Certain factors predict bipolar disorder

A recent study found that there are a number of factors that increase the chance of having bipolar disorder.

Having at least four previous depressive episodes, suicidal acts, cyclothymic temperament, family history of bipolar disorder, substance abuse, younger age at onset and male gender all significantly and independently differentiated bipolar from unipolar disorders in the study of 2146 patients who initially presented with a first episode of major depression.
After an average of 13 years, 642 (29.9%) patients were diagnosed with bipolar disorder and 1504 (70.1%) were diagnosed with major depressive disorder.
Further statistical analyses showed that differentiation of future diagnoses of bipolar from unipolar disorder was maximal when between two and four risk factors were present per person.

I, myself, have about three. A family history of bipolar disorder, a younger age of onset and suicidal thoughts. The list specifies "suicidal acts" but I think suicidal thoughts could possibly count as well.

Why is bipolar disorder so popular?

One person in a Facebook group asked why is it popular to have bipolar disorder and other mental disorders among the young today? One possible answer is that bipolar disorder has been associated with an unusual amount of creativity,intelligence and wealth. Kay Jamison is partly responsible for this romantic notion. Other studies on the topic seem to support the theory regarding creativity and upward mobility but not so much intelligence. I think most people would rather be diagnosed with a disorder that is associated with excess productivity,creativity and wealth than depression or schizophrenia which hasn't been associated with any of these attributes. Here is an excerpt from one article regarding the topic:

We examined clinical features in 877 in- and outpatients affected by depression who were enrolled in psychopharmacological trials, subdivided according to Hollingshead's method into five social classes. The results showed that social class correlated significantly with the subtypes of mood disorders, with bipolar disorder being more frequent amongst the upper than the lower social classes. Furthermore, as already reported in other countries, social class appeared to influence the psychopathological pattern of depressive symptoms: somatization and anxiety were more frequent amongst the lower social classes, while psychic and cognitive symptoms were more common amongst the upper classes.

Another answer might be that the bipolar disorder which many are diagnosed with today isn't Bipolar I but Bipolar II. Bipolar II is less likely to be associated with psychosis which could make it more acceptable. In the past Bipolar disorder or Manic Depression was associated with a severe emotional disturbances, psychosis and a lack of treatment. No one wants a disease with no treatment.

A third possibility is that a small number of celebrities have been diagnosed with bipolar disorder and this could increase the popularity of the disorder. Catherine Zeta- Jones is one such celebrity who has been diagnosed with Bipolar II. She is obviously beautiful, popular and wealthy. Who wouldn't want to be associated with all that? Moncrief  who is a psychiatrist doesn't think Bipolar II patients need drugs and even questions the diagnostic category. Here is an excerpt from an article she wrote:

Bipolar disorder has become the ‘fashionable’ mental health diagnosis – helped, no doubt, by the fact that many celebrities, including Catherine Zeta-Jones and Stephen Fry, have said they, too, are sufferers.

A fourth possiblity is that artists such as Silvia Plath have been diagnosed with bipolar II. Artists share the angst that is more popular among younger people and popular artists are associated with increased social status/wealth.

A fifth possiblity is that bipolar disorder is more unusual than other mental illnesses with a percentage of around 2% of the population. It is also respected as more severe than say depression which is known as the "common cold" among doctors. This combined could make the person feel more unique and respected.

A sixth possibility and the most likely explanation is that Bipolar disorder is now seen as existing on a spectrum by a few bipolar experts. Additionally the concept of a spectrum gave pharmaceutical companies a new market for many of their highest priced medications which they market to psychiatrists and directly to the public.

In conclusion, I think it is popular to be slightly mentally ill but not so much that it is associated with loss of productivity and poverty. Poverty and isolation are what we all are trying to avoid.

