimes I felt crazy without an answer. Twelve years ago I started to explore working with food and diet in the alcoholism treatment center I was running. We got spectacular results! I applied the same ideas to myself and everything changed as the food changed!

David: Can you please define or explain what sugar sensitivity is?

Dr. DesMaisons: It is a theory I developed to explain a three-part problem: reactive blood sugar, low serotonin, and low beta endorphin which can all be inherited from an alcoholic or sugar sensitive parent. Each of these can make us be depressed, have mood swings and low impulse control. I wanted to develop a solution using nutrition.

David: Obviously, sweets are one type of food with sugar. What other types of foods are you referring to?

Dr. DesMaisons: White things - refined flour products such as bread and pasta. Many people who are sugar sensitive use these foods addictively but don't realize that is what is going on. They have no idea that food can affect how they feel so profoundly.

David: When you say, "use these foods ADDICTIVELY," what do you mean by that?

Dr. DesMaisons: Well, just as if they are a drug - sugar actually affects the same part of the brain as heroin or morphine, so we use it to feel better and have withdrawal when we don't get our drug. We only notice that we feel really good when we have sweet stuff, but don't make the connection to when we feel bad as withdrawal.

David: Here's an audience question that relates to what we are talking about:

radiantmb:: How does eating sugar make you depressed? I usually feel much better after eating sugary foods.

Dr. DesMaisons: Sugar evokes beta endorphin which absolutely makes you feel better - until it wears off and then you feel depressed, but you don't make the connection of the down being an aftereffect of the sugar. The problem comes in needing more and more and more often, or in thinking that the down feelings are signs of clinical depression rather than the sugar low. Sometimes people get them mixed up and think they are not getting better, when it is the food making them feel so bad.

David: We have many visitors to our site who have many different types of psychological disorders. Many take medications to ease their depression. Are you suggesting that they don't need Prozac or other antidepressants if they control their diets properly?

Dr. DesMaisons: Absolutely not, but I am suggesting that their symptoms can be made worse by what they eat or don't eat. For example, Prozac does not make new serotonin, it simply recycles the serotonin you already have. By changing the food, you can actually increase the production of serotonin in the brain without any side effects or any cost. I encourage people to change their diet and see how they feel - usually it significantly enhances the effectiveness of the medications.

David: I'm wondering, do you suggest eating 3 meals a day, or little meals throughout the day?

Dr. DesMaisons: Well, I always suggest that people start with having breakfast every day with some sort of protein and a complex carbohydrate. That is the first step of seven and usually it takes weeks to master.

People who are sugar sensitive HATE to have breakfast, because when you don't eat, your body releases beta endorphin and it makes you feel confident and strong, until it wears off!!! Then you feel horrible.

After you master breakfast, then I suggest working on three meals because starting and stopping is very good for your brain. It help to reinforce impulse control or the ability to say no.

David: We have many audience questions. Let's get to a few of those:

jenny23: How do you suggest controlling your meals like that?

Dr. DesMaisons: You start with baby steps. You do NOT try to go off of sugar in the beginning, and you just focus on one thing - breakfast with protein every day.

tinesangel: Are you saying foods with sugar can cause depression?

Dr. DesMaisons: No, I am saying they can contribute to depression. As I am sure you know, depression is a very complex, multifaceted issue, but I do believe that sometimes people are diagnosed for symptoms that come from sugar sensitivity rather than straight clinical depression. We have had thousands tell us that they cannot believe how much better they feel when they change their diets and that sugar makes them crash, even though in the short run it seems like a solution.

David: We have a lot of information about depression in the HealthyPlace.com Depression Community.

TinaB: Do you find that even though we are called 'sugar sensitive', some folks may have a big problem with pasta and breads as triggers rather than sugar?

Dr. DesMaisons: Yes, sometimes those foods can be a bigger problem - especially since we are told that things like pasta are so healthy!!!

David: What's it feel like quitting sugar?

Dr. DesMaisons: Oh my goodness!!!! It's like drug withdrawal! Let me go through the phases.

It takes about 5 days. At first you feel excited and ready, then you get cranky, and then, on the 4th day, you get nasty!! On the 5th day, you wake up and you feel like you died and went to heaven!!! But I do NOT recommend you go off of sugar until you set the foundation. Going off of sugar is the 6th of seven steps!

topmom: Why does your theory relate to "alcoholic" parents?

Dr. DesMaisons: Because the biochemistry of sugar sensitivity is so closely connected to the biochemistry of alcoholism. I think that sugar sensitivity is a gate to alcoholism for some. For many of us, we stay with sugars and food, but for many it drifts over to alcohol. We inherit the biochemical predisposition and it manifests in different ways.

daffyd: You talk about sugar addiction... My problem is that I am addicted to salt and salty foods. How does that relate to your theory?

Dr. DesMaisons: Well it may or may not be connected. You may be addicted to the foods that carry the salt or you may be addicted to the biochemical response that the salt creates in your body. Without knowing your whole story, I don't really know.

David: Also, and please correct me if I am wrong about this Dr. DesMaisons, but many foods that we think don't contain sugar, do.

Dr. DesMaisons: Absolutely true! Sugars are hidden everywhere!!!

EmilyAnne: I once went on a low carbohydrate/high protein diet. After 2-3 weeks I got EXTREMELY depressed and had to stop. Was that withdrawal, or maybe related to the tryptophan/carb connection?

Dr. DesMaisons: Absolutely, those diets actually DEPLETE serotonin, to say nothing of the trauma of sugar withdrawal in stopping that quickly!

What I am trying to do is actually enhance the level of serotonin very carefully. I want to give people a way to understand their own biochemistry so they can work WITH it to feel better.

anothernewone: Is there anywhere one can go when they already have many food allergies (now this is one more thing to eliminate)? I feel much better without sugar, but it's so very hard to say no all day long!

Dr. DesMaisons: No, this is about abundance, not deprivation. The plan I have actually helps to heal allergies. And you don't start taking anything out for a long time. You mostly work at putting things in. I know it is terrifying to think about giving up something which provides so much comfort!

Remember, I am a sugar addict, I KNOW the feelings and the fear, and how hard it is. We are talking about a very simple, very slow, and sort of boring solution. This is NOT a weight loss plan, this is a plan to heal your brain chemistry!

blusky: What's the best eating plan for anxiety disorder?

Dr. DesMaisons: Here is the exciting thing. The plan in the book seems to help a lot of different kinds of issues: depression, anxiety, compulsion. For example, I have treated many people with anxiety and panic disorder, and no one ever asked how much caffeine and sugar they were having, no one!! When they changed the food, things sure settled down!

nirv: In a nutshell what do you recommend "we" should eat to be more balanced?

Dr. DesMaisons: Breakfast with protein and a complex carbohydrate, three meals a day with protein at each (and some complex carbs), and a potato before bed with butter or olive oil on it. This is why the book has potatoes in the title!

David: Just to clarify, Dr. DesMaisons, are you suggesting that people cut out ALL sugar?

Dr. DesMaisons: AFTER they do the other steps, not before, and I recommend being reasonable. I don't think the sugar in ketchup matters so much as 12 cans of coke a day, or cake and candy! I am mostly talking about the big sugars.

adia24: What foods increase serotonin?

Dr. DesMaisons: Protein provides tryptophan in the blood but you have to have a carbohydrate snack three hours later to get the tryptophan up into the brain, hence the potato three hours after dinner. If you only have carbs, there is no raw material. If you don't have the carb snack, you only get tryptophan in your blood, not in your brain.

gailz: So what is so special about the potato?

Dr. DesMaisons: It is tasty, easy to fix, warm, cheap and creates an insulin punch that does the job. Of course, the fact that I am IRIS never influenced my choice!

David: Also can you define complex carbohydrates and give a few examples of what they are?

Dr. DesMaisons: Brown things rather than white (a highly scientific descriptor ). High fiber foods, brown rice, whole wheat, things like that.

David: That makes it simple :)

Dr. DesMaisons: Yes, this is a very simple plan. Shift from white to browns!!!

Nerak: I have heard that some diabetics tend to suffer from depression. I am diabetic and suffer from depression. Is there a correlation between the 2?

RocknBead: Can this type of diet help prevent diabetes?

Dr. DesMaisons: There seems to be a big correlation. I think the blood sugar volatility makes depression worse. By the way, if you are diabetic you should use a sweet potato or something like Triscuits rather than a regular potato.

David: Dr. DesMaisons website is here: http://www.radiantrecovery.com/

David: Here are a few audience comments about what's being said tonight, then we'll continue with the questions:

sad: I cut out sugar and white flour.... It was not so hard to do and it really helped.

anothernewone: I'm so limited at what I can put 'in.' I'm gluten sensitive.

Laurie W: Do you have much success with people who have a LOT of weight to lose? I am really overweight (150 pounds over).

Dr. DesMaisons: Actually, we do, but it is not sexy or glamorous. It is slow and effective because we are HEALING what got you there in the first place. Some people stay fixated on the pounds. I work to moving people towards radiance which is a much bigger issue.

David: I do want to mention again, what was said earlier, Dr. DesMaisons is not encouraging anyone to quit taking their medications... and certainly you should never do that on your own, without consulting your doctor first.

Dr. DesMaisons: Absolutely, we always tell people to talk to their doctors.

David: This is not a substitute for your medications, but rather an adjunct, something you can do in addition, as a way to further help yourself.

Dr. DesMaisons: Often they get the book from their doctor, in fact! It will make the medication more effective and also help you sort out the deeper issues.

EmilyAnne: Do you have any thoughts on caffeine?

Dr. DesMaisons: Many!! Oops, my own struggles are showing! Caffeine is a drug, no getting around it. Caffeine in moderation can help depression, but caffeine in bigger amounts can create havoc and certainly contribute to things like panic disorder. The let down from caffeine withdrawal can make depression much worse.

I also think that many health care people don't understand the relationship between these things and psychotropic dugs. They all interact and it is important to see how they fit so you know which are psychiatric symptoms and which are food or caffeine induced symptoms.

RocknBead: Any advice to a vegetarian just starting your plan?

sad: One thing that makes me nervous is the protein. I don't eat meat or fish, and only small amounts of chicken. What do you do when people are vegetarians?

Dr. DesMaisons: We have many, many vegetarians doing the program. You can get protein from many sources other than meat or fish or chicken, but you do have to work at it to get enough. Lots of people are doing it very successfully. We actually have a special e-list for the vegetarians to help sort it out.

mermaid77: Kathleen, do people doing your program get off of their anti-depressants?

Dr. DesMaisons: Many do. I tell them to do the food steady for 6 months, see how they feel, and then talk with their doctors. There are some for whom the food is not enough, and I tell them to get medicine. We have a very skilled community to support people in finding out how the food fits, but I never encourage someone to drop the medications in favor of the food right off he bat - that would be NUTS!!!

David: Again, though, that is something you should definitely discuss with your medical doctor/psychiatrist.

Kathyb31: What is it with Diet Sodas? What's the addiction?

Dr. DesMaisons: hmm... This one is fascinating. Diet soda has an amino acid called phenyalanine. It is a precursor to dopamine, the neurotransmitter affected by cocaine and amphetamine. Dopamine makes us feel bright and able to take on the world. I think diet stuff activates that response, so we feel really good with it, but if we go off it we actually feel awful. In fact, I experienced a severe depression after flirting around with it. I had no idea what was happening since I don't generally suffer from depression. My first clue came when I had a dose and felt fine. Whew, what a surprise! I don't think people should drink it. It is nasty on the brain!

David: Here's an audience comment:

mermaid77: I see that as my goal. I'm gaining weight steadily, but I really want to do your program because it has worked so well for me in the past. I have regained 50lbs. from 104 lb. weight loss 4 years ago and am back on sugar and miserable.

RocknBead: I am on day 4 of the SARP, and knowing that step 6 is ahead of me, I want to eat lots of my favorite sugar foods NOW! Is that addiction?

Dr. DesMaisons: yep!!!! You are in the right place!!!

Kathyb31: I knew it wasn't the sugar... So it's a drug....WOW! I guess you just answered my question.

Laurie W.: Is exercise a part of your program?

Dr. DesMaisons: Yes, Laurie W, it sure is. Exercise raises beta endorphin as well as all sorts of other things. Exercise is a wonder drug!!!

David: Can eating right alone reduce weight and keep it off without the exercise?

Dr. DesMaisons: For some people it can, for others, no. If you are a middle aged menopausal woman who is tubby, yah gotta exercise!!

David: I also want to mention, we have hosted support groups on our site for many other mental health topics.

Laurie W.: What about using artificial sweeteners like aspartame, splenda, or natural sweeteners like stevia?

Dr. DesMaisons: The problem with artificial sweeteners is that they prime the brain. The taste of sweet, no mater where it comes from, makes cravings come, and of course splenda is chlorinated sugar. I wouldn't want to eat it anyway.

anothernewone: Do you believe this program could help solve some 'food allergies' and intolerances? There's hope?

Dr. DesMaisons: Well, I have seen it happen over and over. Many people try to fix the allergy without going to the root, so it is just harder and harder. When they do this program, the body heals and the allergies quiet, but the program is not billed as an allergy one, just so you don't have unrealistic expectations. It is about healing sugar addiction and sugar sensitivity.

David: I know it's getting late. Thank you, Dr. DesMaisons, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active community here at HealthyPlace.com.

Thank you, again, Dr. DesMaisons.

Dr. DesMaisons: Absolutely my pleasure!

David: Good night, everyone. And I hope you have a pleasant weekend. 

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Dr. Ronald Fieve: is a widely recognized authority in the treatment of bipolar disorder and author of the books "Moodswing" and "Prozac". He is a specialist in diagnosing and treating bipolar disorder.

David: is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our conference tonight is on "Diagnosing and Treating Bipolar Disorder". We are fortunate to have a great guest, Dr. Ronald Fieve.

I'm sure many of you have heard of Dr. Fieve. He is the author of the best-selling books, "Moodswing" and "Prozac". He's widely recognized as an authority in the treatment of bipolar disorder. In addition, Dr. Fieve operates one of the largest clinical trial centers for new antidepressants coming on the market.

Good Evening Dr. Fieve and welcome to HealthyPlace.com. Thank you for agreeing to be our guest. Because our visitors have different levels of understanding, could you please define what bipolar disorder, manic depression is?

Dr. Fieve: It is classified by the American Psychiatric Association, using the research criteria of the diagnostic and statistical manual (DSM4), as a major, and one of the world's major, mental illnesses characterized by mild to wild swings in mood and behaviour, going from elation to depression.

David: From the conferences that we've held here, one thing I've come to understand is that some psychiatric illnesses are difficult to diagnose. How is bipolar diagnosed?

Dr. Fieve: There are no biochemical blood tests used to diagnose bipolar illness, like there is to diagnose diabetes and other medical conditions. It is diagnosed by a psychiatrist, psychopharmacologist expert, preferably using the DSM4 criteria, and taking an extensive family history and personal history of the patient's mood and behavior over his or her lifetime.

