The series kicks off with Joseph F. Goldberg, M.D., director of the Affective Disorders program at Silver Hill Hospital in New Canaan, Connecticut, by defining the bipolar entity, “ not otherwise specified,” as sub-threshold mania or hypomania. This type of bipolar disorder had a prevalence rate of 2.4%. This “expert” also notes "approximately a doubling diagnosing bipolar disorder of any type with “greater screening and surveillance.” Also, approximately 2/3 of bipolar patients will identify their first mood symptoms before early adulthood (note a modal peak between 15 and 19).
Hirschfield et al in J Clin Psychiatry. 2003; 64(2): 161-174., has noted that 60% of patients with bipolar disorder were “misidentified with unipolar depression.” As much as 54% of postpartum women appeared to be experiencing unipolar depression but in fact had a history of bipolar disorder. The fact is that there are so many issues that can mimic bipolar presentation: anxiety, substance abuse, steroids, even anti-depressants They ALL can produce secondary manias. They remind us to also consider Cluster B personality disorder which can share with mania or hypomania features such as mood instability or impulsivity.
Eighty five to 90% of children with bipolar disorder also meet the DSM IV criteria for ADHD. Goldberg emphasizes “both the overdiagnosis and underdiagnosis in patients with suspected bipolar disorder.” He advises “examining…symptoms such as decreased need for sleep, increased psychomotor activity, and the cognitive-behavioral and language features that comprise the constellation of mania or hypomania.” Also, he cautions, family history can be “somewhat challenging as bipolar illness does not follow Mendelian inheritance.” Therefore, if a strong family history is not available, this is not a clear negative predictive value.
Charles Borden, an M.D. at the University of Texas, San Antonio Health Science Center, emphasizes that clinicians RARELY see bipolar patients who do not have an anxiety disorder. “If anxiety disorder is present, patients are more likely to have substance abuse disorders, other impulse control disorders, eating disorders, and other personality disorders.” Borden notes: “In particular, if the prevalence rates of all anxiety disorders are grouped together, they are almost as prevalent as bipolar disorder itself, and clinicians rarely see a patient with bipolar disorder who does not have an anxiety disorder.” (Perugi G et al The temporal relationship between anxiety disorder and hypomania: a retrospective examination of 63 panic, social phobic and obsessive-compulsive patients with comorbid bipolar disorder. J Affect Disord 2001; 67(1-3): 199-206).
One in five with major depressive disorder (MDD) has bipolar disorder. Prevalence studies in MDD show at least 20% of patients with depressive episodes have either type I or type II bipolar disorders. He suggests that clinicians perhaps may fail to elicit histories of hypomanic illness because they are not spontaneously reported.
Claudia Baldassano, M.D., from the University of Pennsylvania, reports a significant reduction in mortality ratios for patients actively in treatment (29.2 versus 6.4% from suicide). Judd et al noted bipolar patients were most likely to be symptomatic with depression. Unfortunately, despite this reality, “monotherapy” is twice as commonly prescribed as mood stabilizers. Aripiprazole (Abilify) “fails to show positive evidence” for bipolar disorder ( despite what seems like a major media campaign touting its benefits for depression).
From a personal perspective, I was relieved to learn that divalproex (Depakote) may be effective for bipolar depression symptoms. She also reports for maintenance therapy “less efficacy” but “better tolerability” for the mood stabilizers. She notes that lamotrigine (Lemictal) is “well-tolerated and that it does not cause weight gain.
Noreen Reilly-Harrington, Ph.D from Mass General Hosptial confirms again that “adjunctive psychological treatments can help reduce relapse and provide patients as well as their families with tools…” She notes that three forms of intensive intervention : (1) cognitive behavioral therapy (CBT), interpersonal and social rhythm therapy, and family-focused treatment, were favorably compared with brief three-session psychoeducational intervention(collaborative care).
She found that any of these three showed (1) Median time to recovery 110 days earlier; (2) Higher year-end recovery rates; and (3) More than one to 1.5 times likely to be clinically well during any study month. She did not report any significant differences between the three intensive treatments. It is interesting that CBT, established in the 1960’s, was primarily used for unipolar depression. However, its main focus still remains education and problem solving. CBT is also effective for co-morbid anxiety, panic disorder, OCD, and social anxiety.
Reilly-Harrington advocates regulating schedules and monitoring moods daily to recognize any early warning signs of relapse. “Patients… take part in the planning of their treatment plan and to exercise choice in control.” Mood charting allows patients to develop awareness about their illness. Such a routine allows successful tracking of medication doses and treatment compliance. We as patients with bipolar disorder are not known for our compliance. She advises regulating daily schedules of activity including sleep-wake cycles, meal times, and work schedules.
In summary, these articles further help emphasize the challenges of identifying bipolar disorder especially with the likelihood of co-occurring and co-morbid problems. Anxiety almost inevitably co-exists with bipolar disorder. These authors offer us appropriate, unique, and effective psychotropic treatment advice. Lastly, although medications remain “the mainstay” of treatment, psychosocial modalities unquestionably enhance and improve outcomes.
Wednesday, April 7, 2010
Tuesday, March 23, 2010
More on Mania and Mortality
by Peter J. Dorsen M.D., LADC
Dylan Murray et al in Mania and Mortality: "Why the Excess Cardiovascular Risk in Bipolar Disorder?" From Current Psychiatry Reports 2009, 11: 475-480, raises more questions why individuals with bipolar disorder have twice the cardiovascular mortality as the general population(prevalence ratio of 1.6). For one thing, metabolic syndrome is more common in this population.
Just being manic increases your chances for such increased mortality. There is a significant history of sudden death from cardiovascular factors in manic individuals. Confounders include behavior, access to treatment, quality of health care, and underlying pathophysiology. I can relate because I have mentioned previously experiencing an MI requiring angioplasty and two stents three years ago. I did not have any of the criteria for metabolic syndrome that include abdominal obesity, diabetes, dyslipidemia or hypertension.
