Treating Bipolar Depression

On average people with Bipolar I Disorder spend three times more in a depressive episode than in a manic or hypomanic state; those with Bipolar II Disorder suffer 40 times more in a depressive episode than in a manic or hypomanic state. According to DSM-5 a bipolar depressive episode and a unipolar depressive episode have the same diagnostic criteria marked by five of the following nine symptoms for two weeks:

• Depressed mood
• Loss of pleasure
• Weight or appetite change
• Change in sleep
• Psychomotor agitation or retardation
• Fatigue
• Feelings of worthlessness or guilt
• Indecisiveness or trouble concentrating
• Suicidal ideation

Bipolar I patients have had at least one manic episode lasting at least one week during which time the person feels euphoric and overly optimistic or is extremely irritable marked by three of the following symptoms:

•  Unrealistic, grandiose beliefs about one’s abilities or powers
•  Rapid speech that makes it difficult for others to keep up
• Acting recklessly without thinking about the consequences
• Racing thoughts, jumping quickly from one idea to the next
•  Distractibility marked by poor concentration and attention
•  Impulsiveness, poor judgment, agitation or excessive goal pursuit
•  Sleeping very little but without loss of energy

Bipolar II patients have had at least one hypomanic episode that differs from mania by intensity and duration. A hypomanic episode is only required to persist for four days instead of seven. Those in a hypomanic state can make bad decisions that harm relationships, careers, and reputations, but they are able to perform without losing touch with reality.

Three medications have been approved by the FDA for the treatment of acute bipolar depressive episodes:

1.  Seroquel (quetiapine)
2.  Symbyax (a combination of fluoxetine and olanzapine)
3.  Latuda (lurasidone)

Seroquel can contribute to significant weight gain and metabolic syndrome as can Symbyax. Both Latuda and Symbyax are expensive.

Lithium listed as first-line treatment for acute bipolar depression in the APA practice guidelines also has the following advantages:

• FDA approval for acute manic episodes
• FDA approval for maintenance treatment for those bipolar patients with a history of mania. 
• Frequently used to augment antidepressants in treatment resistant major depression. 
• Works rapidly (1-3 weeks)
• Is inexpensive
• Substantially decreases suicide risk
• May be useful for episodic rage, anger or violence unassociated with bipolar illness 
• May be useful for self-destructive behavior found in personality disorders

Lithium is underutilized. Because lithium is a generic medication pharmaceutical companies have little incentive to seek FDA approval for Bipolar II depression.

In most cases the benefits of lithium supersede the risks with the following precautions:

• Regular blood levels are necessary because toxic levels characterized by nausea, vomiting, diarrhea, slurred speech, gross tremor and staggering  occur close to therapeutic effects. With proper dosing and monitoring these side effects rarely occur.
• Should be avoided in patients with severe kidney disease, dehydration or sodium depletion
• Category D in pregnancy with positive evidence of risk to human fetus 

The initial dose can be begun at 300 mg 2-3 times daily. Alternatively the cautious clinician can prescribe 300 mg lithium at night. After one week the dose can be increased to 600 mg. Following another week the dose can be increased to 900 mg. Baseline labs and a lithium level can be drawn within a week of starting lithium. Gradually titration slows the time to response.

Parenting: What I Could Have Done Better

I asked my thirty-something friend how his life was going. His reply "Good. My spiritual life is solid. My wife and I love and support each other. I am improving as a parent. I'm enjoying my work."

Wow! My young friend certainly has his priorities straight. At thirty I had no clue. I walked around saying, "What's happening?"I sort of stumbled through early marriage; parenting discombobulated me. How our children turned out to be well-adjusted, successful adults confirms my belief in God's grace.

The encounter with my young friend made me grateful for the correct things Vicki and I discovered about parenting and reminded me where I fell short. Here are five things I wish I had done better:

• Made God the center of our lives. We took our kids to Sunday School, read them Bible stories, prayed at the dinner table, and the bedside but had no depth of conviction and mentioned God only in passing. We were lukewarm Christians. I wish we would have discussed God more, prayed more fervently and spent more time in personal Bible study. Much later Deuteronomy 6: 5-7 became one of my favorite verses: Love the LORD your God with all your heart and with all your soul and with all your strength. These commandments that I give you today are to be upon your hearts. Impress them on your children. Talk about them when you sit at home and when you walk along the road, when you lie down and when you get up.
• Praised effort, not achievement. I emphasized success, winning, being top in the class. I had to learn that some kids were more talented, smarter and prettier than mine. I learned to appreciate essence and uniqueness. Praise for achievement makes kids fear failure, tends to make kids tense and breeds perfection seeking adults who make themselves and others miserable. Praise for effort builds confidence, develops fearless go-getters and encourages perseverance. Rather than empty praise these kind of words are better: 
• Give it your very best!
• Your 100% effort pleased me very much.
• You struck out with the bases loaded, but you swung with all your might. Keep swinging.
• Keep giving it your best. That's all you can ask of yourself
• Your Mom and I are pleased with your giving it your very best.
• You can hold your head high when you do the best you can do.
• Been less effusive with praise. Effusive praise diminishes effort. Why would a child give it their best if they know they are going to receive praise for just showing up. Praise for nothing spoils a child.
• Been more consistent with discipline. I didn't make clear rules, nor did I establish clear discipline for breaking the rules. Posting expectations, rules and regulations and punishment for breaking the rules is a good idea. Rewarding good behavior produces good citizenship. 
• Talked less, acted more. Kids ignore long lectures; they pay attention to our actions. If we don't follow through with what we say we are going to do kids keep doing what they shouldn't. Be firm. Keep promises.     