David: And because there are no tests, per se, is that why some people, over the course of their lifetime, can be diagnosed with, let's say, ADHD (Attention Deficit Hyperactivity Disorder) and later the diagnosis is changed to Bipolar?

Dr. Fieve: Yes - an expert in the fields of these two illnesses, most often can distinguish between the two and make the correct diagnosis. Of course, the two illnesses can exist in the same patient which I have at times seen, requiring treatment for ADHD and bipolar at the same time. ADHD generally comes on in the very early years of childhood and early teens, where bipolar comes on in the early to mid-twenties, but there is no fixed rule for this. When in doubt as to the diagnosis, the family history of bipolar is very helpful in clinching the bipolar diagnosis in the patient, and leading thus to the primary treatment for bipolar instead of putting the patient on Ritalin for ADHD. ADHD is much harder to diagnose, and much less is known about it. And Ritalin, of course, is addictive, unlike the anti-bipolar drugs, which in adults is safer for a first trial, if the diagnosis remains in question by an expert.

David: I imagine it must be more difficult to diagnose children with bipolar than it is an adult. Is that true?

Dr. Fieve: Of course, YES. I would be very careful about it, but less so if there is a strong family history of bipolar, suicide, alcohol, great achievement, or gambling.

David: Is bipolar disorder genetically based, and is it hereditary?

Dr. Fieve: Yes. Genetic studies of bipolar illness, many of which I have participated in at Columbia Presbyterian Medical Center, show that bipolar illness is predominately a genetically inherited illness. It has a spectrum of manifestations in the children and relatives including depression alone, alcohol, suicide, gambling, great achievement and bipolar illness, like I said above. Genetically, we say that there is a gene-gene and a gene-environmental interaction, so that not 100% of bipolar can be considered genetic. We also call it a multifactural genetic illness.

David: Here are some audience questions:

michelle1: My boyfriend and I are both bipolar. Would you recommend us not to have children of our own?

Dr. Fieve: I would recommend that you make a decision based on the knowledge of all the facts and a few visits with a genetic counselor who is an expert in this field. After all is said and done, the genetic counselor can only give you statistical likelihood in percentages, and no-one can tell you that you absolutely won't have one, two, or three, perfectly normal children. It is simply that your risk of having a bipolar child is higher than if only one of you had it. And it would be lower still, if none of you had it. Don't try to outguess God and make you own decision based on the facts. The likelihood is higher than if only one of you had it, but as you know many people with bipolar illness are the movers and shakers of the world and make great contributions to the arts, science and business.

Hayley: I am 13 and my father is bipolar, he was also a alcoholic, and he is trying to get better. I hate how he acts and how my mom always talks about it with other people on the internet in the bipolar chatrooms, so I get mad at her. How can I help my dad and make my mom stay off the chat. It hurts me that she talks about it.

Dr. Fieve: You need two things: a father who is motivated to change via the correct treatment, and a psychiatrist who is an expert in the field and who will treat him. Many motivated people cannot find a bipolar expert, and many bipolar experts simply don't see the patients who need them and would benefit by their knowledge and treatment skills. Your mother should get him to a board-certified psychopharmacologist, preferably University affiliated, for an initial consultation and then go from there. And hopefully your father will go.

David: And that's an excellent point Dr. Fieve. How does one go about finding an "expert" in bipolar disorder?

Dr. Fieve: My first answer to this would be to call the department of psychiatry Chairman's Office in the nearest University of the state you are in. From there, you can get a referral from that office if you cannot go to the University centre itself. Go to the bipolar expert on the faculty for an initial consultation and get a referral if need be to a low-cost clinic or private psychiatrist thereafter.

David: Here's an audience comment, then I want to get into the treatment aspect:

CLIFF: It took me about 6 doctors and 2 full years before I was diagnosed. That was 22 yrs ago. I'm 58 now.

David: What is the most effective treatment for an adult who has bipolar disorder?

Dr. Fieve: First of all, I hear Cliff's history two or three times a week when I do consultations on patients for the first time. It often is much worse and I sometimes hear that patients have been going from doctor to doctor, and from therapist to therapist for over 20 years, without the proper diagnosis and bipolar treatment. According to my own experience, over 30 years and 5000 patients, Lithium is still my first choice for treating classical bipolar illness. This is agreed on by Dr. Mogens Schou, in Denmark who preceded Lithium studies before me, and by Dr. Gershon in Michigan who also started work with Lithium in the late 1950's and early 60's like I did at Columbia. Furthermore, the top psychopharmacologist at Harvard, Dr. Baldessorini, also agrees that Lithium should be tried in most cases in classic manic depression first. Thereafter, we have Lithium alternative (3 - 4), which in fewer instances are the treatment of first choice, i.e. if the patient has failed on Lithium, has kidney problems, alopecia (hair loss) or any other side-effects. Hair loss with Lithium is very rare

David: And correct me if I'm wrong Dr. Fieve, but you were one of the first doctors in the U.S. to do Lithium studies and promote Lithium for treatment of Bipolar Disorder. Am I correct?

Dr. Fieve: Yes, I was. And my team at the New York State Psychiatric Institute and Columbia Presbyterian Medical Centre, was the first American psychiatric and team to do scientific studies of Lithium in manic depression. Dr. Schow preceded me in Denmark and Dr. Cade was the very first in Australia in 1949. Dr. Schou's work was in 1954 and I began trials in 1958.

David: Here's an audience question:

scooby: Is there a particular reason why you and Dr. Baldessorini prefer lithium to other medications as a priority?

Dr. Fieve: My reason is, that after seeing about 5000 bipolar patients and using Lithium and the alternative antiepilectic drugs (Depakote, Tegretal, Lamictal) and now possibly Topomax, (the latter two have not been thoroughly studied, but we are doing trials), I feel that Lithium is superior and has the most scientifically proven documentation in extensive clinical trials that it works, compared to the alternatives. You have to know what you are doing with Lithium, and you have to have considerable experience in treating a number of patients over time with it; since, if used in excess, it can cause toxicity and if used too little, the illness is not stabilized. On the other hand, the anti-epilectics are much easier for the novice psychiatrists to begin using without needing a lot of experience, since you cannot easily harm a patient with the antiepilectics if you don't know what you are doing, but you can harm a patient if you don't know what you are doing with Lithium.

David: You've discussed medications somewhat. I'm wondering how important is psychotherapy in the treatment of bipolar and what role does it play?

Dr. Fieve: Therapy as an adjunct to medication is important in 30-40% of bipolar patients at least, and perhaps even more so for families of bipolar patients. Many classical bipolar patients do not want to have therapy and many do not need it.

Riki: I have been on Depakote and it made me extremely aggressive? Can you explain why this medication had this effect, and is that a normal side-effect?

Dr. Fieve: First of all, I would like to know if you reached a therapeutic level in your blood (50 -100); if you had the proper liver and CBC tests that you needed before you took the medication; and if you had blood tests every two weeks the first 4-6 weeks. Secondly, I have never heard of Depakote causing aggressive behavior, but if the dosage is too low, or if the dosage is correct and the drug is not adequately treating the angry, irritable manic phase, then the aggression will increase for those very reasons. In other words, it is the inadequately treated manic depression that is giving rise to the aggression. I would have to know more about you if this answer does not satisfy you or ring true to you.

David: For the audience, I'd be interested in knowing, if you have Bipolar, what has been the most effective treatment for you? Here's another audience question:

kdcapecod: DO you feel therapy works with children or is it more effective as an adult. This is for a 12-year-old child that is bipolar and ultra-rapid cycler? How do you suggest managing this?

Dr. Fieve: Therapy and medication are of equal importance, and neither can be really successful without the other.

Voodoo: I would like to hear your thoughts concerning the use of Topiramate (Topamax) in the treatment of Bipolar Disorder.

Dr. Fieve: Studies are, to date, very few, but promising. This is another antiepilectic drug that we hope will be effective in both phases of bipolar illness and it is rumored that the weight problem that comes with other drugs maybe less so with Topomax. I am treating a number of patients with it at this point and it looks good, but way off in the distance before trials are completed across the US. Trials are beginning by top investigators throughout the country to fully evaluate the preliminary positive findings in smaller numbers of bipolar patients.

David: Here are some audience responses on the best treatment for bipolar disorder:

valasing: Most effective treatment: Effexor, Depakote, and Wellbutrin.

cassjames4: My parents are both Bipolars. Depakote has done VERY well for my mother, she just started on it last year. Lithium didn't seem to work for her. They are 67 and have been diagnosed for a long time. I am 31years old.

michelle1: Nothing yet.

CLIFF: LITHIUM ! LITHIUM ! AND IN THAT ORDER.!! CHEAP, AND DOESN'T CHANGE TOLERANCE!

carol321: Depakote gave me aggressive behavior and I've heard others complain of the same. The PDR lists hostility as a possible side-effect.

Karen2: Lithium & Celexa & fish oil.

liandrq: Yes, I have bipolar and nothing seems to work.

WildZoe: A mix, Lithobid 900 mg a day, Wellbutrin SR 2 a day, Topomax 1 a day (25 mg since I just began).

vernvier1: I'm bipolar and for the last five years Lithium, Wellbutrin, and Depakote have worked pretty fair.

momof3: Have you noticed particular mood swings with seasonal changes in children. I know that doctors see them in adult bipolar patients. Lots of parents of bipolar kids are saying that their kids seem either manic or depressed right now.

Dr. Fieve: In the literature, mood changes of depression, or breakdowns of depression, or mania, tend to be more frequent in the fall and the spring. Although many people will have swings any time of the year.

Conway: Can you address rages and promiscuity as symptoms.

Dr. Fieve: YES! Both are usually seen in mania, but I refer to manic patients as either happy manics or angry manics. In both cases, medication works but, I still feel Lithium is the first choice in both, the happy and angry manic states ONLY if the doctor knows what he is doing. If the doctor is young or inexperienced, give Depakote or another medication instead.

cassjames4: Both my parents are Bipolar. My mother is finally on medications and in treatment and doing ok, but my father is getting progressively worse and dying from cancer as well. He has even burned down our family house as a result of this mania that he's been in for about 8 years now. He thinks life has never been better. He won't accept help. Is there anything I can do?

Dr. Fieve: Your father has to agree to an evaluation and some treatment since it is more important that he does not burn down another house and harm himself or his family, rather than remain in a happy manic state in his unfortunate terminal illness. If he refuses treatment, you should consider hospitalization, since the next act of violence might be fatal. Was the burning of the house a suicide attempt? This can occur in states of mixed mania as well as depression

liandrq: Thank you, Dr. Fieve. I'm attempting to cure myself. Is there a way to control manic depression? Also, I have a hard time believing that what is happening to me is real. I feel I am just a bad person. What can I do on my own to change this.

Dr. Fieve: Unless you are a very mild case of mood swings, which do not lead to risk-taking, or self-destructive, or angry behaviour to others, you cannot sit out these recurrent mood swings. I would go for an evaluation, and get direction of whether treatment is needed or not. At the end of infrequent consultations, two or three a year, I might say to a patient with very mild moodswings which do not lead to negative consequences in the person and or the family's life, that it is your choice: do you want to ride these out or do you want me to give you a short-term - two to three month trial - of Lithium or alternatives to see which you and your family prefer. Vitamins do not help, and feeling you are a bad person is either a part of your depression, and/or negative self-image, which might be corrected with medication and or lithium, and/or just plain therapy.

David: Dr. Fieve, for those in the audience who are the significant others of Bipolar sufferers, the parents, the spouses, the close friends, how do you survive the unpredictability and mood swings of the person with bipolar over an extended period of time? From comments I am receiving, it has to be very trying and exhausting?

Dr. Fieve: I would like to suggest to the family members to, first have a meeting with the patient and his/her doctor and try to get it all out in the open with respect to your frustrations living with the patient. And ask the doctor treating your relative what to do. Secondly, there are books on the bookstand, that explain the illness, including my own book Moodswing, and there is considerable educational information on the web, community lectures, and manic depressive support groups throughout the country. Finally, if none of these suggestions are helping, assuming the patient is in treatment, I would suggest a second opinion by a psychopharmacologist who has a track record for seeing a large number of bipolar patients and treating them over a long period of time.

David: Here are some more audience comments on what treatment worked best for them:

Farfour: Nothing yet.

thelma: Shock treatment, Lithium (it was toxic), Prozac, Zoloft.

shineNme: Depakote, Eskalith and Vivactil have helped, but not totally eliminated the depression.

bernadette: Lithobid 1200 mg daily.

jeckylhyde: Depakote. My manics have been kept in check, but I can't find relief from the depression.

shineNme: Before I was treated I was very promiscuous, I was a overly happy manic then.

Mongan: Depakote worked, but had to keep upping it. Lithium works OK, but nausea persists.

Karen2: How many years must Lithium be taken for Bipolar?

Dr. Fieve: Karen, for active manic patients, generally in the patients I have treated the correct dosage of Lithium brings them down to normal within ten to fifteen days. If depressive swings follow and the Lithium level is sufficiently therapeutic, .7 to 1.2, then an antidepressant has to be added. This is basically the art of treatment of the individual of the psychopharmacologist who has seen many patients; often atypical and often with complications over time.

JAMBER: How do you know if your child has ADHD (Attention Deficit Hyperactivity Disorder) or Bipolar?

Dr. Fieve: Jamber, often you do not know, and only the factor of time will reveal which of these two diagnoses is the correct one. Do not put labels on these young children too early since many emotional problems, personality disorders, etc., disappear as children get older, and often it is the parents' anxiety that must be addressed. However, children with serious problems must be evaluated and followed by experts, but diagnostic labels should be avoided if possible. Trials, which are exploratory, and time-limited medications can be undertaken with disturbed children. But unless the patient improves, these medications should be indefinitely given. A very understanding therapist is critical for these young people, who are undergoing constant physical, emotional, and environmental changes.

eirrac: Do children, who will eventually develop bipolar in later years, exhibit any behaviors early on that might predict the illness?

Dr. Fieve: They may exhibit hyperactivity, high energy, distractibility, charm and accomplishment. Or they may experience nothing that you can detect. They also may experience sadness, withdrawn behavior and poor socialization.

Jocasta: I was quite taken with your book "Moodswing". I am interested on your current opinions of alcohol use and the combination with antidepressants and Lithium and benzodiazapines. I read your book in 86'. What are the effects on moderate OR binge drinking NOW in 2000, with concurrent use of alcohol or SSRI's and lithium? What is also the preferred SSRI of choice with the least sexual side-effects? Serazone? Zoloft is great but, seems to strike out at high levels. Paxal? Help please, Sir.

Dr. Fieve: Jocasta, there are three or four questions to answer.

David: Why don't you address the alcohol use since I've received several questions about that.

