A level playing field: an illusion?

by Peter J. Dorsen M.D., LADC

It’s been a fair amount of time since I have connected with the blog but am more than ready to do so. The last entry had to do with “ a level playing field,” and whether someone with bipolar disorder can ever return to a place they were at before they were diagnosed and adequately treated.

With a number of additional fiery accusations, I said categorically “yes.” But I have been mulling over my opinion almost continually since I entered my earlier opinion. Between then and now, I have experienced at least one bout of depression and may even have experienced at least one episode albeit brief of hypomania. I usually know about the depression. I actually get irritable. I discussed my emotional state with my psychiatrist and in a collaborative fashion, I began taking a higher dose of Depakote, the anti seizure medication for my bipolar 2 disorder that has served me well of late.

Things all settled back to emotions as usual and the constipation, probably the only physiological manifestation of my mental disarray, vaporized. My ability to deal with day-to-day challenges with my wife and her stepsons improved. Any issues with my sometimes testy students seemed to be of less consequence to them and to me. Perhaps I was showing more tolerance to everyday challenges on all fronts. I doubt this was La belle indifference but more that I was once again properly medicated.

I am not aloof how significant is my interaction with my loved ones or with the students whose tuition goes toward paying my salary. However, that I was once again subject to emotional “issues” even while properly medicated made me look more objectively at what I had written and almost believed as gospel. I don’t doubt that some of my opinions could well have been an element of denial:”I don’t really have a debilitating mental illness,” I insisted. How could I? It’s adequately treated and I am euthymic. Sure, in the same article, I had also taken a poke at psychiatrists in general as drug pushers perhaps even wagged dog-wise by a pharmaceutical industry anxious financially to get a return on their investment after developing all those designer psychotropics.

Recently, the mother of an often oppositional defiant young man still working through grief and PTSD after losing his father in his mid teens, told me an interesting story. Her son thinks anyone wanting to mentor him isn’t genuine. Likewise, he opines, any professional taking on the challenge wanting to guide him along “has to be” motivated by the financial aspect of such a relationship.
However, so much about our patient-therapist relationships get guarded by professionally mandated restraints. For instance, I cannot communicate with my psychiatrist by e-mail. I cannot talk to my psychiatrist directly. I must go through his nurse clinician if I have a problem or if I need medications earlier. This disturbs me. My psychotherapist, a well-meaning MSW therapist tried to categorically explain away this communication pattern as what happens when someone(me) is dealing with a system. My response was certainly testy, “ If we don’t question the system, we will be corrupted.”

There are certainly symptoms and signs that early mania or hypomania, the opposite emotional process to depression, is in motion: am I becoming hypermanic? Here is when taking an inventory by yourself or with the help of a loved one makes sense. How am I sleeping? Am I fairly abruptly needing dramatically less sleep? Am I more edgy with my wife or associates? Am I flying off the handle over seemingly smaller issues? There are co-occurring issues: did you resume drinking or drugging? Then there’s the angle of sexuality. Some is normal, inappropriately more is not.

This addition to the blog is not meant as an apology for what I have said previously but I want it to represent a dramatic reappraisal of how my disorder works. Bipolar disorder sneaks up on you. It wiles you into believing that you don’t own it. I am offering a different message today. We can hope for as level a playing field as compliance with effective medication will allow or by how much an uncontrollable and latent genie inside us will reemerge or fluctuate autonomously. Genuine cooperation with our treatment process may determine a pinnacle we can accomplish despite a chronic illness. I do not eliminate the value of questioning how care is delivered. The studies confirm that collaborative decisions about medications and psychotherapy improve outcome.

A “level playing field” may have some ruts and bumps as those of us with bipolar disorder reconnoiter our opportunities. So, I suppose, I must now say no to my earlier premise that now appears somewhat of an illusion. In my own case I sheepishly admit that all is not as smooth sailing in our perceived “recovery’ as I might have hoped. I have alluded to hints of reemerging depression. It is not unusual that mania and hypomania resurface. Perhaps, we can identify either end of the emotional yo-yo of our illness more quickly and with help collaboratively return to that illusory “level playing field” once again.

Chemical use

One of the problems is that using will provide temporary relief from anxiety, depression and other uncomfortable feelings common to Bipolar Disorder and other mental health problems. However, the longer-term effect will be increased anxiety, depression,etc. Another problem is that chemical use unbalances our brain chemistry, so that each use becomes kindling leading to more symptoms, including in my case and others, an eventual psychotic break from reality. It is best for folks with bipolar disorder to abstain from all chemical use. It could mean no more psych wards, less anxiety and depression and an overall improvement in one's quality of life. It's NOT a death sentence. Life is perfectly enjoyable without chemical use.

Have Hope!

I am at work. As I look out my window I can see the large state hospital campus that I left as a patient in 1970, 40 years ago. The old buildings are still there, now leased by the county, and there is a big new "Treatment Center" in another direction. My friends and I picketed this building, which was the cafeteria, advocating for better conditions. My journey has taken me into many situations, and I have learned much along the way. I now work with people with dual disorders and their families. Today I became a Licensed Marital and Family Therapist, another path to walk on. I want everyone out there to know that your dreams ARE possible. you have a lot to contribute and WE NEED YOU! Lift your head up and continue on your journey. Bipolar Disorder and Chemical Dependency are treatable. Tim Kuss, LMFT,LADC

What Happened to My Denial

 By Tim Kuss, LADC, LMFT

I’m talking about denial of bipolar disorder and the need to take medications daily.

