TREATMENT OPTIONS IN BIPOLAR DISORDER, excerpts from a report on a presentation 1 by Charles L. Bowden, M.D., 2Smooth Sailing, Spring 1996

Dr. Bowden began by noting that responses to medication vary among different presentations (diagnostic varieties) of bipolar disorder. Among these presentations are:

pure mania

mixed mania (symptoms of mania and depression appearing simultaneously)

rapid cycling (four or more cycles or episodes per year)

secondary mania (appearance of mania after the occurrence of another illness)

bipolar disorder with comorbid (coexisting) substance abuse

bipolar disorder type II (characterized by relatively mild manic states)

cyclothymia (chronic mood cycles in which episodes are too mild to be classified as clinical depression or mania).

Dr. Bowden ... discussed three medication options for bipolar disorder: lithium, divalproex (also known as valproic acid [Depakote]), and carbamazepine (Tegretol).

Lithium is the best choice for patients experiencing pure mania, but patients with more history of depressive features and some of the other presentations of bipolar disorder may not respond to it. It is the least expensive of the three options, and it may have antidepressant effects. Patients likely to respond favorably to lithium include those with

a family history of bipolar disorder,

a previous favorable response to lithium,

only a few previous episodes of illness,

a history of full relief from symptoms between episodes.

Disadvantages to lithium treatment include problems with patients' noncompliance (failure to take the medication as directed) because of distressing side effects (including memory problems, confusion, poor concentration, and weight gain); the narrow range of blood levels at which lithium is effective but not toxic; and the potential for more serious side effects.

Divalproex (Depakote) is an effective anti-manic and mood-stabilizing treatment for various presentations of bipolar disorder. In a study of acute mania, outcomes were similar in patients treated with lithium or divalproex, except that

problems related to premature discontinuation and adverse effects were less severe with divalproex than with lithium;

divalproex was more effective than lithium in patients who previously have not responded to lithium;

only divalproex was effective in mixed mania ....

In adolescents, the most common symptoms of bipolar disorder are irritability and anger. This form of illness is often misdiagnosed as attention deficit hyperactivity disorder (ADHD) and is often accompanied by substance abuse. Divalproex is an effective treatment.

Carbamazepine (Tegretol) has been found to be about as effective as the antipsychotic medications and lithium. Most studies of carbamazepine have involved its use in combination with another medication, so that the contribution of carbamazepine alone to the outcome cannot be determined.

Patients likely to respond favorably include those with

a previous lack of response to other treatment

no family history of bipolar disorder

bipolar disorder that is secondary to another illness.

Among the side effects of carbamazepine are sedation, dizziness, and vision problems.

Other classes of medications may be combined with these mood stabilizers to increase effectiveness. These include thyroid supplements, benzodiazepines (certain antianxiety agents), neuroleptics (antipsychotic medications), and calcium channel blockers.

(Dr. Bowden)... recommended the use of antipsychotic medication only for people who are having auditory hallucinations ("voices") or bizarre delusions, and then in combination with divalproex (Depakote), not lithium.

...When asked for a "prescription" for bipolar disorder patients, he mentioned finding a place where you can experience collegiality (such as a support group) and participating with your mental health professional in decisions about your treatment.

1 Presented at a Johns Hopkins symposium March 9, 1996

2 Deputy Chairman and Chief, Division of Biological Psychiatry, University of Texas Health Center

by Anne Heasty, M.S.
Smooth Sailing: Spring 1996

How You Can Survive when They’re Depressed: Living and Coping with Depression Fallout

Sheffield, Anne. New York: Random House, 1999. (Paperback, 306 pages)

In this realistic and helpful book, Anne Sheffield describes what she calls “depression fallout,” the painful, debilitating emotions experienced by those living with a person who has a depressive illness. The valuable insight, information, and advice she provides is designed to help the reader in a battle against depression fallout, a battle that she says “has to be fought simultaneously on two fronts: yours and the depressive’s.”