The authors point out that our U.S. population certainly has its share of both metabolic syndrome and diabetes. Certainly, other studies warn about the dangers as well with associated smoking, an elevated total cholesterol, with specifically a reduced high-density lipoprotein (the “good” cholesterol).
Because of such significant associations, the authors advocate screening bipolar disorder patients for diabetes and metabolic syndrome especially if they happen to be on second-generation antipsychotics. They warn that bipolar disorder appears to negatively affect fat metabolism in women. Bipolar I patients appear to be at higher risk for cardiovascular mortality than bipolar II individuals. They attribute such disparity to a higher incidence of mania in bipolar I disorder. There appears to be less likelihood that the manic patient will have a primary care physician.
There may well be barriers to optimal medical care. Such patients may have difficulties navigating through the health care system. Murray et al suggest better integrated health care. They are suggesting better lines of communication between psychiatrist and primary care giver. They warn as well about QTc prolongation (the repolarization phase of the cardiogram). Ray et al warn about sudden death among atypical antipsychotic users (N Engl J Med 2009, 360:225-235).
Perhaps increased mortality can be attributed to increased smoking, medication-related weight gain, or linking genetic risk or pathophysiologic processes of bipolar disorder to elevated cardiovascular risk. They even ruminate about an overactive inflammatory response in bipolar patients.
These authors note that less than half of psychiatrists actually are monitoring lipid levels or waist circumference. Anyone on second-generation antipsychotics deserves to be monitored for family history of diabetes, body mass-index, weight gain and triglyceride levels. They reflect on compliance as well related to “ limited insight, a negative view of medications, and substance abuse.” They allude to studying cardiovascular risk in youth with bipolar disorder thus eliminating confounding variables.
In their own words, “Further education may improve recognition and screening for traditional risk factors and may result in better cardiovascular outcomes for this at-risk population.”
Dylan Murray et al in Mania and Mortality: "Why the Excess Cardiovascular Risk in Bipolar Disorder?" From Current Psychiatry Reports 2009, 11: 475-480, raises more questions why individuals with bipolar disorder have twice the cardiovascular mortality as the general population(prevalence ratio of 1.6). For one thing, metabolic syndrome is more common in this population.
Just being manic increases your chances for such increased mortality. There is a significant history of sudden death from cardiovascular factors in manic individuals. Confounders include behavior, access to treatment, quality of health care, and underlying pathophysiology. I can relate because I have mentioned previously experiencing an MI requiring angioplasty and two stents three years ago. I did not have any of the criteria for metabolic syndrome that include abdominal obesity, diabetes, dyslipidemia or hypertension.
The authors point out that our U.S. population certainly has its share of both metabolic syndrome and diabetes. Certainly, other studies warn about the dangers as well with associated smoking, an elevated total cholesterol, with specifically a reduced high-density lipoprotein (the “good” cholesterol).
Because of such significant associations, the authors advocate screening bipolar disorder patients for diabetes and metabolic syndrome especially if they happen to be on second-generation antipsychotics. They warn that bipolar disorder appears to negatively affect fat metabolism in women. Bipolar I patients appear to be at higher risk for cardiovascular mortality than bipolar II individuals. They attribute such disparity to a higher incidence of mania in bipolar I disorder. There appears to be less likelihood that the manic patient will have a primary care physician.
There may well be barriers to optimal medical care. Such patients may have difficulties navigating through the health care system. Murray et al suggest better integrated health care. They are suggesting better lines of communication between psychiatrist and primary care giver. They warn as well about QTc prolongation (the repolarization phase of the cardiogram). Ray et al warn about sudden death among atypical antipsychotic users (N Engl J Med 2009, 360:225-235).
Perhaps increased mortality can be attributed to increased smoking, medication-related weight gain, or linking genetic risk or pathophysiologic processes of bipolar disorder to elevated cardiovascular risk. They even ruminate about an overactive inflammatory response in bipolar patients.
These authors note that less than half of psychiatrists actually are monitoring lipid levels or waist circumference. Anyone on second-generation antipsychotics deserves to be monitored for family history of diabetes, body mass-index, weight gain and triglyceride levels. They reflect on compliance as well related to “ limited insight, a negative view of medications, and substance abuse.” They allude to studying cardiovascular risk in youth with bipolar disorder thus eliminating confounding variables.
In their own words, “Further education may improve recognition and screening for traditional risk factors and may result in better cardiovascular outcomes for this at-risk population.”
Monday, March 15, 2010
Alzheimer's and Sleep
by Peter J. Dorsen M.D., LADC
Andrew McCaddon, M.D. and Peter R. Hudson, Ph.D. of North Wales U.K, note utiliizing plasma total homocysteine (tHcy) as a marker, B vitamins deficiencies were found to be highly prevalent in the elderly. These writers note reports of elevated levels of homocysteine in individuals with clinically and pathologically confirmed Alzheimer’s disease (AD). Neuroinflammatory oxidative stress occurs early in AD. Amyloid plaques and neurofibrillary tangles represent end-stage of such oxidative stress.
They note as well an accumulation of methylmalonic acid that appears to be associated with lower cognitive function scores. There is an association as well between elevated homocysteine (Hcy) levels and stroke. Folate supplements serve as affective stroke prevention. They note the association of high Hcy and brain atrophy reversible with high-dose B-vitamin supplementation.
They recommend a naturally occurring product, cerefolin. They also report the efficacy of high doses of ORAL vitamin B12 (1-2mg/day). They emphasize assessing folate, B12 and homocysteine levels in ALL dementia patients and TREATING those with abnormal findings. Especially important, is that clinicians screen EVERYONE presenting with cognitive impairment who has co-occurring vascular risks such as high blood pressure, elevated cholesterol, diabetes, who smokes, or high homocystein levels. McCaddon and Hudson offer some novel warnings about and treatments for AD.