Distinguishing low mood from major depression

I think there is still much confusion between depression(normal mood) and major depression and so I thought I would share my thoughts on how I distinguish one from the other. How I distinguish normal moods from major depression:

• Normal moods usually last a fairly short time and are less severe-- often less than a day. Major depression is a moderate to severe depressed mood for at minimum two weeks. Moderate to severe often means thinking about suicide quite a bit.
• With a normal mood one can often tie it to something that has happened or a given thought
•  The mood within major depression is often connected to the circadian rhythms. Often people feel worse in the morning(often suicidal) and their mood improves in the evening
• Distraction will often work with normal moods but not with major depression
• The depressed mood in major depression is often accompanied with severe fatigue(bedridden), lack of motivation, disrupted appetite, lack of pleasure, cognitive problems, and excessive sleepiness/insomnia
• Major depression affects your ability to function on a basic level. Good hygiene seems optional for people who normal have good hygiene

Antipsychiatrists who could be referred to as "lumpers" don't make the above distinctions. They believe everyone experiences depression which is true but not everyone experiences moderate to severe depression that lasts more than two weeks and is accompanied by other symptoms. They also argue that the criteria that distinguish major depression are arbitrary which is also true but many distinctions in life are to a degree arbitrary and yet are still respected. I , a "splitter", sometimes wish that they would come up with a new name for major depression so it wouldn't constantly be confused with a normal low mood.

My arguments against antipsychiatry

My experience deviates from the experience of the depressed and psychotic people in Anatomy of an Epidemic. I would argue against Robert Whitaker (antipsychiatrists) by making the following points:

• Robert Whitaker said that depression used to be thought of as cyclic and a limiting illness. My experience is that it is more chronic and that chronicity wasn't due to medications . My depression was chronic for about eleven years prior to taking any medication. They don't acknowledge atypical depression which is more chronic and less severe.
• Whitaker believes that medication causes a more severe type of illness. This isn't the case with me. The way depression expresses itself has changed over the years but I would necessarily say that medications made it more severe. Depression tends to be more atypical in younger people and more typical in older individuals.
• Whitaker believes that psychosis is a fairly limited condition and consequently can be dealt with without medication. I experienced psychosis about four years ago and didn't take medication until about a year ago. The psychotic episode didn't seem to be resolving on it's own.
• Whitaker believes that most mental illness is resolved by time and alternative medicine such as diet, exercise and psychotherapy. Prior to experimenting with antidepressants and antipsychotics I tried quite a few natural therapies without much luck.
• He believes that mental illness isn't real, much like Thomas Szasz, due to a lack of pathology. There isn't any test that doctors can run to diagnose someone as "mentally ill". While this is true migraines don't have any particular pathology either and yet are accepted as quite real. Why do antipsychiatrists assume that scientists know everything there is to know regarding mental illness. Antipsychiatrists seem to exist just in the present.
• In many of his comparisons of nonmedicated vs medicated patients he never seems to discuss why the nonmedicated patients were nonmedicated. Did they possibly have a more limited illness or a less severe one?
• Whitaker believes that medication interferes with people taking responsibility for their "illness". Why is there a need to blame the patient with mental illness. Whitaker would like to take us back to the middle ages where mental illness was seen in the context of religion. It was seen primarily as a moral failing and not a physical one.

I agree with Whitaker that antidepressants aren't particularly effective and many people are diagnosed incorrectly however there is still much that I don't agree with him on.

Antidepressant discontinuation syndrome

In the fall of 2010 I experienced psychotic depression at the age of 39. What is odd is that it was the first psychotic episode that I have been diagnosed with.  In the past my psychiatrist mentioned that I tested on the MMPI as slightly paranoid but not psychotic.  The episode in 2010 was dramatically different with voices, paranoia and delusions.

Prior to the fall of 2010 I had experienced much stress; I lost a job, my father had a heart attack and I was in conflict with a neighbor. The neighbor seemed rather sadistic and during the the winter I hid for most of the three months in the medical library. Many people didn't believe the neighbor was threatening but I perceived it that way. Then during the spring I moved to another apartment in order to get away from my neighbor. In the summer I tried to taper off of Wellbutrin and started valproate for migraines.

One day during August or so I started to hear voices and and experience delusions. Looking back I wonder if tapering of Wellbutrin might have played a role in that episode. There are a few case studies where individuals experienced psychosis when they started the drug and some who experienced difficulty discontinuing the drug.

