Healthy Minds With Dr. Jeffrey Borenstein

- Welcome to Healthy Minds, I'm Dr. Jeffrey Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence, with help, there is hope.

Today on Healthy Minds.

Welcome to Healthy Minds, I'm Dr. Jeffrey Borenstein.

Today I speak with Dr. David Miklowitz about bipolar disorder.

What do you need to know if you're concerned that you yourself or a loved one has bipolar disorder?

We discuss that today on Healthy Minds.

(upbeat music) This program is brought to you in part by, the American Psychiatric Association Foundation, the Bank of America Charitable Gift Fund, and the John & Polly Sparks Foundation.

(upbeat music) David, thank you for joining us today.

- Thank you for having me.

- I wanna start off by talking about some of the early signs and symptoms that a person may recognize in themselves or in a loved one, that may point to the possible diagnosis of bipolar disorder.

- Bipolar disorder, as you know Doctor is a disorder of mood thinking and behavior.

In terms of mood, we see either high elated moods, elevated moods, that people are happier than they should be somehow really sort of excessively happy or irritable, extremely irritable, or they get extremely depressed.

And people with bipolar disorder go back and forth between those extremes.

We also see changes in behavior which can include sleep, decreased need for sleep when someone gets high, either insomnia or over sleeping, when they're depressed, and we also see changes in thinking.

People speak very fast, when they're manic, they believe they have special abilities or powers, whereas in depression, we see people slowing down in their thinking, having trouble making decisions, having trouble concentrating.

The early warning signs can be any of those things, although I think what people notice first, if they're a family member is irritability and an impulsive streak or unusual ideas staying up late at night to work on different projects or the person just slowing down and being less responsive to the family.

- What's the typical age or age range that these types of symptoms can begin to show themselves.

- I think you hit the nail on the head when you said the age range, we can say that the average age is about 19, 19 and a half, but the range is anywhere from childhood, up to later adulthood.

We see the majority of cases between about age 15 and about 25, with an average of around 19.

But we certainly see younger and older patients developing the disorder.

- And I know that frequently people can go undiagnosed for an extended period of time.

How can we help fix that for individuals and their family?

- That's been a tough problem, and part of that is because the first episode is often a depression.

And when a teenager gets depressed, we don't always think of bipolar disorder.

The family doesn't always think of bipolar disorder, they may have a depression in adolescence, or they may have some other disorder like ADHD, attention deficit hyperactivity disorder, which portends a later onset of bipolar disorder or severe anxiety, and we spend a lot of time getting the correct diagnosis, being able to assess that there is mania as well as depression.

And the person may go through other treatments for disorders that may be comorbid to the disorder rather than the real disorder.

The other thing of course that happens is that, many families don't see the need for psychiatric treatment.

Think the depression will lift, or the anxiety will lift when a person finishes school, and that doesn't always happen.

So we get these very long, sometimes eight year periods on average, before someone gets properly diagnosed.

What can we do?

I think mental health professionals need to be much more aware of the early signs of bipolar disorder to be aware that this doesn't necessarily look like classic manic depression, when it appears in a child or an adolescent, it might be impulsive outbursts of rage or aggression or combined with a decreased need for sleep or unusual ideas, or hypersexuality or impulsive behavior.

Things that we're not attuned to looking for, can occur in a kid, and that can sometimes be the early warning signs.

- So for an adolescent, it's more than the what we may refer to as the typical moodiness that a teenager may have.

- Yes, yeah, I mean, I think about it this way.

Most teenagers have trouble with their moods and they have trouble with family conflict.

They're struggling for autonomy, all those things are exaggerated in bipolar disorder.

So you have a kid who's really pushing the limits and is aggressive irritable, but also they have trouble with sleep and they have grandiose ideas and they have their thoughts going fast.

It's not just the one or two symptoms that we're typically seeing in adolescents.

It's a group of symptoms that tend to vary together, combined with an impairment in their functioning.

Average teenagers don't miss school because they're feeling down, whereas a bipolar kid may be unable to get out of bed.

So we really have to look at the extremes, to what extent is it affecting their functioning, and do these symptoms go together as a group?

- So what should a family do if they are concerned that their teenage son or daughter, is exhibiting some of these symptoms.

- The first thing they should do is get a medical evaluation.

Preferably from a psychiatrist who knows about mood disorders.

