Getting bipolar therapy right

Though neurologists don't yet know how bipolar disorder develops, the mood swings have been linked to tidal shifts in the levels of chemical messengers in the brain, such as serotonin, glutamate and dopamine, which help people experience emotions


The ideas come in a swarm, and they can be good ones: Move to Prague and teach English. Study jazz piano in the early-morning hours. Start a dot-com; hike the Appalachian Trail; write an opera.

"I wanted to save people," said Agnes Zsigovics, 28, a student in social work living near San Diego, who in her early 20s made plans to teach children living in the mountains of Venezuela - only to ditch the idea at the last minute and fly to Montreal to teach Spanish.
"I just had way, way too many projects in my head I can tell you this: People with bipolar disorder have the most interesting lives."

They can also have dangerous lives. Bipolar disorder is another name for manic depression, an incurable, lifelong mental condition in which people zigzag from these effusive emotional highs to paralysing periods of despair, often accompanied by thoughts of suicide.

Recent studies suggest that as many as 10 million Americans are afflicted with the condition to some degree -far more than previously thought. The illness goes unnoticed or undiagnosed in many people because their manic episodes are neither dramatic nor especially destructive, psychiatrists report. The findings have prompted a wave of research into new drug and talk therapies and an increased willingness among psychiatrists to seek guidance from patients and their families.

"What we're learning is that patients do a lot better if they're collaborating on their own treatment," Dr Gary Sachs, lead investigator of a large national study that is following about 2,500 patients with bipolar disorder and comparing treatment approaches.

Preliminary evidence from the trial, sponsored by the National Institute of Mental Health, suggests that patients are the best judge of what triggers their manias and that their family and friends are crucial allies in managing the disorder. "It's as if you're co-managing a baseball team, working together to decide which combination of drugs and therapy work best, and when," says Sachs, director of the bipolar treatment programme at Massachusetts General Hospital.

For half a century doctors have treated bipolar disorder with regular doses of lithium carbonate, a naturally occurring mineral that acts in many patients like a steady hand on the emotional tiller. Though neurologists don't yet know how bipolar disorder develops, the mood swings have been linked to tidal shifts in the levels of chemical messengers in the brain, such as serotonin, glutamate and dopamine, which help people experience emotions.

Lithium appears to calm these chemical waves, and in the process has spared uncounted millions from suicidal thoughts. Actress Patty Duke, in her autobiography Call Me Anna, which describes her battle with bipolar disorder, calls lithium her saviour, a drug that rescued her from probable suicide.

People with untreated bipolar disorder are about 30 times more likely to commit suicide than the overall population, in which 12 of 100,000 take their own lives. Even patients who receive treatment experience frequent relapses, and many will plunge into drug and alcohol abuse, or contemplate suicide, psychiatrists say. Often, the relapse can be due to the treatment itself.

Researchers at the New York State Psychiatric Institute reported in June last year that about one of every three bipolar patients who visited psychiatrists during the 1990s received no mood-stabilising medication. Many got only antidepressants. The problem is, while antidepressants may lift the mood of someone with bipolar disorder, they also often propel them into a manic episode and depressive rebound, accelerating their cycles and making the problem worse, researchers and patients say.

For all its power to dampen mood swings, lithium also fails to prevent relapse in at least half of people with bipolar disorder, according to Dr Mark Rapaport, a psychiatric researcher at the University of California, San Diego.

But in the last several years doctors have begun to experiment with a variety of anticonvulsant drugs, which appear to be effective at stabilising mood swings, decreasing the frequency of both depression and mania, he said.

Drug treatments almost always work best when combined with some form of psychotherapy, doctors said. For starters, a good therapist makes sure patients take their medication, without fail, no matter how much they may miss the power and energy of their manic episodes. "When you're on, you can feel very good," Zsigovics said. "It can be hard to give that up."

Therapists also can teach patients some of the same self-control techniques that help longtime smokers and drinkers quit: Identify the situations or stresses that trigger episodes; diffuse or avoid them, if possible; and stick to stable daily work and sleep routines. Several recent studies have shown that disruptive events -work pressure, arguments with a spouse -are strongly linked to manic episodes in people with bipolar disorder. "I can tell you that for me being extremely rushed, or being challenged aggressively in an argument, can put me at risk" of a manic episode, said Stephen Propst, 38, of Atlanta, who operates a website at www.atlantamoodsupport.com for bipolar sufferers and their families. "And when you're not up to par, there are things, like social occasions, which only aggravate the illness."

That's where close friends and family members come in. Over the last several years, David Miklowitz, a psychologist at the University of Colorado, has studied the effect of family counselling on the behaviour of patients with bipolar disorder.

In a 21-week course, Miklowitz teaches patients' parents and siblings how to spot the warning signs of an imminent manic episode -the increased irritability, the big plans, the fast talking -and manage them by dialling down tension in the home. One of the techniques is called the "three-volley rule": If a disagreement with the patient prompts an escalating series of three personal attacks, it's time to back off.

"Change the subject if you can, or enlist the person in solving whatever the problem is," Miklowitz said. "In some ways these techniques are similar to marital therapy for high-conflict couples."

In one recent study involving 101 families, Miklowitz reported that bipolar patients who received mood-stabilising drugs and family-focussed treatment had a 29 per cent risk of relapse over the course of a year, compared with a rate of 53 per cent among patients who got medication and no family counselling.

A similar study, due to be published next year, finds that a counselling programme that involves the patient's family is a more powerful check on mood swings than programmes that focus solely on individual therapy.

Relapse rates in those who received drugs and individual counselling were 60 per cent during the year, five times higher than the rate among those whose families were involved in treatment.

Most patients say the emotional seesaw never completely stops. But new combinations of treatment are making the ride easier for many. "The difference is t