According to several case reports, stopping bupropion abruptly may result in a "discontinuation syndrome" expressed as dystonia, irritability, anxiety, mania, headache, aches and pains.[51]

Recently I came across an article by Joanna Moncrieff where she mentioned that some individuals experience psychosis when coming off of antipsychotics. She also stated that various drugs could cause symptoms which could be confused with mental disorders. Wellbutrin has a weak effect on dopamine but it is not blocking it like antipsychotics. According to Moncrieff there is something called super sensitivity psychosis which can develop when coming off antipsychotics. Super sensitivity psychosis is attributed to a reaction regarding dopamine. On antipsychotics dopamine is blocked so when it is stopped abruptly dopamine acivity increases in reaction. Similar to the law in physics, for every reaction, there is an equal and opposite reaction. Here is a quote from her paper.

Adverse effects induced by discontinuation of psychiatric medication include: (1) a somatic
discontinuation syndrome that includes psychological symptoms which may be mistaken for relapse, (2) a rapid onset psychotic reaction after withdrawal of both conventional neuroleptic drugs and some atypicals, notably clozapine(sometimes referred to as supersensitivity psychosis), (3) a psychological reaction to withdrawal, which may be mistaken for relapse or may itself precipitate relapse, (4) a genuine relapse of the underlying condition precipitated by the process of withdrawal

A second researcher by the name of Giovanni Fava found that over time antidepressants can worsen depression and cause hypersensitivity of the HPA axis which is primarily involved in stress regulation. A hypersensitive HPA could potentially cause psychosis since psychotic depression often manifests with abnormally high cortisol levels.

By facilitating 5-HT receptor mediated neurotransmission, 5-HT post synaptic down regulation, a putative  final common pathway of the actions of different antidepressants may induce an activation of the HPA axis.

SSRIs have the potential to disrupt the dopamine balance as well since as seorotonin levels increases dopamine is said to decrease. Consequently SSRIs have the potential to cause psychosis as well when tapering.

When I brought the possibility of Wellbutrin precipitating my episode my pdoc dismissed the idea entirely. Perhaps doctors don't want to acknowledge that there is anything wrong with the drugs that they prescribe, with potential lawsuits and all.

This person had a similar experience tapering off of Effexor. 

Evolutionary Origins of the Depression Epidemic

I recently read a book called "The Depth: The Evolutionary Origins of the Depression Epidemic". Here is a summary of the book from Amazon:

Why are we losing the fight against depression? In this groundbreaking work, psychologist Jonathan Rottenberg explains that despite advances in pharmaceutical science, progress has been hampered by our fundamental misunderstanding of depression as a psychological or chemical defect. Instead, Rottenberg introduces a surprising alternative: that depression is a particularly severe outgrowth of our natural capacity for emotion; it is a low mood gone haywire. Drawing on recent developments in the science of mood—and his own harrowing depressive experience as a young adult—Rottenberg explains depression in evolutionary terms, showing how its dark pull arises from adaptations that evolved to help our ancestors ensure their survival.

For a good part of the book the author tried to make a case that mild depression is the same as major depression and  if mild depression( reactive depression) is the same as major depression( endogenous depression) then neither is a disease. According to him they both have the same causes, similar symptomatology, and respond to similar treatments, therefore they are the same. This didn't seem like an air tight argument to me since there are some things that have similar causes, similar symptomatology, respond to similar treatments and yet are different. For example Subictal Mood Disorders (epilepsy) and Bipolar disorder are exacerbated by stress and can display similar symptomology( mood changes) but yet could have different pathology.

Additionally, one person has argued that the term major depression includes too many people who might not necessarily have endogenous depression. What the author should have possibly been comparing is mild depression to melancholic depression in order to make his case. Melancholic is considered by many to be more endogenous in nature than major depression which might include more of the neurotic/reactive variety.

Another argument that he makes is that depression could be evolutionarily favorable. He makes a better argument here except severe depression doesn't seem to be for the most part evolutionarily favorable. He specifically mentions an experiment where severely depressed people were a better judge of character than controls however this was just one experiment.

The author argues that depression is evolutionarily favorable since it causes people to stop pursuing impossible goals which are causing unnecessary stress. This seems plausible for mild depression which appears to make people more realistic but not so much for severely depressed people since they often have a distorted view of reality.

In conclusion his evolutionary theory in relation to mild depression was quite interesting  and gives depression a more positive image but the inclusion of severe depression needs a stronger argument.

