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Take Charge of Bipolar DisorderA 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability
By Julie A. Fast John Preston
WARNER WELLNESSCopyright © 2006 Julie A. Fast and John Preston, PsyD.
All right reserved.
Chapter OneMEDICATIONS AND SUPPLEMENTS
Medications and supplements represent the first section of the treatment plan. This is a difficult and often frustrating part of having bipolar disorder for many people. How many medications are you taking to manage bipolar disorder? Do you sometimes feel overwhelmed with the thought that you will have to take these medications for the rest of your life? Maybe you feel it's unfair. Maybe you have trouble staying on medications because of side effects. Maybe you go through periods in which you pretend that bipolar disorder isn't real and that it will go away if you just ignore it ... but then you get sick again and have to restart the medications to find stability, and the cycle is repeated.
All of the above behavior is normal. Accepting the bipolar disorder diagnosis is hard enough. Having to accept that you will probably need some form of medication for the rest of your life can be pretty daunting and depressing.
Many, if not most, patients with bipolar disorder experience a significant amount of confusion regarding medical treatment and often receive very littleinformation about the drugs they're taking. Inadequate compliance with medication treatments is the number one reason that there are often negative outcomes for people with bipolar disorder. The goal of this chapter is to offer concise and practical information on the medications currently used to treat bipolar disorder, how they work in your system, and why you need medications in order to stay stable. There is a good reason why this is the first section of the treatment plan: Medications are an essential part of bipolar disorder treatment, and the more you are willing to accept this fact, the better the outcome can be. This chapter does not make light of the significant problems and frustrations people with bipolar disorder have with medications. When you finish this chapter, you will have a clearer idea as to why you truly need the medications, and will also have some tips on how to manage these medications so that they treat bipolar disorder instead of taking over your life.
For Family and Friends As a family member, it may be up to you to help a loved one manage medications, especially if he or she was just diagnosed or is recently out of the hospital. The more you know about the medications used to treat bipolar disorder, the better you can help your loved one. People with bipolar disorder often stop taking their medications, for various and often understandable reasons (for example, because of unpleasant side effects). Appreciating this will give you some perspective when your loved one either goes off medications or refuses to take them. This chapter will give you some tools to help your loved one stay on the medications until he or she finds the right combination with the fewest side effects. Please note that it's very dangerous for you to encourage your loved one to get off medications and learn to manage the illness alone. It's fine to use supplements and other lifestyle changes to manage bipolar disorder, but to do this without at least some help from medications can be quite difficult and dangerous-especially for people with Bipolar I and serious mania mood swings.
UNDERSTANDING WHAT HAPPENS IN THE BRAIN WHEN YOU'RE SICK
When you're sick, it feels so personal and emotional that it's probably hard for you to remember that being sick simply means that your brain isn't working correctly and needs to be regulated. The goal of bipolar disorder medications is to get your brain back on track so that it can operate more normally and effectively. If you approach medications this way, they may not seem so troublesome and difficult to understand.
The human brain is a tremendously complex organ that carries out two primary roles:
1. Monitoring and regulating the functioning of the body (for example, regulating body temperature, respiration, and hormone levels).
2. Ensuring survival.
Regarding survival, the brain is continuously scanning the environment for potential dangers. It also plans for the future and is in a constant state of readiness to launch adaptive responses. Human beings are capable of remarkable abilities to cope with a host of stressful situations. Like shock absorbers, most people periodically encounter difficult situations, feel the impact, react emotionally, cope to the best of their ability, and then, once the stress is over, bounce back, returning to a less stressful state. Successful coping depends on a number of things, particularly including the ability to think clearly, to problem-solve, and to maintain some measure of emotional control. When episodes occur, people with bipolar disorder lose these faculties and therefore lack the ability to bounce back.
