Research on Staying Well with Bipolar Disorder

I found an interesting study conducted by researchers Sarah J. Russell and Jan L. Browne. Results of the study were published in Australian and New Zealand Journal of Psychiatry 2005; 39:187–193. The research was funded by the beyondblue Victorian Centre of Excellence in Depression and Related Disorders Grants Program. The title of the research report is Staying Well with Bipolar Disorder.

The authors state: “Participants found that their wellness depended on a number of things that were within their control. However the data indicated that there was not a simple ‘one fix fixes all’ approach. In the “Stay Well” study, most participants:

• recognized the importance of taking their illness seriously
• demonstrated that staying well was within their control
• made changes in their lives to stay well
• learned to get on with their lives while remaining mindful of their illness.”

To be included in the study, people diagnosed with bipolar disorder must have remained episode free for the past 2 years. The only concern I have with the participant’s being episode free and exhibiting wellness is the possibility that the people in the study may have very mild cases of bipolar disorder and that the techniques they use to stay well may not be effective for people with severe bipolar disorder. I’d like to know more about the participants’ previous episodes and the designation and severity their bipolar disorder.

The definition of the concept of “staying well” included the following: the  acceptance of diagnosis, mindfulness, education, identify triggers, recognize warning signals, manage sleep and stress, make lifestyle changes, treatment, access support, and stay well plans.

According to the article, 100 people were included in the study. There were 63 women and 37 men. Ages ranged from 18 to 83 years, with 86% over the age of 30. Duration of time since last episode of illness ranged from 2 years to > 50 years. In the sample, 76% of participants were in paid employment. In addition, 36% of participants were parents.

The results showed that “Participants actively managed bipolar disorder by developing a range of strategies to stay well. These strategies were based on participants’ individual needs and social contexts. The strategies included acceptance of the diagnosis, education about bipolar disorder, identifying both triggers and warning signals, adequate amounts of sleep, managing stress, medication and support networks.”

One of the keys to staying well was the ability to be mindful of their illness. By being mindful, participants were more fully able to develop individual stay-well plans, including intervention strategies to prevent episodes of  the illness. The full article shares specifics and it is well worth reading. http://researchmatters.net/publications/StayWell.pdf

Anxiety and Bipolar Disorder

One of the participants on a popular bipolar forum set up a poll asking people with bipolar disorder whether they have “social anxiety”. The three responses she allowed were:

• No way – 12%
• Maybe, not sure - 16%
• Yes – 72%

72% of respondents said ”Yes”. 16% said “Maybe”, and 12% responded “No.”  18 people cast a vote. Granted, this is not a scientific poll, but it does give you a higher social anxiety rate than many of the rates reported in the research literature. People also commented about what specifically made them feel most anxious. The overwhelming majority of people wrote about the need to avoid large crowds, parties, and stores, giving talks, and they also indicated being very uncomfortable when interacting with people they did not know well. Most of the respondents said that they do not feel social anxiety when they are hypomanic or manic, and their social anxiety is most prevalent when they are depressed.

For me, one of the most difficult parts of coping with bipolar disorder is dealing with the bouts of anxiety that seem to leap up out of nowhere and knock me off my feet. So, I thought I’d check out the research and other resources to see what experts say about the relationship of anxiety to bipolar disorder.You will see the term comorbidity used quite a bit in the research literature, and that essentially means that there are two separate diseases or disorders existing simultaneously with and usually independently of each other. Research also indicates that anxiety may be an actual component of bipolar disorder and not a separate disorder from bipolar disorder.

Dr. Jim Phelps describes these two different types of anxiety very well. The first is not a separate disorder but is an integral part of  bipolar disorder. With this type of anxiety, the person feels agitated, can’t seem to stay still, and feels uncomfortable in their own skin. To me this sounds like a part of mania or a mixed state rather than the low level kind of anxiety that I often feel. Dr. Phelps description fits me when I’m in a mixed state. He also describes the different types of anxiety disorders that sometimes exist along with bipolar disorder, and they include generalized anxiety disorder (GAD), social phobia, panic disorder, post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), and specific phobias. (1) I find that I especially want to be reclusive and avoid large social groups when I’m in a depressed mood.