Meditation regulates genes involved with inflammation

Dr. Khalsa and a group out of UCLA have shown that KKM resulted in different patterns of brain metabolism compared to other general relaxation methods. Using PET scanning, they saw that KKM resulted in 19 genes being up-regulated and 49 genes being down-regulated, resulting in the production of fewer inflammatory mediators, and increased telomerase activity by almost 50%. Why do we care about telomeres? Well, for starters, the Nobel Prize in Medicine was recently awarded to another research group, which found a connection between increased telomerase activity and greater longevity. Finally, the group taught KKM also had higher scores of mental health and lower depression.

KKM is a type of meditation. Inflammation is thought to be involved in depression and telomere activity is relevant  since depression is thought to accelerate the aging process. Due to the small number of people in research studies, more research is necessary.

Personally I find that meditation immediately helps with my fatigue, irritability and ability to focus. I'm not so sure about the long term effects.

Habits of miserable people

English: Abraham Lincoln, the sixteenth President of the United States. Latviešu: Abrahams Linkolns, sešpadsmitais ASV prezidents. Српски / Srpski: Абрахам Линколн, шеснаести председник Сједињених Америчких Држава. (Photo credit: Wikipedia)

Yesterday I came across an article regarding habits of miserable people. while I know some people like this who are chronically mildly depressed I'm afraid this person would extend it to  the severely depressed. Here are a few quotes that summarize the authors thinking.

• When you’re miserable, people feel sorry for you. Not only that, they often feel obscurely guilty, as if your misery might somehow be their fault. This is good! There’s power in making other people feel guilty. The people who love you and those who depend on you will walk on eggshells to make sure that they don’t say or do anything that will increase your misery.

• When you’re miserable, since you have no hopes and expect nothing good to happen, you can’t be disappointed or disillusioned.

• Being miserable can give the impression that you’re a wise and worldly person, especially if you’re miserable not just about your life, but about society in general. You can project an aura of someone burdened by a form of profound, tragic, existential knowledge that happy, shallow people can’t possibly appreciate.

There are a couple of problems with this article if one extends her thinking to all types of depression. First of all Madanes could be accused of " mind reading" by CBT therapists. She thinks she knows how all depressed people think. Ironically she has the same overly negative perception of depressed people that she is accusing them of. There are some depressed people who gain from being "depressed" however this isn't necessarily true of most of them.(over generalizing) I personally have been treated quite negatively when depressed. Additionally she lumps all "depressed" people together when their depression could differ with regard to degree and source, some more biological and some more environmental.

There are many great people who are depressed, Churchill, Dostevsky and Lincoln. Lincoln was one outstanding example of a person who contributed much to society despite being quite miserable. I wonder how his life would have been different if he hadn't been depressed.

Green tea alleviates symptoms of depression

some of that tea (Photo credit: Wikipedia)

A just came across a recent study that demonstrated that green tea could significantly improve depression symptoms, in particular anhedonia.

Green tea (Camellia sinensis) extracts, as well as their main component, the polyphenol epigallocatechin-3-gallate (EGCG), reportedly have antistress, anticancer, and antioxidant effects. Recent studies suggest a beneficial association between green tea
consumption and symptoms of depression; however, the underlying mechanism behind that association is unclear. Anhedonia, the inability to experience pleasure, is a characteristic of depression, marked by reduced pleasure, altered motivation, and disturbed reward learning.1,2 A reduced reward-learning function has been linked to persistent anhedonia in depressed patients.3

"It has been evidenced that reduced dopamine neurotransmission might
contribute to the anhedonia and loss of behavioral incentive in depressive disorder, therefore it is important to examine the regulatory role of green tea on the brain circuitry activated by reward learning," write the authors.

Compared with the control treatment, the green tea produced significantly greater improvements in the MADRS (P<0.01) and HRSD-17 (P<0.001) total scores.

I've been drinking green tea occasionally and noticed that it seemed more stimulating than regular tea. This seemed odd to me since green tea has approximately half the amount of caffeine compared to black tea. According to this study and others the stimulating effects could be due to an increase in dopamine activity in the reward center of the brain.

Green tea is recommended for Pitta and Kapha types in Ayurveda. Pitta types are said to have more problems with inflammation so green tea, which has an astringent quality to it, would be recommended. Inflammation has been shown to in turn to be associated with depression. I found one recent journal article in addition that supports the idea that tea, black or green, has anti-inflammatory properties.

