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DBSA-NOVA
June 11,2007This is a recap of a talk entitled "2007 Update on Bipolar Disorder and Depression: Research and Treatment Implications" by Frederick M. Jacobsen, MD, at June 11 at George Washington University Hospital.
Dr. Jacobsen, a psychiatrist-scientist and clinical professor of psychiatry at George Washington who pioneered research into the use of Trazadone as a sleeping medication, presented new and recent findings on bipolar disorder and depression last night during a lecture in the George Washington University Hospital auditorium. Among other topics, he discussed new research by Helen Mayberg, M.D., a psychiatry professor at Emory, into tests where bipolar patients hard a heightened reaction in the amygdala -- the region of the brain that governs memory and emotional reactions -- when shown pictures of hostile faces.
He also presented research into a new technique by Dr. Mayberg that involved the permanent surgical implication of electrods in the brain and the virtually immediate reversal of chronic depression. Dr. Jacobsen said that bipolar patients had greater oxygen flow to the amygdala than control patients and depressed patients. Patients with ADHD had increased responses, but not as much as those on the bipolar spectrum. The revelations suggest further research should be done into the emotional responses of those with bipolar disorder when presented with hostile situations. "This suggests that bipolar patients have a different reaction to emotional stimuli in the amygdala," he said.
Dr. Mayberg's research into surgical implants is in its early stages, but "shows a high rate of response" even though "many surgeons do not want to get anywhere near it," he said. Illustrating the degenerative nature of bipolar disorder without treatment, Dr. Jacobsen discussed recent research that shows that those with unipolar depression and bipolar depression have a 50 percent chance of a reoccurrence of a depressive episode after their first one, a 70 percent chance of reoccurrence after the second episode and a 90 percent chance of reoccurrence after the third episode.
He looked at the factors believed to contribute to the development of bipolar disorder, including an individual's biological vulnerability coupled with chemical mood regulatory changes, trauma and situational events. Dr. Jacobsen argued, against general medical belief, that mania and hypomania can be diagnosed in those with abuse substances or have general medical conditions, such as lupus, that are known to induce mania.
Dr. Jacobsen discussed the definition of bipolar disorder, calling it a spectrum of illnesses. He said that anyone who has had a single manic episode is labeled as Bipolar I, and that Bipolar I is the illness that was once called Manic Depression. He said that those with Bipolar II, Cyclothymia and Recurrent Depression do not fit into the definition of Manic Depression but are on the bipolar spectrum. He said Bipolar I, or Manic Depression, only makes up 10 percent of the bipolar spectrum. At the same time, it makes up the vast majority of the people who seek consistent help. He discussed rapid cycling -- where individuals switch between normal, hypomania, mania and depression in rapid cycles -- and mixed state -- where mania and depression present at the same time with anxiety, agitation and irritability.
Dr. Jacobsen said that rapid cycling and mixed state are the more likely to be treatment resistant than other forms of bipolar disorder. The key relevance of these designations, he said, is that Bipolar I -- because of its striking manic episodes -- is most readily diagnosed in clinical practice, while Bipolar II, Cyclothymia and Recurrent Depression are more likely to be diagnosed as ADHD or depression, and patients are likely to be treated, at first, with the wrong medications.
When looking at the entire spectrum, it usually takes 10 years from the first clinical visit to a proper diagnosis, he said, because of the overlap in symptoms with other disorders, the cognitive difficulties some have while manic and depression, the short periods of time the most obvious symptoms are present, reluctance to share because of stigma and other problems.
Discussing mania, he added, "Very few people complain about these symptoms," adding that most people reach out for help when they are depressed and they can lead to incorrect diagnosis. When it comes to mania, he added,"Its very rare for people to claim because its like being Superman. They are convinced that its their natural state." Dr. Jacobsen said that 40 percent of those with bipolar disorder have a co-morbid anxiety disorder that needs to be treated with sleep medications, benzodiazipines and/or therapy.
Dr. Jacobsen discussed the kindling theory put forward by Bob Post, the retired chief of the psychiatry branch at the National Institute of Mental Health. He said that situations such as sleep depreviations, hormonal changes, other physiological changes, stress, alcohol, drugs and other factors can kindle and cause what appears to be depression to develop into rapid cycling bipolar disorder, then longer cycling or mixed state bipolar.
