Managing Bipolar Moods

Being bipolar must be so very consuming, it involves being aware of every aspect of changes in mood and it must get exhausting. Constantly evaluating, “Am I happy or am I moving into a manic state?” “Am I sad or is this going to be a major depressive episode?” Constantly evaluating the ebb and flow of mood shows an awareness of this chronic mental illness that comes only after tremendous experiences in both directions. Having the support of those around you to help you “see” the changes in mood for what they are versus what they can be helpful but overwhelming. The stigma of what used to be called manic-depression can also be debilitating in its own way. Will people judge…probably. Will people understand…probably not. Folks just don’t get interested in mental health issues until they hit the media in some major shit-storm, a celebrity shares their woes, or it hits home in themselves or someone they love.
This illness can affect as many as 10 million individuals in the US alone.
Signs and symptoms of the manic phase can be: extremely elevated mood, irritability, fast speech, flight of ideas, racing thoughts, risky behavior, (including gambling, sexual promiscuity and substance abuse), poor judgement, and decreased need for sleep. Depressive phase can include: extreme sadness, inactivity or lack of interest in usual activities, crying, anxiety, or irritability, hopelessness, or overwhelming guilt, weight loss, or weight gain, substance abuse, suicidal thoughts. The diagnosis is usually first made in young adults or even late teens, but can occur any time. Symptoms are variable and it may be difficult to diagnose right away. Medical history and physical examination should be performed to look for other causes of symptoms, this should include bloodwork. Family and friends can be enormously helpful in helping to evaluate an individual.
Since this is a chronic illness, continuous treatment is needed to prevent relapse or manic or depressive symptoms, to improve overall health and to maximize the quality of life. Several types of medications may be used, some alone or some in combination with others to treat bipolar disorder. All medications have adverse effects that must be considered and there may be several changes in the course of the treatment to maintain a steady mood state over many years. I call that finding the right recipe. Patience is required on the part of the provider, the patient, family and friends till the recipe is just right. Making the client most comfortable, functional and without side effects that make them want to stop taking medications. Psychotherapy can be helpful but here again, finding the right therapist can take time and many trials. Yoga and meditation can help keep you centered and in a mind body aware state that can keep mood on an even keel.
The key to all of the treatment is to continue, to be consistent and to not give up or give in. 
Call today if you think you need to be evaluated or help with management of your medications for your mental health. I’d love the opportunity to meet with you.
To your mental health!

The Surgeon General weighs in…


The first Surgeons Generals report on Addiction was released last month. While the reported statistics were staggering, very little of the data was surprising. The vast majority of our population has now been touched in some way by addiction and many of us know intimately the cost to life, liberty, love and happiness. If you are one of the few who has not personally been touched in some way, you have no doubt noted the increased number of “died suddenly” entries in the obituary section of your local paper.

This report indicates that now is the time to abolish the stigma that accompanies substance use and substance dependence. As with most things in life attempting to understand and come together as a society that substance dependence is a chronic disease is the first step. This disease of the brain circuitry requires not only initial intensive treatment but (often) ongoing lifelong g maintenance to manage health. This is not unlike the care required for infectious disease, diabetics, cardiac and oncology patients. It was not so very long ago that diseases like cancer and HIV were diseases that caused patients harm in terms of judgement, appropriate medical care and financial hardship. Today it would be unthinkable to blame a breast cancer patient for his/her disease with the thinking that this was some divine retribution for past sin. The shame and discrimination surrounding dependence can be the very tall wall that prevents individuals and their loved ones from seeking help. Helping people understand their innate worth as human beings with a physical disorder can provide a ladder to help them climb over the wall and ask for help.

In addition to the shame that exists in our communities there is also judgement within the recovery community. People who utilize medications such as methadone, buprenorphine, naltrexone, etc…are managing their disease in a manner that contradicts those in recovery who do not believe in the use of support medications. This too is a form of stigma that needs to be avoided. As a community we must support any and all initiatives (including medication assisted treatment) that keep patients involved in the recovery community and engaged in their care. We must also show patience through the process that leads to sustained recovery (remission of at least one year). Currently, in order to manage this time in recovery it can take as long as 8-9 years after first seeking formal treatment. Therefore, while we address the changes in programs of prevention and care, we must exhibit patience and support in all aspects of care. This patience is needed because this disease will not go quietly, even after 2 years of remission is achieved, it can take 4-5 more years before the risk of relapse falls below 15%.