Sleep Problems
John W. Winkelman, MD. Ph.D. in Primary Psychiatry 16: 12 (suppl 8), differentiates between insomnia and sleep deprivation (reduced opportunity to sleep –voluntary or imposed. He recommends that someone who has trouble sleeping keep a 1-2 week sleep diary. Winkelman stresses that a polysomnogram (PSG) is NOT recommended routinely for insomnia unless a clinician suspects sleep apnea, periodic limb movement disorder or narcolepsy ( falling to sleep anywhere anytime inappropriately).
Many with insomnia spend more and more time in bed trying to get adequate sleep but don’t. He cites one such patient in whom “sleeplessness and anxiety symptoms are locked in a vicious cycle…”
Andrew Krystal, M.D. in this same monograph addresses treatment. He recommends Cognitive-Behavioral Treatment (CBT) for insomnia. CBT deals with such crucial issues as sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. Cognitive therapy addresses “the maladaptive thought and emotional processes that often occur.” Consider “problem solving” BEFORE bedtime and something relatively simple like progressive muscle relaxation (one of Tim’s favorites). CBT compared more favorably compared with progressive muscle relaxation and imagery.
Utilizing medications like the hypnotic Zolpidem seem to work best with CBT when medication treatment at, let’s, say six months moves to an as-needed regimen. Clinicians aim for the speed of onset of pharmacotherapy with the durability of CBT. Krystal recommends a taper at 2-3 months and ultimately deciding whether to stop the medication altogether based on how well someone does.
These investigators emphasize not to minimize the potential side effects of the benzodiazepines for cognitive or psychomotor impairment and abuse potential, They advise: "initiate periodic tapers." One group cited treated patients three nights a week according to the patients’ preference. They reduced cost and minimized adverse effects. M Vaughn McCall, MD. MS, addresses co-morbid insomnia. “Relentless insomnia may be a prelude to development of a classic mental disorder such as depression.” He notes that it is important to investigate for a primary sleep disorder “ if a depressed insomniac complains of both insomnia and sleepiness.” Insomniacs, he reports, DENY daytime sleepiness complaining instead of "tiredness and exhaustion."
Certainly, appropriate for insomnia AND depression are the SSRIs. Insomniacs and depressed persons may well demonstrate remission on these medications. However, a large number continue to experience insomnia. If this does not resolve, and especially if a patient has hypersomnia (sleeping all the time) in addition to insomnia, they advise other modalities that include CBT-I for making changes in sleep schedules (avoiding going to bed too early or staying there too long); and dealing with distorted ideas about sleep (bedtime anxiety or fearing that they will be unable to fall asleep).
Consider bedtime hypnotic therapy. Evidence-based statistics, at this point, supports adding a FDA –approved hypnotic RATHER than a sedating antidepressant like trazadone. They advise “high level oversight” when using “benzo’s” or non-benzodiazepine receptor agonists (NBBRA’s). Why? Suicide! Note too, that insomnia is an independent indicator for suicidal ideation, behavior or death in depressed patients. Especially dangerous is an overdose of an accumulation of hypnotics and alcohol. As a result, clinicians should prescribe only 1-2 weeks of theses medications.Depression and insomnia often co-occur.These investigators offer some helpful advice that can stabilize both successfully.
Alzheimer's
"Novel treatment options: cognitive decline in Alzheimer’s disease" (Primary Psychiatry 17:1 (suppl 1). As we age, are afflicted with bipolar disorder, and might require a panel of mood stabilizers and more, we certainly can experience a decline in mental function (executive/cognitive as well?). Thirty million individuals will have (some form of ) dementia in 2010!Andrew McCaddon, M.D. and Peter R. Hudson, Ph.D. of North Wales U.K, note utiliizing plasma total homocysteine (tHcy) as a marker, B vitamins deficiencies were found to be highly prevalent in the elderly. These writers note reports of elevated levels of homocysteine in individuals with clinically and pathologically confirmed Alzheimer’s disease (AD). Neuroinflammatory oxidative stress occurs early in AD. Amyloid plaques and neurofibrillary tangles represent end-stage of such oxidative stress.
They note as well an accumulation of methylmalonic acid that appears to be associated with lower cognitive function scores. There is an association as well between elevated homocysteine (Hcy) levels and stroke. Folate supplements serve as affective stroke prevention. They note the association of high Hcy and brain atrophy reversible with high-dose B-vitamin supplementation.
They recommend a naturally occurring product, cerefolin. They also report the efficacy of high doses of ORAL vitamin B12 (1-2mg/day). They emphasize assessing folate, B12 and homocysteine levels in ALL dementia patients and TREATING those with abnormal findings. Especially important, is that clinicians screen EVERYONE presenting with cognitive impairment who has co-occurring vascular risks such as high blood pressure, elevated cholesterol, diabetes, who smokes, or high homocystein levels. McCaddon and Hudson offer some novel warnings about and treatments for AD.
Sleep Problems
John W. Winkelman, MD. Ph.D. in Primary Psychiatry 16: 12 (suppl 8), differentiates between insomnia and sleep deprivation (reduced opportunity to sleep –voluntary or imposed. He recommends that someone who has trouble sleeping keep a 1-2 week sleep diary. Winkelman stresses that a polysomnogram (PSG) is NOT recommended routinely for insomnia unless a clinician suspects sleep apnea, periodic limb movement disorder or narcolepsy ( falling to sleep anywhere anytime inappropriately).
Many with insomnia spend more and more time in bed trying to get adequate sleep but don’t. He cites one such patient in whom “sleeplessness and anxiety symptoms are locked in a vicious cycle…”
Andrew Krystal, M.D. in this same monograph addresses treatment. He recommends Cognitive-Behavioral Treatment (CBT) for insomnia. CBT deals with such crucial issues as sleep hygiene, stimulus control, sleep restriction, and cognitive therapy. Cognitive therapy addresses “the maladaptive thought and emotional processes that often occur.” Consider “problem solving” BEFORE bedtime and something relatively simple like progressive muscle relaxation (one of Tim’s favorites). CBT compared more favorably compared with progressive muscle relaxation and imagery.
