Is there such a thing as a "bipolar spectrum"? I am undecided on this question and welcome any new perspective. Joel Paris, a personality disorder expert, had written a book on the topic in 2012 and tried to make the case that much of what falls in the "bipolar spectrum" is really a problem with "emotional dysregulation"( borderline personality disorder). He also tries to make the case that Bipolar I,Bipolar II and melancholic depression are diseases despite the lack of any physical tests or genetic evidence.

Its crucial to remember that that the bipolar spectrum is an unproven concept. The alchemy that turns depression, impulsive disorders, childhood behavioral disorders, and personality disorders into bipolarity depends on entirely superficial resemblances between observable behavioral symptom patterns. Its not based on any basic understanding of the disease process.

For the most part the book was a logical and interesting critique of the "bipolar spectrum" concept however I had the feeling that, given the fact that Paris was a personality disorder expert, he might be jealous of all the money that goes to fund bipolar spectrum research and would like to divert some of those resources.

I have been diagnosed with Dysthymia and Psychotic depression and might, according to this book, be labeled with Borderline disorder. To label everyone with mood instability as Borderline or another personality disorder seems just as unreasonable as labeling everyone as bipolar given the fact that personality disorders aren't defined much better than Bipolar disorder. In my case the instability could be explained by PMS and an extreme diurnal mood variation. According to Paris my personality disorder should have abated by middle age however I don't think my condition has improved much since it began.

Finally, affective instability has a different outcome from bipolar disorder. It gets better with time, but never completely disappears. It remains the chief complaint of patients with personality disorders who are followed into middle age.

Patients with unstable mood experience daily life differently than bipolar patients according to Paris.

They describe their life as on an "emotional roller coaster." they wake up feeling normal but get rapidly upset by each and every life event . In the course of the day, they feel sad and hopeless, angry to the point of uncontrollable rage, or happy enough to briefly feel slightly "high". Each mood lasts for a few hours. These emotional reactions are intense, and can take some time to "come down" from them.

He seems to believe that the only true diseases in the DSM are melancholic depression(severe depression) and Bipolar I/II. One could still argue that the previously mentioned categories are still quite arbitrary and vague in comparison to many other diseases. Further more the definition of severe depression varies between different researchers and "severe" depressives only fared slightly better on antidepressants according to some experts(Moncrieff) who have written critiques of antidepressant research.

The relationship between diet, inflammation and depression

A new study by the Centre for Addiction and Mental Health (CAMH) found that the measure of brain inflammation in people who were experiencing clinical depression was increased by 30 per cent. The findings, published in JAMA Psychiatry, have important implications for developing new treatments for depression.

A growing body of evidence suggests the role of inflammation in generating the symptoms of a major depressive episode such as low mood, loss of appetite, and inability to sleep. But what was previously unclear was whether inflammation played a role in clinical depression independent of any other physical illness.

More research has come out which supports the link between inflammation and depression. While this link hasn't been confirmed my experience has piqued my interest in the topic. For about fifteen years I have been experimenting with Ayurveda which is a form of medicine which originated in India a thousand years ago. In Ayurveda the world is divided up into three different categories(doshas in human body), Vata, Pitta and Kapha. Vata is associated with air, Pitta with fire/water and Kapha with water/earth. In the human body the various categories govern certain functions and areas. Pitta governs metabolism, heat regulation and the immune system. It is located in the eyes and small intestine. Various tastes/qualities are said to balance the doshas. Pitta is said to be balanced by sweet, bitter, astringent and coolness.

For many years I have experimented with Ayurveda and discovered that balancing Pitta was very helpful, even more than balancing Vata which is associated in Ayurveda with the nervous system. Balancing Pitta is helpful especially in regards to anxiety, irritability and depression. Perhaps Pitta's association with inflammation in Ayurveda might explain this. In addition, Ayurveda recommends a vegetarian diet for a Pitta type of imbalance, a vegetarian diet has been shown in western medicine to help with inflammation.

Balancing Kapha, which is said to be localized in the stomach, has been helpful in regard to lack of motivation and energy. Balancing a dosha can aggravate another. Whenever I balance Kapha I notice Pitta becoming imbalanced. Balancing or pacifying Kapha can increase irritability which is a Pitta imbalance. In Ayurveda there are different methods of balancing more than on dosha. One way is to balance Vata which is believed to govern the other doshas. The second method is to balance the two using the qualities that balance the two doshas. In the case of Pitta and Kapha they are both balanced by bitter and astringent tastes. While this balancing act can be consciously performed I think it is also subconsciously performed when we have desert after a meal that has had too much salty and sour taste to it.

Somewhat interestingly healthy food tends to be higher in bitter and astringent qualities while junk food is higher in salty, sour and sweet tastes. According to Ayurveda salty, sour and sweet all balance Vata which is associated with the nervous system and stress. Perhaps this preference is one reason why western cultures seem to have more problems with inflammation and depression.

