Treating Bipolar Disorder: A Q & A with Dr. Candida Fink, Part 2

An estimated 5.7 million American adults have bipolar disorder, which is a mental illness characterized by dramatic changes or shifts in mood, energy and intensity. Since there is no cure for bipolar disorder, the chronic illness requires lifelong treatment and monitoring. Prescription medicines used to treat bipolar disorder range from traditional mood stabilizers like Lithium and Depakote to newer antipsychotics like Abilify and Zyprexa; all of these drugs have serious side effects. Behavior changes -– like maintaining sleep hygiene and keeping anxiety in check — can also help people manage this illness.

Dr. Candida Fink

This is the second part of a two-part interview on the Diagnosis and Treatment of Bipolar Disorder with psychiatrist Candida Fink, MD (pictured), one of the leading experts in Bipolar Disorder. Part I focused on the diagnosing of the illness and included a list of Fast Facts about bipolar disorder. Dr. Fink is the co-author of The Ups and Downs of Raising a Bipolar Child (with Judith Lederman, Simon and Schuster, 2003) and Bipolar Disorder for Dummies (with Joe Kraynak, John Wiley & Sons, 2015). Based in New Rochelle, NY, Dr. Fink specializes in child and adolescent psychiatry, with expertise in developmental disabilities, ADHD, pediatric anxiety and mental healt issues in school settings. You can read her blogs on bipolar disorder at www.finkshrink.com.

Suelain Moy: What are some of bipolar disorder symptoms and the treatment options for people with bipolar disorder?

Dr. Candida Fink: Part of the long-term treatment is to help people try to build in systems with themselves and the people around them to flag early symptoms before they’re completely sucked into a manic episode, so that they can take action before they’re so far into it that they lose insight. Try to stay ahead of the game, track their moods, track their sleep, track their energy, and hopefully be willing to allow their loved ones and friends to be part of that. To try to catch it sooner rather than later because once you enter a full-blown episode, it’s very hard to control.

SM: What’s the hardest aspect about treating bipolar disorder?

Dr. Candida Fink: The unwillingness to accept treatment is far and away the most difficult aspect of treating bipolar disorder. Some of the things individuals struggle with most intensively is that they just don’t feel like there’s anything wrong, and they’re unwilling to go for care. In the meantime, lives are falling apart and being destroyed.

SM: Which medications are most commonly prescribed for the treatment of bipolar disorder and what are their side effects?

Dr. Candida Fink: Lithium is one of the oldest medications for bipolar disorder. It does a number of things. I call it the “Swiss Army Knife” of psychiatry medications. It reduces mania. If someone is actively in a manic episode, lithium will often help to reduce that. It also has some anti-depressant effects so usually not alone — but in some cases alone — it will actually relieve depressive symptoms. It helps on both ends of the polarity. It is helpful in preventing or reducing the frequency of dramatic mood shifts. And it has a very specific anti-suicide effect that is not well-explained, but it reduces frequency of successful suicide. It definitely decreases the rate of completed suicide and we don’t really know why. It has a lot of uses. It is one of the core medications for people with bipolar disorder and they’re going to take it their whole life. It’s not such an easy medication to take. It often causes some weight gain. It can cause acne, especially in younger people. It can cause tremor. Long-term, it can impair thyroid function. You can’t go on lithium for a long time without needing thyroid replacement medication. And kidney function can be impaired and that should be monitored over the years.

And then kidney toxicity is another side effect of lithium. Because it’s cleared in the kidneys, you can get a kidney problem after being on it for many years. It can make you nauseous, give you a headache and it can make you tired but not everybody has all of these side effects and certainly for many people, it’s a lifesaver. The other thing about lithium is that it has a very narrow window between a blood level that is therapeutic and helpful, and a blood level that is toxic. There’s not much room between getting to helpful and getting to dangerous, so we do monitor blood level closely. Toxicity can be deadly. That has to be monitored regularly. It can cause fatal cardiac events. So we check levels all the time. Levels are affected by people’s hydration status. So especially in the hot months, we have to make sure people stay hydrated because if you get dehydrated, your blood level of lithium can go up very high.

If someone is out in the sun or working out, or it’s just a hot day and they’re not rehydrating enough, then the concentration of lithium goes up in the blood and that can become dangerous.

With the older, first-generation antipsychotics, the biggest problem was a permanent disorder called tardive dyskinesia, a movement disorder that can cause involuntary movement. The older antipsychotics had that as a big side effect. This side effect is less common in the newer ones but it does still happen.

SM: I can imagine if someone is an actress or something, they might not want to take lithium because of the weight gain or the tremors.

Dr. Candida Fink: Years ago, I treated a young woman who was a pianist but the tremors from the lithium were just unbearable. She couldn’t remain in her profession and stay on lithium. It’s hard.

