DBSA-NOVA      July 19,2007

Everything You Always Wanted to Know About Depression and Bipolar Disorder *
But Were Afraid to Ask
Q & A Dr. Fred Goodwin October 18, 2007 at George Washington University

Provided by -- Moria, DBSA-National Capital Area

Part 1
 
John McManamy blew his didgeridoo and Dr. Goodwin arrived at the auditorium of the George Washington University hospital auditorium.
 

Dr. Goodwin opened his remarks by sharing that he’d been at the birth of DBSA, formerly the National Depressive and Manic-Depressive Association.  He remembered attending a reception with his friend, Katherine Graham, publisher of The Washington Post.  There she felt comfortable speaking in public about the suicide due to bipolar disorder of her husband, Phil Graham.  Dr. Goodwin reassured Katherine Graham that mental illness touches all of us.  Half the members of Congress are mentally ill, he opined.

 
DBSA is an organization of people doing well by supporting research, seeking effective treatment.  DBSA has authenticity, passion and sophistication because it is patient run.
The patient is the best source of information.  And the Internet is a great source.
 
Dr. Goodwin spoke about the difficulty of getting families involved…of the reluctance to discuss the elephant in the living room.  Getting input from family members and close friends is essential in making proper diagnosis.
 
He spoke about how difficult it is to spot bipolar disorder even for him.  He shared the story of a lawyer patient of his who came to see him about depression.  Dr. Goodwin tired to elicit information from the man about hypomania and mania and came up dry.  When Dr. Goodwin asked the fellow’s wife the same questions, she remembered the summer her husband bought three cars.  She remembered the time he told all his colleagues they were assholes and got fired.  She recalled times when he was so irritable that his own children wouldn’t sit down to dinner with him.  56% of the patients referred to as unipolar are bipolar.  The trouble is that missed diagnosis leads to wrong treatment.
 
He spoke about efficacy trials for the FDA, Food and Drug Administration.  He said the tests are run on unusual patients under artificial conditions—each subject has one diagnosis only and goes on one med only.  Medication adherence is assumed to be 100%.  Sedation, for example, isn’t seen as a problem during a typical 10 week med trial.
 
In the real world the issue is effectiveness.  Dr. Goodwin guessed that most people in the audience take 4-5 meds…25% have anxiety disorders and 50% have alcohol and drug dependence in addition to mood disorders. 
 
The tolerability of the medication is critical in the real world.  Dr. Goodwin talked about going over the menu of reasonable choices (developed by Dr. Gary Sacks) to find the right meds at the right time. 
 
Acute treatment is easy he said.  An episode is brought under control.
 
The continuation phase is about maintaining control over that episode.
 
Within 6-9 months, episodes of mania burn themselves out and go into remission spontaneously without treatment.  Treatment shortens episodes.
 
Maintenance treatment is prophylactic treatment.  Drugs useful for this, lithium, Lamictal, Depakote, prevent new episodes.
 
Whatever works for an acute episode, should work for the long haul?  That’s just marketing.  An educated patient keeps psychiatrists on their toes.
 
If a psychiatrist is treating depressed teenagers, he needs to be an expert on bipolar.  We’re making bipolars with antidepressants! 
 
Part 2
 
50% of psychiatrists miss the diagnosis of bipolar.  The MDQ, Mood Disorder Questionnaire, won’t help if the patient doesn’t recognize her own mania.  If drugs poop out, you’re dealing with bipolar.  If a depressed patient isn’t better after three good trials of different classes of antidepressants, you’re dealing with unipolar.
 
Dr. Goodwin is going to be giving a talk about recurrent depression in New York in a few weeks.  The problem is cyclicity and not polarity.  With bipolar and unipolar genetics, we need to look for cyclicity.
 
Audience questions:
 
Regarding ADHD and bipolar disorder, Dr. Goodwin mentioned the lack of agreement about what bipolar IS in children.  Children don’t meet the durational requirements of the DSM.  Hypersexuality at an early age (he used a six year old molesting another as an example) and grandiosity (child thinks he knows everything and his teachers know nothing) would be red flags.  Dr. Goodwin feels physicians should treat these children as bipolar first and see what happens following the principle, DO NO HARM.  Stimulants used to treat ADHD could make bipolar disorder worse.
 
Mixed moods, rapid cycling, episodes tripping over each other, the illness has changed.  Over 50% of bipolar patients experience missed states, 25% endure rapid cycling.  The average age of onset was 32 in the pre-1990’s.  Average onset is way down to age 17 today.
 
Lithium resistance is way up.  The explosive use of antidepressants, the second generation antidepressants--Wellbutrin, Prozac and their 17 sons and daughters, represents a 10 fold increase in AD’s prescriptions from the tricyclic era.  Our efforts to educate all MD’s and help people who would never have gone to a psychiatrist were too successful.  Now Dr. Goodwin rarely sees an adult bipolar person who hasn’t been on antidepressants.
 
In hypomania vs. mania, 40% of mania’s are psychotic--out of touch with reality, delusional, paranoid.  You can’t tell a stage 3 mania (psychotic mania) from schizophrenia.
 
With hypomania, some grandiosity and decreased need for sleep can be useful.  Each person must know where to draw the line between mild hypomania and more serious mania.  Dr. Goodwin draws the line at self destruction--running bank accounts down, ruining marriage, losing job.  If a hypomania is gently pulled down, a depressive episode is less likely.  Hypomania is always associated with depression.
 