The author writes in a straightforward, no-nonsense style, with imaginative phrasing. She chooses everyday language, using the old, familiar term “manic depression” rather than “bipolar disorder.” Her stated assumption is that the readers are persons living with someone with depressive illness. Thus, she addresses the reader as “you,” creating the feeling that she is sitting down with you and a few others and giving frank, “tell-it-like-it-is” advice and information. In this context, she often uses the phrase “your depressive” or “your manic depressive” to refer to the person with the illness. Ms Sheffield describes five predictable stages of depression fallout: confusion, self-doubt, demoralization, anger, and the desire to escape. Beginning with her own personal experience, gaining further insight in a family support group, and continuing to learn from other sources, she found these reactions surprisingly common, despite many differences in individual situations. She provides examples involving spouses, lovers, parents, and children—rich, and poor. Donald Klein, M.D., in his preface praising the book, finds that these stories “ring true.”

Ms. Sheffield’s premise is that obtaining effective treatment and staying in it is the critical element for both the ill person and those living with him or her. But compared with similar passages in many mainstream books, her approach is more realistic and down-to-earth, acknowledging the frequency of misdiagnosis, inadequate treatment, failure of the depressed person to take prescribed medication, and problems that remain even with good treatment. Her advice is tailored to overcoming these difficulties.

Emphasizing that knowledge about the illness is an essential tool in the battle against depression fallout, Ms. Sheffield includes up-to-date, succinct information about the illness, written from the perspective of the family member. For example, she lists the “official” list of symptoms of depression and then lists what she calls “unofficial” symptoms, which most often affect those living with a person who has a depressive illness.

The book provides an overview of the often conflicting medical and psychological theories and treatments available, with useful suggestions for negotiating the maze. Ms. Sheffield emphasizes the primary need for those with a depressive illness to get an effective medication. She maintains that the treatment is most likely to succeed when the patient, the family member, the psychiatrist, and the psychotherapist (if there is one) work as a team. She notes that many times the family member is the person most aware of the signs of the patient’s illness. If the treating professional refuses to accept calls from the family member, Ms. Sheffield urges that the professional be left messages when the patient stops taking medication or talks of suicide, or when there is other important information to communicate.

In the chapter title “Setting Boundaries,” the author makes clear that accepting the patient’s illness as a biological one does not mean that the family member or other person involved should passively accept the ill person’s behavior. On the contrary, she argues that the illness necessitates setting boundaries is two-fold: to help the person with the illness and to help those living with him or her to avoid demoralization and depression fallout.
Ms. Sheffield describes demoralization as the most common element of depression fallout, “arriving early and staying late.” The examples she gives throughout the book make its eroding presence crystal clear. In some individuals, the demoralization slips into a serious depression that needs treatment.
Although the insights, perspectives, and advice outlined in How You Can Survive when They’re Depressed cannot be expected to apply to every situation, they can be very helpful for persons struggling to cope with a family member or friend who has a depressive illness. As one rader said, this book can be a “light in the darkness.”

By Delphine Peck and Connie Pryor

Note: David V. Seaman contributed to this review.

BENEFITS OF DONATION

Individuals, corporations, foundations and other organizations are welcome to make a contribution to DRADA. Your donation will:

Help eliminate the stigma surrounding depression and bipolar disorder.

Help DRADA expand its educational programs and support services.

Help raise awareness of mental health issues.

Support DRADA's mission to educate, inform, and support.

Make you feel good about yourself!

Donate Now!

You can also contribute to DRADA through the United Way of Central Maryland or Combined Charity Campaign for Baltimore City. Fill in your employer's card with our full name (Depression & Related Affective Disorders Association-DRADA) and our designation number: 3621.

Funding is obtained from membership dues and from activities including an annual fundraising appeal, fundraising events, project grants, program fees, and proceeds from the sale of materials.

Click here to learn about the benefits of membership.

A copy of our current financial statement is available upon request. Documents and information submitted by DRADA, in accordance with the law, which governs charitable organizations in Maryland, may be obtained from the Office of the Secretary of State for the cost of copies and postage.

WELCOME

DRADA is a community organization; we serve individuals affected by a depressive illness, family members, health care professionals and the general public. We are committed to our mission to alleviate the suffering arising from depression and manic depression by assisting self-help groups, providing education and information, and lending support to research programs. DRADA understands the need to eliminate the stigma that is attached to mood disorders, and we are constantly striving to promote public knowledge of signs, symptoms, and resources available to persons affected by these illnesses.