Utilizing medications like the hypnotic Zolpidem seem to work best with CBT when medication treatment at, let’s, say six months moves to an as-needed regimen. Clinicians aim for the speed of onset of pharmacotherapy with the durability of CBT. Krystal recommends a taper at 2-3 months and ultimately deciding whether to stop the medication altogether based on how well someone does.
These investigators emphasize not to minimize the potential side effects of the benzodiazepines for cognitive or psychomotor impairment and abuse potential, They advise: "initiate periodic tapers." One group cited treated patients three nights a week according to the patients’ preference. They reduced cost and minimized adverse effects. M Vaughn McCall, MD. MS, addresses co-morbid insomnia. “Relentless insomnia may be a prelude to development of a classic mental disorder such as depression.” He notes that it is important to investigate for a primary sleep disorder “ if a depressed insomniac complains of both insomnia and sleepiness.” Insomniacs, he reports, DENY daytime sleepiness complaining instead of "tiredness and exhaustion."
Certainly, appropriate for insomnia AND depression are the SSRIs. Insomniacs and depressed persons may well demonstrate remission on these medications. However, a large number continue to experience insomnia. If this does not resolve, and especially if a patient has hypersomnia (sleeping all the time) in addition to insomnia, they advise other modalities that include CBT-I for making changes in sleep schedules (avoiding going to bed too early or staying there too long); and dealing with distorted ideas about sleep (bedtime anxiety or fearing that they will be unable to fall asleep).
Consider bedtime hypnotic therapy. Evidence-based statistics, at this point, supports adding a FDA –approved hypnotic RATHER than a sedating antidepressant like trazadone. They advise “high level oversight” when using “benzo’s” or non-benzodiazepine receptor agonists (NBBRA’s). Why? Suicide! Note too, that insomnia is an independent indicator for suicidal ideation, behavior or death in depressed patients. Especially dangerous is an overdose of an accumulation of hypnotics and alcohol. As a result, clinicians should prescribe only 1-2 weeks of theses medications.Depression and insomnia often co-occur.These investigators offer some helpful advice that can stabilize both successfully.
Wednesday, March 3, 2010
Bipolar disorder and Medical Co-morbidities Peter J. Dorsen, M.D. LADC
by Peter J. Dorsen M.D., LADC
Three years ago, I experienced excruciating chest pain with exercise, ultimately underwent angiography, required two stents and angioplasty, and subsequently was found to have experienced a heart attack in the process.
I had been taking lithium for an extended period of time for my bipolar II disorder.
What I could not completely comprehend was why, if I was thin and exercised regularly, did I continue to run a modestly elevated total cholesterol as well as an ongoing upper limit normal LDL (the “bad” cholesterol) and, no matter how fit I thought I was, I could never elevate my HDL (the “good” cholesterol) to a favorable level. I had a significant family history of high cholesterol. I chose not to take a lipid-lowering drug like simvastatin for fear of liver injury. Doctors are the worst patients!
The good news is that I have fared well with a “clean” angiogram one year after my stents and an acceptable fairly recent maximal graduated stress test several months ago. Initially, I had an elevated blood pressure transiently but am now off all blood pressure medications. I have never had any of the other criteria for metabolic syndrome such as diabetes or centripetal obesity. Metabolic syndrome is excess fat in one’s abdomen with a reduced sensitivity to insulin’s effects (insulin resistance), a high blood sugar level, abnormal cholesterol levels, and high blood pressure. Some have referred to such an insulin resistance syndrome as “Syndrome X.”
My BMI and waist circumference have never been excessive. However, metabolic syndrome is especially prevalent in developed countries with over 40% of those over 50 having it. This syndrome has the “apple-shape” in men or post menopausal women versus the “pear-shape” more commonly seen in women as adiposity collecting around the hips.
Aripiprazole (Abilify) has been advertised on TV recently as an adjunctive medication for depression. According to Page CU Expert Opin Drug Saf. 2009 May; 8(3) 373-86, it does have FDA approval for treatment “as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD).” These reporters state that it has “favorable safety compared to other atypical antipsychotics” with “minimal propensity for weight gain and metabolic disruption.” However they report abnormal body movements(akathisia) “that may limit its clinical use…especially in bipolar disorder and MDD.” It is actually one of the newer “atypical” antipsychotics with all the provisos and considerations that go with that class of drugs.
When I went on the medication, I developed tardive dyskinesia (TD) meaning that my chin began twitching and I developed uncontrollable spastic movements in my right hand. Secondly, it is important that you alert your provider if you have ever had a history of heart failure, a heart attack, high or low blood pressure, or a stroke or seizures if you elect to take this drug. Caveat emptor, “may the buyer beware.” These are not necessarily benign medications!
Here’s an interesting one: there are somewhat anecdotal reports that ginseng of one variety or another, functioning as an anti-oxidant, can lower low density lipoproteins (LDL). Not only is it reputed that ginseng may lower blood sugar in Type II diabetes, but it can decrease the risk of heart disease, improve blood pressure, and decrease symptoms of coronary heart disease. So not try some of this herb?
Wildes et al in J Clin Psychiatry. 2006 Jun; 67(6): 904-15, reviewed 92 studies and found that “(studies) targeting physical inactivity and overeating in bipolar disorders are needed, as are better screening and treatment for binge eating.” The authors want to explain both ” the causes and consequences of obesity…”
McIntyre et al in Ann Clin Psychiatry. 2007 Oct-Dec, advise: “ A comprehensive management approach for depressive disorders should routinely include opportunistic screening and primary prevention strategies targeting metabolically mediated comorbitity (eg. Cardiovascular disease).” Also, they say “ explore innovative treatments for mood disorders which primarily target aberrant metabolic networks.” They go so far as to “propose the notion of ‘metabolic syndrome type II’ as a neuropsychiatric syndrome.”