SM: So what did you prescribe instead?

Dr. Candida Fink: Well, the next choice is often Depakote. Depakote is an anti-seizure medicine that also has a very long history of being used to treat bipolar disorder. It is anti-manic. It appears to reduce the frequency of mood cycles. It doesn’t have a lot of anti-depressant quality to it, not as much as lithium. But it is commonly used as a sort of maintenance medication like lithium for long-term maintenance to help reduce the frequency of episodes and to stabilize somebody. It has its own side effects. In rare cases, it can cause a deadly inflammation of the pancreas called pancreatitis. It can cause liver function changes. It can affect the white blood cell counts. It can cause hair loss. It can cause some weight gain as well. In young women, it appears to potentially increase the risk of something called polycystic ovary syndrome, which affects menstrual cycles and fertility and insulin metabolism. Many people will avoid using it in women of reproductive age, especially with young women who have not had children yet. You have to check the blood levels on Depakote and you have to check other labs as well regularly just as you do with lithium.

SM: And is there a third medication or are these the two primary ones?

Dr. Candida Fink: Then there’s a third class of medication that is very commonly used and is increasingly at the forefront. These are what we call the atypical antipsychotics or second-generation antipsychotics. These are medications like Risperidone and Abilify and Seroquel and Zyprexa.

These are the new, fancy, shiny drugs that the drug companies are spending a lot of money to market and get doctors to use and they’re very good. They bring down mania. They are antipsychotic. People with bipolar disorder can have psychotic symptoms like the delusions of mania and depressive psychotic symptoms. They’re very good at controlling these symptoms, but they also have a lot of potential downsides.

With the older, first-generation antipsychotics, the biggest problem was a permanent disorder called tardive dyskinesia, a movement disorder that can cause involuntary movement. The older antipsychotics had that as a big side effect. This side effect is less common in the newer ones but it does still happen.

The bigger long-term side effects that people worry about with the second-generation antipsychotics are changes in metabolism and insulin and glucose metabolism. They can highly increase the risk of developing type-2 diabetes. They can cause a lot of weight gain. They can cause disruption in a lipid level, so they can increase cholesterol. They can be damaging to the system that has to do with metabolic stabilization, which can increase cardiac risk factors. They require close maintenance and observation. You have to check blood tests on them every three to six months as well. You want to check for movement disorders regularly. They were initially marketed as the saviors, with far fewer movement disorders but then of course, they turned out to have their own very significant side effects. And weight gain is, by far and away, front and center even before any of those other side effects develop. People gain weight on these drugs.

It’s very hard. People aren’t feeling good about themselves. They’re depressed. They don’t have energy and then you put them on a medication that is going to make them gain weight and feel badly about themselves. It’s really a terrible catch-22 for so many people. They’re good medications that are effective but they can be so problematic for just that reason alone. The weight gain negatively affects people’s quality of life and how they feel about themselves.

SM: So people with bipolar disorder must really need to have a comprehensive insurance plan and coverage.

Dr. Candida Fink: As you can imagine with all that level of need, it’s a very difficult disorder to manage, even with insurance and resources. Financial issues are very common because people don’t or can’t work as much or sometimes have to leave work completely. Certainly, some people qualify for disability.

SM: What are the lifestyle changes a patient can make to help manage bipolar disorder?

Dr. Candida Fink: Things like keeping sleep hygiene and keeping sleep schedules as regular as possible, those are pretty universally valuable for everyone, because sleep deprivation is a very common trigger for mania. It’s an easily observable symptom. Monitoring and being as proactive as possible, keeping stress to a manageable level, working with a therapist, working with whatever supports you need to try to keep life manageable, it’s very challenging to families who live with it.

There is a type of beneficial therapy for bipolar disorder called Interpersonal Social Rhythm Therapy, ISRP. The goals of it are valuable and it’s been studied and has benefit. It’s basically keeping the rhythms of the day as predictable as possible including sleep-wake cycles, assisting and getting skills training and interacting with other people effectively and trying to eliminate or reduce contact with very stressful people or situations. So really looking at the rhythms and the social connections as key factors to try to manage and handle skillfully as a way to help reduce the chances of relapse – the chances of recurrent mood episodes. So that whole picture of regulating and absolutely monitoring mood, trying to track mood on a regular basis just to see if you can begin to detect early signs of elevation or sinking of mood. Because it can be hard when you’re just day-to-day trying to say, “What’s my mood like? What’s my mood like?” But when you go back and you look at it on paper or on your phone, you can really start to get a feel for trends, and those are really valuable. Monitoring the trends of your mood, is it trending up or trending down, and when you glance at it in hindsight or check every week, you can say, “Oh, I see there’s a pattern here.” It can be very valuable.

