32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page i 100 Questions & Answers About Bipolar (Manic-Depressive) Disorder Ava T. Albrecht, MD New York University School of Medicine Charles Herrick, MD New York Medical College 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page ii World Headquarters Jones and Bartlett Publishers Jones and Bartlett Publishers Jones and Bartlett Publishers 40 Tall Pine Drive Canada International Sudbury, MA 01776 6339 Ormindale Way Barb House, Barb Mews 978-443-5000 Mississauga, Ontario L5V 1J2 London W6 7PA [email protected] CANADA UK www.jbpub.com Jones and Bartlett’s books and products are available through most bookstores and online booksellers. To contact Jones and Bartlett Publishers directly, call 800-832-0034, fax 978-443-8000, or visit our website www.jbpub.com. Substantial discounts on bulk quantities of Jones and Bartlett’s publications are available to corpora- tions, professional associations, and other qualified organizations. 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Production Credits Executive Publisher: Christopher Davis Production Director: Amy Rose Manufacturing Buyer: Amy Bacus Associate Editor: Kathy Richardson Associate Marketing Manager: Laura Kavigian Composition: Northeast Compositors, Inc. Cover Design: Kate Ternullo Cover Image: © Photos.com Cover Image: © Photodisc Printing and Binding: Malloy, Inc. Cover Printing: Malloy, Inc. 6048 Library of Congress Cataloging-in-Publication Data Albrecht, Ava T. 100 questions and answers about bipolar (manic depressive) disorder / Ava T. Albrecht and Charles Her- rick. p. cm. Includes index. ISBN-13: 978-0-7637-3231-8 ISBN-10: 0-7637-3231-1 1. Manic-depressive illness—Popular works. I. Herrick, Charles. II. Title. III. Title: One hundred ques- tions and answers about bipolar (manic depressive) disorder. RC516.A37 2007 616.89’5—dc22 2006028729 Printed in the United States of America 10 09 08 07 06 10 9 8 7 6 5 4 3 2 1 2963 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page iii Contents Introduction v Contributing Patient Biographies ix Part I:The Basics 1 Questions 1-10give background information about bipolar disorder with such topics as: • How does the brain affect behavior and regulate emotional states? • What is bipolar disorder? • What causes bipolar disorder? Part II: Diagnosis 29 Questions 11-24outline the steps in determining whether you have bipolar disorder, including: • What are the symptoms of bipolar disorder? • How is bipolar disorder diagnosed? • Are there different types of bipolar disorder? • How does bipolar depression differ from major depression? Part III:Risk/Prevention/Epidemiology 57 Questions 25-34explore details of bipolar disorder, such as: • What are the risk factors for development of bipolar disorder? • Are people from different ethnic backgrounds more susceptible to bipolar disorder? • Is there a link between epilepsy and bipolar disorder? • I have been treated for bipolar depression in the past. Can I prevent an episode in the future? Part IV:Treatment 77 Questions 35-66discuss the methods for treating bipolar disorder and concerns about medications, including: • What are the different types of treatment for bipolar disorder? • What are the different types of talk therapies and what do they do? • What are the different types of medication used to treat bipolar disorder? How does my doctor choose a medicine? • Can I take other medicines while I am on an antidepressant? • Are there long-term dangers to taking medication? 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page iv 100 QUESTIONS & ANSWERS ABOUT BIPOLAR (MANIC-DEPRESSIVE) DISORDER Part V:Associated Conditions 147 Questions 67-73 provide information for bipolar patients with more than one con- dition, such as: • I have been diagnosed with bipolar disorder and anxiety. How is the combination of conditions treated? • How are alcoholism and bipolar disorder connected? • What are the similarities and differences between borderline personality disorder and bipolar disorder? • Is there an overlap between ADHD and bipolar disorder? Part VI:Special Populations 161 Questions 74-88 address children, family planning, and other considerations, such as: • Do children get bipolar disorder? • I want to get pregnant but take medication for bipolar disorder. What can I do? • Are there any medications I should avoid if I have bipolar disorder? • Are there any medical conditions that can cause mania or depression? Part VII:Surviving 195 Questions 89-100address personal rights, family involvement, and survival issues, including: • Will I get manic or depressed again after I have recovered? • What is the risk of suicide when someone is diagnosed with bipolar disorder? • Where can I find out more information about bipolar disorder? Appendix A 221 A list of web sites, organizations, and literature to help bipolar patients and their families find additional resources on general and specific topics related to bipolar disorder. Appendix B 225 Medications used in the treatment of bipolar disorder with dosing ranges and average costs. Appendix C 227 Antidepressants with dosing ranges and average costs. Glossary 231 Index 243 iv 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page v Introduction After completing our first book, entitled 100 Questions & Answers About Depression, it was only natural to collaborate again on a book about a mood disorder that is so commonly discussed in the media of late—bipolar disorder. Although this disorder is not as common as depression, the number of bipolar disorder diagnoses appears to be rising, mainly because of new research and consideration of symptoms that do not meet the full criteria for bipolar but do have many similar symptoms that cause significant impairment. Such symptomatology may comprise other bipolar categories that are considered part of the “bipolar disorder spectrum.” Of course, as occurs with any expansion or new development of existing ideas, the psychiatric community is divided in regard to what constitutes true bipolar illness. In this book we present the data and evidence at hand, although active research continues on the subject as the DSM-V committee works toward refining diagnostic criteria for the future. Historically, the diagnosis has been through many changes. Emil Kraeplin first described bipolar disorder, also known as manic-depressive disorder, in the early twentieth century. Prior to that, the condition was characterized as cyclic psychosis.The term was prompted, in large part, by the curious phenomena that some patients with a psychotic illness recovered fully and then relapsed in a cyclic nature, while others appeared to deteriorate slowly over time. Physicians were puzzled by this difference, and Kraeplin, through careful observations,determined that it was not so much a psychotic