According to well respected researchers in Brazil: ”Epidemiological and clinical studies have reported a high prevalence of anxiety symptoms in bipolar disorder, either in manic or depressive episodes, although these symptoms do not always meet criteria for a specific anxiety disorder. In addition to anxiety symptoms, bipolar disorder frequently presents with co-morbid anxiety disorders.” These researchers agree with Dr. Phelps. There is anxiety that is a part of bipolar disorder illness, and there are separate anxiety disorders that a person can have along with bipolar disorder. Most of the research studies that I’ve read deal with the cormorbidity of anxiety disorders with bipolar disorder rather than studying instances where anxiety is an integral part of the bipolar illness. (2) How you might tease out those two distinct types of anxiety in a study could be tricky.

According to Freeman, et al., “Symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder…. A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder.” (3)

The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study was a huge research study that lasted five years and included over 4,000 participants. The study provided an enormous amount of data that will be studied and disseminated for quite some time.  STEP-BD was funded by the National Institute of Mental Health (NIMH). Researchers discovered that there are many people with bipolar disorder who also cope with anxiety.  More than 50% of the study participants also had an anxiety disorder in addition to bipolar disorder. (4) 50% is significant and that may not include those whose anxiety is an integral part of their bipolar illness and not a separate anxiety disorder.

A Turkish study investigated the prevalence of anxiety disorders in bipolar participants whose illness was in remission, and their influence on the illness severity. The authors state: “Bipolar subjects with anxiety disorders were younger, had earlier age at onset of illness, and were over represented by female participants. Those with earlier onset illness were compared to those without anxiety disorders. The study demonstrated that (1) anxiety disorders were highly prevalent in the bipolar study participants , (2) individual anxiety disorders, particularly social phobia and panic disorder impacted illness severity, (3) bipolar participants with comorbid anxiety disorders tend to have a poorer outcomes and are less responsive to treatment, and (4) anxiety tends to be associated with an earlier age at onset of bipolar disorder and results in a more complicated and severe disease course.” (5)

Another interesting study examined the comorbidity of anxiety disorders among patients with bipolar 1 disorder who were currently in remission.  This  study assessed the occurance of lifetime and current prevalences of anxiety disorders among 70 patients with bipolar 1 disorder. Researchers used structured diagnostic interviews to gather data regarding the association between anxiety disorders and bipolar disorder including demographic and clinical variables. The researchers found that forty-three or 64.1% of bipolar 1 participants met the DSM-IV criteria for at least one anxiety disorder. Obsessive-compulsive disorder at 39% was the most common coexisting lifetime anxiety disorder, followed by simple phobia at 26% and social phobia at 20%. The authors state that: “The presence of anxiety disorders was related to significantly higher scores on both anxiety and general psychopathology scales. The results of the present study support previous findings of a high rate of anxiety disorders in bipolar 1 disorder cases and indicate that the presence of an anxiety disorder leads to more severe psychopathology levels in bipolar 1 patients.” (6)

In yet another study conducted by a group of scientists from the National Institute of Mental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies, researchers reported that participants with bipolar 1 disorder and bipolar 2 disorder had similar demographic characteristics and ages of onset of their first episode. The bipolar 2 disorder group had significantly higher lifetime prevalence of anxiety disorders in general, and had more social and simple phobia disorders in particular compared to those with bipolar 1 disorder. (7)

In summary, there appears to be compelling evidence that there are two distinct types of anxiety that can impact bipolar disorder illness: one that is an integral component of the bipolar illness itself, and another that includes separate, measurable, and disgnosable anxiety disorders that exist independently from the bipolar illness itself. I’m not sure how clean cut the lines of demarcation are between these two types of anxiety patterns, or what the treatment implications might be. If anyone has any information to contribute please do.

1. Dr. Jim Phelps, http://www.psycheducation.org

2. CNS Drugs. 2009 Nov 1;23(11):953-64. doi: 10.2165/11310850-000000000-00000. Epidemiology and management of anxiety in patients with bipolar disorder. Kauer-Sant’Anna M, Kapczinski F, Vieta E. Bipolar Disorders Program and Molecular Psychiatry Unit, INCT-TranslationalMedicine, Hospital de Clinicas(HCPA), Federal University of Rio Grande do Sul, Porto Alegre, Brazil.

3. Affect Disord.  2002 Feb;68(1):1-23.  The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and
treatment issues. Freeman MP, Freeman SA, McElroy SL. University of Cincinnati College of Medicine, Biological Psychiatry Program, Department of Psychiatry.

4. American Journal of Psychiatry, 161, 2222-2229.Simon, N.M., Otto, M.W., Wisniewski, S.R., Fossey, M., Sagduyu, K., Frank, E., Sachs, G.S., Nierenberg, A.A., Thase, M.E., & Pollack, M.H. (2004, December). Anxiety disorder comorbidity in bipolar disorder patients: Data from the first 500 participants in the systematic treatment enhancement program for bipolar disorder (STEP-BD).