A child psychiatrist is ideal, someone who's studies or has treated other bipolar kids, and knows what to look for with the symptoms that usually involves an interview or series of interviews with the kid and the parent, and that doctor may or may not recommend medications, it depends upon their orientation or how severe the symptoms are, but at minimum, they should educate themselves about what the disorder looks like.

Talk to other parents online for example, who have bipolar children, see if they're describing behaviors similar to your child.

At minimum, they should go to see their general practitioner.

But keep in mind, the general practitioner may not have a lot of experience with child psychiatric disorders.

There's really no substitute for getting a full diagnostic evaluation, which of course may not be available in rural areas and may involve traveling to a city for a day or two to get a full evaluation.

Fortunately, we're doing more and more by telehealth, Zoom for example, nowadays than we used to.

So and now it's possible to get a full evaluation far away from where you live.

- So first is to see if you could get a diagnosis and then begin treatment.

- Yes.

- Tell us a little bit about what that treatment entails.

- Well, there's what treatment is actually given in the community and what it should be.

For kids who have have bipolar disorder, diagnosable bipolar disorder, not a mild form of it, but true bipolar I with mania and depressions.

We usually recommend starting either with a second generation antipsychotic as we call it.

An example might be resperidone or aripiprazole what's also called Abilify.

There are a number of different antipsychotics, and often we combine it with a mood stabilizer like lithium we're using divalproex or Depakote less often these days, but lithium is still the main stay.

And we usually start off with, either a combination of medications or one medication at an optimal dose.

We try not to overmedicate the kid, but it also depends upon whether he or she is presenting with other disorders, whether there's ADHD, aboard which we may not know until the kid is stabilized somewhat.

So medication is the first line treatment.

But then what we believe, not everybody agrees with us on this.

We believe that family education is very critical.

Bringing in the parents, bringing in everybody who lives with the child and teaching them about bipolar disorder, having the kid describe their experiences.

So everybody's on the same page about what the disorder is, and what it isn't.

And to learn what the facts are about this disorder, what the course is going to be, to learn different ways to communicate about it as a family, it's really a combination of medications and psychosocial treatment for the family that we think is going to be optimal.

- The treatment for the family, 'cause I think that you're hitting on something that's very important, and that I know is, one of the main areas of your research.

Tell us a little bit more about how that works and how that really ends up helping the identified patient, as well as a family?

- We developed a treatment called family focused therapy or FFT as we call it, it's right now a 12 session treatment, and it consists of three components.

First there's psychoeducation about the disorder, which is teaching as I mentioned, teaching the family and getting the child to talk about their episodes, how to recognize early warning signs as a family, how to talk about them when they're present, know what stressors are triggering these symptoms, whether it's school pressure or family conflicts or relationships outside of the family.

And we work up to developing what we call relapse prevention plan.

And that's knowing what the family should do if their kid is showing really warning signs, what should everybody in the family do?

Should they call somebody?

Should they call the physician?

Should they keep the environment low key?

Should they be able to communicate about it?

And how should they communicate about it?

What can the kid do for themselves?

Use self-talk for example, relaxation, maybe meditation, if they're feeling agitated and wired, so we develop a sort of a toolkit of coping strategies that the family and the kid can use.

Then we move on to a different phase, which involves communication, training, and problem solving.

These are well known strategies for negotiating conflicts, learning to listen to each other, learning to give positive feedback, as well as negative feedback in a constructive way, knowing how to identify family problems, and go through the stages of solving a family problem related to the illness or separate from the illness, this strategy of these 12 sessions with psychoeducation, communication, training, and problem solving, we found in a number of trials, is effective as an adjunct to medication in preventing recurrences of bipolar disorder in both teens and young adults or adults.

And most recently we've found that it's effective in preventing depression in kids who are showing early warning signs of bipolar disorder.

- One of the challenges that people with bipolar disorder often have and their families is that, they may not see the need for medication or not want to take medication at all.

Talk a little bit about what to do in such circumstances.

- I think it's a very understandable position.

No one wants to put their kid The family has to really decide the cost/benefit of being on a medication.

So for example, if a child is suicidal, not going to school, being aggressive to others, medication may be necessary to help him or her function at school.

And on the other hand, if it's depression, that's only sort of interfering with their lives or causing some family conflict, but manageable at home.

Then we may take more of a wait and see approach or get them into some individual therapy before we bring in the heavy hitting medications.

I think it's important not to jump to, we need to use extreme strong medications before we know, what the course of this illness is going to be.