As I was writing all the parenting traits I could have improved on I thought of some of the things Vicki and I did right.

• We were very affectionate. We gave butterfly kisses and hugged---a lot. We still hug. Our actions showed that Vicki and I loved each other and our children.
• We had fun together. We laughed together. We played together. We didn't take ourselves too seriously.
• We kept our kids inside the white lines by giving them enough latitude to learn from their mistakes while disallowing them to break the rules of society. We did not overprotect or hover over them. We encouraged independence and risk taking. We insisted, however, that they put on a parachute before jumping off a cliff. Here were our three rules for our teenage kids:
• Don't do anything that would hurt someone, embarrass us or seriously injure you.
• No drugs or alcohol.
• Nothing good happens after midnight.

In my view the chief aim of parents is to develop children into God-trusting, law-abiding, honest, fun-loving, and resourceful adults who feel confident to follow their dreams. To paraphrase Khalil Gibran: We are the bows from which our children as living arrows are sent forth. 

Nurses: The Most Valuable Medical Team Members

Nurses provide the foundation for excellent medical care. Nurses spend 8-12 hour shifts with their hospitalized patients. Doctors see their patients for 15 minutes or so each day. Good doctors respect nurses and listen to their advise.

Sadly nurses are overworked and unappreciated by administrators. In addition to providing patient medical care, they also must spend hours each shift completing electronic medical reports, most of which provide little information or may duplicate reports made by other staff members. They are responsible for keeping patients clean and cleaning their messes. They keep the patients' rooms tidy. They have learned how to maintain a pleasant attitude around difficult, passive-aggressive, and needy patients.
   
Several friends have questioned the validity of the August 27th blog entry accounting my recent Carilion emergency room experience. "Bizarre, exaggerated, fabricated," they said. Weird maybe, but every word was true.

Neither did I concoct nor exaggerate the following interaction:

While I was lying on the stretcher waiting for someone to do something a woman was wheeled to the space next to my gurney.

Nurse (kindly): Will you please move over from the ambulance stretcher onto our gurney.

Patient: I can't. I'm too heavy.

She was right about that. She must have weighed at the very least 350, maybe 400 pounds. It took four aids to place a sheet under her and  move her over to the gurney.

Nurse: What's been going on?

Patient: I had a lithotripsy (procedure for kidney stones) three days ago. When I woke up this morning I felt sick, nauseated. My stomach hurt. I took my temperature. It was 102. I told myself to call an ambulance.

Nurse: We will look into it. Have you been here before?

Patient: Oh yes. I have been here many times. Blood sugar problems, high blood pressure, gall bladder, back pain, headaches, nerves. I'm surprised you don't know me. I know just about every nurse and doctor here (giggling, cheerful, a I-sure-am-happy-to-be-here-among-my-friends-attitude).

Nurse: Did you call your doctor about your temperature?

Patient: No. It takes a long time to get him on the phone. You call and the voice tells you to punch one, then you have to punch more numbers, then you are on hold, then the receptionist comes on and tells you the doctor is not in the office. It's easier to call an ambulance.

Nurse: Where was your procedure done?

Patient: Lewis-Gale (a competitor of Carilion)

Nurse: We don't have the capability to get your electronic medical record from Lewis-Gale. Why didn't you take the ambulance to Lewis-Gale?

Patient: I don't know. I guess I like it better here.

Enter doctor who takes a history, examines the patient: Your temperature was normal when we took your vital sounds but you may have a urinary tract infection. Would you give us a urine specimen?

An hour or so later the nurse enters: Have you been able to pee in the bed pan yet?

Patient: No. I strained and strained. I just can't get any. Maybe I have an obstruction.

Nurse: We'll have to catheterize you then.

Curtain closes. I hear the nurse struggling to get beyond the fat so that the patient can be catheterized. Suddenly I hear the nurse scream and jump back.

Patient: I'm sorry (nervous giggling). I didn't think I could pee then it all came gushing out. I must have really been full.

Thank you nurses for your invaluable service and for all the things you have to put up with.