UNDERSTANDING WHY THE BIPOLAR DISORDER BRAIN IS DIFFERENT
The problem is that your brain doesn't always do what it's designed to do. People with bipolar disorder have brains that are less resilient and simply don't respond correctly to the environment. At times, your brain doesn't monitor and regulate the functioning of the body the way it should. Your bipolar brain often creates problems instead of helping you cope with them. Often it simply isn't possible to think clearly, problem-solve, and maintain an appropriate measure of emotional control, because certain brain structures that regulate emotions lose their ability to function appropriately. This appears to be due to abnormal chemical regulation of these brain mechanisms. It can also be caused by actual brain damage, which can begin to gradually occur when people with bipolar disorder either do not get treatment or have poorly controlled, recurrent episodes. What is becoming increasingly clear is that not only do many of the medications used to treat bipolar disorder reduce symptoms and help people maintain emotional stability, but some have what are called neuroprotective properties: They are able to protect the brain from being damaged by the illness, and may actually activate natural mechanisms for the growth of new nerve cells. This has been demonstrated with the mood-stabilizing drug lithium. Lithium promotes the production of a protein, BDNF, which has been shown to activate the birth of new nerve cells in certain areas of the brain (this process is referred to as neurogenesis). Unfortunately, some people view psychiatric medications as a "crutch" that operates only to make or suppress symptoms. Although the drugs do help to control symptoms, in a very real sense they also operate to protect and assist the brain in carrying out certain functions in a more normal and adaptive way (for example, by controlling emotions and mood swings). In much the same way that insulin does not cure diabetes, these drugs do not cure bipolar disorder-but can help normalize biological functioning.
About 30 percent of people who take bipolar disorder medications experience minimal to no side effects, but the truth is that the majority of people do encounter side effects, and often these are considerable. Bipolar disorder medications are often tough to deal with; not only are their side effects difficult to live with, but the medications can also take a number of weeks or even months to start working. However, if you look at the alternative-the fact that a brain with bipolar disorder often has severe functioning limitations-the medications start to look more appealing. It is critical that family members and friends be supportive of these much-needed medications. Getting completely off medications should not be your goal, as it almost always leads to disasters. Asking for help in finding the right medications at the right dose is much more realistic.
THE COMPLEX INTERACTION OF BRAIN CHEMICALS
Your ability to adaptively control strong emotions relies on a very complex interaction of brain chemicals operating to regulate the millions of nerve cells in a part of the brain called the limbic system (also commonly referred to as the emotional brain). The limbic system and a closely related brain structure, the hypothalamus, are responsible for igniting appropriate emotional reactions (for example, the fight-or-flight response); for maintaining some degree of control, which is necessary for clear and adaptive thinking; and for getting the brain and body back into a state of homeostasis once the stressful circumstances have subsided. In addition, these brain structures also influence a number of biological functions such as sleep, appetite, sex drive, physical and mental energy, and activity levels.
To carry out these necessary functions, the brain must maintain a delicate balance of neurochemicals-most notably serotonin, norepinephrine, glutamate, GABA, and dopamine. A good analogy is that the brain is like a thermostat in your home. There is a comfort range set on most thermostats. The built-in thermometer in the thermostat is constantly monitoring the temperature in the room. If the temperature rises above a certain point, the air conditioner automatically turns on. If it falls below a particular temperature, the furnace comes on. Such automatic monitoring and fine-tuned adjustments also are constantly at work within the brain, to maintain a relative emotional comfort zone.
Your Thermostat Is Broken
The problem for people with bipolar disorder is that the thermostat in the brain doesn't always do its job correctly. Medical research has clearly documented that bipolar disorder involves a biologically based impaired ability to effectively regulate intense emotions-just like a broken thermostat that can't monitor the temperature correctly. There is nothing wrong with you psychologically; instead, there is something wrong with your brain's neurochemistry.
Your Brain Is Very Sensitive
Because your brain doesn't function as a normal brain should, outside events and your own behaviors can lead to serious mood swings. Sleep deprivation or disruption is a notorious trigger for bipolar mood swings, as are other factors that can significantly alter hormonal functioning and brain chemistry. Stressful life events can provoke shifts into overwhelming states of mania or depression. And even in the absence of specific stressors, abnormal neurochemical functioning in the limbic system can, at times, spontaneously provoke the emergence of intense mood swings, like a thermostat that for no apparent reason turns on the furnace, even though the house is already warm. This explains why you can't by willpower alone just get a handle on your emotions.
Medications are designed to regulate your emotions and get your brain back on track so that it can respond correctly to life events. It's not the goal of medications to take away your creativity, numb you to the reality of life, or change your personality. They are simply meant to regulate your brain thermostat so that it can work correctly. Understanding and appreciating the biological basis of bipolar disorder is critical for those with the illness and for family members and close friends. As you will read in this book, a number of very effective strategies can help to stabilize and normalize brain chemistry for people suffering from bipolar disorder, and certain psychiatric medications are the most direct and powerful way to accomplish this.