Dr. Fieve: There are no studies that Lithium and/or antidepressants make a difference in moderate to severe alcoholism or binge drinking, even though one study 22 years ago suggested Lithium helped in binge drinking, but this was refuted by another study later. The alcohol itself must be treated as an illness with abstinence and preferably AA (Alcoholics Anonymous), and thereafter, if manic depression is an accompanying co-morbid illness, it can be treated with an antibipolar drug and therapy. If you have no alcoholism in your past history or family history, I prescribe a very modest amount of alcohol, like a glass of wine at dinner, if the bipolar illness is stable. Other doctors might object to this since alcohol and bipolar are genetically related and they fear any alcohol becomes a deterrent in treating bipolar illness. I don't, since the patient's overall quality of life must be maintained if at all possible with a minimal risk. The drugs with the fewest sexual-side effects (antidepressant) include Serzone, Wellbutrin, and possibly Remeron and maybe Celexa.

Nancy Smith: Is the diagnosis of bipolar often used when a teenager is really just antisocial or delinquent? (Not that antisocial behavior isn't a serious problem!)

Dr. Fieve: Nancy: It is possible, if you are going to an inexperienced doctor/psychiatrist/teacher who has read a lot about bipolar in the newspapers or magazines that are current, that this could occur as a simple label to explain this behaviour.

David: Well, it is getting very late. Dr. Fieve, thank you for being here tonight. You were a wonderful guest and we appreciate you sharing your knowledge and insights with us. I also want to thank everyone in the audience for coming and participating. I hope you found the conference helpful.

Dr. Fieve: It was a pleasure to participate in this stimulating discussion with your audience, and congratulations on developing and moderating such an educational force in the community.

David: Thank you doctor, and we hope you'll come back again in the not too distant future. Here are the links to Dr. Fieve's books: "Moodswing", and "Prozac". And here's Dr. Fieve's website: www.fieve.com.

Dr. Fieve: Thank you, and I would be very pleased to return - GOODNIGHT.

David: Good night everyone and thank you again for coming.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Dr. Eric Bellman has over 20 years of experience working with people who have bipolar disorder. The discussion focuses on channeling your manic energies in a positive manner, medication non-compliance and dual diagnosis issues.

David HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Bipolar Disorder: A More Detailed Look". Our guest is Dr. Eric Bellman.

We are going to take a look into some of the details of Bipolar Disorder. We'll be covering medication non-compliance, self-medication, and how to channel your manic energies. If you need general information about Bipolar Disorder, here's the link to the HealthyPlace.com Bipolar Community.

Our guest Dr. Eric Bellman, is a clinical social worker near Los Angeles, California. He has over 20 years of experience working with bipolar individuals in psychiatric hospitals, group homes, and in private practice. Dr. Bellman has performed everything from psychological work-ups of patients to treatment.

Good evening, Dr. Bellman, and welcome to HealthyPlace.com.. From reading the bulletin boards posts in our bipolar community, one gets a sense that, for some at least, remaining faithful to taking the prescribed bipolar medications is a difficult thing to do. Why is that?

Dr. Bellman: Hello! People often do not take prescribed medication because of the powerful nature of the manic episode. In the flow of experience, the power surge of a true manic episode leads to a sense of grandiosity, mixed with paranoia and disconnection from others. Once we are into huge projects, or the secret life of a manic episode, people absolutely resent the loss of power and the sense of loss of self that medications for bipolar disorder cause.

David: What are the ramifications of coming off the bipolar medications? And I'm referring not only to the medical or physiological issues, but the psychological issues too.

Dr. Bellman: The flip side of not taking medications for a manic episode is a tremendous crash into depression. This leads to a disconnection from one self and all of our important relationships, not to mention our work and our lifestyle. Thus, at the end of the day, we wind up fragmented, with no energy to finish tasks, and a terrible sense of shame that can cycle back into another manic episode, substance abuse or isolation and impulsive actions.

David: A moment ago, you talked about a "sense of loss of self" that having to take bipolar medications may bring about. Can you explain or elaborate on that?

Dr. Bellman: Yes. The person experiencing a manic episode is a universe unto themselves with a flow of seratonin, adrenalin, powerful surges of sensory awareness, grandiosity and paranoia, that minimizes the connection with the world around us and our relationships. In a sense, we are the masters of our own universe. This experience is not recognizable to the very person who is not going through it the next day. Thus, we have such disconnected states of feeling internally, that it is difficult to integrate our sense of our self, especially afterwards when we experience the feedback guilt and shame from others so that we cannot trust ourselves to be consistent or experience ourselves as whole.

David: So, I'm assuming that you believe it's very important to continue taking your medications for bipolar disorder. If that's the case, and it's relatively easy to see, why would anyone want to quit?

Dr. Bellman: People quit because they get caught up in a biologically and externally stressful combination. This combination triggers what causes a manic episode, that again puts us into the world of the manic power surge of the true manic episode. These episodes are marked by feelings of grandiosity, paranoia, huge projects and secret compulsions. These compulsions can include gambling, promiscuity, and buying sprees. Therefore, the manic episode acts as it's own drug and creates it's own internal world that we become addicted to.

David: Here are a few questions, Dr. Bellman, on the topic of taking bipolar medications:

Melody270: Why do doctors take you off of medications, when they think you are doing better, since bipolar disorder is a life-long thing?

Dr. Bellman: There are doses for acute episodes to come down off of. Then, there are what we call "maintenance" doses to help prevent re-occurrences. And then, sometimes we want to take a medication holiday because there may be long-term side effects. Generally, it is foolish to take somebody with fairly frequent episodes or tremendous life stress off of medication. I train people to look for red flags so they can prevent manic episodes by using the following techniques:

For example, I often have my clients keep a note card in their pocket with phrases and thoughts that are red flags as to the beginning of a manic episode. For instance, we might think "I don't feel like sleeping tonight because the great American novel is sitting right inside of me." But even if it is, the flow of creativity is better if we control the manic peaks and valleys.

LeslieJ: Do you ever see anyone being non-compliant when they are in their depressed cycle? You have only mentioned the manic phase. Is that the most dangerous time for us in terms of becoming non-compliant?

Dr. Bellman: Indeed, the depressed cycle involves not only the loss of the up manic phase, but the reality of the wreckage that we just created in our lives and relationships, as well as a biological component. This time is thus ripe for acting our behaviors, suicidal thoughts and substance abuse, and giving up in therapy and on ourselves. Substance abuse also, is antagonistic to most medications for bipolar and we can also fall into that trap too at that time. So, in times of depression, we are indeed at risk, but it also presents the opportunity for reflection and reconnection with our lives, and can be the beginning of an upward movement to change.

David: What do you think about the idea of "mood charting"? Do you find it to be a useful tool and does it help with medication compliance?

Dr. Bellman: I think it is very important to evaluate all the cycles of life, and this is one. I would also pay attention to the family experience genetically in their life cycle and to hormonal and other biochemical cycles in the body as we are learning more-and-more about this illness. Sometimes, I wish it was a hundred years from now when we will be able to computer-simulate the actions of the brain. This also emphasizes why we will always need a therapeutic relationship that is safe to share in the experience.

pookah dedanaan: I take medications faithfully, but still suffer from the highs and crashes. I know the highs are happening, yet, I am unable to regulate it. I know when the crashes are about to occur, and this is the time during which I am more likely to self-injure. Any suggestions?

Dr. Bellman: I hope you are in intensive psychotherapy because I have a feeling that you, like many other people, have multiple situations and stress going on in your life at the same time. Self-injury may not be directly related to the episode but to your experience of your relationships around you. Please explore this in therapy.

David: What about people self-medicating - drinking alcohol, taking drugs to ease the manic and depressive episodes. If that frequent among bipolars? And it probably creates more problems, am I correct?

Dr. Bellman: Yes. Substance abuse is the number one dual diagnosis with bipolar disorder. This happens because people do not even realize they are bipolar, or they want to ease the depression that follows manic episodes. Or again, in the case of methamphetamines, they self-medicate in an attempt to recapture the power of the manic episode.

So, chemical dependency can then become its own problem and addiction, reformatting the brain to experience pleasure through neuropathways that are only artificially induced via chemicals.

A third problem is, that medications for bipolar and chemical dependency cannot co-exist at the same time, so we can subconsciously maintain the addiction to use against any medication.

Finally, the way that the mental health care system is constituted is, there is more powerful political influence involved in treating substance abuse, rather than identifying bipolar disorder, but both must be treated at the same time. Let me give you an example:

Years ago a young woman went to a therapist. She had been living on the streets after a manic episode. Her family stated that she had just been released from a hospital for bipolar disorder. When the therapist saw her, a good connection was made and she was put on good medication for bipolar, but the manage care company took her away from the therapist and put her in an N/A partial hospitalization program. Even though she was three months sober. She went back to the street.

This type of thing is too bad and we need to be aware of it.

David: I'm getting some general questions about bipolar. If you need general information about Bipolar Disorder, here are the links to the HealthyPlace.com Bipolar Community and to the transcripts from previous Bipolar conferences.

Here's a diagnosis question, Dr. Bellman:

okika: Is Bipolar always a difficult diagnosis? I spent nearly 15 years without the diagnosis and correct treatment. Simply, I think, because I 'cycled' so slowly.

Dr. Bellman: Yes, it can be a difficult diagnosis because to get a good and accurate history you need a report from the patient or the family members going back 10 years. Some people do cycle very slowly, which is why therapy is important so we can backtrack life experiences. Often times, that college dropout year was chemical use masking a bipolar episode.

David: So given the fact that alcohol and drugs can give a bipolar person a soothing, or not so bumpy experience, what are the alternatives?

Dr. Bellman: The alternatives are to channel the energy into creativity that we can modulate, while using medications for bipolar, to enjoy true accomplishments in the arts and relationships, in the flow and experience of life.

David: Which brings us to channeling manic energies in a positive fashion. Many bipolars in manic states are involved in spending sprees, hypersexual experiences, etc. What creates those feelings and how can they be controlled?

Dr. Bellman: The unregulated power surge of the manic state releases the inhibitions that surround the primitive drives. This is why the power is so addicting and we need medications for bipolar. They can be controlled by being pre-empted, as I said before, red flags, listening to feedback from others around us to warn us and to help us learn to trust.

Helen: Why couldn't we use cognitive therapy to teach ourselves to do "reality" checks? Are medications the only way?

Dr. Bellman: Helen, I absolutely agree that we need the tools of cognitive therapy as that means that we are maintaining an internal dialog with ourselves and have the ability to step back and have an objective prospective. But, meds are necessary as well during a full-blown manic episode for most people because that would be like asking an epileptic during a seizure to stop.

Judyp38: What about bi-polars who are experiencing mild forms of these so-called "red flags". It is hard for me to determine if they are red flags or not. If the person won't listen, what is the next best step? (for a spouse).

Dr. Bellman: Yes Judy, it is hard to determine the difference between everyday stress and anxiety and true red flags. What concerns me is that the person "won't listen". I think relationship counseling is very important as this is a definite trust issue.

David: But isn't it true of many individuals who suffer from a mental illness, at least at first, that they are in a state of denial. They just don't want to believe it's true.

Dr. Bellman: Yes, and this is very similar to an intervention of an alcoholic, although done more lovingly. There are also issues that may involve family dynamics and secrets that add to the denial. Again, that is why a good history is necessary. But, especially with my teenagers who are bipolar, I find the impact on the parents and their denial almost harder than that of the young person experiencing bipolar. This is one of the most challenging parts of family therapy work.

David: I want to return to channeling your manic energies. Can you give us some specific alternatives to deal with those manic phases?

Dr. Bellman: First off, If you are a musician, artist or a writer, write down your ideas and thoughts and still take medications. Even in the more solo arts, and I include mathematics, engineering and physics in these, we need to stay connected to our colleagues, family and other significant relationships during these times so that two things happen:

One, the energy is dammed and channeled, like a great river that does not overflow it's banks because of the medications and our connections around us with other people. Secondly, we can then actually finish projects because we pace ourselves instead of hitting a manic peak and fragmenting.

David: By the way, if anyone in the audience has some tips that worked for them during manic episodes, please send them to me and I'll post them. Hopefully, that will help some others here tonight.

Here are a few audience responses to what's been said tonight:

okika: I think that when I was 'hypo' my doctors thought this was maybe the correct medication and improvement of my depression. My Diagnosis is actually Bipolar II. I have now been stable AND sober for 6 years.

Helen: I agree about relationships. Maintaining them helps me avoid withdrawal into a distorted inner world and is a good check on whether my behavior is getting inappropriate - "red flags".

derf: If you feel your head tingling or are getting goosebumps from "profound" thoughts, force yourself to sleep.

David: Here are some more questions, Dr. Bellman:

Bemused: What about complete and total trust in a relationship turning all-consuming, not being able to be comfortable at all without that trusted person's physical presence?

Dr. Bellman: For adults, trust and dependency is voluntary, not involuntary. That does not mean that there are not great attachments, loves and soul mates. It just means that there are more evolved feeling states to be explored beyond the dramas of need, abandonment and betrayal. Please explore these in therapy, Bemused.

Bounder: What about the effects of caffeine during a manic episode?

Dr. Bellman: Bounder, caffeine can have a paradoxical effect during manic episodes that relax one. I would look at the heavy use of caffeine as red flags in two ways:

One, that the person is trying to preempt the beginning of a manic episode, or two, there are other stresses in a person's life that can trigger either pole of bipolar disorder.

David: What about sugar and carbohydrates? Would you put that in the category of self-medicating?

Dr. Bellman: Absolutely, as well as compulsive eating, but I am also very careful to get all my patients a good physical workup because there could be thyroid or low blood sugar or other physical conditions and disorders that can mimic bipolar disorder.

kbell: Can you give some example of family dynamics that contribute to the denial?

Dr. Bellman: Yes. If there has been any mental illness, substance abuse, or suicide, or cataclysmic events such as the holocaust, the families are reluctant to accept that the experience could happen again thus "re-opening old wounds". Plus, there may have been criminal activities, physical, sexual or emotional abuse that led to family secrets that the family hoped would die with their generation.

Judyp38: I am not bi-polar but my husband is (for two years only). How do bi-polars want to be treated? Do they take responsibility for their character or should we take into consideration that they are "bi-polar"?

Dr. Bellman: Most people want to be treated as loving human beings and not be looked at as being weird. We need to remove the stigma of mental illness, and perhaps even that phrase. I think the best way to talk about it with your husband is as an epileptic that has seizures that need to be treated with medication.

derf: On a mood scale of 1 to 10, 1 being severely depressed and 10 being out of this world manic, where would you say the most productive and creative BP people operate at?

Dr. Bellman: Five to seven is optimum; again as long as we are creative and connect with others, a little bit on the high side is OK. But keep in mind that research indicates that 0-1 is not most at risk for suicide, but 2-3 is because they have more energy.

David: I want to thank Dr. Bellman for coming tonight and sharing his knowledge and experience with us. I also want to thank everyone in the audience for participating. I hope you found it helpful.

Again, thank you Dr. Bellman for coming tonight.

Dr. Bellman: Thank you, and everyone in the audience. Good night.

David: Good night everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Dr. Emanuel Severus, is a research fellow in psychiatry at Harvard Medical School where he works with the Bipolar and Psychotic Disorders Program. His research consists of new treatment options for bipolar disorder, schizophrenia, and other psychotic disorders.

David HealthyPlace.com moderator.

The people in blue are audience members.