Someone asked him about the varieties of manic depression and he talked about some European system that I don’t understand:  D (depressed) M(mostly manic) dm  Dm (BP2)  Md  MD (BP1) 
 
He spoke about the benefits of the Life Chart.  He’s doing a research project comparing Life Charts done online with Life Charts done in person:  https://www.moodchart.org/Default.aspx
 
Imaging techniques, functional MRI’s, help with treatment, but not yet with diagnosis.  Images show that connections between the limbic system and cortex are not buffered enough.  These views on the brain are extremely helpful for drug development.
 
When asked about the relationship of diet and wellness, Dr. Goodwin lamented that not enough research is being done.  Most patients are in the diabetic spectrum with carbohydrate problems.  Both mood disorders and diabetes are membrane disorders—one the brain and one the pancreas. 
 
Sleep diet exercise are key.
 
He recommends a high protein diet especially early in the day.  He puts his patients on the something similar to the South Beach diet.
 
Stability does lead to new self-identity.  That’s what DBSA is all about.  At NIMH, we used couples  group therapy to help patients adjust to stability.
 
CBT is very useful in manic depressive illness.  The psychoanalytic…encouraging people to remember the bad stuff…digging into your past is kindling stuff.
 
People with depression have trouble forgetting.  Forgetting is a very important mechanism.
 
Psychotherapy should help sort it all out.
 
Regarding bipolar 1 and aging, from studies in the pre-lithium era, we know there’s a latency period, an acquiescence that seems adaptive during the prime child bearing years for women.  The illness doesn’t necessarily get worse with age. 
 
Dr. Goodwin recommends advance directives.  Here’s an explanation of advance directives from About.com:  http://bipolar.about.com/b/a/256974.htm
 
Part 3
 
When stopping a medication, Dr. Goodwin recommends a gradual tapering off…buffering…never sudden changes.  Don’t let anyone take you off a medication abruptly.The illness may be gone for 10-15 years, but it will come back.
 
Klonopin is a safe med and is very useful for nipping hypomania.
 
 
Staying stable requires much less medication than getting stable.  Stability begets stability. 
 
Integrity of the sleep cycle is the #1 issue.  It’s like a harmonic system…think tuning fork…inertia.
 
Lots of people as they get older, find it’s easier to stay stable.  Psychiatrists seeing seniors need to bone up.
 
On the propensity to become violent, advocates are afraid to admit that the severe mentally ill are prone to violence.  Improperly treated people are violent.  He sited studies from Sweden.  (My husband blames Viking blood there).
 
At Virginia Tech, tragedy may have been averted if everyone had been less afraid of violating rights, privacy rights.  Cho died with his rights on.  This situation is a bad hangover from the 1960’s.
 
Dr. Goodwin relayed an example from his own practice of a successful social worker from a wealthy family who flipped quickly into mania.  Her family and Dr. Goodwin committed her.  She got a lawyer and left the hospital manic.  She ended up heading to Manhattan, spending all her money, getting into the drug culture.  She lost her husband and her children in the process.  It took her 10 years to recover from that one episode.
 
Sleeping medications play a role in temporary situations.  Ambien is not good for long-term use.  Dr. Goodwin suggests that Neurontin (Gabapentin) at doses between 100-1000 mg. may be a wiser bet.
 
Be careful with computer activities before bedtime.  The wavelength of the light from the computer screen stimulates the ponti nuclei (sp?).  Stay away from the computer and the TV up to an hour before bedtime.
 
Melatonex OTC releases melatonin over 6 hours.  People with bipolar disorder have lower melatonin.  Dr. Goodwin uses Melatonex for himself and for his patients short-term.  It’s useful for jet lag.
 
The sedative properties of mood stabilizers work to our advantage with sleep.  Aerobic exercise is a sleep factor.  Body temperature sets the body clock.
 
For treatment of movement disorders caused by antipsychotics, Dr. Goodwin recommends meds that stimulate dopamine…Requip, for example.
 
With the new atypical antipsychotics, watch out for tardive dyskinesia, too.
 
Zyprexa is in trials to see if it prevents depression in bipolar disorder.  Metabolic side effects are worrisome and must be closely monitored.  Geodon and Abilify help some people.  Livers react differently.  Atypical antipsychotics are necessary sometimes because the threshold for mania has gone down.
 
 
Where are you keeping the data?  He complained about the uneven distribution of computer savvy psychiatrists.  He complained about scientology sites and the well paid MD’s who lend them credibility.
 
A man who has been on lithium for decades starting at NIMH wondered about damage to his kidneys from lithium.  Dr. Goodwin said that in the early years of lithium use (20+ years ago), the doses were too high.  Most psychiatrists don’t know how to use lithium.  Levels at .6-.8 are considered optimum now for bipolar 1.  When lithium must be stopped, taper it down.  In an emergency only, go off cold turkey.  In lithium withdrawal, suicide goes up 20 fold.  pdocs prescribe lithium at much lower doses now.  At the lower doses, less renal damage occurs.  Pdocs must keep an eye on creatinine and thyroid levels with lithium.
 
It’s important to see somebody who knows what they’re doing!
 
Dr. Goodwin communicates with family members about patients, but he doesn’t like to get a back channel going.  A clinician needs all sources of information.

 

-- Moria, DBSA-National Capital Area