Cortisol: The Stress Hormone Unless bipolar disorder is well controlled, most people suffering from this illness will spend many, many months in episodes of depression. One very significant health consequence of untreated depression is an extreme elevation of the stress hormone cortisol. Cortisol is normally not at all dangerous to the body, but the exposure to prolonged elevations seen in severe depression is considered to be toxic and to influence general health. High, sustained levels of cortisol damage the interior walls of blood vessels. This eventually can lead to artery disease and a very significant increased risk of strokes and heart disease. Death rates from heart attacks among people with poorly controlled depression are twice those seen in age-matched adults without bipolar disorder. High cortisol also has a significant impact on the immune system, resulting in a weakened ability to fight diseases. Rates of death due to infectious diseases are two to three times higher in people experiencing prolonged periods of depression. Finally, high cortisol levels also reduce the release of growth hormone. This greatly contributes to an increased risk of developing osteoporosis. Effective medication treatments for bipolar disorder not only target devastating mood swings, but also can contribute significantly to lowering risks for these serious medical disorders.
KNOWING YOUR CURRENT MEDICATION OPTIONS
The choice of medications used to treat bipolar disorder depends on the mood state you're currently experiencing-mania, depression, or another major symptom such as psychosis or anxiety. In addition, medication choices always must take into consideration the ultimate goal of preventing recurrences.
Currently, there are eleven medications approved by the Food and Drug Administration (FDA) for the treatment of bipolar disorder: lithium, Thorazine, Risperdal, Seroquel, Geodon, Abilify, Equetro, Symbyax, Depakote, Lamictal, and Zyprexa. However, a number of other highly effective drugs are in common use. The use of medications not approved by the FDA for the treatment of certain conditions is referred to as off-label use; it must be emphasized that off-label use of medications is very common in every branch of medicine.
Why So Many Pills for One Illness?
Recent surveys reveal that in the United States, only 11 percent of people being treated for bipolar disorder take just a single drug (called monotherapy). On average, most people being treated for bipolar disorder take three or four medications simultaneously. The reason for this is simple: Medication combinations are often necessary to adequately treat the wide array of symptoms seen in this illness.
What to Expect from Medication Treatment
Bipolar disorder is like a number of other chronic medical conditions, such as diabetes, asthma, or arthritis. It's not a condition that can be cured by currently available medications. However, the medications discussed later in this chapter are effective in relieving many of the more serious symptoms of bipolar disorder and often can reduce the frequency of mood episodes for most people, if they receive appropriate treatment.
With aggressive, appropriate, and ongoing medication treatment, which is started during the first or second mood episode, about 30 percent of people do not experience severe recurrences. Thus, in about one out of five people, the medications are highly successful in preventing significant relapses (as long as people continue to take them). This of course leads to the question: What about the other 80 percent of people with bipolar disorder, especially those who go through many episodes before being adequately diagnosed and treated? The facts are that when people do not receive effective medication treatment during the first several episodes of bipolar disorder or are given the wrong medications because they have been misdiagnosed, medication outcomes are not as positive as they are for those who receive the correct treatment during the first episode. Certainly in the case of people who are diagnosed later than the first or second episode, many people do respond to medication treatments, but delays in getting treatment can make it more challenging to successfully control the disorder. Still, people can find significant relief. Even after starting medication treatment after the first or second mood swing, the recurrence rates for severe episodes can be reduced by about 75 percent, and hospitalizations can often be avoided when the correct medications are used. Subsequent episodes that do occur tend to be milder (as opposed to severe) depressions and hypomanias. These statistics show that medications work in preventing serious bipolar disorder relapses, but they are far from perfect. And, as mentioned in this chapter, it may take quite awhile to find the right combination.
Hazel's Story Age 46 I've never seen anything like the difference in my daughter since she started medications. She was manic from the time she was sixteen. In fact she was out of control and living on the streets for a while. She got in trouble with drugs and when the police found her purse on the roof of a drug house, they found her and took her to the station for questioning. It was the best thing that ever happened to her. She was clearly manic and they put her in seventy-two-hour observation where she received medications and took them for the first time in her life. About the third week she was there, I walked in and she said, "Hi, Mom." And I could tell I had my daughter back. It was like someone was in her body for all of those years. I know it's an illness and it was never her fault, but I get so angry for the lost years. Then I remind myself that she's back. I think she was just finally old enough to see where her life would be without medications. She works now and has a family. She still gets mood swings, but they are nothing like they were before medications-we can deal with them as a family now that we have a treatment plan for the tough times.
Excerpted from Take Charge of Bipolar Disorder by Julie A. Fast John Preston Copyright © 2006 by Julie A. Fast and John Preston, PsyD.. Excerpted by permission.
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