---

online conference transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Recovery Issues in Bipolar Disorder." We have an excellent guest tonight. Dr. Emanuel Severus, M.D., is a research fellow in psychiatry at Harvard Medical School where he works with the Bipolar and Psychotic Disorders Program (New and Experimental Psychopharmacology Clinic/Lab). His research consists of new treatment options for bipolar, schizophrenia and other psychotic disorders. Dr. Severus won the 1999 Glaxo Wellcome Research Award.

Good evening, Dr. Severus and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Before we get into the meat of the conference, can you tell us a bit more about your expertise in Bipolar Disorder?

Dr. Severus: Thank you for the invitation! Since 1995, I have been interested in new treatment options for bipolar disorder. In 1995, Dr. Stoll and I came up with the idea of using omega-3 fatty acids.

David: Can you expand on that a little more? Maybe explain what omega-3 fatty acids are and how they are used?

Dr. Severus: Omega-3 fatty acids are essential Polyunsaturated Fatty Acids (PUFAs). They are found in flaxseed oil and fish oil, and of course, fatty fish. Some examples include salmon, herring and mackerel.

Those fatty acids seem to share similar properties with the established mood stabilizers, with regard to signal transduction at the postsynaptic membrane.

David: In non-technical terms, what is the impact, then, of ingesting these fatty acids?

Dr. Severus: Down-regulating of post-synaptic pathways, resulting in improved membrane stability.

David: Since you are in the research field, what is the "best" treatment for bipolar disorder available today?

Dr. Severus: It really depends on the individual, and it also depends whether you are just focusing on pharmacological treatment options, or not.

David: Let's start with bipolar medications, or natural remedies for bipolar, and then we'll progress from there.

Dr. Severus: Okay. We can start with natural remedies for bipolar. Omega-3 fatty acids are definitely a good choice for patients with bipolar depression, however, they also seem to have mood-stabilizing properties.

Another benefit, is the beneficial side-effect profile. Apart from gastrointestinal distress, there are practically no adverse effects. In fact, omega-3 fatty acids seem to protect individuals with myocardial infarction from sudden cardiac death. And as you might know, patients with affective disorders are at an increased risk of developing Coronary Artery Disease and myocardial infarction.

David: I have not heard of many doctors recommending omega-3 fatty acids as a first line treatment. Usually, they start with medications like Lithium, etc. Would you suggest that some with bipolar disorder try omega-3 fatty acids first, before turning to some of these other medications?

Dr. Severus: It is true that Lithium is the most established mood-stabilizer. It seems to have potent anti-suicidal properties, apart from its mood-stabilizing properties. On the other hand, it seems to prevent manic episodes more effectively than depressive episodes. Some patients also complain about the side-effect profile, like increased thirst, cognitive dulling, weight gain, acne, tremor. I think it really depends on the individual.

KcallmeK: How does the use of omega-3 measure up in regard to anti-suicidal properties?

Dr. Severus: We don't know yet. There are some data from Finland which suggests that it also has anti-suicidal properties.

erycksmom: Can you try the omega-3 if you are currently on Lithium and still not stable?

Dr. Severus: Sure. I think adding omega-3s to Lithium or Valproate is a very good option. You also don't have to be concerned with drug interactions.

David: How much omega 3 is recommended, and what is the "best" form to take it in?

Dr. Severus: Good question! There is alpha-linolenic acid, which is found in flaxseed oil, and there is EPA (eicosapentaenoic acid) and docosahexaenoic acid (DHA). Double-blind controlled data exist for fish oil (EPA and DHA) with a ratio of EPA/DHA:3/2. During the last few years we have got the impression that DHA alone is not very helpful. So, we suggest that you start with a high EPA fish oil.

Other characteristics you should look for are:

• High concentration of omega-3 fatty acids per capsule.
• No fishy aftertaste.
• Quality brands of fish oil manufacturer use nitrogen to produce the fish oil.
• No fish liver oils due to high levels of vitamin A and D.
• No cholesterol.
• Start with a high EPA brand, approximately 3 grams of EPA.
• If you are a vegetarian, use flaxseed oil (1 to 2 tablespoons is a good starting dose).
• Using a lignan rich flaxseed oil might have some advantages. Barlean's offers such a flaxseed oil.
• You should always keep it refrigerated.

David: Just a note here: I received a couple of messages from people who are concerned that we may be advocating dropping your bipolar medications and taking omega-3 fatty acids instead. That is not the case. As I said at the top of the conference, any information presented here is for your information only. If you find it useful, I suggest you talk it over with your doctor. But please, do not stop taking your medications based on what is presented here.

Pjude9: How long before one would notice any effect from omega-3?

Dr. Severus: You might notice beneficial effects within the first two weeks, however, you should take it for four weeks to be sure whether it is helpful for you, or not.

I would also like to support what David just said: We don't encourage people to drop their current bipolar medications. In addition, omega-3 might be a good option, if you are not stable on your current medications. Furthermore, always talk to your Primary Care Physician or psychiatrist before changing any medications.

L.Lee: I am Bipolar II, and am on 400 mgs. Topamax (Topiramate) and 400 mgs. Wellbutrin. Lately, I've been having a problem with rages. Is this due to medication? I have always have been passive.

Dr. Severus: Well, any antidepressant may worsen the course of the disease and trigger manic or mixed episodes. On the other hand, Wellbutrin is the one which is very well tolerated in general. The side effect profile of Topiramate does not include rages as a common side effect.

David: One of the things we get a lot of email about is people who are prescribed antidepressants, when they really needed mood stabilizers. How does a person know which type of medication would be right for them?

Dr. Severus: I agree. Mood stabilizers should be the first-line treatment. And it might be a good option to add Lamotrigine instead of an antidepressant, because Lamotrigine seems to have mood-elevating and stabilizing properties.

sadsurfer: Dr. Severus, if mood stabilizers and antidepressants are used, and a patient achieves some degree of stability, does this necessarily confirm the diagnosis of bipolar disorder, even if the patient has never had a "true" manic episode?

Dr. Severus: The diagnosis should not rely on a treatment response. Bipolar 1 disorder requires a manic or mixed episode, Bipolar 2 disorder "just" hypomania. Sadsurfer, if you click on this link you'll find the criteria for diagnosing bipolar disorder.

e: I'm concerned with the idea of my bipolar illness being hereditary. I was diagnosed after my son was born, and have been told the pregnancy might have triggered my illness to surface. I am Bipolar and have Obsessive Compulsive Disorder (OCD). My question is what chance is there that my son will suffer from a mental illness?

Dr. Severus: It is hard to tell, but you should remember: Even if the genes are involved in bipolar illness, environment also plays an important role. So don't get discouraged.

webbsspyder: How can psychotherapy be helpful in managing and treating bipolar?

Dr. Severus: Sure, there is a new psychotherapeutic approach called: Social rhythm therapy. This sound very promising to me!

David: Can you explain more about that?

Dr. Severus: Yes, social rhythm therapy focuses on restoring and maintaining personal and social daily routines to stabilize body rhythms (especially the 24 hour sleep-wake cycle).

David: Also, webbsspyder, we've had many conferences here where the doctors talk about the importance of therapy in dealing with your personal issues, feelings, and thoughts. The medications can stabilize your moods, but they don't resolve psychological issues. That's what therapy is for. Here are the transcripts from those conferences.

victory: How does improved membrane stability affect bipolar disorder?

Dr. Severus: Well, we think that it translates into increased mood stability. It may also decrease the stimulation threshold, however, this is a hypothesis.

rwilkins: I have been on Lithium for over twenty years. I do pretty good for myself. Christmas holidays are usually the hardest, but not all the time. My levels are always good. My question is would Omega 3 possibly be a plus?

Dr. Severus: You can try it, but you should start then pretty soon. Another, and maybe better option, might be to invite friends for Christmas, if it is possible.

ripley: I was on Lithium for two years, and can no longer take it due to a goiter in my thyroid. How can I get back on it? It has helped me greatly otherwise.

Dr. Severus: You could take a thyroid supplement. Have you developed the goiter under Lithium?

ripley: Yes.

Dr. Severus: Are you hypothyroid, or do you have elevated T3/T3 levels?

ripley: I'm not sure, I wasn't told.

Dr. Severus: You should find out. Taking a thyroid supplement might be good option for a "hypothyroid" goiter if you developed it under Lithium.

Pjude9: Could you explain why anti-psychotics such as Zyprexa and Seroquel are used in treating bipolar?

Dr. Severus: Zyprexa has acute anti-manic properties. We don't know yet whether these drugs also have good mood-stabilizing properties in the long term.

techie: Would you recommend medicines like Depakote and Celexa along with the omega-3 fatty acids?

Dr. Severus: If you are suffering from severe depression, than this combination alone is not helpful, you might consider adding the Omega-3s. By the way, I would always recommend a daily mood chart to monitor symptoms and improvement when you change medications. I think that this is extremely helpful, especially also in retrospective.

techie: I'm on 1250mg of Depakote, 20mg Celexa and 10mg Zyprexa, but I can't seem to stay stable for more than a month. Is this common?

Dr. Severus: Unfortunately, it does occur. This is why polypharmacy (taking several medications) has become so frequent.

David: A few notes here, then we'll continue with a few more questions. Here's the link to the HealthyPlace.com Bipolar Community. 

erycksmom: I attend a bipolar support group, and there is a lady there who has been on Lithium for over 20 years. She mentioned that when she was first diagnosed, that they gave her some test that pointed to manic depression. I have been told no such test exists. Was there ever such a test, and will there ever be a definitive test to prove medically that I suffer from bipolar?

Dr. Severus: I doubt that this test was reliable, and I am a bit skeptical whether we will have such a test in the near future. However, we can diagnose bipolar disorder even without a "test" pretty well. This is why we have the diagnostic criteria.

PSCOUT: Can you please discuss the use of Neurontin as a mood stabilizer?

Dr. Severus: Gabapentin seems to be especially helpful in the treatment of anxiety in bipolar disorder. Another advantage is its lack of interactions with other drugs, however, it may cause fatigue, sedation, and dizziness. Furthermore, I am not aware of any well-controlled data regarding long-term mood-stabilizing properties.

David: Just to make sure, Gabapentin and Neurontin are one and same, correct?

Dr. Severus: Yes.

garfeld: Can this be used with children with bipolar and an anxiety diagnosis?

Dr. Severus: To tell the truth, I don't know the data in children with bipolar disorder, if there are any. Sorry.

SaxDragon78412: I have read some reports that people with bipolar should not take Melatonin supplements, and other reports that we should. Which is correct?

Dr. Severus: Melatonin might be helpful to improve sleep during a depressive episode, but it does not have anti-depressive properties. It might also be useful to treat jetlag, which is especially dangerous for people suffering from bipolar disorder.

cris7448: I was misdiagnosed and went through hell on other antidepressants, but Wellbutrin has worked very well for me. However, even on the medications, I still have some mood fluctuations. What besides medications and omega 3, can I do to try to keep my moods stable?

Dr. Severus: Here are some suggestions for maintaining mood stability:

• Exercise on a regular basis.
• Maintain a stable sleep pattern.
• Don't use any alcohol, try to avoid caffeine.
• Some people also report that white sugar makes them feel worse.
• Start some kind of relaxation technique (Diaphragmatic breathing for example seems to be helpful for some).
• Try to reduce stress at work and during your leisure time!

David: Those are excellent recommendations, Dr. Severus. I'm also getting some audience requests re: the correct daily dosage level for omega-3? Could you give that to us, please?

Dr. Severus: Sure. Start with approximately 3 grams of EPA per day, or 1-2 tablespoons of lignan-rich flaxseed oil.

David: And is there a maximum limit on that?

Dr. Severus: We don't know yet, but I would not recommend more than 4.5-6 grams of EPA or 3 tablespoons of flaxseed oil, and always closely monitor your symptoms. We have seen a few hypomanias on flaxseed oil and EPA/DHA, however, on high doses.

missdjv: My mother has been very unstable for months, so we had to move her to my home. Will this Neurotin work quickly, or should she be hospitalized while adjusting to this medication? I really want to do what is best for her.

Dr. Severus: You should talk to her psychiatrist regarding hospitalization. It really depends on her condition. In general, if there is a significant risk of suicide or homicide, you should definitely consider hospitalization.

truckdog: How can you help your loved one gain" insight" that they have Bipolar?

Dr. Severus: Good question! The best thing might be to tell him or her, is to read some books on this condition. Or to attend a meeting of a self-help group and to talk to other people with this illness.

terri/co: Does omega-3 fatty acids in combination with other medications tend to moderate side effects such as weight gain?

Dr. Severus: We don't know yet. In our study we have not seen any significant weight gain. There are some studies in obese non-psychiatric patients which point to the fact that omega-3 have beneficial effects on the blood lipid profile in that population. However, you should also get some advice from a nutritionist.

David: I know it's getting late. Thank you, Dr. Severus, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active bipolar community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others http://www.healthyplace.com.

Thank you, again, Dr. Severus for joining us this evening.

Dr. Severus: Thank you for the invitation. And to the audience, one last piece of advice: Never ever give up!

David: Good advice. Good night everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Carol Watkins, M.D., our guest, is board certified in adult and child psychiatry. She has written numerous articles on the treatment of Bipolar Disorder, Manic Depression and Depression in children and adults.

David Roberts is the HealthyPlace.com moderator.

The people in blue are audience members.

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David: Good Evening. I'm David Roberts, the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Depression and Bipolar Medications." Our guest, Carol Watkins, M.D. is board certified in adult and child psychiatry. She is a clinical assistant professor of psychiatry at the University of Maryland and maintains a private practice in Baltimore, Maryland. She is the author of many published psychiatric papers and a frequent lecturer at workshops and seminars. Dr. Watkins has also written numerous articles on the treatment of Bipolar Disorder and Depression in children and adults.

If you are looking for information on particular depression medication or medication for bipolar disorder, you might want to try the HealthyPlace.com psychiatric medications area.

Good evening, Dr. Watkins and welcome back to HealthyPlace.com. We appreciate you being our guest tonight. Lately, we've been hearing a lot about children with depression, teens with depression. What do you think about children under age eighteen receiving antidepressants?

Dr. Watkins: In some cases, medication can be useful for depressed children and adolescents. Depression in young people is often overlooked, sometimes with tragic results. We are generally more cautious when using medications in those under eighteen. In the past decade, we have gotten more safe and effective antidepressants for young people.

David: What makes an individual "qualified" for medication for depression?

Dr. Watkins: It varies depending on the severity of the depression, the individual's medical condition, and the individual's preferences. For milder depression, we are more likely to recommend psychotherapy first. For more severe depression, antidepressant medication is more likely to be necessary.

David: We've heard a lot about "brain chemical" depression, an imbalance in a person's brain chemicals. Are antidepressants the only way to treat that?

Dr. Watkins: The term "chemical imbalance" is misleading. Many things start with a chemical abnormality and become much more. For example, type 1 diabetes seems to be a simple chemical abnormality. The pancreas does not make insulin. The disorder is treated by insulin. However, living with diabetes is much more complex. It involves lifestyle issues, and many behavioral and emotional issues.