In an older article, Morriss R, Mohammed FA J. Psychopharmacol. 2005 Nov;19(6 Suppl): 94-101 report that lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.” They observe increased mortality from cardiovascular causes as well as morbidity from obesity and type 2 diabetes increased compared with the general population. They note an increased risk in people with bipolar disorder as well due to less exercise, poor diet, frequent depressive episodes, and co-morbidity with substance misuse.
Saravane D et al in Encephale. 2009 Sep; 35(4): 330-9 (in French), posit that bipolar disorder is associated with “undue medical morbidity and mortality…with a 15-30 year shorter lifetime…” This is, after all, the same population who have “higher rate of preventable risk factors such as smoking, addiction, poor diet , lack of exercise.” Treatment of such co-morbitities is crucial, they advise as significant “ for their psychosocial functioning and overall quality of life.” Detect medical illness at “the first episode of mental illness.” They admonish: “ identify…crucial modifiable risk factors, such as… obesity, dyslipidemia, diabetes, hypertension, and smoking.
This team relates such metabolic and cardiovascular risk factors in population with significant mental illness “to poverty and limited access to medical care but also to the use of psychotropic mediations.” They advise in the first three to four months of treatment that patients with severe mental illness obtain baseline weight, height, waist circumference, blood pressure, fasting plasma glucose, and a fasting lipid profile. Obtaining a BMI ( Body mass index) which is weight(kg) over height(meters) squared can be extremely helpful.
Getting a baseline EKG is essential if a patient is taking an atypical antipsychotic which can increase your QT interval (the repolarization phase of the cardiogram) and lead to fatal arrhythmias. We need to know about the cardiovascular and metabolic risks of our medications! Prescribing antipsychotics carries responsibility for monitoring metabolic abnormalities as well. An ideal world MUST BE coordination among psychiatrists, GP’s, endocrinologists, cardiologists, nurses, dietitions, our families and US.
It is crucial that clinicians stay vigilant for metabolic syndrome among their stable of bipolar patients. Individuals who develop this complication are susceptible to coronary artery disease ( like I was), high blood pressure, Type 2 diabetes, abnormal fats, fatty liver, gout, polycystic ovaries, and chronic kidney disease. Men with abdominal girth over 40 inches and women over 35 inches may have it.
As Tim has suggested, changes in diet accompanied by a commitment to regular exercise is crucial. Medications that increase the body’s sensitivity to elevated glucose like metformin, thiazolidine, or rosiglitazone WITH exercise can improve sugar utilization. If weight reduction and exercise totally fail and after appropriate screening, bariatric surgery can certainly be a viable alternative. But that subject is for another time and blog.
Three years ago, I experienced excruciating chest pain with exercise, ultimately underwent angiography, required two stents and angioplasty, and subsequently was found to have experienced a heart attack in the process.
I had been taking lithium for an extended period of time for my bipolar II disorder.
What I could not completely comprehend was why, if I was thin and exercised regularly, did I continue to run a modestly elevated total cholesterol as well as an ongoing upper limit normal LDL (the “bad” cholesterol) and, no matter how fit I thought I was, I could never elevate my HDL (the “good” cholesterol) to a favorable level. I had a significant family history of high cholesterol. I chose not to take a lipid-lowering drug like simvastatin for fear of liver injury. Doctors are the worst patients!
The good news is that I have fared well with a “clean” angiogram one year after my stents and an acceptable fairly recent maximal graduated stress test several months ago. Initially, I had an elevated blood pressure transiently but am now off all blood pressure medications. I have never had any of the other criteria for metabolic syndrome such as diabetes or centripetal obesity. Metabolic syndrome is excess fat in one’s abdomen with a reduced sensitivity to insulin’s effects (insulin resistance), a high blood sugar level, abnormal cholesterol levels, and high blood pressure. Some have referred to such an insulin resistance syndrome as “Syndrome X.”
My BMI and waist circumference have never been excessive. However, metabolic syndrome is especially prevalent in developed countries with over 40% of those over 50 having it. This syndrome has the “apple-shape” in men or post menopausal women versus the “pear-shape” more commonly seen in women as adiposity collecting around the hips.
Aripiprazole (Abilify) has been advertised on TV recently as an adjunctive medication for depression. According to Page CU Expert Opin Drug Saf. 2009 May; 8(3) 373-86, it does have FDA approval for treatment “as adjunctive therapy or monotherapy (manic or mixed episodes) as well as an augmentation therapy of major depressive disorder (MDD).” These reporters state that it has “favorable safety compared to other atypical antipsychotics” with “minimal propensity for weight gain and metabolic disruption.” However they report abnormal body movements(akathisia) “that may limit its clinical use…especially in bipolar disorder and MDD.” It is actually one of the newer “atypical” antipsychotics with all the provisos and considerations that go with that class of drugs.
When I went on the medication, I developed tardive dyskinesia (TD) meaning that my chin began twitching and I developed uncontrollable spastic movements in my right hand. Secondly, it is important that you alert your provider if you have ever had a history of heart failure, a heart attack, high or low blood pressure, or a stroke or seizures if you elect to take this drug. Caveat emptor, “may the buyer beware.” These are not necessarily benign medications!
Here’s an interesting one: there are somewhat anecdotal reports that ginseng of one variety or another, functioning as an anti-oxidant, can lower low density lipoproteins (LDL). Not only is it reputed that ginseng may lower blood sugar in Type II diabetes, but it can decrease the risk of heart disease, improve blood pressure, and decrease symptoms of coronary heart disease. So not try some of this herb?