Did you know about the website devoted to teenage depression?

What’s New

Soon to come
DRADA's popular "Day for Night" video will soon be available on DVD!

Support Group
Would you like to find help through a mutual support group? Please click here for a list of support groups. [PDF]

SUPPORT AND
COMMUNITY SERVICES

Support Services Disclaimer

Support Groups

There are a growing number of mutual-help groups for persons with an affective disorder and/or family members. of mutual-help groups for persons with an affective disorder and/or family members. These groups provide a supportive environment for sharing experiences and solutions to problems common among people living with these illnesses.

Additional benefits of support group participation include:

A feeling of connectedness with others who are sharing similar experiences.

Provides an outlet to discuss and share personal experiences in a friendly environment.

Developing fulfilling relationships with others who are trying to cope with these illnesses.

For over ten years, DRADA has provided training for group leaders of mutual help groups (persons with affective disorders and/or their families). DRADA also provides consultation and periodic seminars for support group leaders who have gone through the training program. Currently DRADA lists more than 75 support groups in the Baltimore-Washington area, whose leaders have participated in the group leader training.

FINDING A SUPPORT GROUP
DRADA has a list of more than 75 DRADA support groups, whose leaders have taken the DRADA leadership training course. Some of these groups are for persons with the illness and some are for family members. The majority of these are in the Baltimore-Washington area or in the nearby areas of Delaware, Virginia or Pennsylvania.

If you would like information about support groups listed by DRADA within the geographic area of Maryland, Virginia, Washington DC., Delaware or southeastern Pennsylvania:

Call 703-610-9026.

Email us at info@drada.org

For the location of other support groups throughout the country we suggest you look at the listings of chapters and support groups on the web page of the Depression and Bipolar Support Alliance (DBSA) at http://www.dbsalliance.org.

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Peer Support

DRADA's Peer Support Program provides an opportunity for people to communicate one-to-one with someone who also is affected by a mood disorder. Sharing your experiences with someone who has had similar experiences can be a big help and an important adjunct to treatment. This program is designed to help people who have been diagnosed with depression or bipolar disorder, as well as family members of people with these illnesses. This is a service for people who cannot attend support group meetings, or who want additional support. Matches are made by geographical area, illness, personal interests, and by criteria specified by the individuals, such as age or gender. Program participants determine the frequency and type of contact (telephone, email, written correspondence, etc.).

This program strives to:

Lessen the feelings of isolation and stigma.

Help others learn how to cope with the illness and treatment.

Provide a means to share emotions, experiences, and solutions to problems.

For more information call DRADA at 703-610-9026.

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Leader Training

DRADA offers a one-day program for individuals interested in leading or developing support groups. Participants receive a copy of the 88 page, The Manual for Affective Disorder Support Groups, published by DRADA, which contains information about organizing, developing, and maintaining an effective group. The program provides information on how to develop and maintain a group, be an effective leader, use technical skills to make a group successful, manage challenging behavior in a group and deal with obstacles that inhibit a group's success.

After completing the training individuals will be able to:

Facilitate group discussion.

Understand and appreciate group dynamics.

Use the tools learned to lead mutual help support groups of all kinds.

The program is currently held every other month in Baltimore, Maryland and Northern Virginia, on a Saturday or Sunday from 9:30 A.M. to 4:30 P.M., and classes are usually filled to capacity. Registration includes the training, related materials, the 88-page manual, and a deli lunch. The training manual is also available for purchase separately. Advance registration is required.

The training is conducted by the Support Group Director, Wendy Miller Resnick. Ms. Resnick, a clinical specialist in psychiatric nursing, has a master's degree with a specialty in group dynamics and group leadership. She has 20 years of experience in working with groups and in training both professionals and lay persons to develop and maintain effective groups.

If you would like more information about the training program:

To determine space availability and details of the program, call 703-610-9026.

After determining availability, you can register by sending a check or money order to DRADA, 8201 Greensboro Drive, Suite 300, McLean, VA 22102.

The training manual is sent to those participating in the training session. To purchase the manual separately click here to go to the order page.

Contact DRADA at 703-610-902 for information on the next training group program.