David: I was under the impression that antidepressants were primarily used to balance the brain chemicals. Is that not true?

Dr. Watkins: Yes, they are. However, we do not completely understand how the brain chemicals get the way they are. I suspect that there are still a number of factors that we do not yet understand. Non-pharmacological things that make you feel better may themselves alter brain chemistry.

David: We also have a very large Bipolar Disorder community here at HealthyPlace.com. So, I want to touch on that too, before we start taking some audience questions. Can Bipolar Disorder be effectively managed without medications?

Dr. Watkins: I think that Bipolar Disorder is one of the conditions that usually requires long-term medications. Fortunately, we have more and better choices in that area. However, other factors can help the medications for Bipolar Disorder be more effective. For instance, getting the right amount of sleep is very important to a person with Bipolar Disorder.

David: Let's get to some audience questions, Dr. Watkins.

Dr. Watkins: O.K.

Wende: My son does not seem to have the "depressive" traits usually associated with bipolar. It's the manic side that we see more often. What meds do you recommend?

David: Wende's son is four years old.

Dr. Watkins: I can't really recommend specific medications without evaluating your son. It can be difficult to diagnose bipolar disorder in a preschooler. He should have a complete physical, neurological and psychiatric evaluation. Psychological testing may also be useful. You need to be very thorough in a preschooler with manic-type symptoms.

David: We've had a lot of doctors on talking about bipolar in children and many are hesitant to classify a young child as having bipolar. What are your thoughts on that?

Dr. Watkins: I have seen a few that did seem to have bipolar disorder. I feel more confident in making the diagnosis if there is a strong family history of bipolar disorder, and I have had a complete evaluation. I may try to hold off on mood stabilizers for a few years if I can manage things behaviorally. I might get a second opinion if I really thought that a four-year-old might need a mood stabilizer.

nrivkis: On the subject of bipolar disorder in kids, I'm bipolar and am trying to have a baby. Is there any advice you can give me about how to raise a child who may potentially inherit the disorder, what to look for, etc.?

Dr. Watkins: First, love your child, and take good care of yourself. There is some data to suggest that children do better if their parents are in a good frame of mind. You might look back and get information on how you were as a child. Watch for those symptoms in your child and take him or her in for an evaluation, if you have concern about excessive mood shifts or irritability. However, you should not over-react and label normal childhood tantrums.

David: We apparently have a lot of mothers, or women wanting to be mothers in the audience tonight. Here's another pregnancy question.

lobc42: What are the chances of having a baby if you are schizoaffective and take Depakote, Resperidal and Effexor?

Dr. Watkins: You should talk to your psychiatrist and your obstetrician well before you try to become pregnant. Go to an OB who is comfortable dealing with this sort of thing. Make sure that you are aware of the risks and benefits of medication during pregnancy. You should also make sure that you are in a stable time in your illness. It is best if you are married or in a long-term stable relationship. If you have a breakthrough, your partner can help you and the child.

Una: Would you elaborate on the importance of sleep for a Bipolar person?

Dr. Watkins: If you are going into a manic spell, you often begin to sleep less. The sleep deprivation can further charge the mania. It can also increase the chances of paranoia. Many people find that they have fewer breakthrough mood swings if they maintain a regular sleep-wake cycle and a regular amount of activity. Even time shifts and jet lag can set off some mood shifts.

revdave9: Dr. Watkins, I'm David and I'm thankful for HealthyPlace and this opportunity to speak to you. I've been taking Effexor for close to five years now. Because of financial considerations and geographic distance, it is difficult to get professional help. My question concerns side effects of Effexor and long term use of it. I'm currently taking 225 mg of Effexor XR. My side effects are sweating on my upper body with the least amount of activity, and sweating on the sides and back of my head when I rest.

Dr. Watkins: The SSRI medications can cause excessive sweating in some people and I would expect that Effexor might do this also. You could talk to your doctor about a medication change. Alternatively, you could wear loose clothing and turn down the thermostat.

David: In this case, what other medications might prove effective without these side effects?

Dr. Watkins: Most of the SSRIs could cause this. Wellbutrin, Serzone and possibly the tricyclic antidepressants might be less likely to cause sweating.

David: On the subject of side-effects from psychiatric medications, should people taking these meds expect side-effects? Is there any getting away from it?

Dr. Watkins: The SSRI medications generally cause fewer side effects than some of the older antidepressants, but they can cause side effects in some people. Many people, especially those on high doses of SSRIs, get sexual problems from medications; often decreased desire or delayed orgasm. SSRIs can cause sedation. They can cause agitation or restlessness. I see restlessness more in children and adolescents. That is why I am less likely to use Prozac as my first choice for an SSRI in some children. There are a number of other side effects of SSRIs including weight gain and headaches.

If you have decreased sexual desire on an SSRI, there are several options. You might switch to another class of medications such as Wellbutrin or Serzone. If despite the sexual side effects, you wanted to stay on the SSRI, you could lower the dose, or you could add Ritalin or Wellbutrin. Sometimes these help, sometimes not.

David: Here's an audience comment, then we'll continue:

batiking: Sweating excessively is why I switched from Paxil to Zoloft, then to Celexa. Sweating is one of the side effects listed for Effexor in Healthy Place psychiatric medications list.

Dr. Watkins: The sweating is usually more annoying than serious. If it were accompanied by confusion, excessive salivation or other bad side effects, then call the doctor.

princessdez: Every month, I seem to stabilize and then extreme PMS throws me off. What can help this?

Dr. Watkins: Some women with PMS, take a higher dose of an SSRI the five or six days before their menstrual period. Before you do this, you and your doctor should chart your moods daily for about three months. See if there is a correlation between your monthly cycle and your moods.

Moody Blue: What do you think about the drug Topamax being used for patients with mixed states?

Dr. Watkins: It has been used for Parkinson's and I have heard that some people are using it as an adjunct for mood states, but I have not used it yet.

vetmed00: Are there any natural remedies for depression and bipolar that can be used in conjunction with antidepressants?

Dr. Watkins: I have used St. Johns Wort in a few patients who did not do well on several other antidepressants. I have also used Fish Oil (Omega 3 Fatty Acids) for mood swings. However, I prefer to try more established medications first. Since we have very little data on mixing these herbal compounds with traditional medications, I prefer the person to be off other antidepressants before we try the alternative treatments for depression or bipolar disorder.

Rasha: I have a ten-month-old son and Depression seems to run in my family and on my husband's. Is it possible my son can get depression, and are there ways I can help prevent serious depression?

Dr. Watkins: You should be sure that your son gets a lot of affection from family. Encourage him to develop a mindset that he can solve problems and that life is not a helpless situation. Some people think that one's cognitive mindset can be protective against depression. If he does get depression, you may be in a good position to see it and get him help early.

I recommend that children with a family history of depression or bipolar disorder get education about drug abuse and responsible sexual behavior. They are at increased risk for these problems, and a lot can be done for prevention.

David: How important a role does nutrition play in maintaining mood stability?

Dr. Watkins: My patients sometimes say that I act like their mother: Eat your breakfast, eat a balanced diet and exercise regularly. I believe that there was a recent study out of Duke that suggested that regular exercise helped depression. I am not a fan of extreme diets. I have sometimes thought that the extreme Ketogenic diets make some people more irritable.

David: Here's the link to the HealthyPlace.com Bipolar Community. You can click on this link, sign up for the mail list at the top of the page so you can keep up with events like this. Then, here's the link to the Depression Community.

Also, here is the link to Dr. Watkin's site.

nrivkis: I've heard a lot about St. Johns Wort is dangerous in combination with certain foods, much the way the MAOIs are. I've also heard this is nonsense. What's the real story?

Dr. Watkins: Initially, there was a suggestion that St. Johns Wort acted like a MAO Inhibitor. At this point, I don't think that we are worried about having a crisis when you take St. Johns Wort and eat Tyramine-containing foods. The jury is still out on combining it with other medications. One could get a build up of Serotonin. Also the herbal compounds are not tightly regulated like regular medications. The dose of St Johns Wort can vary from pill to pill. That could influence interactions too.

David: Here's an audience comment relating to that:

batiking: I am a chemist, and wish to address "natural" remedies for depression. There is an active ingredient in SJW that is a chemical, just like the active ingredient in traditional meds are chemicals. Just because something is labeled natural doesn't mean that it is safe.

armand: I have been diagnosed with Bipolar since1976. I have never stayed on medications for long. I am forty-eight and I am feeling alright under the doctor's care, but not following up. I have Hepatitis C and I am worried about the effects that Lithium will have on my liver.

Dr. Watkins: With Lithium, we keep track of the kidneys and the thyroid. Some people develop low thyroid functioning while on Lithium. If not corrected, this can exacerbate rapid cycling. One can either switch to another mood stabilizer or add thyroid.

Sometimes Lithium can affect the kidneys. Diabetes insipids (not sugar diabetes) can be a side effect. The kidneys cannot concentrate the urine and the individual needs to drink and urinate a lot. One can switch to another mood stabilizer, or sometimes you add a diuretic medication.

batiking: I am BPII, Rapid cycler. I was recently treated with Topamax as an adjunct to Lamictal (400 mg). I had incredibly bad side effects, including suicidal depression. Is this a typical response to such a promising medication?

Dr. Watkins: I haven't heard of that. Lamictal is a good medication for Bipolar II disorder because it helps the depression without causing a mania. If your mania is well-covered with the Lamictal, you might ask your doctor about cautiously adding Wellbutrin. It has the potential to cause a manic breakthrough, as do all antidepressants. However, it may be less likely to do so than Tricyclics or MAOIs.

dayna: How long should you stay on one antidepressant before you should try a new one?

Dr. Watkins: If you are not getting a good result in 4-6 weeks, consider a switch. If you are getting bad side effects, you may need to switch earlier.

princessdez: I just discovered my 80-year-old grandmother has Bipolar. How do I explain that she needs medication after all these years?

Dr. Watkins: If an elderly person gets their first symptoms of Bipolar disorder at that age, she may need a neurological work up. Sometimes other illnesses can mimic depression or bipolar disorder.

blink7: I am on Zyprexa as a mood stabilizer. Is that a good move? The confusion is getting me out of my teaching job. It is hard to focus on anything.

Dr. Watkins: The newer atypical antipsychotics such as Zyprexa can help stabilize mood. Often they are used in conjunction with a mood stabilizer such as Depakote. The Zyprexa might have some antidepressant qualities. If the Zyprexa is causing mental cloudiness, or slow thinking, you might want to talk to your doctor about whether the dose is high or whether a mood stabilizer such as Lithium or Depakote might be helpful.

David: With wintertime coming on, I'm sure there are some people who are concerned about their depression levels increasing. They may suffer from seasonal affective disorder (SAD). What do you recommend for that?

Dr. Watkins: For winter depression, (seasonal affective disorder, SAD) I often prescribe a light box. You are better off using one from a legitimate company because you have to make sure that the light filters out any ultraviolet rays. Since the light is so bright, home made ones may have damaging bright spots. The reputable ones are fairly safe. It is better to use one under medical supervision. There is a clear dose/response curve depending on time and duration of light exposure. If you do not want to use the light, Prozac or another SSRI can work for SAD. I think that the lights have fewer side effects. It is just that some people do not have the patience to sit with one for 20 minutes a day.

David: One of our audience members would like to know if a tanning bed would be effective in treating seasonal affective disorder, SAD?

Dr. Watkins: Do not use a tanning bed. The UV rays could harm your eyes. The conventional light boxes have the light striking the open eyes. You do not want to look at the tanning lights. You also would not know the exact amount of light you were receiving.

Alohio: My mate is bipolar; how can I best help her?

Dr. Watkins: Educate yourself about the disorder. Some couples therapy can also be useful. You and your mate might make up an advance plan about how each of you will recognize and react to the beginning of a mania or a depression. You need to watch out for breakthroughs, but do not go too far and label each minor mood change as a mania.

jsbiggs: Recently, I experienced a violent reaction while making a transition from Epeval to Limictal and I have been without meds except for Omega 3. I feel the need to go back on a more conventional medication. Do you have any advice?

Dr. Watkins: I don't know what you have tried before. Some people use an Antipsychotic or a Benzodiazepine temporarily while waiting for a mood stabilizer (like Tegretol or Neuroltin) to take effect.

glow: What is normally the maximum dose of Effexor - XR?

Dr. Watkins: I usually do not go much beyond 300mg. I check blood pressure fairly often when I am using it in the higher range. You can go up to 375, but I am a bit cautious because I have had a few people have elevated blood pressure on higher doses.

karensue76: One of my diagnoses is major depression for which I take Prozac and Neurontin. Are these medications for clinical depression only, or can they be helpful in situational depression?

Dr. Watkins: If you have an adjustment disorder, minor depression, temporally related to a stress, we often don't medicate. If your symptoms are severe enough to merit the diagnosis of major depression, then medication could be helpful.

Maggie2: Can depression be treated with drugs only?

Dr. Watkins: In some cases, depression responds to medication alone. I like to use a combination, so that the person can develop the cognitive tools to cope better. However some people prefer not to use therapy and do well.

AMtDew4Me: A few months ago, I decided to use St. Johns Wort because I had taken so many quizzes for depression online and tested majorly depressed. I could tell the change in my moods and the way I acted and so could my friends. Recently my mom was diagnosed positive for depression and anxiety. I'm thinking of going back on St. Johns Wort now because my moods, and the way I'm acting, are starting to go crazy again . Do you think that I should consult a doctor first? Or should I trust my previous experience?

Dr. Watkins: There is the saying among doctors, "A doctor who treats himself has a fool for a patient." That may be a bit harsh, but there is a moral in it. Someone else can be more objective. If one of my children became depressed, I would not treat him myself. I could not be objective.

David: AMtDew4Me brings up an important thing here. The online tests for depression or any other mental health disorder are really just a very initial screening. We have them, but please don't take them and think you are getting a diagnosis. For a real diagnosis, please see your doctor or therapist.

breanne: Dr. Watkins, I was wondering if you could tell me whether the drug Topiramate will bring up the drug level of Desipramine. The reason I ask is because I am currently taking 150 mg of Desipramine with that drug and I want to increase it by 50 mg.

Dr. Watkins: A better way to increase the Desipramine level is to take more Desipramine. Have you and your doctor decided that 150 is the right level for you?

David: I know it's getting very late. Thank you, Dr. Watkins, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others. http://www.healthyplace.com/.

Also, Dr. Watkin's website is here.

Thank you again for coming tonight, Dr. Watkins.

Dr. Watkins: Thank you, it was a pleasure and thanks to everyone for the good questions.

David: Good night everyone, and I hope you have a pleasant weekend.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Two of our journalers, David and Jean, discuss what it's like living with bipolar disorder, from hypomania to severe depression.

They also shared how being bipolar effects their relationships and what treatment for manic depression and bipolar medications they use to control the symptoms of bipolar disorder.

David HealthyPlace.com moderator.

The people in blue are audience members.

