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Mental Health Matters Journal for Psychiatrists & GP's

MHM Volume 7 Issue1 small

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Literacy is a luxury that many of us take for granted.  We depend on written communication for information, guidance, and access to heath care information That is why SADAG created SPEAKING BOOKS and revolutionized the way information is delivered to low literacy communities. It's exactly what it sounds like.a book that talks to the reader in his or her local  language, delivering critical information in an interactive, and educational way.

The customizable 16-page book, accompanied by local celebrity audio recordings, ensures that vital health and social messages can be seen, heard, read and understood..

We started with books on Teen Suicide prevention , HIV, AIDS and Depression, Understanding Mental Health and have developed over 30 titles, such as TB, Malaria, Polio, Vaccines for over 30 countries.

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I'm standing on the edge of a bridge about to bungee jump, surrounded by people who not only love me, but also love being around me. I feel a rush of exhilaration as I fling myself off. I'm alive - excited and independent. The rope jolts suddenly. I've reached the bottom. But instead of being hoisted back up, I'm left dangling upside down. Terror sets in. Does anyone realise my predicament? I'm alone, afraid, spiralling out of control. I'm tired - a tiredness so overwhelming that part of me just wants the rope to snap. Tears stream uncontrollably down my face. One minute I had the energy of an Olympic athlete - now, I'm paralysed by fear. This is life with bipolar," explains 31-year-old medical student Olivia Sharpe.

 First diagnosed with BMD II years ago during her second year at varsity, Olivia's nightmare began when she couldn't get out of bed, shower or get dressed in the morning. "I desperately wanted to; I just couldn't muster enough energy to perform daily tasks that before had seemed so simple. What was even more distressing for me was that I couldn't quite put my finger on what was causing this absurd sense of dread." She spent her days sleeping, sometimes for 20 hours, but it brought no respite. In the meantime, the world around her kept functioning. "It felt like I was tuned into a different TV channel and all I was left with was a fuzzy picture of low-grade reception and white noise. Then the suicidal thoughts started and I knew I was in trouble:' A few days later she was admitted to hospital and diagnosed with BMD II.


 While the term "bipolar mood disorder" was coined fairly recently, there's nothing new about the illness that, previously, was known as manic depression. Famous diagnoses include Catherine Zeta-Jones, Sting and Demi Lovato. But with BMD becoming so common that the term "bipopular disorder" has found its way into conversation, you'd be forgiven for secretly wondering whether it's just the latest convenient catch-all. Experts agree that diagnosis of BMD has increased significantly over the past 20 years. In fact, psychiatrist Dr Eugene Allers says medical aid claims for BMD have increased by 30 percent each year since 2008. And with a growing number of Internet users trusting in Dr Google, inaccurate self-diagnosis is also on the rise. The problem is that there's real danger in over-diagnosis, particularly — as psychiatrist Mark Zimmerman points out — the (often nasty) side effects of those happy pills. Yet research suggests that misdiagnosing BMD is still far more likely than over-diagnosing it. "The perception that 'everybody is bipolar' and that it is over-diagnosed stems from ignorance," says Prof Piet Oosthuizen, a private psychiatrist and lecturer at Stellenbosch University. "People love expressing opinions about things they know nothing about. And this is particularly true for mental illness." Dr Sheldon Zilesnick believes the over-diagnosis perception is a result of the "bipolar umbrella" being so wide. Medically speaking, BMD is actually a spectrum of disorders (see "Shades Of Bipolar" on p133) that can comprise mostly manic episodes ("I have so much energy, I can do anything"), mostly depressive episodes ("I'm too down to get out of bed"), alternating manic and depressive episodes, or even manic and depressive episodes occurring simultaneously. What they all have in common, explains psychiatrist Dr Willem van Rooy, are recurrent, dramatic mood changes. These aren't your everyday mood swings — you're looking at extremes, from unnatural highs to crippling lows, that can last for hours, days or weeks at a time. "We know from brain imaging studies that the brains of patients with bipolar disorder look and function differently from those of normal controls:' says Oosthuizen. There's also an imbalance of neurotransmitters in the brain that can be physically measured — depression is associated with a depletion of serotonin and dopamine, while mania involves increased dopamine activity.