Could depression be a form of adaptation?

The most recent theory on depression is that it could be some type of adaptation. I have written regarding this idea before in a post titled Evolutionary origins of the depression epidemic. The author of the book in that previous post was making a similar argument. He believed that depression was not a pathological condition but a way of adapting to stressful conditions. For example if a person lost a job and became depressed the depression could perhaps be a way of conserving energy or the depression might be suggesting that a person should change their goals.

In that previous post I wrote that depression in its milder forms could conceivably be seen as an adaptation however in its more severe forms not very likely. After all severely depressed people have problems functioning on a very basic level and aren't analyzing problems in the most objective or productive manner. Often depression seems to reduce flexibility and brainstorming. The only solution for many severely depressed people is suicide. It is more accurate to say that majorly depressed people obsess more than they analyze.

I, for example, have experienced chronic depression for most of my life and while being rather obsessive and analytical still have not gained  much insight into why I have felt depressed for most of my life. I have experienced many periods where I felt normal and quite productive but it wasn't necessarily due to some kind of insight. Those normal periods just happened and sometimes they occurred in a diurnal pattern or in a menstrual pattern which makes no sense in regard to the theory. Why would one person feel severely depressed in the morning and normal at night for a number of days? Why would I often feel normal to euphoric when I had my period? Various levels in hormones and their effect on neurotransmitters seem more likely.

This most recent research is suggesting the adaptation theory once again only instead of conserving energy depression focuses our energy obsessively on one thing and supposedly solves it.

The research suggests that depression may be a natural condition in which the mind concentrates involuntarily on a complex issue to the point where it allocates resources to analyzing the problem at hand, diminishing concentration on other aspects of living, perhaps giving rise to disrupted eating, sleeping and social interaction that are associated with depression.

This theory seems to assume the idea that depression is due to excessive stress which is debatable. One can feel more stressed pursuing a goal and yet have a reduced level of depression.  For example, I have given up on a number of goals which I found stressful and have not noticed any positive change in my level of depression. In fact, I felt worse for giving up on my goal. A proponent of this theory might also argue that I haven't made the right changes in my life. How does one falsify this theory if this is their answer. Additionally, the proponents of this theory keep pointing out that there is no conclusive evidence of pathology in major depression. True but it doesn't necessarily follow that pathology won't be discovered in the future. The fact that depression increases the likelihood of dementia is sufficient reason to keep looking for pathology in regards to depression.

CBT: a questionable form of therapy for depression

CBT is a therapy based on the belief that one's negative illogical thoughts can cause depression and correcting them can treat the depression. CBT therapy is usually performed with a therapist however now computer programs are being created to help depressed individuals. While CBT therapy is endorsed by psychiatry it has a number of problems.

Depression is known to cause distorted thinking so what comes first the depression or the distorted thinking? CBT doesn't clarify this issue. It just says that correcting illogical thinking treats the disorder.

CBT therapy has been shown to be as effective as antidepressant therapy and prevents relapses better than drugs. The problem with this is that antidepressant therapy isn't all that effective. Antidepressants are, in reality, only slightly more effective than a placebo. Additionally, since major depression is cyclical how does one know for sure if the treatment was actually helping. Many experiments are performed over rather short periods of time and a certain percentage of people will have spontaneous remissions. This of course could be the same issue for antidepressant trials.

Experiments involving CBT vs antidepressants are not double blind which is considered essential for the highest level of objectivity. If the researchers and the patients know what type of therapy is being performed objectivity is diminished.

A major criticism has been that clinical studies of CBT efficacy (or any psychotherapy) are not double-blind (i.e., neither subjects nor therapists in psychotherapy studies are blind to the type of treatment). They may be single-blinded, i.e. the rater may not know the treatment the patient received, but neither the patients nor the therapists are blinded to the type of therapy given (two out of three of the persons involved in the trial, i.e., all of the persons involved in the treatment, are unblinded). The patient is an active participant in correcting negative distorted thoughts, thus quite aware of the treatment group they are in

Researchers say that brain scans show that CBT "works" and yet brain scans are not considered a reliable way to diagnose mental illness. People with mental illness often have more than problem such as depression and ADD. This confounds diagnosing a mental disorder or saying confidently that an individual is in remission. This excerpt from Scientific American explains the problem.

During testing, the system analyzed the shapes of brain regions in each test scan and assigned it to the group it most resembled. The scientists checked its work by comparing the new labels on the test scans with the original clinical diagnoses. They repeated the procedure several times with different randomly generated sets. When the system chose between two disorders or one ailment and a clean bill of health, its accuracy was nearly perfect. When deciding among three alternatives, it did much worse.

The basis of CBT doesn't explain how people with a rapid cycling form of bipolar disorder cycle between depression and mania. Do they start off having negative thoughts during a depressive episode which eventually cycles with mania  and the mania consequently produces delusional thinking? CBT has not been shown to be effective for preventing depressive episodes in bipolar disorder.