---

David:Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Living With Bipolar Disorder." Our guests are Jean and David, two of the journalers in the HealthyPlace.com Bipolar Community. I'm going to tell you and a little about each and you can click on their names above to read the biographical sketches each sent me.

The reason I invited them here this evening is because I thought it would be interesting to have two "regular" people talk about how they experience bipolar disorder and how they cope with the different aspects of it, instead of inviting an "expert" on to talk about how it should be done. I'm going to talk to them for about 10 minutes each and then we'll open the floor for your questions and comments.

David is 30 years old. His parents first noticed symptoms of manic depression when David was 4. He has been married for 11 years and is a photographer and digital artist.

Jean is 49, married twice with a total of 5 children from both marriages. Jean is unusual in that her bipolar symptoms didn't first appear until 5 years ago, when she was dealing with the stress and depression that stemmed from the autism diagnosis of her fifth child. The doctor prescribed an improper dosage of an antidepressant and six months later she became hypomanic.

Good evening, David, and welcome to HealthyPlace.com. So we can get a little better feel for who you are, please tell us a bit more about yourself?

David W: Hi. It's nice to be here. I have been bipolar for most of my life and go up more than down. I actually feel that there are advantages to being bipolar, although it makes life difficult at times. I'm a rapid cycler, so no mood lasts too long, usually.

David:You mentioned having bipolar most of your life. How did your family members deal with that?

David W: Pretty well for the most part, but I was not taken to a therapist or anything. My father is a pastor and counselor and dealt with most of my issues himself. I hid my depressions for many years, and since I go up more than down, it was assumed that I was only a very active and creative child.

David:Why did you hide your depression?

David W: I didn't understand it. I was ashamed to feel so bad for no reason. I felt like I was supposed to just have faith or choose to be happy. I didn't know how to express suicidal thoughts at 8 and 9.

David:In your adult years, have you been able to share with your family how you feel and the impact that bipolar disorder has had on your life?

David W: Yes. Thankfully, my family has been very supportive and helpful. I wouldn't have made it this long without them.

David:What do you attribute that to? I ask that, because many people are afraid to share things like this with their families for fear of rejection.

David W: I attribute it to many nights of my opening up and telling them exactly how I feel and what's happening in my mind, even when it's embarrassing. I am sometimes to scared to say it or unable to, and I have written them letters, much like my bipolar journal entries. Mainly, I attribute it to their love for me. I am lucky.

David: It sounds like you are fortunate. One of the other things about your situation is that you have been married for 11 years to the same person. It seems to me that given your bipolar, this is a bit unusual. How have you managed that in your relationship?

David W: I married a great woman. I know that sounds simplistic, but I really don't know how else to answer that. I can't imagine anyone else putting up with me that long. I have even not wanted to. It hasn't been easy, but we are happy now.

David:And I say "unusual" because many times, having a person with a mental illness in the family puts a lot of stress on the relationship. Maybe you could share with us what it's like for you to be, first, manic, then depressed.

David W: Well, as I mentioned before, I go up more than down. My "normal" state is a low grade hypomania. When I go up, I vary between low mania and extremely high mania. I have psychotic manias that get really hard to deal with and are quite frightening at times. The depressions for me usually go too far down or last too long, but after an extreme high or if it lasts a long time, I become suicidal quite often.

David:Now, when you use those terms, low mania and extremely high mania, can you describe what that's like for you?

David W: The low depressions usually consist of lethargy and a desire to sleep a lot. I find myself with little or no energy and just feel bad, both physically and mentally. It's like being in a fog of darkness in my mind. The high manias are worse. I have absolutely no impulse control at the extreme high end. My thoughts race until I can't think about anything and I experience "white noise" and hallucinations. I sometimes have periods of "lost time" that I can't remember what happened.

David:We have a lot of audience questions for you, David. Before we get to that, can you please tell us about your experiences with treatment for bipolar disorder. Have you received any? Has it helped? Are you taking prescribed bipolar medications?

David W: I have been receiving treatment for almost three years now. Before that there was a lot of self-medicating. It has helped, although I am still cycling fairly regularly. I am on several different medications. I take Neurontin daily and Zyprexia to control psychotic symptoms and mania as needed. I also take Wellbutrin as needed for depression.

David:And just to clarify, by "self-medicating," you mean what?

David W: I started using drugs and alcohol as a teenager in an attempt to somehow "fix" what was wrong with me. Although I didn't understand it, I knew that I had mental problems.

David: Here are some audience questions for you, David:

lizzyb_74: David, when you are manic are you more agitated and angry with a lot of energy behind that?

David W: On the low-grade manias, I am usually euphoric and feel great. I do not tend to be dysphoric. I do have a lot of energy and have gone days without any sleep. I do sometimes become angry and agitated if I go really high.

ronnie@tnni.net: David, a couple of year's ago I became very manic, and it lasted for days. I hated myself and my mind raced so much I wanted to die. Did this ever happen to you? Is this the worst side of bipolar or does it get worse?

David W: Yes, that has happened to me. My manias often last for weeks. It can get worse.

David: Earlier you said that you suffered "psychotic manias." Can you describe what you go through?

David W: What I refer to as psychotic manias consist of extreme confusion with racing and scattered thoughts. Add to that mix hallucinations and episodes of time passing with no memory or understanding of it, and it gets very scary.

jpca: David, do you hear voices and see people who really aren't there?

David W: I usually don't see people, but I have seen "creatures" and other visual hallucinations. Yes, I do hear voices at those high-end manias and occasionally at the low end as well.

David: I'm getting some questions about what manic depression is and the signs and symptoms of bipolar disorder. You can also get that information by clicking on this link.

crafty: Here is a question for David. Have you ever, in a psychotic state, forgotten where you are going or what you are doing?

David W: Yes. Those are the periods I call "lost time." Actually, that happened the other night. I was looking out at a lake and watching the stars from my truck and the next thing I remember, I was standing on a pier over the lake and the sun was up. Four hours had passed. I have no memory of what occurred.

woodyw3usa: Is your bipolar medication working?

David W: Believe it or not, I am actually much better at the moment than I was unmedicated. So yes, the medication is helping a lot, but I don't think I would say it is working since I am still cycling so high.

David: I have a few audience comments here and then I'm going to bring on Jean, our second guest tonight. I'll interview her for about 10 min. and then we'll take some more audience questions for both our guests.

ronnie@tnni.net: I was on my own with this illness. I didn't have parents to back me up. I never knew what was wrong with me until 13 years ago. The family was sick. Father raped me and mother put me in the middle of it all. I imagine it is so helpful to have your parents on your side.

Butterfly998: I am glad there is someone out there.

woodyw3usa: I agree, maybe another combination may work for you. I self-medicated for 20 years before I got under control.

crafty: David, I once started to my Mom's house and couldn't remember how to get there.

David: Jean is 49, married twice with children ages 23, 21, 10, 9 and 7. She first started showing signs of manic depression five years ago when her fifth son was diagnosed autistic. His older brother (child #4) is autistic as well.

Jean became depressed and very stressed dealing with the autism diagnosis and was put on antidepressant pills for the first time in her life. Apparently, she was given an improper dosage and then became manic. She was hospitalized for six days.

Good evening, Jean, and welcome to HealthyPlace.com. One of the things I found interesting about you was that your family thought that mental illness is something that should be hidden from public view. Your mother wanted to institutionalize your two autistic children. I'm wondering how that impacted you when you discovered you had bipolar disorder?

Jean Y: I actually thought that as soon as I came home, I was fine. That was five years ago. In fact, it wasn't until this year that I came to grips with the impact and confusions I have had to deal with because of this disorder.

What Impact has Bipolar Disorder Had on You?"

David: What impact has bipolar disorder had on you?

Jean Y: Now that I realize that I have this disorder and am not just the same old me, I am quite angry. I find that writing in the journal helps assuage this.

David: What aspect of it are you angry about?

Jean Y: I am angry that I spent time working so hard on my family and just pushed it to the side. There are many interesting aspects of it. I do believe I am a creative person, and this plays a part. However, I am fearful at times that my children might be taken from me, simply because I am bipolar.

David: Have you actually been threatened with that?

Jean Y: No! But I was really really sick when I was hospitalized and there were a lot of people working with my autistic children in and out of the house. My behavior was so aberrant, there could have been a time...

David: From what I know, many people with bipolar or other mental illnesses, live with different fears, but they are "extreme fears." How do you deal with that in your life?

Jean Y: Strangely, I have always been a very happy person until this depression and mania that occurred after my second child was diagnosed with autism. Then I did become anxious, almost agoraphobic. I didn't like driving anywhere, for example. I made my husband pick up a lot of the slack for ages.

David: Did that impact your relationship with him?

Jean Y: He is divine. He is extremely understanding. Frankly, he saved my life. He literally DRAGGED me to the hospital.

David: What about your ability to work?

Jean Y: I do not have to work, fortunately. But I am very intense, and I write at home. I have been published as a writer in several small publications.

David: Do you think you could work, if you had to?

Jean Y: HAHA. GOOD QUESTION! Could I be an actress?

David: One thing before we get to more questions -- what kind of treatment for manic depression have you/are you receiving including therapy and bipolar medications; and if you are getting treatment, has it helped?

Jean Y: My treatment has been essential in maintaining my health. I go to an excellent psychopharmacologist who monitors my medications and listens to me yell and generally is a terrific person. When my lithium wrecked my thyroid, he switched me to Depakote, and together, within a week, I was ok - not high.

David: Here are two audience comments regarding having bipolar disorder and children:

lizzyb_74: Jean, I have been hospitalized many times and I have a son and he has never been taken away from me because of that.

ronnie@tnni.net: Jean, my children were taken from me because I was sick, and no one could diagnose me for 48 years.

Jean Y: This saddens me deeply.

David: Ronnie, I am sorry to hear that. Jean, here's the first audience question:

BHorne75: Jean, how do you manage the stress involved with having 2 sons with autism so that it doesn't trigger another manic episode if that's possible?

Jean Y: Hello my friend. I laugh a lot, I take my meds religiously - every day - and I yell around the house loudly. Good thing we have over 2 acres of property!

David: Jean, has your bipolar disorder affected your children in any way or the way they relate to you (including your older children)?

Jean Y: Yes. My oldest is afraid to come to this site and read my bipolar journal. He is 23. He doesn't understand that my illness is not "me" - just part of me. My second oldest is just, totally, not interested. He is in college. I am concerned that one of my autistic children may have bipolar disorder, underlying his disorder.

David: Here are a few more audience comments:

snugglez:I understand you. I have a sister who is 17. I am 16 and she is afraid of me because of some of my past actions.

rayandkat1: First I was ashamed, then I was in denial. Now I am just proud. I think it is nice to be able to say, yes I have bipolar, but I am still as successful as the next guy/gal.

woodyw3usa: I am bipolar and have an 18-year-old daughter who was diagnosed at age 14. She is still having a rough time.

tnm1133: Jean, I just went through a divorce and have three boys, 6, 6, and 5. I have very little help and go to school full-time. My ex is trying to exploit the bipolar. I am off meds because of this, and I am deeply involved with my boys. Do you ever experience feeling like you are under a microscope because of the disorder, even having support?

Jean Y: I spend a lot of time thinking. I put my own self under a microscope, in a sense. I am concerned when I go to school meetings, and they know about me, that they are thinking of the effect it has on my children, yes.

David:I want to bring David in on this next question because many with manic depression go through a deep depressive phase, like you mentioned earlier. Do you actually feel that coming on and is there anything you can do to deal with it?

David W: Right now, I don't feel the depression coming on, but I am actually manic at the moment. It is varying between high and medium level. Luckily, right now, it's not high so I can do this. But I know that what goes up must come down, and the crash is coming. It worries me at times, but I don't think about it much when I feel euphoric.

David:But when it's coming, is there anything you can do to prepare for it or reduce the level of severity?

David W: Yes. First is the communication with my wife, so she can help me deal with a quickly changing mood. Another important thing is to try to force myself to sleep and rest. Finally, writing out my feelings and making sure that I am in a place where I feel safe sometimes helps keep the depression from being too great. I watch a lot of films as an escape from the darkness as well.

David:How does your wife help you deal with a quickly changing mood? What kinds of things does she do, specifically?

David W: When I quickly slip into depression from a high mania, it is very hard on me emotionally. She does several things to help me deal with that. She will stay with me and let me know that I'm not worthless or useless or hideous or a host of other things that I feel when that happens. A lot of time spent being held by her often helps. Also, when I need to just be left alone she is good about doing that. She also encourages me to spend time with my support group.

David: Do you go to a face-to-face manic depression support group or an online bipolar support group? And how does that help?

David W: I use a few online bipolar support groups. The closest face-to-face one to me is an hour away, and I am not really able to do that. It helps a lot because I can talk to people who really understand what I'm feeling because they have been there. They listen to me and encourage me with understanding and experience. Also, I can get on Instant Messenger and talk one-on-one with a friend who knows how I feel if I am in a bad place.

David: I have a few site notes, then we'll continue with the audience questions.

Here's the link to the HealthyPlace.com Bipolar Community. You can click on this link and sign up for the mail list at the top of the page so you can keep up with events like this.

We have several excellent sites that deal with many aspects of Bipolar Disorder / Manic Depression like "A Manic Depression Primer" and other sites.

Here is the next audience question:

tnm1133: David, have you ever attempted suicide, and if you did, can you relate to what you were feeling at the time now, in a higher state?

David W: I have attempted suicide more than once, I am afraid to say. The last time was in October of 1999. My father found me in the last minutes that I could still be helped. I can remember what I was feeling and know what was happening in my mind, but no, I cannot really look back and feel those emotions while I'm in a manic state. I could write an essay or poem about them describing the sensation, but not feel it.

Donna 1: Jean, do you see any signs of bipolar disorder in any of your children?

Jean Y: Yes Donna. I am afraid that my older autistic son, my fourth boy, may be bipolar underneath his autism, but we don't know yet because he is nonverbal. He gets very euphoric and abusive very rapidly.

David: Here's an audience member in a similar situation, Jean.

wwoosl: My 8-year-old has bipolar and is very violent. We are considering placement.

Jean Y: I am so sorry. My heart goes out to you.

kayfa37: I'm really nervous about my 5-year-old son who is showing signs of panic and anxiety. He also has full-blown migraine attacks. This is how I started. I really want to know about David being bipolar at age 5.

David W: I can remember times of just sitting in the yard and crying for no reason, but most of the time I was up and just couldn't sleep. I had really vivid dreams and can remember some of them even today. I was never deeply depressed at the extreme young age, but I was already having a few hallucinations.

tnm1133: David, thanks for sharing that. I have had several serious attempts and am really ashamed of it and can't relate to it at all. It's as if I were another person.

David: And, here's another comment on the possibility of passing bipolar onto your children:

rayandkat1: I work in a medical research clinic and I see bipolar patients all the time. A lot of parents that have bipolar are afraid their children may obtain it from them. It is very possible, if a family member has depression, bipolar can develop in the children as well.

David: I should mention here that we've had several "expert" guests talk about bipolar treatment and the genetics of bipolar disorder. The transcripts are here.