Diet could affect mood via bacteria in gut

Lord of Ayurveda,Dhanvantari (Photo credit: Wikipedia)

I have tried a number of diets in order to improve my mood and one that seemed to help the most was the Pitta diet of Ayurveda. This diet consists mainly of food that has the flowing qualities: bitter, astringent,  and sweet. Additionally the diet specifies eating little to no meat,no eggs, and avoiding certain oils. The Pitta dosha is associated with inflammation in Ayurveda.

Recently I read in NPR that a diet consisting of just meat, eggs and cheese increases a type of bacteria your gut that could lead to inflammation and inflammation has in turn been associated with depression. A vegetarian diet on the other hand increased other types of bacteria which haven't been associated with inflammation.

Scientists are just beginning to learn about how our decisions at the dinner table — or the drive-through — tweak our microbiome, that is, the communities of bacteria living in our bodies. But one thing is becoming clear: The critters hanging out in our intestine influence many aspects of our health, including weight, immunity and perhaps even behavior.
"The relative abundance of various bacteria species looked like it shifted within a day after the food hit the gut," David says. After the volunteers had spent about three days on each diet, the bacteria in the gut even started to change their behavior. "The kind of genes turned on in the microbes changed in both diets," he says.

Four day rule of hypomania questioned

Published by the American Psychiatric Association, the DSM-IV-TR provides a common language and standard criteria for the classification of mental disorders. (Photo credit: Wikipedia)

A group of researchers are questioning the validity of the four day hypomanic threshold needed for a diagnosis of bipolar II. The four day rule could potentially exclude a considerable number of individuals with bipolar II.

They found that 186 bipolar II disorder patients who met the 4-day criteria did not differ significantly from 315 patients whose manic episode lasted less than 4 days on a number of illness correlates on the Mood Swings Questionnaire (MSQ).
“Our study findings are strongly consistent with previous studies arguing that the clinical phenotype of [bipolar] II disorder (and its existence) is not dependent on a minimum duration of four days as imposed by DSM-IV and DSM-5, but further advanced by validation against a number of clinical correlates and not simply by examining phenomenological expression,” the researchers Gordon Parker (Prince of Wales Hospital, Sydney, Australia) and colleagues comment.
The only difference was that patients with brief manic episodes were more likely to rate manic symptoms as being less severe than those whose episodes lasted for 4 days. The average total MSQ scores were 49.6 and 57.0, respectively.

I personally have experienced a significant mood change for less than four days. It often occurred  over a a period of three days and the mood switches within a day were almost like clock work. Given the arbitrariness of the rule I'm not surprised by this study's finding.

Psychosis increases risk of bipolar disorder

Danish researchers have identified characteristics in people with psychotic depression that predict an increased risk for conversion to bipolar disorder.

The researchers analyzed data from several Danish registries to identify conversion to bipolar

disorder among patients with an initial diagnosis of unipolar psychotic depression between January 1995 and December 2007.
Among the 8588 patients included in the study, 609 were diagnosed with bipolar disorder (defined as a new diagnosis of hypomania, mania, mixed affective episode, or bipolar disorder) during follow-up, giving a conversion rate of 7.1%.
Comparison of patients who did and did not convert to bipolar disorder identified a range of differences, seven of which emerged as significant risk factors in multiple logistic regression analysis.
These were: younger age at onset of unipolar psychotic depression (adjusted odds ratio [AOR]=0.99 per year of increasing age); recurrent depression (AOR=1.02 per episode); living alone (AOR=1.29); receiving a disability pension (AOR=1.55); and the highest educational level being a technical education (AOR=1.55), short-cycle higher education (AOR=2.65), or medium-cycle higher education (AOR=1.75).
Further analysis of the impact of age at psychotic depression onset found that, compared with people aged 20 years or younger at onset, the AOR for bipolar disorder was 1.64 for those aged 20–29 years, 1.58 for age 30–39 years, 1.80 for age 40–49 years, 1.36 for age 50–59 years, 1.19 for age 60–69 years, 0.85 for age 70–79 years, and 0.40 for age 80 years or older.

The researchers said that in comparison to previous studies the risk was underestimated in this latest study. Interestingly people in the age group (40- 49) appear to have a greater risk than younger groups. I was under the impression for some time that bipolar disorder developed much earlier. Perhaps a greater fluctuation in hormones levels might increase the risk as well.