Wildes et al in J Clin Psychiatry. 2006 Jun; 67(6): 904-15, reviewed 92 studies and found that “(studies) targeting physical inactivity and overeating in bipolar disorders are needed, as are better screening and treatment for binge eating.” The authors want to explain both ” the causes and consequences of obesity…”
McIntyre et al in Ann Clin Psychiatry. 2007 Oct-Dec, advise: “ A comprehensive management approach for depressive disorders should routinely include opportunistic screening and primary prevention strategies targeting metabolically mediated comorbitity (eg. Cardiovascular disease).” Also, they say “ explore innovative treatments for mood disorders which primarily target aberrant metabolic networks.” They go so far as to “propose the notion of ‘metabolic syndrome type II’ as a neuropsychiatric syndrome.”
In an older article, Morriss R, Mohammed FA J. Psychopharmacol. 2005 Nov;19(6 Suppl): 94-101 report that lifestyle, illness and treatment factors in people with bipolar disorder (BD) may confer additional risk of morbidity and mortality to the increasing rates of obesity, metabolic syndrome, diabetes mellitus and cardiovascular mortality in the general population.” They observe increased mortality from cardiovascular causes as well as morbidity from obesity and type 2 diabetes increased compared with the general population. They note an increased risk in people with bipolar disorder as well due to less exercise, poor diet, frequent depressive episodes, and co-morbidity with substance misuse.
Saravane D et al in Encephale. 2009 Sep; 35(4): 330-9 (in French), posit that bipolar disorder is associated with “undue medical morbidity and mortality…with a 15-30 year shorter lifetime…” This is, after all, the same population who have “higher rate of preventable risk factors such as smoking, addiction, poor diet , lack of exercise.” Treatment of such co-morbitities is crucial, they advise as significant “ for their psychosocial functioning and overall quality of life.” Detect medical illness at “the first episode of mental illness.” They admonish: “ identify…crucial modifiable risk factors, such as… obesity, dyslipidemia, diabetes, hypertension, and smoking.
This team relates such metabolic and cardiovascular risk factors in population with significant mental illness “to poverty and limited access to medical care but also to the use of psychotropic mediations.” They advise in the first three to four months of treatment that patients with severe mental illness obtain baseline weight, height, waist circumference, blood pressure, fasting plasma glucose, and a fasting lipid profile. Obtaining a BMI ( Body mass index) which is weight(kg) over height(meters) squared can be extremely helpful.
Getting a baseline EKG is essential if a patient is taking an atypical antipsychotic which can increase your QT interval (the repolarization phase of the cardiogram) and lead to fatal arrhythmias. We need to know about the cardiovascular and metabolic risks of our medications! Prescribing antipsychotics carries responsibility for monitoring metabolic abnormalities as well. An ideal world MUST BE coordination among psychiatrists, GP’s, endocrinologists, cardiologists, nurses, dietitions, our families and US.
It is crucial that clinicians stay vigilant for metabolic syndrome among their stable of bipolar patients. Individuals who develop this complication are susceptible to coronary artery disease ( like I was), high blood pressure, Type 2 diabetes, abnormal fats, fatty liver, gout, polycystic ovaries, and chronic kidney disease. Men with abdominal girth over 40 inches and women over 35 inches may have it.
As Tim has suggested, changes in diet accompanied by a commitment to regular exercise is crucial. Medications that increase the body’s sensitivity to elevated glucose like metformin, thiazolidine, or rosiglitazone WITH exercise can improve sugar utilization. If weight reduction and exercise totally fail and after appropriate screening, bariatric surgery can certainly be a viable alternative. But that subject is for another time and blog.
Friday, February 26, 2010
Bipolar disorder and Exercise
By Tim Kuss, LADC, LMFT
Research by Sylvia, et al suggests that outcomes are suboptimal for patients with bipolar disorder who are treated with pharmacotherapy ALONE. They say that exercise can improve acute and long-term outcomes. Jamie Blumenthal did a study of 150 participants with depression. One third were assigned to take Zoloft, 1/3 assigned to an exercise regimen, and 1/3 to both. At the 6 month follow-up, the exercise only group had a significantly lower relapse rate than the other two groups. In studying this topic, I found numerous personal endorsements of exercise by people with bipolar disorder. There are so many articles about this on the internet that I find it hard to say anything new on the topic.
I will say, however, that I personally get close, if not achieve, the three-times a week of recommended exercise. I walk my dog around our block almost every day, which takes us 20 minutes, walking briskly. I get to the gym two to three times a week, swim for 30 minutes, and am now also gradually increasing my time on the stationary bike. Outdoor exercise is still my favorite because I can get some light therapy from the sun as well. I enjoy flowers in the spring, animals, trees, creeks and other nature "eye-candy."
As with any other healthy goal, it is best to start small and gradually improve. I am quick to forgive myself for getting off schedule. However, I don’t forget about the "big" plan. Here’s where my manic grandiosity pays off as I believe that I have a lot of important stuff to do and can’t afford episodes that disable me. Besides, hospital wards are not much fun.
“Bipolar disorder self-care,” www.mhsanctuary.com
Raven, Robin, “How to exercise for bipolar disorder,” ehow.com
“Dreaded exercise”, McMan’s depression and bipolar web
Research by Sylvia, et al suggests that outcomes are suboptimal for patients with bipolar disorder who are treated with pharmacotherapy ALONE. They say that exercise can improve acute and long-term outcomes. Jamie Blumenthal did a study of 150 participants with depression. One third were assigned to take Zoloft, 1/3 assigned to an exercise regimen, and 1/3 to both. At the 6 month follow-up, the exercise only group had a significantly lower relapse rate than the other two groups. In studying this topic, I found numerous personal endorsements of exercise by people with bipolar disorder. There are so many articles about this on the internet that I find it hard to say anything new on the topic.
I will say, however, that I personally get close, if not achieve, the three-times a week of recommended exercise. I walk my dog around our block almost every day, which takes us 20 minutes, walking briskly. I get to the gym two to three times a week, swim for 30 minutes, and am now also gradually increasing my time on the stationary bike. Outdoor exercise is still my favorite because I can get some light therapy from the sun as well. I enjoy flowers in the spring, animals, trees, creeks and other nature "eye-candy."