I believe that failure to take meds is, ultimately a denial of bipolar disorder—mine in particular. It’s not that I never had denial. In 1974, I left a psychiatric ward on pass and signed myself into a long-term chemical dependency treatment. It was easier for me to admit chemical dependency than “mental illness”. I had been in a state hospital twice, on commitment, and while there, had learned that others had been there for 20-30 years or more.

Today, we don’t see a lot of lengthy mental health stays. But two 5-month stays back then scared the be Jesus out of me. Fortunately, my treatment center did not insist that I take those horrid anti-psychotics, which they had prescribed because I had been misdiagnosed with schizophrenia. At that point, I had 25 years of sobriety with no medications and no hospitalizations for addiction issues per se. However, I had had plenty of problems with hypomania over those years, resulting in divorce, breaking up with several partners, and losing several jobs.

When I was FINALLY diagnosed with Bipolar Disorder in 1999, I believed it, but did no truly understand it. I had taken myself off anti-psychotics (and anti-depressants) in the past, and eventually went off my mood-stabilizer. I was hospitalized again in 2002. This time I almost died. My mania had me running myself ragged physically and my blood pressure was dangerously high.

I have been “med compliant” now for 8 years. I think of it as an insurance policy. My body has aged and no longer can take the physical exertion of mania. I used to go days with little or no sleep, walk for miles for days on end, and eat very little food usually with no attention to its nutritional value. Plus, I never liked psychiatric units, or the loss of freedom.

My meds do not provide negative side effects. I read about possible negative effects today, but could find none for the dose I’m taking. So why should I have denial.

I work as a chemical dependency counselor. I have seen literally hundreds of clients hospitalized because they would not accept that their chemical use has contributed to psychosis (“going crazy”). I have also seen clients try to manage without medications. My freedom requires 2 small concessions: 1. don’t use; and 2.I take my meds.

I have a pretty good life. I think I’ll keep it.

Doomed or Can We Reach a Level Playing Field?

My blogmate, Tim Kuss, recently emphasized accepting one's mental illness-in our case, this is bipolar disorder-just as much as building and maintaining sobriety. You know, it's worked for Tim, I daresay, and for me especially since we both have been clean and sober for an impressive amount of time, take our medications deliberatively, and “take an active role in the design and delivery" of our care.

I really love Mathew Mattson and Sue Bergeson of the Depression and Bipolar Support Alliance (DBSA)'s remonstration that "the ultimate goal of treatment should be to engender hope." However, sometimes I wonder how that can actualize if we realize that we will continue to always have a chronic illness that will be there to haunt us especially if we do not walk the straight and narrow.

Dr. Jeffrey L. Sussman, in The Primary Care Companion to the Journal of Clinical Psychiatry, waxes profound when he notes, " The goal of treatment (for bipolar disorder) has changed in recent years from one of symptom abatement to one of recovery; that is returning patients to their level of functioning prior to the onset of illness."

Mover and shaker psychiatrist, Dr. Nada Stotland, allude to "moving beyond symptomatic recovery to also encompass functional recovery" She advocates ways to make this happen: (1) She wants “ policy and system changes to facilitate recovery.”
(2) She asks for “ improved funding for recovery-oriented care.” (3) She wants “implementation of recovery-oriented, collaborative care models that bring together psychiatrists and primary care providers.” Lastly, (4) She wants the “dissemination of improved tools for monitoring changes in symptoms and level of functioning.

Mattson and Bergeson emphasize that “the ultimate goal of treatment must be recovery” and that “consumers should take an active role in the design and delivery of their own care"

I want to dig deeper because I am not convinced the majority of practicing clinicians buy into this view. Many behavioralists, I suspect, focus on the "flavors" of one or the other presentations of bipolar disorder: are you manic and depressed, just a little off the wall, or rapidly cycling between ups and downs? The DSM IV has a diagnosis that fits you.

There are plenty of naysayers who would suggest that there is a greater tendency to define and treat in this New Age of twenty-minute Psychiatric visits. Is there a fiscal relationship between the plethora of psychotropics on the market and how many the average bipolar patient now takes? Does the tail wag the dog? Has "pushing" psychotropics to whatever extent supplanted interactive psychiatry?

Is there a financial impropriety based on the incredible profits engendered by so many medications? Have psychiatrists literally been "bought out" by the mega pharmaceutical companies?

So what is the incentive that anyone with bipolar illness will actually ever "get better?" I am not advocating that the bipolar patient as soon as they feel good again stop taking their medications. Sussman advocates utilizing an effective treatment team. I heartily agree with him and feel, to the bottom of my soul, that collaboration between the patient and physician is crucial. Such an approach demands mutual communication between physician and someone with bipolar disorder. Also, collaboration between primary care providers and specialists (psychiatrists, psychotherapists) is proven to have better outcomes.

