About 1% of the adult population has a bipolar disorder. It most commonly first appears in young people in their early 20s. Men and women are equally likely to be affected. 25-50% will make one suicide attempt. 10-15% will succeed. The risk is highest in the initial years of the illness. 60% of people will abuse drugs or alcohol at some point in their lifetime.

Bipolar disorder is classified differently depending on what diagnostic manual is used by clinicians. The most widely used is the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, current version V (DSM-V) which was released in May 2013. However there is also the World Health Organization’s ICD-10 Classification of Mental and Behavioural Disorders.



For a broad overview of the classifications and differences between the two manuals I suggest:

http://blogs.psychcentral.com/bipolar/2012/02/bipolar-diagnosis-treatment-guidelines-us-uk-dsm-icd/

http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-adults/index.shtml#pub12

For diagnosis, treatments and management of bipolar disorder standards in the UK take a look at the National Institute for Health and Care Excellence’s website:

http://www.nice.org.uk/guidance/cg185/chapter/1-recommendations#recognising-and-managing-bipolar-disorder-in-adults-in-primary-care-2

For more general information for people with bipolar disorder in the UK:

http://www.bipolaruk.org.uk/

http://www.mind.org.uk/information-support/types-of-mental-health-problems/bipolar-disorder/

What is your own personal story, with this disorder?

My mental health issues started at an early age, when moving at age eleven to secondary school. I was relatively quiet and reserved, enjoying nothing more than a good book and the local library.

Family life was relatively easy, although my father was an alcoholic and looking back I can see the signs of bipolarism in his behaviour, although this is purely conjecture and he certainly didn’t receive any mental health intervention. I read somewhere, although I can’t remember where, someone say that ‘I never saw my father drunk, but I never saw him sober either.’ I think that about sums him up. Given that current medical opinion suggests that bipolar disorder is frequently inherited, with genetic factors accounting for approximately 80% of the cause of the condition,[1] I cannot help consider whether his drinking was his way of self-medicating against his own hidden mental health issues.



If one parent has bipolar disorder, there is a 10 per cent chance that his or her child will develop the illness, if both parents have bipolar disorder the likelihood of their child developing the illness rises to 40 per cent[2]. However this has to be balanced by theories of chemical imbalances in the brain (neurotransmitters such as noradrenaline, serotonin and dopamine) and environment factors such as stressful triggers which can include the breakdown of a relationship physical, sexual or emotional abuse or the death of a close family member or loved one. Bipolar disorder may also be triggered by physical illness, sleep disturbances and overwhelming problems in everyday life, such as problems with money, work or relationships.

Even as a teenager I was clearly depressed, attempting to take my own life by overdose on at least three separate occasions. This is one of the reasons I turned to Far Eastern philosophies with the hope that they might allow me to rectify my situation and bring some meaning and purpose to life.

So it was I began my Buddhist practice, firstly three years with Japanese Rinzai Zen, then around ten years in the Tibetan tantric tradition. This gave me some respite from my mental health condition right up until I was in my early thirties when the above mentioned disruption to both my own Buddhist practice and consequently my academic studies occurred and as a result I left both behind me. It was an extremely difficult time for me as I was experiencing what I now know to be a full-on manic phase of bipolar and I went, let’s just say a little crazy. It was as though all the anger and sense of meaninglessness in my teenage years had been kept ‘under wraps’ by my Buddhist practice and now came back to haunt me. Overnight I lost everything and everyone I knew and was left trying to figure out what ‘ordinary’ people did with their days. I was initially diagnosed with depression although my symptoms clearly suggested something else was amiss. I later found out that people with bipolar disorder wait for an average of 13.2 years before they are diagnosed, and often spend years receiving treatment for other conditions.[3]

So it was that I continued to receive antidepressants - selective serotonin reuptake inhibitors (SSRIs) such as citalopram, fluoxetine, paroxetine and duloxetine. None of these seemed to have any effect other than shower me with a host of side-effects such as dry mouth, slight blurring of vision, constipation, drowsiness and sexual dysfunction. Several suicide attempts and hospitalizations later I met my current wife.

She was the first person to notice that alongside my depressive episodes I sometimes experienced periods when I would be full of energy and feelings of extreme and intense happiness – feeling excessively ‘high' with an increased confidence and self-esteem. There would be increased talkativeness and talking very fast, feeling full of ideas and racing thoughts an exaggerated sense of my own importance. I would feel restless and would have had difficulty relaxing, with a lack of concentration and being easily distracted. It was also at these times that I would tend to engage in more risky behavior, such as going on a spending spree or exhibiting poor judgement. I also could become increasingly irritable and impatient.

I did not really notice these phases - I just felt good and was glad not to be feeling depressed. However I spoke to my GP about it and she suggested an assessment for bipolar. This I did at my local Community Mental Health Centre (CMHT where I lived in Cardiff at the time) and after initial assessment I was deemed to experience symptoms suggestive of bipolar disorder and began treatment. There are several types of bipolar disorder but I mostly fall into type II bipolar where you experience less extreme manic attacks – labelled hypomania.[4] I also experience mixed states, more often referred to now as mixed episodes – where both mania and depression occur simultaneously or alongside each other. During a mixed state, you tend to feel very sad or hopeless while at the same time feel extremely energised. It is a particularly dangerous time with regards to suicide as you have all the hopelessness of depression with the energy to carry out the act. However, clinicians do now seem to be steadily phasing out a distinct typology of bipolar disorder in favor of a broad spectrum of bipolar symptoms. This certainly seems in my experience to best fit the pattern of symptoms experienced.[5]



What medications have you tried?