CBT has given no biological explanation for how it works and yet implies that possibly negative thoughts might exacerbate stress which in turn precipitates a depressive episode. Even though stress has long been thought to cause depression stress(HPA activation) is not distinctive to just depression. Stress is implicated in numerous health problems in a rather vague manner. To further complicated matters what is stressful to one person isn't stressful to another. Consequently it is complicated to study stress.

In the end CBT emphasizes that depressed people are responsible for their depression which is still questionable in the eyes of science.

Fish intake might improve antidepressant response

Approximately half of the people suffering with depression don't respond to SSRIs. Recently a group of Dutch researchers discovered that adding fish oil to antidepressants increases the response rate.

According to a lead researcher they saw that depressed patients had an altered metabolism of fatty acids, and this altered metabolism was affected by stress hormones. In the experiment the researchers planned on examining the relationship between depression and fatty acids, and hormones such as cortisol.

They took 70 patients with depression and compared them to 51 healthy controls, by measuring their fatty acid levels and cortisol levels. They then gave the depressed patients 20mg of an SSRI daily for 6 weeks, and in those who did not respond to the SSRIs the dose was gradually increased up to 50mg/day. Fatty acid and cortisol levels were measured during the trial.
They found that the MDD patients who didn't respond to the SSRI also tended to have abnormal fatty acid metabolism, so they checked the dietary habits of all those taking part in the trial. Fatty fish is rich in fatty acids, such as the well-known Omega-3 DHA. So the researchers looked at the amount of fatty fish in the diet of all involved in the trial. They categorised the patients into 4 groups, according to their fatty fish intake, and they found that those who took the least fish tended to respond badly to anti-depressants, whereas those who had most fish in the diet responded best to anti-depressants. Those who ate fatty fish at least once a week had a 75% chance of responding to antidepressants, whereas those who never ate fatty fish had only a 23% chance of responding to antidepressants.

There were a couple of problems with this study. For one thing the study was on the small side and should be replicated with a larger one. A second problem is that the researchers appeared to know the fatty acid status of the depressed patients so they might have subconsciously altered the depression scores in order for their hypothesis to be proven correct. How the depression scores were measured is unclear from the article.

Andrew Stoll was one the first researchers to notice the antidepressant effect of fish oil. He theorized that fish oil might effect the composition of nerve cell membranes and consequently neurotransmission. Barry Sears, author of " The Zone", was another researcher who mentioned that stress could effect the type of fatty acids. They both probably inspired this study. I did not read the original article so if you are curious you will have to pay for the article through ECNP.

One way exercise could act as an antidepressant

Researchers have recently discovered that there is an enzyme in muscle that detoxifies a substance which tends to be high in the mentally ill. The substance Kynurenine is produced when an individual is exposed to stress. Exercise has long been considered as an antidepressant with stress reducing properties. This could perhaps be one explanation and a new way to target depression.

The researchers discovered that mice with higher levels of PGC-1a1 in muscle also had higher levels of enzymes called KAT. KATs convert a substance formed during stress (kynurenine) into kynurenic acid, a substance that is not able to pass from the blood to the brain. The exact function of kynurenine is not known, but high levels of kynurenine can be measured in patients with mental illness. In this study, the researchers demonstrated that when normal mice were given kynurenine, they displayed depressive behaviour, while mice with increased levels of PGC-1a1 in muscle were not affected. In fact, these animals never show elevated kynurenine levels in their blood since the KAT enzymes in their well-trained muscles quickly convert it to kynurenic acid, resulting in a protective mechanism.

In comparison to medication I have received more benefits from exercise with respect to stress reduction. Many antidepressants can also reduce stress however they have side effects, one of which is sedation with a loss of motivation.

Do antidepressants cause weight gain?

Antidepressants have been associated with weight gain however a new study refutes that idea.

Yet according to a study published a few days ago in the online issue of JAMA Psychiatry, this should not have happened. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. Using electronic medical records to gather information on weight change among more than 19,000 patients on antidepressants, Dr. Roy Perlis and colleagues of the this hospital in Boston found only minimal changes in weight. ..... Conclusion: The researchers said that patients should not be scared of taking antidepressants because they think they will gain weight. [1]
Weight was gained among those who had depression, but according to the author, only among those who had what she described as atypical depression, a depression characterized by increased appetite.

The majority of my 50 pound weight gain started 4 years ago after I stopped taking Wellbutrin. Ten of the 50 pound weight gain could be due to taking Risperdone in the last year. I doubt the author's speculation about an increase in appetite. My calorie intake was about the same over that four year period since I am rather rigid/consistent when it comes to eating. The fact that the weight gain could be related to atypical depression could be supported in my case however I didn't gain much weight while on Wellbutrin. Atypical depressives can also gain weight independent of calorie intake.

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.