Those lucky enough to have been treated collaboratively admitted better attitude about taking their medications and how bad they felt. They also just functioned better. Here again, these innovative psychiatrists are directing our attention toward returning to a level playing field; that is, somewhere before we began our struggle. Is that possible?

We circle around to the question whether someone like myself with known bipolar disorder can ever function normally again? "But you demonstrate compromise of executive and cognitive function on psychometric testing," they may tell you. However, the same psychologist may have performed testing under less than ideal emotional circumstances or under stressful conditions possibly contaminating the results.

In summary, it is my opinion also that a bipolar patient, collaboratively with appropriate medications from a perceptive yet vigilant psychiatrist and a knowledgeable therapist with co-occurring issues in check (anxiety, alcohol and drugs) CAN return to a level playing field.

Managing Depression

MANAGING DEPRESSION
Tim Kuss, LADC, LAMFT

I am suggesting a bio-psycho-social approach to understanding and coping with depression. The biological component comes in as we have noticed that mood disorders, such as depression, bipolar disorder and anxiety disorder tend to be found in successive generations of a family. As with alcoholism, what is inherited is a genetic predisposition to mood disorders. That means, if you have a parent, grandparent or other family member with a mood disorder, you are more likely than others to have one. It might not even be the SAME mood disorder. For example, someone’s grandmother may have had Major Depressive Disorder (depression) and that person may have Bipolar Disorder. We have learned that people with depression and Bipolar disorder have a chemical imbalance. Medications can allow our bodies to work properly and maintain the right balance of neurotransmitters. SSRI’s and other chemicals work as antidepressants, while Lithium and certain anticonvulsants work as mood stabilizers to help manage bipolar disorder. Taking medications consistently can help us to avoid episodes of depression.
The biological approach for managing depression intersects with the behavioral approach in that behaviors such as regular exercise, proper nutrition and sleep hygiene help us to avoid or cope with episodes of depression. Exposure to the sun or artificial sunlight also helps our body to relieve depression.

The best psychological approach for managing depression is Cognitive Behavioral Therapy. In their book, Depression:Causes and Treatment, Aaron Beck and Brad Alford state that major depression is the leading cause of disability worldwide. They note that studies have shown changes in thyroid hormone levels in response to cognitive therapy, showing that our bodies and minds are linked. They say that depression results in a complex pattern of deviation in feelings, thoughts and behavior.

Symptoms of depression include low mood, pessimism, self-criticism, agitation, problems with memory and concentration, and physical complaints, such as pain. There may be a loss of gratification with activities that starts with a few areas and expands. Activities that involve responsibility, obligation or effort become less satisfying and there is greater satisfaction in passive pursuits, including recreation, relaxation and rest..

People with depression begin to distort reality, They become preoccupied with continuous, repetitive negative thoughts. There is often a contrast between a depressed person’s image of themselves and the objective facts. They dwell on mistakes, imperfections and inabilities, convinced that others will reject them, and that they will lose jobs, relationships, and friendships. They continue to think in themes of deprivation and defectiveness

Depression seems to be a reversal of human nature, of the survival instinct to eat and sleep and the desire to experience pleasure. Others need to respond with concern, empathy and acceptance and to be aware of the client’s difficulty in concentration and in formulating thoughts. People with depression re hypersensitive to rejection and discouragement.
The cognitive approach to managing depression involves recognizing the negative thoughts, or negative self-talk that continues and increases depression. We can learn to challenge the negative thinking and replace it with neutral or positive thinking. For example, if I notice that I’m not functioning as well as normally at work, I can encourage myself to do the best I can. Instead of thinking that “I can’t do anything right” or “I’m doing so badly, that I might as well quit”, I can realize that this thinking doesn’t help the situation, and pay more attention to what I am doing well.

The behavioral approach involves doing things that help relieve depression. A depressed person is likely to withdraw from emotional attachments and tends to isolate from others. We can notice this and purposely spend time with others. If necessary, we can ask others to just let us be there without demanding conversation or interaction. Depression includes lethargy, but it is better to be active. Daily rituals such as walking the dog, and biking, walking or swimming several times a week can be helpful. Routine and structure can provide relief from nagging negative thoughts and feelings, so it is best to go to work or school, or to do volunteer work, or be involved in group activities, like crafting, or sports. A person with depression needs to “Push the envelope” in terms of involvement and activity, striving to get beyond one’s comfort zone. It’s best to start with a few small steps and keep expanding.

There is no reason why we pay attention to our biology, our thoughts and our behavior during the same time frame. There is no shame in taking medication for depression. Would we not take an antibiotic because of what people might think of us? We need to pay attention to seasonal changes, including the amount of sunlight we are getting, to healthy sleep habits, to proper nutrition and to exercise. We need to avoid isolation and too much unstructured time. We need to adjust our thinking to encourage ourselves to do all of these healthy things. Depression IS treatable. We are the prime agents in our own recovery!

“Recognition and treatment Strategies for Bipolar Disorder Across the Life Cycle,” Primary Psychiatry 17:2 (Suppl 3) adapted by Peter J. Dorsen, M.D., LADC

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.