I think it's also important to educate families about the realities of what these medications do and don't do.

Yes, it is true that they can bring about weight gain, there are ways to control that with injunctive medications.

They do not destroy brain cells, which is what a lot of people think, they do not destroy the kidneys.

Lithium can have an effect on the kidney over a very long period of time, and there are ways to monitor for that by assessing creatinine levels and other methods.

I think while it's a cost benefit decision, most families come down on the side of trying medication to see if it really does modify the behavior and get the kid back on a normal developmental track.

- The risks of not receiving appropriate treatment clearly outweigh any side effects and other risks from the medication.

- I would say that's true for most kids who have severe bipolar illness.

If again, if it's mild, then I think the cost benefit ratio is a little different.

- Now, aside from the family, once the family the parents are in favor of medication, sometimes the patient themselves at all ages, may not wanna take the medication.

What's the approach with that?

- That's one of the main issues we deal with in family therapy.

Because first we wanna make sure the kid understands why a medication is being recommended.

They may not agree, they have bipolar disorder, they may see themselves as acting similar to their friends, they may think their parents are in the wrong, so part of it is clarifying, what are your symptoms versus what is the environment, and why would we think a medication might help with that?

We might tell the kid, try it for a little while, and see if it helps you - maybe three months.

Let's see if you see an improvement, or if you're not feeling so down or so low in energy, or so hyped up, we try to put it and frame it in terms of what does the kid want?

The kid usually wants more freedom, more time with friends.

Well, maybe that's going to be possible if their mood is stable.

Partly it's educating them about what the illness is, and helping them realize there are certain things that are in it for them to have these medications on board.

But we also talk to them about the side effects, that there is a certain equation that has to be considered involving side effects.

The stigma of being on a psychiatric medication, which is a huge issue for some younger people, particularly those who are just going off to college, have to admit to being on these medications, although that's getting better I think over time, since more and more kids are on these medications know what they're all about.

But it is a developmental process I think of coming to accept an illness and coming to accept the medications that go along with that illness.

- I wanna get back to what you spoke a little bit about if somebody has suicidal thoughts or risk.

One of the important issues in bipolar disorder as in other illnesses is the issue of suicide prevention.

Tell us a little bit about what people should be thinking about for their loved ones, with regards to that?

- First, I think it's to know that bipolar disorder is associated with a high rate of suicide attempts and unfortunately, suicide completions.

Usually this is during an episode of either depression or what we call mixed episodes, which are combinations of depression and mania together.

That actually turns out to be the high risk when people have symptoms of both depression and mania.

So they're slowed down, feeling depressed, but also having high anxiety and their thoughts are going fast, and they're loaded with energy.

It's this tired, but wired feeling, so to speak.

And that's a risk factor along with anxiety for a suicide attempt.

If a child is talking about suicide thoughts, I always counsel families take it seriously.

If the kid feels acutely suicidal, take them to the emergency room.

Take them to the emergency room of a hospital, have an assessment done, keep in touch with them.

If the emergency room sends them home, have someone stay with them overnight, so they don't hurt themselves during the night, show a lot of compassion and support don't get critical, or this is not the time to get evaluative or demanding to just show a lot of compassion and help the person through it.

The other thing is of course, to get rid of all the means of attempting suicide.

Get rid of the knives, the pills, the poisons, the guns, if you have them in the household, all should be out to reach of the child.

One of the best ways to prevent suicide is to make it impossible to do it, for there not to be means around.

Of course, there are longer term issues the child has to face about what they think of the future or feeling hopeless or helpless about the future, encouraging them to consider that things could change about how if they get their moods stable, they may feel much better about themselves in the future.

So there's kind of a short term and a long term way of approaching this short term, being go with the emergency, take them to the ER, take away all means of attempting suicide, but also show compassion and help them get the care they need over the long term.

So many people who do attempt or commit suicide, never received any treatment before they attempted.

And we don't want that to be the case, especially for children.

- I think an important point and I'd like you to speak about it is that, people who have bipolar disorder, are able to live full healthy lives, with appropriate treatment and support.

And I'd like you to speak about that.

- That's one very important positive attribute of this illness.

And we have some data on it actually, we followed some kids who were showing early warning signs of bipolar disorder.

They had early signs of depression and hypomania sort of low level mania.

And they also had family histories of bipolar disorder.