David: For David:

bre5800: How does being bipolar effect your photography?

David W: I think that I am able to see things a little different from most people. When I am hypomanic or low manic, I experience high levels of creative energy and a strong flow of ideas. That helps a lot. Also, at low up times, I can really relate to other people and put them at ease, which helps with live subjects. The "life of the party" symptom.

David: Someone asked about books on bipolar disorder. Please check out our online bookstore. You'll find many excellent books on the subject there.

seankmom101: David, how open are you about the disorder?

David W: I am very open about it now. I used to be ashamed of it and hide it because I was afraid of rejection. I have struggled to accept myself for who I am, and now that I have done that for the most part, I have decided that if others can't accept me for who I am, then I don't want them to accept a mask I put on to hide who I am.

Also, I have found that I can help other people understand that there are people, like me, who are not in institutions and can be accepted. It helps take some of the fear away from the idea of mental illness.

David:There are many people out there who are looking for the "right way" to share their disorder with someone they care about. Jean, you can answer this question first, then David can respond.

crafty:I would like to know how to tell my family how I feel being bipolar and what it's like. They don't seem to understand me at all and it upsets me.

Jean Y: I think that you need to express the aloneness of this disorder and how very hard it is to maintain a semblance of being a part of the world without their help.

David W: Expressing how you feel is important, as Jean said. I would add that I understand that talking to your family and explaining these feelings and moods is difficult. Sometimes when you start talking to them, you lose track of what you are trying to say and go off on different areas as the conversation goes on. Or if they are not reacting like you expected, it can throw you too.

You might try sitting down one day when you can think fairly well and write out exactly how you feel and what you want them to know. You can then give the letter to the family member that you are most comfortable with, and write down at the end that you would like to discuss it with them once they have read what you wrote.

David:Those are all excellent suggestions. One of the things to remember is that others haven't had the experience like you have. It may be difficult for them to understand at first. It may be helpful to copy some things off the internet or give them a pamphlet or a book on the subject. And I know that this may be difficult, but it's important to be direct. Not unkind, but direct. Tell the person exactly how you feel and what, if anything, you want from them, because many times, after someone tells their story, the other person is left wondering "well, what can I do." It's kind of a helpless feeling.

catherinel:I struggle sometimes to determine what a 'normal' range of emotions feels like. Is this true for others?

David:David, why don't you take that.

David W: To be honest with you, I don't really even understand the concept of "normal." I think that is because I have had this disorder for my whole life and have a hard time knowing what is part of my illness and what is just my personality, but I have an idea of what is normal for me, and I do have problems recognizing that at times.

David:Jean, this is for you:

tnm1133:I have a real problem with my family (parents, brother, and sister) looking at my disorder as it suites them. Now that I am going to school, everything is fine, but when I am hospitalized it has been viewed as if I have failed, and the suffering and isolation that I am feeling is totally discounted. I have realized that they have some problems in their own lives though. Have you had any similar experiences? Kind of a double standard?

Jean Y: Absolutely. My sister thought I was fixed after I came out of the hospital, and I would never have an episode again. My father never discusses it. I lean on my husband and leave them out of it because it, frankly, would take too much effort for me to bother to bring it to the fore. My children take enough out of the family - you know?

David: I just realized how late it is. Thank you, David and Jean, for being our guests tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful.

Thank you, again, Jean and David.

Jean Y: Thank you for having me, David.

David W: I am glad to have had this opportunity. Thank you.

David: Good night, everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Madeleine Kelly, author of "Bipolar and the Art of Roller Coaster Riding," discusses how to limit the damage bipolar disorder can cause to your life.

Madeleine Kelly, author of the ebook: "Bipolar and the Art of Roller-Coaster Riding" is our guest. She is joining us from her home in Australia. Ms. Kelly has been living with severe mood disturbances and bipolar disorder since the age of 16. She is very involved in being a mental health advocate and educator in Australia.

Natalie is the HealthyPlace.com moderator

The people in blue are audience members.

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Natalie: Good evening, everyone. I want to welcome everyone to the HealthyPlace.com website.

Our guest is joining us from her home in Australia. Madeleine Kelly has been living with severe mood disturbances and bipolar disorder since the age of 16. She is very involved in being a mental health advocate and educator in Australia.

Ms. Kelly says that at one point, "Bipolar ruined my life. Over and over I'd get sick and whammo - rugged to the eyeballs, couldn't finish university, no job, debts to high heaven, kicked out of home, not even allowed to see my baby."

We'll be talking about: how to make informed choices about your bipolar treatment techniques to limit the damage bipolar can cause to your life, how to develop confidence to get what you need and not suffer discrimination because you have bipolar disorder.

Good evening Madeleine and welcome to our site. Please tell us a bit about yourself.

Madeleine Kelly: Hi Natalie and everyone. I'm in my mid-forties, and I live in a beautiful part of the world in the hills on a 5 acre property a couple of hours from Melbourne, Australia. I have a son who is 19 and studying at university, and a daughter in her second year at school. Both are happy and healthy. My partner and I are preparing our land to be planted with blueberries next year so we can be self-employed. In the meantime, he also works in disability services and I write and develop the website.

Natalie: The reason we invited you to our bipolar chat conference was because of your personal experience with bipolar disorder and how you have come to deal with having bipolar disorder. When did it start? How old were you?

Madeleine Kelly:Looking back, it started when I was about 7 or 8. I was diagnosed at the age of 26. I remember struggling to be happy for most of the time in my childhood and teenage years.

Natalie: What kind of symptoms were you noticing?

Madeleine Kelly:The symptoms of bipolar changed over the years. When I was about 8, we went to visit my aunt in the outback, and Mum told me later this aunt was horrified at how distressed and tearful I was every bedtime. We went to a family holiday to Europe when I was 17. I just could not enjoy it. No one, including me, had any idea what was going on. When I was about 20, I had headaches that couldn't be diagnosed. After that, I had stomach complaints, and apparently, there was nothing wrong. The symptoms were mainly bleakness, a lack of enjoying anything. I was over-eating and oversleeping. Later I got very upset and agitated. I couldn't make friends. After the idea of depression was suggested to me by a family doctor, I started to realise that how I was feeling wasn't necessarily the 'real me'. That helped a little. I was eventually tried on antidepressants (this is 25 years ago, so you can imagine the side effects!). They sort of worked a bit.

Natalie: What was life like for you during the initial stages of the disease?

Madeleine Kelly:I just tried to keep on going. I was in medical school and I got good marks first year, so-so the second year, just passed third year and had to pull out in fourth year. I was so upset I couldn't even talk to the patient, and often couldn't stop crying. So I took the rest of the year off. I went to work in an insurance company, and couldn't stop crying at my desk. During my uni days I felt totally out of it, it was hard to make friends because it was like I was totally distracted and not 'with it' enough to have proper conversations or be witty. In second year I realised I was upsetting the rest of my family and to make matters worse, my mother agreed! So I moved out and spread bleakness through West Brunswick instead of Camberwell!

Natalie: As time went on, how was having bipolar disorder impacting your life through adulthood?

Madeleine Kelly:In my twenties, everything was in chaos. Eventually I got married but that didn't mean settling down. I would be so agitated each morning I'd thump the tiles in the shower. I'd utter phrases involuntarily, and often loudly, stuff like 'Why would you bother? Sometimes I just screamed. I cried buckets when I realised I would never be able to complete the medical course. So instead I tried to carve out an alternative career in human resources with the state government. I would always bounce back at work but I'd usually end up losing the job. So each new job in my resume represents a major episode! Partly because of my out of control mood state, my first marriage failed and my baby went to live with his father. He came back to me 4 years later. I didn't know it at the time but I was experiencing classic mixed states.

Natalie: So with this chaos and sense of failure, what was your self-esteem like?

Madeleine Kelly:I just chuckled then at this question! Pretty rotten. I was convinced I was an utter failure and waste of space. I nearly succeeded in a suicide attempt. Other times I felt ruined were the loss of custody of my first child which was because of discrimination to do with bipolar. Countless jobs lost; countless friendships burned or not made in the first place; countless friends who couldn't cope with my disorder; separation from my current partner; separation from my son later in his life; continuing grief over a lost career in medicine; constant self-blame that I have not done as much with my life as I should have; hospitalizations representing months in drug-induced delirium.

But you bounce back. You bounce back because this is your own life, here and now and if you've got a problem, you don't moan or blame anyone. You just fix it, get on with it. You only live once, they say.

Natalie: What is your life like today?

Madeleine Kelly:I have tons of projects that I can do whether I'm hypomanic or flat. I operate my website and keep it up-to-date; I am researching another book; my partner and I are preparing to plant blueberries on our land; I am the active mother of a wonderful 19-year-old man and a very special little girl; I am married to my best friend and we laugh together all the time; I do small writing projects and at present I am working part time in a day education centre for people with intellectual disabilities. And I wonder, constantly, at how lucky I am. I work hard at cognitive behavioural thinking (CBT) every day to make sure I live in the moment, even while having plans, projects and goals.

Natalie: So that's a big change from before. Was there a turning point for you - an event, a feeling, an experience - where you can say "this is when my life started to change and I decided to take control?"

Madeleine Kelly:Yes, there's a story to it. In 1993, I was in hospital with two others with bipolar disorder. We spontaneously started teaching each other how we limit the damage of bipolar and stay well. I thought we could repeat this on a larger scale. So MoodWorks was born. At MoodWorks, we invited guest speakers to address people with bipolar and their supporters on all sorts of things bipolar could impact on - medicines, employment, discrimination, housing, banking and insurance, everything we could think of. I developed this over the years and included it in the first edition of my book. I now had a technique for spotting early signs of my illness in time to do something about it.

To summarise, I got onto the idea of educating people with bipolar for a better life. With MoodWorks and the step-by-step approach in the book, I had something of value to give to my community. I felt okay at last.

Natalie: We'll start with some questions from the audience now. Here are some of them.

seperatedsky : Do you take medication for bipolar disorder?

Madeleine Kelly:Oh yes! Won't go into details because that's not helpful, but I can say that like most people I tried going without. At the end of the day, I have a better, wealthier, happier life when I take the stuff, so it's a no-brainer for me.

Lstlnly: How do your kids handle your bipolar?

Madeleine Kelly:This is important. The 19 year old understands the basic mechanics of the illness. But he copped a lot of scary behaviour, which I tried to give him space to discuss / complain about to me and others while growing up. The little one has a way of thinking about it: "mum's brain is broken at the moment' and a strong attachment to other adults in the extended family.

eve: How often were the mood swings and did meds help or hinder you?

Madeleine Kelly:The pattern has changed over the years. Presently, I'll have a six week hypomania then about four months flat. The degree of distress/dysfunction is much less now that I'm on a really good meds regime.

thankyou: How do you deal with stress in reference to getting along with others when you've hit your breaking point?

Madeleine Kelly:I'm laughing out loud now, it's such a good question. I hide from people outside the household; I like to think that I listen to my partner when he says 'go for a walk' or 'pull your head in.' PRN medication (i.e. when needed) is so important in situations like that.

Dwarf: I would like to know if your husband also has a mental disorder, and how the two of you manage to keep your relationship going smoothly. Being the spouse or a family member to someone with a mental disorder such as this isn't always easy.

Madeleine Kelly:It would be inappropriate for me to comment on anyone else's medical status so I won't answer the first part of that. However, I do have experience living with someone else with bipolar. Provided you both are going after your own health (bipolar or not) and it is possible to learn ways of being happy even so. There's a page called 'caregivers' on my website which gives more.

Natalie: Madeleine, In your e-book: "Bipolar and the Art of Roller-Coaster Riding," you acknowledge that there are different paths to wellness, but you say there are ways to manage bipolar and live well. How?

Madeleine Kelly:Basically to get to first base, you have to acknowledge that you have had a problem that could return, and you would be better off if you did something about it. In other words, don't put your head in the sand. Or worse, turn into a professional manic depressive. Once you start thinking in a helpful way, you can learn to spot the signs of illness and put brakes and safety nets in place.

Natalie: As you, and I'm sure many others with bipolar disorder have experienced, there is a lot of wreckage that can result when the person and the disease are out-of-control. Damaged relationships. Excessive spending. Loss of employment. What techniques have you learned and used to limit the damage that bipolar illness can cause to your life?

Madeleine Kelly:The most important is to identify your own warning signs, and you can learn how to do that, signs that are idiosyncratic or unique to you - then devise some 'Brakes' to stop illness worsening, and then you can look at 'Safety Nets' just in case, so as to protect your job, work, money etc. You need to tailor your 'Brakes' to your own specific illness pattern. When it comes to Safety Nets, it's best to look at your own history of illness and loss, because those events often tell you what you need to do. I'll give 3 examples:

1. If you're in a partnership or marriage, consider giving the other partner an enduring power of attorney or its US equivalent.
2. If possible, get a month or two ahead in your rent or mortgage payments.
3. If you know you get sick quickly if you miss a dose or two of your medicine, get to know your pharmacist (I think you call them some other name) and see if they will be prepared to give you a day or two's dose even if you have lost your prescription or it has run out.

It's most effective if you do this brakes and safety nets work as a team with a supporter and your usual doctor / clinician.

Natalie: One last thing I'd like to address and then we'll get to some more audience questions: discrimination against people with bipolar disorder or any mental illness for that matter. And by that, I mean how people - friends, relatives, employers - react to you once they discover you have bipolar. Have you had personal experience with that?

Madeleine Kelly: I have certainly had personal experience. Some friends stay the same but others pretend to be the same, only you can tell they are somehow distant. Others just say 'pull up your socks'. In employment, I've been unlawfully sacked, my contract not extended, invited for sham interviews, and shifted sideways. If like me, you live in a small town, your reputation will be history as soon as people know your secret. In that case, you can giggle because you have no reputation left to lose. Be as mad as you like! However, with relatives, you have to remember that life is a long journey! Some people in my family of origin seem to blame me for my actions while ill and haven't actively stayed in my life. Suits me. If someone doesn't want to continue a relationship with you, shrug. Maybe things will change with time; maybe they won't. Don't wait around to see! Get on with your own stuff.

Natalie: What can someone, and I'm talking on a personal basis, do to effectively cope with the stigma and discrimination when they come face-to-face with it?

Madeleine Kelly: First, remember you can't make anyone else change. If someone reacts badly to your bipolar disorder, that's their inadequacy, not yours. Next, define yourself by who you are, not by your relationships. Love yourself calmly and love your life patiently. Go after your own goals. Decide what's important for you. You can't avoid telling some people, so invent and practice a little spiel that explains but does not apologise. Separate yourself from the disorder at all times. Also, get used to telling half-truths to protect yourself and your reputation. With employers, never, never, never disclose your condition. If you do get sacked or demoted, don't bother to take them to court and waste energy being angry. Use that energy to get a better job or become self-employed. It's just not your job to be the knight on a white horse changing society for the better.

Natalie: Here's an audience comment:

misssmileeyes: great advice! TY! (On my daughter's behalf)

Natalie: Here are some more questions:

frustratedmother: I'd like to know how to help a child with bipolar who does not want help?