Most people with bipolar disorder are treated using a combination of different treatments. These can include one or more of the following: medication to prevent episodes of mania, hypomania (less severe mania) and depression – these are known as mood stabilisers and are taken every day on a long-term basis. Medications can also be used to treat the main symptoms of depression and mania as and when they occur independently of each other. You can also learn to recognise the triggers and signs of an episode of depression or mania ahead of time in order to receive the treatment required. There are psychological treatments – such as talking therapies that can be offered to help you deal with depression and provide advice on how to improve relationships etc. Lastly there is lifestyle advice – such as doing regular exercise, planning activities you enjoy that give you a sense of achievement and advice on improving diet and developing healthy sleep hygiene.

I began my bipolar treatment prescribed with 600mg lithium carbonate daily. This is a relatively low dose because I was also taking diclofenac sodium for ankylosing spondylitis (an arthritic disease of the – in my case – lower spine) which has the effect of increasing the level of lithium in the blood and is recommended not to be taken at the same time. Nonetheless I had been taking them for twenty something years and needed them to function physically. In the UK, lithium carbonate is the medication most commonly used to treat bipolar disorder.[6] For lithium to be effective, the dosage must be correct and you have regular blood tests every three months to make sure it remains within the safe yet effective boundaries. Serum levels should be determined twice a week during the acute phase, and until the serum levels and clinical condition of the patient have been stabilised. Desirable serum lithium levels are 0.6 to 1.2 mEq/L which can usually be achieved with 900 to 1200 mg/day.[7] As I said, taken along with non-steroidal anti-inflammatory drugs (NSAIDs), in order to keep serum levels safe you usually require a lower dosage in order to avoid lithium toxicity. Your kidney and thyroid function will also need to be checked every two to three months if the dose of lithium is being adjusted, and every 12 months in all other cases.[8]

I remained on lithium for two years during which time it almost completely eliminated my mood swings and other symptoms. To me it was a wonder drug despite the side-effects of weight gain, psoriasis, and ‘lithium fog’ where you feel drowsy and somewhat removed from the world. After two years I decided I’d been ‘cured’ and came off the lithium slowly and in accordance with my GP’s instructions so as to limit the possibility of a relapse. However, a serious suicide attempt led to me being put back onto the lithium alongside 300mg quetiapine (an anti-psychotic) and 15mg daily diazepam - more of that below.
I experienced roughly a further six months without experiencing any mood swings before my wife suggested I might be acting a little hypomanic. This was quickly followed by depression and in February of this year I took over three hundred and fifty pills in an attempt to end my life. I was rushed to my local hospital ICU where I was put on life support. A week later I woke up (much to my annoyance) and after a day or two was discharged.

My psychiatrist, as I had obviously come off of the lithium whilst in hospital, took the opportunity to put me onto lamotrigine, an anticonvulsant drug that can also be used to treat bipolar as a mood stabiliser.[9] As with lithium, you are supposed to build up your dosage slowly, but given the crisis conditions I was put on 200mg daily - the usual effective dosage. A second overdose and hospitalisation and this was increased to 250mg. I was also put onto 90mg duloxetine daily (an antidepressant already mentioned above) which was hoped would work in tandem with the lamotrigine to control the depressive and suicidal ideation.[10]

This brings us to the present day. I am still deeply mired in depression and suicidal ideation. As a result and after eight years I have lost my job. My wife and I have separated and I have had to move to cheaper accommodation. I am now swamped in benefits’ forms and continuing on the medication regime mentioned above, although I have requested a review with my psychiatrist as it clearly is not working. The difficulty of treating bipolar disorder is finding the right combination of drugs to treat both the manic and depressive symptoms. And there are plenty left to try: valproate, carbamazepine, olanzapine and risperidone to name but a few. There is no cure, only management of these symptoms and the first port of call is to try to get the meds right. Tricky, at best.

Part 2 is HERE

Image #1: Credit Photobucket

Notes

1. http://www.blackdoginstitute.org.au/public/bipolardisorder/causes.cfm
2. http://www.blackdoginstitute.org.au/public/bipolardisordercauses.cfm
3. http://www.theguardian.com/society/2012/jun/27/bipolar-disorder-diagnosis-survey
4. http://www.bipolaruk.org.uk/are-there-different-types-of-bipolar.html
5. http://www.gnmhealthcare.com/pdf/06-2009/04/dist_1067-3229_3996864232595_1067-3229_v17n3s5_912030914.pdf
6. http://www.blackdoginstitute.org.au/public/bipolardisorder/treatments/bipolardisorder.cfm
7. http://www.drugs.com/dosage/lithium.html
8. http://www.drugs.com/dosage/lithium.html
9. http://www.drugs.com/mtm/lamotrigine.html
10. http://www.drugs.com/drug-interactions/cymbalta-with-lamotrigine-949-2273-1430-0.html