Lastly, but incredibly importantly there needs to an understanding among us all that prevention works can help prevent the issues of substance misuse from moving people into the dependence realm of treatment needs. There are a number of age appropriate evidence based programs available to provide support for schools, families, primary care offices and occupational medicine offices that can be used. The overall healthy, finance and safety issues that will be prevented when we treat this disease pro-actively are innumerable and lasting.

Support for the government agencies that are embracing this issue as a Public Health concern is paramount to saving lives. Please write, email or call your representatives today to show your support for these initiatives.

Are Medications the Answer?


Patients often share with me the concern that too many medications are used today. They feel that health care providers have only a few goals in mind, collect the fee, see the patient as quickly as possible, write the prescription and send them on their way.

On the surface it does seem to be true. The evidence on the number of prescriptions that are written for mental health issues annually is pretty impressive. According to the American Psychological association one in five adults is now taking at least one psychotropic medication. In 2010, Americans spent more than 11 million dollars on anti-depressants. With the launch of Prozac in 1987, the research and development of medications to treat depression skyrocketed. The reasons were many, but the side effect profile was the big seller. Believe it or not prior to Prozac most anti-depressant medications caused so many side effects that only the very, very symptomatically depressed would entertain the notion of medications. Then, low side effect profiles for the new drugs made them much more palatable to a larger group of mildly/moderately depressed patients. Prescribers of all specialties also felt more comfortable writing prescriptions for these medications especially if the patient declined the idea of alternate first line psychotherapy. However, the vast majority of people would be wise to trial an experience of something called cognitive behavioral therapy first. The vast amount of science done in this area indicates that therapy is THE initial treatment for depression symptoms. Yet, most patients and prescribers don’t start with that treatment. Patients must indicate that the first line treatment is what they are looking for. First line treatment just means that the recommendations are ranked in order of priority. Practitioners should always start with first line treatment and then move down the list to more intrusive/invasive recommendations. For mood issues, Psychotherapy is almost always first line. Clearly there are patients who require medications to manage or treat the acute (short term flares) of their depression symptoms, however it shouldn’t necessarily be the first treatment.

In my experience, patients can be a little resistant to therapy for many reasons. It takes time, it takes research, it takes money and finally it takes work.
Prioritizing the time for psychotherapy on a weekly, bi-weekly or even monthly basis tends to be a barrier to treatment for some patients. It seems like a lot of effort to put in when there are pharmaceutical alternatives. Many patients prefer to take their pill in the morning and get on with their day. My recommendation is to see a therapist for a few weeks, one to three visits and get their expert opinion on whether they think medications could be helpful. Take the time to work through a few things prior to treating with medications.
Also, it can be difficult to find the right therapist. As the saying goes, you may have a kiss a few toads before you find the prince in many cases. So it is with therapists. Finding the right person to work with is key. Therefore, my recommendation is to get several recommendations from friends, family, your primary care provider and your insurance company. Then start making calls. Finding a therapist with convenient location, hours, insurance panels will inevitably cancel out a few choices. However, you’re bound to find one that works. Make a appointment and go with an open mind and heart. If you get through a couple of appointments and don’t feel like the relationship works for you. Start the above process again, and keep going until you find the one that fits your personality and needs.
Another barrier to treatment is financial, not all therapists take insurance or participate in a limited number of panels. Often therapists will take self-pay only and provide a receipt for the patient to submit to insurance to be reimbursed. Patients need to decide what kind of budget they can allow for therapy.
The final barrier to treatment is that therapy is work. Patients must commit to intensive self-study during this period. Managing symptoms often requires noticing them, noticing the responses to them and bringing that information into the session with the therapist. It’s hard work to look hard within and try to change responses to emotions. This can be a huge barrier to treatment if the patient is not ready.

Make no mistake, I am a Nurse Practitioner who prescribes medications. I often write prescriptions to help patients over the hurdles of their symptoms in their mental health issues.Yet, most medications can be trialed temporarily and managed with expert recommendations. Nothing has to be forever.

However, my treatment recommendations for mood disorders never end there. I also very often write very serious prescriptions for things like regular exercise (outdoors), a very healthy diet with limited sugar and stimulants like caffeine, quitting smoking, as well as the old fashioned hard work of meeting with a therapist regularly to work through emotions, feelings and behaviors. Because the science continually tells us that medication is only an adjunct to those treatments not in place of them.