As with any other healthy goal, it is best to start small and gradually improve. I am quick to forgive myself for getting off schedule. However, I don’t forget about the "big" plan. Here’s where my manic grandiosity pays off as I believe that I have a lot of important stuff to do and can’t afford episodes that disable me. Besides, hospital wards are not much fun.
“Bipolar disorder self-care,” www.mhsanctuary.com
Raven, Robin, “How to exercise for bipolar disorder,” ehow.com
“Dreaded exercise”, McMan’s depression and bipolar web
Healthy Diet for Bipolar Disorder
By Tim Kuss, LADC, LMFT
Diet in this case does not indicate a goal of weight loss, but rather a regimen that will promote physical health AND mood stability. However, besides promoting mood stability, these diet suggestions may also help to prevent stroke, heart problems, and diabetes.
Eat at least 3 meals a day. Six smaller meals are better. Try to have these meals about the same time daily. Breakfast is IMPORTANT!
Omega-3 fatty acids have been proven to help PREVENT manic episodes. For example, Northern European countries in which people eat larger quantities of fish, have lower rates of bipolar disorder and manic episodes. In our home, we try to have three meals of fish a week. Avoid breaded fish entrees. Broiled fish is best.
Tuna, salmon, and trout, high in omega-3’s, are excellent choices. We eat salmon 1-2 times weekly. Just microwave it and add a little lime or lemon juice, YUM!
Fish oil supplements are available in many health food stores, pharmacies, or vitamin stores. While you are at it, pick up a multivitamin to take daily. Look for a multivitamin that contains the daily requirements of B6 and B12.
Flax seed oil actually has a higher concentration of Omega-3’s than fish oil. Flax seed needs to be ground to avoid releasing “free radicals," so be cautious of commercial brands. Canola oil, olive oil, and sunflower oil also have omega-3’s.
Omega-3 is also found in beets
Folic acid in many multivitamins has been shown to relieve bipolar depression and mania. Folic acid is present in dried beans, peas, oranges, whole wheat products, broccoli, Brussel sprouts, and spinach.
Inosital is a B vitamin that is reputed to provide relief from depression, panic attacks, and obsessive compulsive disorder (OCD). It is found in oranges, nuts, seeds, bran cereals, and legumes.
Make sure that you eat the daily recommended 6 servings of fruits and vegetables. Leafy green vegetables such as spinach, are vitamin rich and good for your diet. Fresh fruit is great! Use it as a substitute for high calorie sugary deserts.
USE whole grains if possible. We enjoy whole grain pasta in spaghetti and there are many whole grain cereals. Use 1 or 2% milk.
Eggs, soy products, nuts, and seeds are protective and nutrient dense. Include them in your meal plans. For example, my wife has several salad recipes that include nuts. We put walnuts and brown sugar substitute in oatmeal. I am a Type II diabetic.
Cut down on red meat. Limit that to 1 to 3 times a week. Such alternatives as chicken, turkey or tuna are better for you. Avoid saturated fats, trans fats and simple carbohydrates(candy bars, rich deserts, ice cream).
Avoid fried foods as they increase omega-6, which competes with Omega-3.
Grapefruit juice may have negative interactions with some bipolar medications.
Reduce sugar intake as much as possible. Splenda, according to my review, seems to be the best sugar substitute (no indication of negative effects).
Avoid caffeine, alcohol, and drugs.
Bibliography:
Reese Heather, “A healthy diet: tips for individuals with bipolar disorder.” healthcentral.com
“Bipolar disorder self-care.” mhsanctuary.com
“Bipolar diet: “foods to avoid.” WebMD.com
“Diet and manic-depression.” Bipolar-Lives.com
“Managing bipolar disorder.” www.psychologytoday.com
Diet in this case does not indicate a goal of weight loss, but rather a regimen that will promote physical health AND mood stability. However, besides promoting mood stability, these diet suggestions may also help to prevent stroke, heart problems, and diabetes.
Eat at least 3 meals a day. Six smaller meals are better. Try to have these meals about the same time daily. Breakfast is IMPORTANT!
Omega-3 fatty acids have been proven to help PREVENT manic episodes. For example, Northern European countries in which people eat larger quantities of fish, have lower rates of bipolar disorder and manic episodes. In our home, we try to have three meals of fish a week. Avoid breaded fish entrees. Broiled fish is best.
Tuna, salmon, and trout, high in omega-3’s, are excellent choices. We eat salmon 1-2 times weekly. Just microwave it and add a little lime or lemon juice, YUM!
Fish oil supplements are available in many health food stores, pharmacies, or vitamin stores. While you are at it, pick up a multivitamin to take daily. Look for a multivitamin that contains the daily requirements of B6 and B12.
Flax seed oil actually has a higher concentration of Omega-3’s than fish oil. Flax seed needs to be ground to avoid releasing “free radicals," so be cautious of commercial brands. Canola oil, olive oil, and sunflower oil also have omega-3’s.
Omega-3 is also found in beets
Folic acid in many multivitamins has been shown to relieve bipolar depression and mania. Folic acid is present in dried beans, peas, oranges, whole wheat products, broccoli, Brussel sprouts, and spinach.
Inosital is a B vitamin that is reputed to provide relief from depression, panic attacks, and obsessive compulsive disorder (OCD). It is found in oranges, nuts, seeds, bran cereals, and legumes.
Make sure that you eat the daily recommended 6 servings of fruits and vegetables. Leafy green vegetables such as spinach, are vitamin rich and good for your diet. Fresh fruit is great! Use it as a substitute for high calorie sugary deserts.
USE whole grains if possible. We enjoy whole grain pasta in spaghetti and there are many whole grain cereals. Use 1 or 2% milk.