disorder as it was a mood disorder.Despite this reclassifi- cation, American psychiatry lagged behind its European counter- parts in making this fundamental distinction. It was not until the late 1970s and early 1980s that the distinction in America was complete, partly because of the reintroduction of lithium into the 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page vi 100 QUESTIONS & ANSWERS ABOUT BIPOLAR (MANIC-DEPRESSIVE) DISORDER American pharmacopoeia and partly because of the work of two American psychiatric researchers,Harrison Pope and Joseph Lipin- sky, that distinguishing between schizophrenia and manic depres- sion became more than just an academic curiosity.This distinction now had real treatment implications, as the treatment of schizo- phrenia required lifelong antipsychotic medication while manic- depressive disorder could be managed more safely and effectively with lithium alone. When Dr.Herrick was in training in the mid to late 1980s,the emphasis in making a diagnosis was on not mistaking manic depression for schizophrenia.Since the late 1990s,however,manic- depressive disorder has been called bipolar disorder and is solidly ensconced as a mood disorder, with little to no concern that clini- cians will misdiagnose it as schizophrenia. The concern nowadays is the possibility of mistaking the disorder for unipolar depression and other psychiatric conditions such as personality disorders or drug and alcohol abuse. Why did the change of emphasis occur? The answer is long and complicated. In brief we offer several rea- sons: Psychiatry’s understanding and characterization of bipolar dis- order has changed. For example, bipolar II disorder and childhood bipolar disorder did not “exist”in the 1980s. The explosion of psychiatric medications into the marketplace has exposed more patients to medications that had both positive and negative effects on their moods, allowing for a broadening of psychiatry’s understanding of mood disorders and how they could be pharmacologically “manipulated.” For example, the SSRIs, because of their relative ease of use and tolerability, have been used more widely than their counterparts, the tricyclics. The growing numbers of patients asking for and receiving these medications was followed by greater numbers of persons being unwittingly switched into manic or hypomanic episodes, thereby leading to a change of views within the profession about the nature of mood disorders. In addition, the atypical antipsychotics, also because of their relative safety and ease of use, were found to help patients with “mood vi 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page vii 100 QUESTIONS & ANSWERS ABOUT BIPOLAR (MANIC-DEPRESSIVE) DISORDER I n t swings”that did not respond to SSRIs and who were otherwise not ro d viewed to warrant treatment with traditional mood stabilizers. u c t Because of larger cultural changes in a variety of areas affecting io n psychiatry, the importance in distinguishing between these other psychiatric disorders is more complete. These changes occurred in deinstitutionalization, commitment laws, and, most notably, de- stigmatization of certain psychiatric conditions.Having the likes of Jane Pauley and Brooke Shields talk openly about their own strug- gles with mental illness has gone far toward people accepting the idea that these are real diseases in need of medical care. Deinstitu- tionalization and commitment laws have changed the types of patients hospitalized in psychiatric settings. Commitment laws now emphasize dangerousness rather than the presence of psychi- atric symptoms. Increasing numbers of patients are being admitted primarily with impulsive aggression, whether it is directed toward themselves or others,rather than merely because they are depressed or psychotic. Many of these patients have underlying personality disorders and substance abuse disorders.This has radically changed the focus of psychiatric care from treating psychotic illness to treat- ing explosive moods and behavior. A greater degree of overlap now exists between bipolar disorder and impulsive aggression than between bipolar disorder and schizophrenia, which has become increasingly an ambulatory condition managed primarily in the community. Each of these changes,whether it is the number of medications available, new scientific understanding, broadening of the classifi- cation of the disorder, commitment laws, or destigmatization, has led to larger numbers of patients being diagnosed with bipolar dis- order, as well as greater interest in understanding what the condi- tion is and how it is best treated. Hopefully, this book will address the myriad questions you may have about this most curious condi- tion and its dizzying array of presentations—and more dizzying numbers of medications used in treating it. Ava T. Albrecht, MD Charles Herrick, MD vii 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page viii Intentional Blank viii 32311_FMxx_Albrecht.qxd 11/8/06 11:41 AM Page ix Contributing Patient Biographies On August 31st,1962,Scott Weinmann was born in Lansdale,PA. His mother, married three days shy of one year, was all of 19 years old. Raised in Queens, NY, and attending the Bronx High School of Science, Scott was the typical early overachiever. A straight “A” student throughout elementary and middle school, Scott enjoyed his middle-class upbringing. Scott attended SUNY Stony Brook, where he met the woman who became his wife 41⁄ years later. 2 Scott and his wife have been working on their relationship since 1987, when they began couples therapy in Los Angeles. In 1998, Scott became enraged by something his wife said and played out a scenario that his wife had seen too many times before.Prone to fits of rage, particularly at home, Scott’s wife walked on eggshells as a result. Never certain if she would trigger Scott’s rage, she tried to choose her words wisely, but the task was arduous. This particular day was different, as Scott became acutely aware that something was not right with him. He recalls feeling the rage overwhelm him that afternoon and describes the sensation as, “Literally unable to control the rage that was coming over me.” Scott felt it physiologi- cally and knew that he couldn’t continue living that way.Psychiatric consultation revealed the diagnosis of bipolar disorder. After he was prescribed medication, he and his wife reported a dramatic change in Scott’s mood and character, claiming symptoms remain under control as long as he stays on his medication.No longer wor- ried about his hair-trigger responses, his wife is able to communi- cate with him more effectively.Their relationship has grown closer, and he is much happier with the behavior he is modeling for his children—moderate, tolerant, and compassionate. Today Scott works as a subject matter expert in IT process automation at a