This study was of interest because I have experienced depression since age twelve and also experienced psychotic depression around age 14 and at 39. Despite experiencing some characteristics of bipolar disorder my doctors didn't think bipolar disorder was likely.

Treatment of insomnia also improves depression

Insomnia again (Photo credit: Foodie In Disguise)

"The new report, from a team at Ryerson University in Toronto, found that 87 percent of patients who resolved their insomnia in four biweekly talk therapy sessions also saw their depression symptoms dissolve after eight weeks of treatment, either with an antidepressant drug or a placebo pill — almost twice the rate of those who could not shake their insomnia. Those numbers are in line with a previous pilot study of insomnia treatment at Stanford."
"Dr. Carney acknowledged that the study was small — just 66 patients — and said a clearer picture should emerge as the other teams of scientists released their results."

This study is interesting and shows promise however there is a considerable  percentage of depressed people who over sleep rather than suffer from insomnia. In my case I have experienced a combination of the two-- insomnia at night and oversleeping during the day. Additionally, I noticed that if I went to bed earlier than usual I would be more likely to have insomnia. This latest theory doesn't explain this.

Other problems with the study were that it was on the small side and the tools for measuring depression are questionable. They didn't appear to use a test that was specific for depression but one that was specific to rumination and insomnia. Why not use the same test as other depression studies?

Related articles

• Have Researchers Discovered a Quick Fix for Depression? (psychologytoday.com)

Joanna Moncrieff and the anti-psychiatry movement

Recently I visited the Mad in America website and commented on an article and video by Joanna Moncrieff.

Moncrieff is a psychiatrist in the UK who has written a number of books against the use of drugs and the idea of a bipolar spectrum. Since we both appeared to have the same opinion regarding the efficacy of antidepressants I thought some exchange might be interesting. In a comment, I wrote that I wish I had taken medication sooner than I had and that anti-psychiatrists appear to be  in a hurry to normalize mental disorders despite the lack of evidence for many of them one way or the other. In response a man replied that I hadn't paid attention to the previous discussion and how disastrous all psychiatric drugs/labels are. Here is an excerpt from her article.

Professional interests drove the transformation of antipsychotics from special sorts of tranquilisers into so-called ‘magic bullets’ back in the 1960s. It was this idea that antipsychotics constituted a sophisticated and targeted treatment, rather than a chemical suppressant, that obscured their unpleasant, mind-altering effects, thus enabling the pharmaceutical industry to expand their use over recent years

Now, I can see pluses and minuses to psychiatry however the people on this site are quite black and white. I am willing to bet for every story of someone harmed by psychiatry there is at least one who feels like he/she was saved by it. It is true that many people are being treated with drugs they don't need and perhaps mislabeled but there certainly are people who desparately need drugs and some name to describe their problem. For some reason we expect psychiatry to perform on par with other medical specialties even though we still know very little about the brain.

Is Bipolar disorder over diagnosed?

Joanna Moncrieff believes that psychiatrists are over diagnosing Bipolar disorder. Bipolar

disorder used to consist of extreme mood swings, hallucinations, bizarre beliefs and dramatic changes in energy which all occurred over weeks to months but now many "normal" people are receiving the label.

The manufacturers of rare antipsychotic medication have set about changing the meaning of this once rare and distinctive condition, expanding its boundaries beyond recognition so that 'bipolar disorder' has become a label that can be attached to a whole myriad of common personal difficulties, who then become legitimate targets for antipsychotic treatment.

I tend to still favor the idea of a mood spectrum since many traits in nature tend to be distributed in a bell curve like fashion. Extroversion/Introversion is one example of this. In the Myers and Briggs indicator extroversion/ introversion preferences are being tested for and when researchers looked at distibutions of scores of various preferences, most had a bell curve distribution. In this distribution most people fall on the borderline and the test somewhat arbitrarily says you are either an introvert or an extrovert.

I can see mood disorders being distributed in a similar fashion except this time perhaps the dichotomy would be instability/stability of mood. Many people would fall in the middle with a mild mood disturbance. What is questionable though are those Bipolar II individuals who border the "normal" area and one tail of the curve. Moncrieff would like to absorb the Bipolar II individuals into the normal part of the curve which would make Bipolar all or nothing however nature is rarely this black and white.