Eggs, soy products, nuts, and seeds are protective and nutrient dense. Include them in your meal plans. For example, my wife has several salad recipes that include nuts. We put walnuts and brown sugar substitute in oatmeal. I am a Type II diabetic.
Cut down on red meat. Limit that to 1 to 3 times a week. Such alternatives as chicken, turkey or tuna are better for you. Avoid saturated fats, trans fats and simple carbohydrates(candy bars, rich deserts, ice cream).
Avoid fried foods as they increase omega-6, which competes with Omega-3.
Grapefruit juice may have negative interactions with some bipolar medications.
Reduce sugar intake as much as possible. Splenda, according to my review, seems to be the best sugar substitute (no indication of negative effects).
Avoid caffeine, alcohol, and drugs.
Bibliography:
Reese Heather, “A healthy diet: tips for individuals with bipolar disorder.” healthcentral.com
“Bipolar disorder self-care.” mhsanctuary.com
“Bipolar diet: “foods to avoid.” WebMD.com
“Diet and manic-depression.” Bipolar-Lives.com
“Managing bipolar disorder.” www.psychologytoday.com
Wednesday, February 24, 2010
Sleep Hygiene #2
Here are some tips on getting the sleep you need:
1. Try to go to bed and get up about the same times every day. This will help you establish a rhythm and structure to your sleep pattern.
2. The ideal setting is a cool dark room. Also, reduce the noise level. Use ear plugs or eye shades if needed.
3. You can always put a CD on with mellow relaxing music.
4. I reommend that you learn and practice deep breathing, visualization, and progressive muscle relaxation. Many bookstores sell CD's that help guide you or make your own!
5. Avoid napping during the day.
6. Use your bed only for sleeping and sex. If you can't sleep, go into another room and read, or do something else relaxing and quiet
7. Too much light can keep you awake. Keep light levels low.
8. Avoid stimulating activities, including video games, internet surfing, or social networking close to bedtime
9. Exercise regularly, but not for 6 hours before bedtime, as it is stimulating.
10.Try to eat your heavy high protein meals earlier in the day. Breakfast is best.
11. Avoid caffeine in coffee, tea, and certain soft drinks, especially in the evening. Set limits!
12 Nicotine is stimulating. Don't smoke before bed or if you wake up.
13 Alcohol and other drugs may make you "pass out" but will contribute to disrupted sleep. Your balance and sleep cycle are endangered by chemical use.
14. Try changing your sleep position, like sleeping on your side rather than your back.
15 Yoga, tai chi and other disciplines can help you relax and sleep
16 Exercise for at least 20 minutes every other day
17 Try to have your meals at about the same times every day
18 Avoid rigid, rapid weight loss, use a slow, sensible plan!
19 Get enough calcium. Calcium and vitamin supplements can help
20 A glass of milk and a turkey sandwich could help
21 Have a pre-bedtime ritual, like washing, getting into pajamas, or reading a chapter in a book
22. Writing in a journal can help. Also, use a day planner so you worry less about getting to appointments. I also write "to do" lists before bedtime
23. Don't be afraid to ask your doctor for sleep meds. Use them "as needed"
24 Connect with people who love or support you on a regular basis
25. Use visualization to imagine that you are in a beautiful relaxing place
26. Accept your wakefulness when you have it. Relax, enjoy
27 Hide the bedroom clocks
28. Try a warm bath before bed
29 Affirm yourself. Make lists of your abilities, deeds, gratitude, etc before bedtime, and use them as part of your relaxation
I would like suggestions and feedback on this post. Tim Kuss, 2-24-10
1. Try to go to bed and get up about the same times every day. This will help you establish a rhythm and structure to your sleep pattern.
2. The ideal setting is a cool dark room. Also, reduce the noise level. Use ear plugs or eye shades if needed.
3. You can always put a CD on with mellow relaxing music.
4. I reommend that you learn and practice deep breathing, visualization, and progressive muscle relaxation. Many bookstores sell CD's that help guide you or make your own!
5. Avoid napping during the day.
6. Use your bed only for sleeping and sex. If you can't sleep, go into another room and read, or do something else relaxing and quiet
7. Too much light can keep you awake. Keep light levels low.
8. Avoid stimulating activities, including video games, internet surfing, or social networking close to bedtime
9. Exercise regularly, but not for 6 hours before bedtime, as it is stimulating.
10.Try to eat your heavy high protein meals earlier in the day. Breakfast is best.
11. Avoid caffeine in coffee, tea, and certain soft drinks, especially in the evening. Set limits!
12 Nicotine is stimulating. Don't smoke before bed or if you wake up.
13 Alcohol and other drugs may make you "pass out" but will contribute to disrupted sleep. Your balance and sleep cycle are endangered by chemical use.
14. Try changing your sleep position, like sleeping on your side rather than your back.
15 Yoga, tai chi and other disciplines can help you relax and sleep
16 Exercise for at least 20 minutes every other day
17 Try to have your meals at about the same times every day
18 Avoid rigid, rapid weight loss, use a slow, sensible plan!
19 Get enough calcium. Calcium and vitamin supplements can help
20 A glass of milk and a turkey sandwich could help
21 Have a pre-bedtime ritual, like washing, getting into pajamas, or reading a chapter in a book
22. Writing in a journal can help. Also, use a day planner so you worry less about getting to appointments. I also write "to do" lists before bedtime
23. Don't be afraid to ask your doctor for sleep meds. Use them "as needed"
24 Connect with people who love or support you on a regular basis
25. Use visualization to imagine that you are in a beautiful relaxing place
26. Accept your wakefulness when you have it. Relax, enjoy
27 Hide the bedroom clocks
28. Try a warm bath before bed
29 Affirm yourself. Make lists of your abilities, deeds, gratitude, etc before bedtime, and use them as part of your relaxation
I would like suggestions and feedback on this post. Tim Kuss, 2-24-10
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