Managing the Medical Muddle

After recently escaping mayhem in an emergency room encounter, I began a search for a health care survival manual. Luckily I found one, The Patient's Playbook by Leslie D. Michelson. Here is a summary of Michelson's wisdom:

• Prepare for illness when you are healthy by getting a copy of your medical records. (Electronic medical records don't work outside of your hospital system because the software of separate hospitals and clinics don't match with other hospitals.)
• Find a hospital you want to go to in an emergency.
• Develop a relationship with an informed, empathetic primary care physician who will take the time to talk with you about you medical challenges. A specialist may take care of your left arm but know nothing about your right. Having several specialist take care of you puts you at risk for over treatment. We all need a guide, a referee to explain what the advice from specialists indicates. Tragedies occur when there is no oversight.
• Develop a list of qualities you feel are important in a doctor. Solicit recommendations from friends, acquaintances, your dentist, your attorney. Check out credentials. Where did the physician go to school? Where did the physician get their residency training? Finally, check out the physician with a visit when you are healthy. 
• Sadly when primary care physicians see 30-40 patients daily they have no time to think and communicate about your case so you may want to consider paying extra money to find a primary care physician in a concierge practice who will give you quality time. 
• For serious medical problems seek a super specialist at top academic medical centers.Be intensely involved in your own care. Use reliable Internet resources such as the National Institutes of Health website or the UpToDate medical website.
• Remember that over treatment can be just as dangerous as under treatment. You want smart care not more care. Quiz your physician. Is he a critical thinker? Can he back his decision by reciting the literature.
• Understand that electronic medical records are your biggest enemy. Because hospital administrators are more interested in having forms and check lists completed than your personal medical care and because clerks (inspectors) with no medical knowledge put pressure on the staff to duplicate useless information, you get ignored. In the past medical progress notes were invaluable in communicating what the physician was thinking about your case to other physicians and staff. Now electronic medical records become useless cut and paste items insuring that the hospital administration gets paid and you get poor care. Showing empathy for the harassed medical staff will get you better care. Telling them that you understand the burden of electronic medical records will get you the best care.  
• If your attempt at developing a good doctor-patient relationship fails, insist that the doctor and nurses look at you and not the computer. 
• Because 10% of patients or more (depending on the hospital) suffer hospital associated complications such as infections, falls or drug reactions be a vigilant inpatient. Don't assume doctors or nurses know what they are doing. 
• If at all possible avoid emergency rooms and hospitals. 
• Post a summary of your medical history near your hospital bed.
• Develop a friendship with your health care providers. You want to become a person to the staff instead of a gastric ulcer in bed 101B.
• Don't take new medicines until you know exactly what they are for.
• Don't submit to procedures unless you are given a logical reason for why they were ordered.
• Insist that new symptoms---a fever, swelling, dizziness---be promptly evaluated and explained.
• If the doctor or nurse fail to explain procedures and medicines to you ask for another doctor or nurse. 

I empathize with doctors and health care staff in our current age of oversight medicine. Most physicians and health care professionals entered medicine to develop strong emotional bonds with people and help them through health care challenges. Now they find themselves bound to government rules and regulations that separate them from patients. Government red tape erodes time that could be spent in keeping up with medical advances. The ticking clock keeps them moving toward the door instead of explaining medial approaches and procedures. They are harassed and helpless, dominated by needless rules and regulations.

You can help them out by being friendly and kind while taking charge of your own health care.  

The Science of Happiness

The online Berkeley Wellness Newsletter from the University of California covers nutrition, fitness, emotional health, community harmony, and self care. A recent edition covered the science of happiness the key points of which are summarized here:

• Money increases happiness when it moves people from a threatening environment to personal security and safety. 
• After we reach an income level around $75,000 annually our emotional well-being doesn't increase with income. Think of it this way: The boat that gave us so much happiness the first few months soon becomes moored to the dock; our large home requires more maintenance than we originally thought and when the kids move away the empty space engulfs us; the second home becomes difficult to manage; our flashy sports car makes us happy until driving it becomes routine. All those toys we were so excited about soon collect dust in the attic. Clutter and an overabundance of things makes our lives more complicated and less happy.
• Hormone measurements indicate that the happiest people are those with strong social connections. 
• The mesolimbic dopamine system that is linked to addiction is also activated when we help others.
• Functional MRI studies have shown that giving money to charity stimulates the brain's pleasure center as much as earning money. 
• Social psychology tests and neuroscience research has shown that being alone produces much more stress than being together with others.
• Affluence, marriage, and having children accounts for 10% of the variance in happiness while our daily life experiences---the friendships we cultivate, the people we interact with, the activities we  participate in, the things we learn, our world view---accounts for 40% of the variance in happiness. 
• Those who cultivate a more courageous and cooperative lifestyle can boost their happiness factor. Those who look on the bright side can have brighter lives.
• Twin studies show that about 50% of the happiness factor depends on genetics. Some people are born happier.
• People who focus on the pursuit of happiness tend to accentuate personal gain that can damage social connections actually reducing happiness.
• Constantly seeking emotional highs by frequent partying or high risk taking or becoming an adrenaline junkie decreases creativity and flexibility.
• Perfectionism decreases happiness.
• Maximizing---the idea that if we fail to get the most out of every moment we will be dissatisfied---reduces happiness.

Science has shown what we innately know. Gratitude, forgiveness, kindness, friendship, emotional support, generosity, gentleness, goodness, faithfulness, self-control, someone to love and someone to love us brings happiness.