SM: Do you recommend people keep a journal?

Dr. Candida Fink: Yeah, a journal. There’s actually now a bunch of apps out there for mood tracking. There’s one I have on my phone called T2 Mood Tracker but I think there are some others now coming out. A phone app makes it very easy to monitor and it acts like an electronic journal. You can personalize it or just devise your own little system. Plug it in every day, and the app will graph your mood. You can see how your mood is doing and how your anxiety is and how your sleep is. You can select different dimensions that you’re going to check in on every day and they will each have a rating scale.

SM: I imagine diet has some importance too.

Dr. Candida Fink: Sleep, energy, eating, focusing, concentrating, definitely controlling the level of anxiety because anxiety is very commonly comorbid. It happens commonly with bipolar disorder. All of these factors are important to maximizing positive results for people with bipolar disorder. These are important considerations but then again they require encouragement from family members who are involved and checking in periodically. It’s important for family members to find creative ways to help their loved one monitor their moods and sleep, consume a healthy diet, maintain interactions with the doctor’s office or schedule regular visits with the therapist. There are some coaches now who will go out into the home and be supportive and help in that sort of day-to-day stuff. It depends on the level of impairment and people’s resources. Someone who’s more impaired may have someone come into the home and help them make sure they’re dressed for the day, eating well or taking care of the bills. So it really requires a lot of outreach and support and reinvigorating all the time because this is exhausting. Everyone gets tired and they feel hopeless and overwhelmed so if someone is available to reach out and reconfigure and problem-solve, that is really such a big part of the care.

SM: So a team approach can be helpful.

Dr. Candida Fink: Absolutely. The core people on the team are a prescriber and a therapist of some kind. But there are lots of different ways you can build a team creatively and of course, family members of the patient are the primary team members. It’s important to make sure that we’re thinking about that factor in that context, that family members are important and equal team members to the caregivers.

SM: It’s very clear from what you’ve said that this is a lifelong condition and that there’s no quick fix.

Dr. Candida Fink: There is not. There is a sub-type, probably some kind of genetic variance, that has a wonderful response to lithium and they get better when they take their lithium. They’re in great shape when they take it but when they don’t, they’re in terrible shape. You know, they have this discrete mood episode that’s kind of a simpler, dramatic form of bipolar, it’s very lithium-responsive and that’s very genetic. In other words, if the father has it, you know the kid has it too. They’re both likely to have this positive response to lithium. So clearly it’s a heterogeneous disorder.

The label is very much man-made—trying to organize from what we see on the outside and it certainly encompasses a wide range of actual changes in the brain but even with the most straightforward story and response, it’s still very complex. And that’s why it’s so crucial for families to be supported and to be involved as much as possible and for the caregivers to work as a team because this is just not something one person can do alone. Just showing up at your doctor’s office once a week or once a month, that’s not going to help you manage this illness.

SM: What happens if a person does not receive adequate treatment for bipolar disorder?

Dr. Candida Fink: There’s certainly some evidence that untreated, your episodes become more frequent, that it take less to trigger an episode. Episodes happen more easily and more frequently. The condition itself seems to worsen untreated. Function declines significantly. People end up in and out of the hospital repeatedly. People stop working. They go on disability. Families try to stick it out but many can’t—it’s just too destructive and too damaging if someone is not treated or not able to be treated. Certainly suicide is a very high risk. People die from this disorder. It is a fatal disorder. And the other big sort of sidepiece to that is the evolution of substance abuse in the untreated. Substance abuse occurs in a very high percentage of people with bipolar disorder along with progressive untreated alcoholism. People will get sick and die from the alcohol or from other drugs. It’s very sad.

SM: So do you think that the substance abuse is a result of their trying to treat themselves?

Dr. Candida Fink: I think it’s probably very complicated. I think there’s probably no one linear connection. There’s definitely self-medication but there’s probably increased vulnerability to addiction just in the neurophysiology of the brain with bipolar disorder. I think that story is definitely still being written in terms of trying to understand the neurophysiology of it, but alcoholism is very common with bipolar disorder.

SM: What are the most promising areas of research for the future study of bipolar disorder?

Dr. Candida Fink: The area of genetics is most promising because that will aid in more accurate diagnosis and in the development of more effective treatments. As we understand the genes that are involved, this helps us begin to piece together the proteins and body processes that are disrupted in bipolar disorder. There are now huge banks of genetic data that will be part of piecing the puzzle together. In combination with some evolving information from imaging studies – that look at structure and function in different areas of the brain — we are moving toward a much better understanding of the condition itself and how best to treat it.

For more about Dr. Fink, visit her website at finkshrink.com. To read her blog posts, visit PsychCentral’s Bipolar Beat.

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