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Outreach

Community Outreach Speakers Bureau
DRADA has a variety of speakers, including professionals from local hospitals, DRADA staff, and volunteers, who are willing to go into the community and speak about mood disorders and the services DRADA can offer individuals and the community at large. Our speakers are eager to support DRADA and help to eliminate the stigma attached to depression and bipolar illness. The program's team visits community centers, churches, synagogues, schools, etc. to:

Increase awareness of mood disorders in the communities.

Educate people about different resources that can help people cope with these illnesses.

Decrease stigma associated with depression and bipolar disorder.

Increase overall understanding of these disorders and resources DRADA can provide.

For more information on community outreach, call 703-610-9026.

Hospital Networking
DRADA's Hospital Networking Program joins the efforts of DRADA staff, volunteers, hospitals, and patients. DRADA volunteers go into the hospitals to speak to patients about their own situations and how DRADA and other organizations helped them cope with their illness. In addition, DRADA staff visits hospitals and other mental health organizations to speak about DRADA and our programs.

This program helps to:

Connect patients in the hospital to a supportive community prior to their release from the hospital.

Increase patients' awareness of the option they have for additional support when settling back into life at home.

Raise hospital staffs' awareness of DRADA and our program so they may recommend our services to patients in need.

For more information contact DRADA.

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Support Services Disclaimer

By agreeing to participate in any of DRADA's Support Services Programs, including Support Groups and Peer Support, you agree to hold harmless DRADA and its officers, directors, employees, and volunteers from all claims arising out of or related to your access or use of, or your inability to access or use, any of the DRADA Support Services Programs. You also agree that DRADA or the contributors of information to this program shall NOT be liable to you or anyone else for any decision made or action taken by you in reliance on information provided by this program for any consequential, special or similar damages, even if advised of the possibility of such damages.

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Excerpts from SCHIZOPHRENIA VS MOOD DISORDER: A PUZZLE SOLVED, by Godfrey Pearlson, M.D. 1, Smooth Sailing, Fall 1996, 1-2

Clinicians have always struggled to distinguish among various mental disorders. These distinctions are important because they can predict which patients will respond to which treatments and identify which individuals will do better than others....

One hundred years ago, the German psychiatrist Emil Kraepelin...made the first clear distinction between...schizophrenia and manic depression/mood disorders....

...Some eminent present-day psychiatrists, however, ...still claim that schizophrenia and bipolar disorder are only extremes or represent different aspects of the same disease....

...Because we increasingly recognize mental illnesses as being brain diseases, one relevant question we can ask is, "When people with schizophrenia or mood disorders are compared with healthy volunteers (controls), are the observed brain changes the same or different for the two illnesses?"

Our research group recently tried to answer this question in a series of patients clearly diagnosed with either manic depression or schizophrenia....We used magnetic resonance imaging (MRI) to measure brain structures believed to be involved in the normal functioning of moods, emotions, and perceptions.

These structures included the amygdala, an almond-shaped nugget of brain tissue buried deep in the temporal lobe; the entorhinal cortex, a section of primitive "smell brain" that helps map events in the outside world into our consciousness; and asymmetries, areas of the brain that are normally bigger on one side than on the other (for example, in right-handed people, brain areas concerned with language are significantly bigger on the left than on the right side of the brain). These measurements were made from MRI brain scans of 27 people with mood disorders, 42 people with schizophrenia, and 58 healthy controls with no personal or family histories of mental illness.

Somewhat to our surprise, the results were fairly clear-cut. Compared with the healthy controls, schizophrenic patients had greatly shrunken entorhinal cortexes and striking reversals of some key brain asymmetries, but in manic-depressive patients these structures looked just like they did in the healthy controls. The amygdala was moderately shrunken but of equal size on the right and left sides of the brain in schizophrenic patients. In mood disorder patients, however, the amygdala was unchanged on the right side but very significantly shrunken on the left.

So, what can we carry away from this research? The observation that in both patient groups, brain structures differed in size from the same structures in healthy controls helps confirm our basic idea that both mood disorders and schizophrenia are brain diseases. However, the sizes of the brain structures in the two patient groups differed from the normal sizes in different ways, strongly suggesting that mood disorders and schizophrenia are distinct diseases, associated with distinct patterns of brain changes.

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1 Professor, Department of Psychiatry, Johns Hopkins University School of Medicine