Madeleine Kelly:How old it the child?

frustratedmother: He's a 17-year-old teenager.

Madeleine Kelly: Oh boy! No getting around - it's hard. Sometimes you have to let disaster fall and limit yourself to helping pick up the pieces. That goes for any age. Often the best help is to let the person decide for themselves what sort of life they want but it is so hard as a parent to let go. I suggest trying to focus on living your own life in your own moment; also remind yourself that things will probably get better - somehow. Good luck.

Natalie: Here is a great question from Katie:

katie: If you are in a slump-and can't get moving in a positive way (depression has a hold on you), what techniques do you have for getting out?

Madeleine Kelly:Walk, walk, walk. Last thing you want to do, but it's now being shown that rhythmic, side-to-side exercise like walking or swimming is actually beneficial. Other than that, force yourself to keep going.

Lost2: If you get sacked from a job because they found out about your condition and you don't take them to court or at least voice the fact that you are aware of the reason, isn't that just like letting them trample on you; especially if it happens more than once?

Madeleine Kelly:Yes, and I have found it is in the interests of getting on with my life that there are certain groups and individuals whose behaviour I would like to change

lejamie: What methods, aside from medication, have you found useful when an episode strikes fast? What preventative measures did not work?

Madeleine Kelly:You would need to go over the lead-up events carefully to see if you could influence them to intervene next time. Sometimes though, people just get ambushed. I would recommend getting an expert psychiatric opinion on medication, as sometimes a simple change can help. In this situation you have to rely on your safety nets much more, rather than on stopping the illness as it gets worse. Is this helpful?

Erica85044: I have an 8 year old daughter who currently is without meds (the costs). Until assistance comes through, I have the choice of hospitalization. What impact do you think this will have on her? I can't lose another job and I'm very confused.

Madeleine Kelly:Erica this sounds grim, but I really can't comment as I have experience only in adult hospitals in Australia. I assume you're in the US because we have subsidised meds here.

Natalie: Madeleine, you mentioned not telling people at work about your disorder. Zippert, an audience member, wants to know: What about telling other family members and friends about having bipolar disorder?

Madeleine Kelly: Do they need to know? Do you need to disclose to them? Do you want to get them to realise all those 'bad' things you did were just bipolar? Well, in my experience people just say 'too much information' and rarely change there opinion anyway. Be careful, be selective in what you say and to whom you say it.

Natalie: Our time is up tonight. Thank you, Madeleine, for being our guest. You were extremely helpful and we appreciate you being here. 

Madeleine Kelly: Thank you and good night.

Natalie: Thank you everybody for coming. I hope you found the chat interesting and helpful.

Good night everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

Prominent researcher claims current treatment guidelines for bipolar depression may actually lead to a bipolar depression relapse.

A study led by a UCLA Neuropsychiatric Institute researcher challenges standard treatment guidelines for bipolar depression that recommend discontinuing antidepressants within the first six months after symptoms ease.

Study participants treated under the guidelines relapsed at nearly twice the rate of those who continued taking antidepressants in conjunction with their mood stabilizer medication during the first year after remission of acute bipolar depression. The researchers found no increased risk of manic relapse in those who continued the medication for one year.

The findings appear in the July 2003 edition of the American Journal of Psychiatry.

"The common clinical practice of discontinuing antidepressant use in bipolar patients soon after remission of depression symptoms may actually increase the risk of relapse," said Dr. Lori Altshuler, a professor at the UCLA Neuropsychiatric Institute and the study's lead author.

"Long-held concerns regarding a risk of switching into mania may actually interfere with establishing effective guidelines for treating and preventing relapse of bipolar depression," she said. "Guidelines more similar to those of maintenance treatment of unipolar depression may be more appropriate for individuals with bipolar depression who respond well to antidepressants. A controlled, randomized study is needed to address these questions."

Bipolar disorder is characterized by alternating cycles of depression and mania. Symptoms of mania include elevated or expansive mood, inflated sense of self-esteem or self-importance, decreased need for sleep, racing thoughts and impulsive behavior. Overall, about 3.5 percent of the population has bipolar disorder, occurring equally between men and women.

The study examined 84 individuals with bipolar disorder whose depression symptoms eased with the addition of an antidepressant to an ongoing mood stabilizer. Researchers compared the risk of depression relapse in 43 individuals who discontinued antidepressants within 6 months of remission with the risk of relapse in 41 who continued taking antidepressants.

At one year after improvement of depression symptoms, 70 percent of the antidepressant discontinuation group had relapsed, compared to 36 percent of the continuation group.

The research was supported by the Stanley Medical Research Institute, a Bethesda, Md.-based nonprofit organization that supports research on the causes and treatment of schizophrenia and bipolar disorder. Three pharmaceutical companies provided free medication but no other financial support.

Altshuler is director of the Mood Disorders Research Program at the UCLA Neuropsychiatric Institute. Researchers from seven other Stanley Bipolar Treatment Network sites participated in the study.

The UCLA Neuropsychiatric Institute is an interdisciplinary research and education institute devoted to the understanding of complex human behavior, including the genetic, biological, behavioral and sociocultural underpinnings of normal behavior, and the causes and consequences of neuropsychiatric disorders.

This story has been adapted from a news release issued by University Of California - Los Angeles.

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Adherence is an issue that confronts anyone working to manage a difficult medical condition like bipolar disorder. bp Magazine investigates the unique challenges faced by those with mental illness and offers insight for those facing the medication journey.

Peter Newman spent his youth in Birmingham, England and got what he calls "a quite nice telecom job in London." He had his first depressive episode at age 17 and was finally diagnosed with bipolar disorder at age 25. During a particularly acute manic episode, he applied to a Cambridge PhD program and was rather surprised to find himself accepted.

Today, almost 50, Peter Newman, PhD, works as a software engineer in Silicon Valley, enjoying long periods of health, stability, and clarity. These are interrupted unpredictably by episodes of illness, mostly manic ones.

Looking back at the course of his up-and-down existence, Peter says, "I have been taking prophylactic medication for over 20 years. I've had episodes during this time. I had my doubts about the efficacy of the medication, but I kept taking it. Recently, when I changed my medical insurance, there was a period when I could not obtain the medication. I doubt it was just a coincidence that my first episode in eight years occurred while I was not taking the tablets. I should have paid for the medication myself and claimed it back on the insurance later."

Taking drugs doesn't seem natural

For various reasons, "it's the nature of people not to adhere to medical treatment. People with any condition are in general better at not adhering rather than adhering," explains Michael E. Thase, MD, professor of psychiatry at the University of Pittsburgh School of Medicine. However, mental illnesses pose special adherence challenges, explains Dr. Thase, making a point voiced by many experts. "You don't want to be mentally ill and have to take annoying treatments. You want this [problematic behavior and emotional state] to just be your personality what is unique and idiosyncratic about you. This is how bipolar disease differs from heart disease or ulcers. When you have ulcers, you don't have to come to sense who you are as involving having an erosion in your stomach."

And just as an ulcer patient may need to be careful about diet and other lifestyle choices as well as taking medicine, so must a person living with bipolar look at his or her treatment in broad terms. Careful use of medication coupled with a sound diet, regular exercise, and plenty of sleep all contribute greatly to the best health for those affected.

Finding self-awareness

Solid new research has shown that in someone diagnosed, physical changes in the brain hamper that person's ability to fathom the truth of his or her own situation. In other words, the brain dysfunction that is part of bipolar itself often impairs the development of insight or self-awareness concerning the disorder and how best to cope. For relatives of a consumer, this fact can be of critical importance when they offer help. "When you face the frustration of trying to convince a loved one to get or to adhere to treatment, urges Xavier Amador, PhD, remember that the enemy is brain dysfunction, not the person"a point he underscores in his book, I Am Not Sick, I Don't Need Help: Helping the Seriously Mentally Ill Accept Treatment: Practical Guide for Families and Therapists.

Dr. Amador says that ample research has shown that vigilant adherence is key for the best health outcomes. "It's always been clear that consistent treatment is critical in the prevention of suicide, violence, and all sorts of dangerous behaviors," he says. "What had not been clear until quite recently is the huge positive effect that early, ongoing treatment has on the lifetime course of this illness. Whenever someone with serious mental illness has another episode, the long-term outlook for them gets worse. When you can intervene early and limit the number of full-blown psychotic episodes that a person has, he will have much better health and a much higher level of functioning later on in life." Many scientists believe that psychotic episodes are toxic to the brain; Dr. Amador says that there is a great deal of indirect evidence to bolster this notion.

Understanding means doing better

Experts differ on the exact extent of the bipolar medication nonadherence problem, but agree that it is significant. "Most studies find that about half of the people with serious mental illness don't take their medication," says Dr. Amador. Charles Bowden, MD, cites somewhat more encouraging numbers, stating that most studies find "the range of people [living with bipolar] who are in poor compliance to be in the range of 25 percent to 40 percent." He serves as a professor of psychiatry and pharmacology at the University of Texas Health Science Center.

Experts do agree that good understanding about bipolar disorder promotes adherence. Dr. Amador says that a consistent finding among most studies is that the more aware a seriously mentally ill person is of his or her illness and of the benefits they can gain from treatment the better they will do. Research he has done with colleagues has shown that the two crucial aspects of insight that promote good adherence and good outcomes are:

• awareness of certain early warning signs of deterioration, and
• understanding of the benefits of treatment.

Still, learning to deal with bipolar can prove hard and that's understandable, says Dr. Bowden, when you consider that both the disorder itself and the means to treat it are quite complex. He explains: "This condition is multifaceted. It's not something you can learn enough about through ten minutes of reading, or looking on the Internet." Understanding bipolar can prove especially hard both for consumers and their loved ones, because its very nature often involves long stable periods interrupted by spells of illness. The range of treatment options struck Peter Newman as an important hurdle: "Everybody responds differently," he says. "Some stuff works for some people. Some stuff works for others."

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Consumers often think of their disorder as something that comes and goes, and both the medical experts and others contacted for this article agreed. So a person may acknowledge the disorder during an episode, but decide after things improve that they no longer need medicine. Such people "treat their medications like antibiotics," says Dr. Amador. "When the bottle is empty, they think they are cured." A better comparison, he explains, would be to think of bipolar medications as insulin is for diabetics—something needed on a constant basis. For family members, too, it's tempting to think that when a person diagnosed as bipolar has stabilized, the problem has gone away. Dr. Amador calls this tendency among healthy relatives their own form of denial.

She did what needed to be done

Jacqueline Mahrley, 39, lives in Anaheim, California, and works part time as a home health aide. She also works closely with the Depression and Bipolar Support Alliance (DBSA). Jacqueline became mentally ill as a teenager, but wasn't correctly diagnosed as having bipolar disorder until she was 28. "That diagnosis changed my life—the medication worked and all of a sudden my life had meaning that it had been lacking," she says.

Despite her relief at finally obtaining a sound diagnosis, she fell into the common trap described by Dr. Amador. As Jacqueline explains, "Basically when you are feeling well you don't want to take medicine and I have had to learn to overcome that."

Although she was only nonadherent once or twice, Jacqueline says the impact was huge. "I've lost a lot going off the medication. The worst consequence for me was that my child wanted nothing to do with me. I have this one son and he is my life. And I lost custody of him through being sick. It happened five or six years ago when I went off my medicine and I can say with complete confidence that I will never do that again."

Jacqueline's mother, with whom she is close, won custody of the boy (who is now grown). Jacqueline's regimen involves numerous drugs. "I take a lot of pills but they work," she says, "and I'm lucky not to have a lot of side effects." She saw five or six psychiatrists before finding a doctor who acts as a true partner in her care. "When I finally found a doctor I could really trust and I knew he had my best interests at heart, it wasn't hard for me to do what he wanted me to do," she says.

While Jacqueline did not experience many side effects, many others suffer keenly from them. When this occurs, Dr. Bowden encourages consumers to persevere and work with their doctors to get the drug plan right. "You can have both sanity and a life that is not badly encumbered" by awful side effects or "medically jeopardized" by potentially severe ones, says Dr. Bowden. Finding such a winning combination of medicines may require "a doctor who is patient and committed," he says, but it can be done.

Medical and non-medical people interviewed for this article pointed out that beyond side effects, practical matters, too, can impact adherence. People give up because of insurance problems (as did Peter Newman), cost, and exasperation over taking many different medicines. The experts advise that if you have problems like these, discuss them with your doctor, a practical-minded loved one, or both. Just don't stop taking your medicines. Work toward a drug program you can afford and comfortably manage.

Living a healthy lifestyle

Staying with the program means much more than reliable use of drugs. "Although most discussions of the issue do center on medicine," Dr. Bowden says, "lifestyle issues can be equally important [in matters of adherence. Factors such as] what the person is drinking or consuming in terms of other substances ... and how much they are sleeping make a huge difference. There is a positive side to this discussion because bipolar is a condition that is to a substantial degree under the patient's control. This reflects the importance of the person being willing to live a healthy life, beyond whether he or she is simply taking the bipolar medication."

The global nature of medication adherence, says Dr. Bowden, represents a common theme regarding bipolar management among the most up-to-date, best-informed mental health practitioners. It is a theme heard less often, he says, in "a financially strapped public sector program because this [aspect of management] does take some time."

Everyone controls his or her own wellness

Psychiatrists and psychologists, who are knowledgeable about bipolar medication adherence, stress that consumers must learn to understand these issues, because they are so squarely within each individual's control. They agree about the value in choosing healthy foods, being very prudent with caffeine and alcohol, avoiding recreational drugs, and eating meals and exercising at regular hours. Dr. Thase cautions against workouts late in the day, which can be overstimulating. He and other physicians and therapists strongly emphasize the need for enough sleep each night. "If your normal is seven or eight hours, get it," he says. "If it's nine hours for you, get nine." Sensible lifestyle steps such as these can matter greatly in staying healthy. Difficulty in maintaining these healthy habits can also provide warning signs, especially with regard to sleep. "Adequacy of sleep is a sine qua non for doing well," Dr. Bowden says.

Peter Newman learned directly that when he started having trouble falling asleep at night, he was teetering at the edge of a manic episode. "I know that the biggest problem with mania is loss of sleep," he says, "If I'm heading into a second night without sleep, it's time for me to hit the sleeping tablets, benzodiazepine. I have enough experience now to know what it feels like [to start becoming seriously ill] and enough motivation to know that I do not want this manic holiday. I could bring on an episode by staying up for several nights and getting overexcited. But I have staved them off."

Peter has done more than ward off his "manic holidays." He's decided to "always do what the doctor tells me. "My main reason for taking the medications is to keep the doctor happy. You want a happy doctor. You don't want to piss off the doctor because you need him. You figure this out after a few bad episodes. I shall keep taking the tablets, probably for ever and ever. Amen."

Peter developed a very deep and worthwhile Web site where he shares with others the wisdom learned following his path "to survival with bipolar." Visit www.lucidinterval.org for a sample of his insight.

Milly Dawson writes about health, parenting, and business topics for major magazines and newspapers including The New York Times, Newsweek, Good Housekeeping and Cosmopolitan.

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