The idea is that the illness progresses over its course and is generally not considered static in any of the categories. When asked about bipolar and ADHD, Dr. Jacobsen said almost all of the symptoms of mania overlap with ADHD with the exception of the lack of sleep required for those having manic episodes. In addition, he said, the two illnesses present in slightly different fashions. "Sleep is the biggest difference," he said, noting that there is research being done at Harvard's McLean Hospital of patients who have both bipolar and ADHD.
"Having said that, there is a significant overlap." When asked about the different between mania and hypomania, Dr. Jacobsen said, "The different between mania and hypomani is that with mania people go to the hospital or jail.
They are so out of control that the people on the street know. They send up in the hospital, jail, they have affairs and do all of the things that others would not do." Dr. Jacobsen said that there is evidence that mania itself alters the DNA code and that stressors impact vulnerability to repeated episodes. He discussed new research that suggets -- although does not definitively prove -- that a connection can be found between an abnormal writing of information into the genetic code. Through generations, this amount of abnormal writing multiples and increases biological vulnerability to bipolar in each successive generation. This may help to explain why symptoms of bipolar are presenting themselves in at younger ages.
"What goes wrong in the DNA code is a greater number of abnormal requests that build up in the code," he said. He also talked about research that has shown that Omega-3 (he recommended 2 to 3 mgs of a pill that is USP tested), the SSRI class of antidepressants and Lithium provide some regeneration of damaged brain cells that could help prevent recurrence of episodes.
Dr. Jacobsen defined four types of depression: (1) recurrent depression -- where depression presents in cycles but the patient never reaches normal (note: drugs like Lamitcal have been shown to lift people up from recurrent depression); (2) dysthymia - a general low-grade lack of enjoyment and pleasure, (3) bipolar depression and (4) unipolar depression. He said that dysthemia and recurrent depression can present in combination with bipolar depression and unipolar depression, complicating treatment. Dr. Jacobsen also discussed research into ECT, deep-brain stimulation, cognitive behavioral therapy, RTM magnet treatment and other methods in dealing with treatment resistant bipolar disorder.
In spite of breakthroughs, Dr. Jacobsen said, "Do not underestimate the role of psychotherapy. Well designed and controlled studies have shown that both medication and psychotherapy are the best combined treatment for these illnesses." -- Jayson Blair
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Jayson did a good job of summing up the content, but I will add my thoughts anyway and share a few I think were overlooked but made an impression on me. I think a big element that needs a little more stress was that Dr. Jacobsen shared his belief that the next version of the DSM, and well as the general medical thinking, is moving toward the idea of a bipolar spectrum.
He says even unipolar depression, as long as it reoccurs cyclically, belongs along this spectrum. He was thinking that bipolar will be expanded from the limited manic-depression definition most people associate it with to encompass more of a category of illnesses rather than thinking of it as one illness only. For me the presentation really hit home with the notion that there is truly a physical basis for a Bipolar diagnosis.
There was a large focus on the more tangible physical elements in the presentation like brain scans and brain cell microscope slides. Another point of interest about taking medicine that I think Jayson missed was one startling statistic that patients who were on Lithium longterm had a very small number of suicides compared to those who were not. This statistic is important and I remember it as something like 80-90% less suicide attempts but my memory might be faulty. One more interesting statistic was about creativity tests.
Dr. Jacobsen mentioned that patients on medicine longterm scored highest on creativity tests when they were asymptomatic and on medicine, than when they were asymptomatic on not taking any medicine yet. Dr. Jacobsen also shared that patients have come to him saying they had tried everything over the years and nothing seemed to work. Upon gathering further medical history it had come up for the patients that they had only really even been prescribed medicines from one or two types of bipolar medications, and that they had responded well to one of the other ones not yet tried. -- Dan Narkieiwcz
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Thanks Dan. I forwarded this to the bipolar support group. The one point of clarification I would make is regarding the DSM.
The definitions are as follows: Manic Depression, historically, is what we now call Bipolar I and it occurs when an individual has a at least one manic episode and depression.
Bipolar II is in the bipolar spectrum, but is not manic depression, and involves hypomania and depression.
Cyclothymia is in the bipolar spectrum, but is not manic depression, and involves hypomania and what is known as subdepression
Recurrent Depression is likely to be added to the bipolar spectrum in the new DSM and it involved depressive mood swings that do not rise to the point of hypomania and rarely reach normal -- Jayson