5. Anxiety Disord. 2011 Feb 21. [Epub ahead of print] The comorbidity of anxiety disorders in bipolar I and bipolar II patients among Turkish population. Ibiloglu AO, Caykoylu A. MersinTarsus State Hospital, Department of Psychiatry, Mersin, 33400, Turkey.

6, Psychopathology.  2002 Jul-Aug;35(4):203-9.  Comorbidity of anxiety disorder among patients with bipolar I disorder in remission. Tamam L, Ozpoyraz N.

7. Affect Disord. 2003 Jan;73(1-2):19-32. The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders? Judd LL, Akiskal HS, Schettler PJ, Coryell W, Maser J, Rice JA, Solomon DA, Keller MB. National Institute of Mental Health Collaborative Program on the Psychobiology of Depression-Clinical Studies, USA.

Research on Bipolar Disorder Treatments

Prominent research scientists working to tease out the relative effectiveness of medical treatments for Bipolar Disorder use evidence based methodologies to provide relevant data for clinicians to use when prescribing medications for their patients. Clinical epidemiology uses evidence based methods and is  ^“a basic science for clinical medicine”, and one that provides an additional approach to traditional medical research methods  and to patient care (Sackett et al, 1991).
The Lithium Anticonvulsant Evaluation (BALANCE) study was a large-scale, randomized, and controlled trial that compared the long-term efficacy of lithium alone and valproate alone or in combination with each other. The principal investigator of the study, Dr. John R. Geddes and his research team collaborated internationally to conduct this ground-breaking study. The results are impressive, and of course more studies will need to be conducted to replicate their findings.

 
Overall:

• Lithium did better than Vaproate for mania.
• Lithium in combination with Valproate did better than Valproate alone. 
• Lithium did better for depression.
   
   
   
   
   
   

Sackett, D. L., Haynes, R. B., Guyatt, G. H. & Tugwell, P. (1991) Clinical Epidemiology: A Basic Science for Clinical Medicine. Boston, MA: Little, Brown.

Slides leveraged from online slide deck titled:  Why we need research: a short history of evidence-based psychiatry. John Geddes
Oxford Clinical Trials Unit for Mental Illness.
 
 
 

Research on Strategies for Managing Bipolar Disorder

I found a couple of recent articles that highlight the importance of exercise and self-management strategies in controlling and maintaining mood stability. The first research study followed a group of high functioning people with Bipolar Disorder to see what strategies they used to control their Bipolar Disorder, and the second study investigated the role of exercise in managing Bipolar Disorder.

In the article, What works for people with bipolar disorder? Tips from the experts. Journal of Affective Disorders, Dec. 2009,  the authors acknowledge that there is a large gap in the literature about strategies for managing Bipolar Disorder. Treatments are inadequate and there are few effective self-management strategies that have been studied, validated, and documented for use. In this study, the investigators monitored high functioning people with Bipolar Disorder and recorded the self-management strategies that they used to successfully manage their Bipolar Disorder.

The self-management strategies found to be effective were in the areas of: 1) Sleep, rest, exercise and diet; 2) Ongoing monitoring; 3) Enacting a plan; 4) Reflective and meditative practices; 5) Understanding Bipolar Disorder and educating others; 6) Connecting with others.  Hear the authors, “The findings constitute hopeful stories for people affected by the disorder and suggest further research to confirm and refine mechanisms of beneficial effect in Bipolar Disorder.”

In another article, Exercise and bipolar disorder: a review of neurobiological mediators, Neuromoleculcar Medicine, 2009;11(4):328-36, researchers reviewed articles published between 1966 and July of 2008. In their abstract they state, “Individualized exercise interventions are capable of alleviating the severity of affective and cognitive difficulties….”

In order to find appropriate studies to review, they cross referenced the term Bipolar Disorder with the following terms: exercise, neurobiology, brain, cognition, neuroplasticity, etc. They reviewed the literature and found evidence that structured exercise regimens do have positive health effects as well as ”robust anti-depressant effects”. They suggest that structured exercise is capable of “improving psychiatric and somatic health in Bipolar Disorder”.

In summary, these two studies focused on people with Bipolar Disorder. The results of both studies conclude that exercise and other self-management strategies can have significant beneficial effects on Bipolar Disorder.