According to the South African Depression and Anxiety Group (SADAG), a whopping 69 percent of patients with BMD report having received a misdiagnosis. Disturbing, yes, but actually not that surprising. Diagnosing BMD is tricky. It's not a simple matter of having an X-ray or going for blood tests. "It often takes time to reach the diagnosis and the doctor needs to get to know the patient well," explains Oosthuizen. "There are times when the diagnosis is straightforward, but many cases are subtle and may take a long time to unravel:' he says. Van Rooy agrees, saying that it can take up to 12 years to make a proper diagnosis. During this time, the doctor needs to take a detailed family history, interview the patient's spouse where applicable and rule out other possibilities such as depression — a common misdiagnosis as a person's first few BMD episodes are usually depressive ones. "Many patients are initially diagnosed with major depression as opposed to BMD," says Van Rooy. "It has been one of the major developments in psychiatry to recognise that there is a bipolar spectrum with thousands on it." In children, diagnosis is even trickier as kids often don't meet the criteria established for adults. In fact, the medical community has only recently accepted the existence of early-onset bipolar and opinions are still divided. According to the Journal of the American Academy of Child and Adolescent Psychiatry, the number of children diagnosed has doubled in recent years. But Joburg-based psychologist Adele Romanis believes it's just the new flavour of the month. "We saw it in the Nineties with the surge of children being diagnosed with ADHD," she says, voicing the concerns of the many doctors who remain reluctant to confirm the diagnosis of BMD in children. Cape Town mother-of-two Isabella Ross underwent a long and difficult journey to reach a diagnosis for her son Mark. As a baby, Mark hit normal developmental milestones, but by the time he was 18 months, his family had already recognised that he had no brakes. "He was rough with other children and lashed out in frustration," says Isabella. Mark's slow speech development and lack of age-appropriate social skills prompted Isabella to send him for speech and occupational therapy at age four. But something didn't feel right. In the ensuing months, Mark saw numerous specialists and was stuck with a string of labels, including ADHD, PDD (pervasive developmental disorder), even possible autism. He was five when the possibility of early-onset bipolar was suggested and it was only after receiving a second opinion, careful analysis of his behaviour, a detailed family history and consideration of his strong reaction to previous medication that the diagnosis was confirmed and treatment began. With doctors so reluctant to diagnose BMD, the likelihood of an over-diagnosis pandemic seems less plausible — which points to another, scarier, possibility: that BMD really is extremely common. The World Health Organisation estimates that BMD is the fifth cause of worldwide disability among young adults. In South Africa it affects up to one percent of the population, which may not seem high until you consider that this figure translates into 580 000 people. Van Rooy, who has been in private practice for 18 years, diagnoses 40 to 45 patients with BMD monthly. And, while there may be a stereotype of BMD Bipopular Culture A few famous portrayals of BMD

 SILVER LININGS PLAYBOOK In this endearing Academy Award-winning fliek, Bradley Cooper plays a man with BMD who is discharged from a psychiatric hospital and moves in with his parents while trying to win his estranged wife back.

 HOMELAND DStv's popular political thriller series stars Claire Danes as Carrie Mathison, a CIA agent with BMD investigating terrorist threats to the United States.

 THE INFORMANT! Based on the true story of price-fixing whistle-blower Mark Whitacre (played by Matt Damon), the film focuses on his growing struggle with BMD under the pressure of being an FBI informant.

 THE HOURS The film chronicles a single day in the lives of three women, living in different time periods, and bound by Virginia Woolf's novel Mrs Dalloway. One is Woolf herself (played by Nicole Kid man, who won an Oscar for the role), who struggled with BMD before taking her own life.
Spot the signs that could indicate you or someone close to you has BMD

 MANIC EPISODE Three or more symptoms lasting at least seven days: elevated or irritable mood, grandiosity, reduced need for sleep, racing thoughts or ideas, distractibility or impaired attention span, involvement in pleasurable yet potentially dangerous activities, increased pressured speech and increased involvement in goalorientated activity.

 DEPRESSIVE EPISODE Five or more symptoms within a two-week period: a depressed mood (most of the day, nearly every day), markedly diminished interest in activities, sleep disturbances, psychomotor agitation, feelings of worthlessness and guilt, lack of energy, difficulty in concentrating and suicidal ideation.

 If you suspect you, a family member or a friend has bipolar disorder, contact SADAG on 0800 21 22 23, 8am to 8pm, seven days a week, or log on to for help.
 being a women's disorder, he says it doesn't discriminate. "It's far greater than we previously thought, and many patients who received other diagnoses in the past, do, in fact, suffer from BMD," agrees Oosthuizen, who sees on average five or six patients with BMD a day. "The [idea of a] spectrum is a far wider concept and it has implications for the way we treat people" It may also provide answers for the thousands of South African women who have yet to put a name to the struggle they face daily.