So by all counts, they were on track to develop the disorder.

But yet after two or three years, they looked more stable.

About 25, 30% of the kids we followed looked pretty good by the time they were 19, 20, 21 years old, and we're not the only ones who found that.

So there is some evidence that the disorder may mollify over time, but even in people who continue to have episodes, sometimes the episodes can get further apart over time, particularly if they're taking a proper medication regimen, the stressors that go along with being a 20-year-old are not the same as it goes along with being 40 or 50.

And although they're still stressors, they don't tend to provoke episodes as much as they did earlier, also people are less likely to abuse substances, which of course always portends a worst course of illness.

So if they're able to maintain a good treatment regimen and stay away from drugs and alcohol, they may have a very productive life.

And we know that artists and writers and musicians, famous ones, have had this disorder and coped with it.

- There's been reports of people who similar to the type of person that you are referring to who report that having bipolar may have helped them be more creative.

I'd like you to speak toward that.

- Yeah, that's an interesting issue.

There is this belief, particularly among artists and writers, that the mania allows you to kind of think outside the box and create more artwork.

Here's what we know.

Mania itself and I'm talking about the really charged up mile a minute speaking and delusional thinking is not particularly associated with good work.

It's associated with a lot of production, but not necessarily good poetry or music or art.

What is, is a little bit of hypomania, and by that, I mean, thoughts going a little faster, a little bit less need for sleep, a little bit more sort of open-minded creativity, which can be present in the lower levels of mania, or it might even be a personality characteristic for some people.

One thing we encourage people to do is after they're stable and they've been stable for a while, have a talk with your psychiatrist about whether your medications can be tapered just enough to allow you a little bit of hypomania without it getting out of control.

This is something Kay Jamison wrote about a lot in her book "An Unquiet Mind."

About how she was able to negotiate a lower lithium level, which allowed her to do more writing, more research, and operate at a more productive level.

I think what's a mistake, is to go off of all one's medication, and then assume a great artist will emerge from this manic person.

Because more often what happens is a person starts producing a lot of things, but aren't things they can really look to and say, that's my best work.

- A lot of work is being done on developing new treatments and new approaches for bipolar.

And I'd like you to speak a little bit about what's coming down the road?

- Sure, the new treatments, a lot of them are still in the trial phase where we're still testing whether or not they work, and who they work for, and they fall into two categories.

The medication of pharmacological treatments and the psychosocial treatments.

For pharmacotherapy, we have new medications that have come out new antipsychotics, like lurasidone just came out, which has some antidepressant effect as well as antipsychotic effects, we're using lamotrigine a lot more for people with bipolar II who have depressions that don't remit easily.

And one thing I did mention earlier is that depression, is in some ways the bigger puzzle for psychiatrists, and trying to get control over these long standing depressions and more and more treatments are coming out that might address the ongoing depressions even more so than the mania.

We're more hopeful now about the different medications and what they do and who they work for.

But what we really need to do is be able to have treatments that we agree are delivered at the beginning.

Because that's when we have the most leverage is after the beginning signs or the first episode, is when we really could get in there and start doing prevention, which is what we're all about is trying to identify the disorder before it gets out of hand, intervene with the family, get their kid on a good medication regimen, and hopefully they won't have to have a lifetime in and out of hospitals or in and out of episodes.

But that's still a question mark.

- Final word of wisdom to anybody watching right now.

- Don't give up.

- Bottom line, what should they, don't give up?

- Don't give up, there are better treatments coming down the road, people have rough periods of time in their life and things improve, when they get in a different setting or have a different set of supports family, or interpersonal supports, their illness can change, and its presentation over time, medications can get better, dosages can be adjusted.

There'll be times when you feel like, I'm gonna be dealing with this for the rest of my life, but many people who've had that thought have gone on to have very successful and fulfilling lives.

- David, thank you so much for joining us today, and thank you for all the work that you've done, to help so many people with bipolar disorder, thank you.

- Thank you for having me, and thanks for listening.

(upbeat music) - If you or a loved one has bipolar disorder, you can live a full, healthy, happy, and productive life with appropriate treatment.

Remember with help, there is hope.

(upbeat music) To not suffer in silence, with help there is hope.

(upbeat music) This program is brought to you in part by, the American Psychiatric Association Foundation, the Bank of America Charitable Gift Fund, and the John & Polly Sparks Foundation.

Remember with help, there is hope.

(upbeat music)