 Gabriella Davids, 32, an accountant and mother of two, has landed herself in financial difficulty as a result of BMD. "During highs I've spent excessive amounts of money, making drastic and erratic decisions, which have left me in an overwhelming amount of debt. The disorder also put strain on my previous marriage because my ex-husband didn't understand, nor did he try to educate himself about BMD — he just blamed me, saying that I was crazy." "It's especially difficult when you aren't suffering from an episode, but are in between poles, because then people think you're doing well and show less support," says Olivia. For Isabella, having an eight-year-old child with BMD isn't easy, but she lives by the motto "every day is a new day" and deals with issues as they arise. "Mark is Mark, not the condition," says Isabella. For her, trying to build Mark's selfesteem is key. "The hardest part is not to judge Mark for the illogical and inexplicable things he sometimes does" Olivia's sister Carly has two family members affected by BMD: Olivia and their brother David (36). "If I try to think of how normal moods can affect how we do things at home, at work and our motivation behind certain actions, I can only imagine what the extremes of that can be like for my siblings," she says. "There is an invisible 'bogeyman' they're constantly trying to keep in check, yet because BMD has a chemical imbalance at its core, this is, to a high degree, beyond their control. So I can understand that both my brother and sister have lots of days when they feel that life is not fair" Carly tries to support her siblings by asking directly how they're feeling, observing and listening for possible warning signs. Having that kind of support is key, but it's only one aspect. Oosthuizen believes the best approach for managing any chronic disorder, including BMD, is to adopt a holistic approach that combines meds with lifestyle adjustments, psychotherapy and social interventions. "There is no simple solution to complex problems, although people often expect and want that. This is a complicated disease to treat and it needs to be addressed on all fronts" he says.


 While "happy pills" may be common — and even trendy — handbag essentials for the millennial woman, treatment of BMD is far from sexy. Currently one of the most effective procedures for acute episodes is electroconvulsive therapy (ECT). Simply put, doctors place you under anaesthetic, then use a small electric current to induce a seizure with the aim of "jump-starting" your central nervous system. While critics have expressed concern that it may negatively affect brain function and short-term memory for up to four weeks following treatment, ECT has been proven to promote neuron growth, restore brain chemical balance and even revive affected parts of the brain. "I can say with certainty that it saved my life," says Olivia. For her, the worst part was being put onto a posttreatment maintenance course of lithium. This is probably the most widelyused drug for treating BMD as it also promotes neuron growth and can keep BMD in remission for years, but is also known for nasty side effects like weight gain, hand tremors, persistent thirst, frequent urination, hair loss, acne, weakness and drowsiness. It also interacts badly with several other drugs, including NSAIDs, so popping, say, aspirin or ibuprofen for a headache is out of the question. Eleven years of treatment, three relapses of bipolar depression and six sessions of ECT and Olivia is still waiting for the wonder drug that will cure her once and for all. "At the moment I swallow 12 tablets a day. I think I could live with this if I knew for sure I wasn't going to have another episode, but the truth is there's no guarantee — the depression can catch you off-guard at any time:' There are ongoing studies looking at alternatives to ECT, such as light therapy and transcranial magnetic stimulation (a kind of pacemaker for the brain that uses electromagnetism), while the anaesthetic ketamine has been called the greatest breakthrough in the treatment of mood disorders. "It offers the hope of rapid treatment for depressive phases. It's registered by the FDA in the US and is also being used in some centres in South Africa," says Oosthuizen.

 Shades OfBipolar Bipolar mood disorder encompasses a spectrum of conditions. This is how the DSM-V defines them:mania mild depression
 Bipolar disorder NED (not otherwise specified)
 Bipolar disorder I: one or more manic or mixed (manic and depressive at the same time) episodes. Frequently accompanied by major depressive episodes. Bipolar disorder II: one or more major depressive episodes with at least one hypomanic (mildly manic) episode. Absence of mania or mixed episodes. Cyclothymia: frequent hypomanic episodes plus frequent episodes with depressive symptoms that do not meet the criteria for a major depressive disorder. Bipolar disorder NED (not otherwise specified): does not meet the criteria for any of the abovementioned disorders. Psychiatrists also classify the illness in terms of the number of episodes within a certain time period.
But the answer doesn't simply lie in medical intervention. "What assists me is having a supporter who knows and sees the signs, usually before I notice them myself, and helps me assess my moods and behaviour," says Gabriella. She also attends a monthly BMD support group and tries to keep stress to a minimum. While experts believe genetics play a considerably bigger role in a person's predisposition to BMD than environmental stressors, sticking to a healthy routine can also assist in managing the illness. Exercise is important as it triggers endorphins, the body's natural feel-good hormones, as is getting enough shut-eye because sleep deprivation can trigger a BMD episode. Afternoon naps are out of the question, as are caffeine and alcohol — the more you can restore your body's natural rhythm, the better you'll feel. These strategies, along with regular counselling, have helped Olivia. "She's done more in the decade of suffering the most from the disorder than people without any diagnosis could dream of doing," says Carly. "So I know that she has the ability to succeed despite living with BMD.

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