“I have been and am battling a depression. It is as if my life were magically run by two electric currents: joyous positive and despairing negative – which ever is running at the moment dominates my life, floods it. I am now flooded with despair, almost hysteria, as if I were smothering.” (Plath, 1982, p.239)
These are the words of the American poet, Sylvia Plath, who was treated for major depressive illness in her twenties and committed suicide when she was thirty. More commonly known as manic depressive illness, bipolar mood disorder commonly affects 1% of the population. The usual onset is late adolescence and early adulthood. Many claim to know what it is like to be depressed, because they have gone through a divorce, lost a job or a loved one. However, manic depression is described by one sufferer as entirely different from these experiences. Whereas these experiences carry with them feelings, manic depression is instead flat, hollow, unendurable and quite out of proportion to what is going on in one’s life: “You are irritable and paranoid and humorless and lifeless and critical and demanding and no reassurance is ever enough.” (Jamison, 1995, p217). Bipolar disorder, then, is a physical illness characterised by extreme changes in mood, energy and behaviour.
The disorder is characterised by two alternating episodes: depression and mania. People differ in terms of the frequency and duration of these episodes. Untreated, a manic episode or a hypomanic episode (which is not quite as severe as a manic episode) can last a few months, while depression usually lasts for more than six months.
Are you or is someone you know depressed? Medical attention is advisable if you recognise the following symptoms for at least two weeks: feeling ‘down’ and a loss of interest in activities that you used to enjoy. In addition, the disorder is characterised by four or more of the following symptoms: change in sleep patterns, fatigue, feelings of worthlessness or guilt, inability to concentrate, persistent thoughts of suicide or death, overwhelming sadness or crying spells, feeling slowed down or too agitated to sit still, pessimism, indifference or social withdrawal, loss of interest in sexuality. In addition, there may be hallucinations (perceiving things that aren’t there) and delusions (believing things that aren’t true).
Symptoms, which may signify a manic episode, include feeling unusually “high”, euphoric or irritable. At least four of the following symptoms need to be experienced or observed in order to be diagnosed with the illness: needing little sleep yet having enormous amounts of energy, talking so fast that others have difficulty keeping up with you, having racing thoughts, being easily distracted, having inflated sense of your own importance, behaving recklessly with little regards for the consequences, especially regarding money, sex, drugs or alcohol, extreme irritability. In addition, there may be hallucinations and delusions.
Another particularly debilitating symptom of bipolar disorder is the belief that nothing will help. However, with a combination of therapies, nearly all sufferers of depression can be helped to manage their illness. Unfortunately there is no definitive cure.
Three main options are available for treating bipolar illness: medication, ECT (electroconvulsive therapy) and counseling.
The alternating mood in some forms of bipolar disorder, mania is described as periods of abnormally marked euphoria and activity. It is this manic state that often seduces bipolar disorder sufferers into discontinuing their medication. For many patients, the feeling of having boundless energy and enthusiasm and requiring little sleep outweighs the drawbacks of the depression phase of the illness, not to mention the side effects of medication. It is an important aim of therapy to convince patients of the need to continue with their medication even when they are feeling well. This is because stopping medication can lead to a disastrous relapse. Another confounding factor in treating mania is the fact that when the person feels euphoric, he or she has little awareness that the feelings and behaviors are abnormal.
Mood stabilizers are the main means of reducing symptoms of both mania and depression. The three main mood stabilizers are lithium, carbamazepine and valproate. Other pharmacological alternatives are verpamil and olanzapine. In addition to a mood stabilizer, an antidepressant drug is also often administered to counter the depressive episode.
Despite its controversially, electroconvulsive therapy (ECT) is a recommended alternative for pregnant patients. It is often helpful in treating severe depression and/or mixed mania that does not respond to medications. However, distressing side effects of ECT could include temporary memory loss and disorientation and even irreversible brain damage.
Counseling is an important adjunct in the treatment of bipolar disorder. Not only can it help to ensure that patients stay on their medication, but it can also help the patients to deal with the psychosocial stressors that may trigger or exacerbate episodes.
Woman with bipolar disorder face risks both in taking medication and in letting the illness go untreated during pregnancy. The patient needs to evaluate the risks together with the psychiatrist, obstetrician and the patient’s significant other.
RISKS THAT YOU SHOULD KNOW ABOUT
· The highest risk period for the fetus is between conception and the eighth week
· If medication is discontinued abruptly, risk of bipolar illness recurrences increases
· Derailed careers and relationships, death from suicide an accident, and exorbitant financial cost are some of the risks of non-treatment
· The type of risk to the fetus depends on the type of medication taken
· Risks to the fetus may range from intra-uterine fetal death to malformations
· Despite these risks, many mothers with bipolar disorder bear normal children
You need to be aware of the risks of the various treatment options and about your own values. For example, one pregnant woman may decide that the risks of taking medication may be too high (where, for example, she is the sole breadwinner and has other children to support.) The decision to take or not to take medication during pregnancy is not necessarily a final one, but will change according to the progression of the pregnancy. Women with bipolar disorder who have just given birth are particularly vulnerable to a recurrence of episodes of bipolar illness. Lithium has been found to reduce the risk of psychosis during this crucial period. Recommended drugs during breast-feeding include carbamazepine and valproate, according to the American Academy of Pediatrics. Lithium is not as compatible as these drugs, since it passes too readily into breast milk, causing infants to become dehydrated.
Despite the clinical fact that bipolar disorder is an illness that can be managed with a combination of therapies, a stigma often attaches to sufferers of the illness. Kay Redfield Jamison, a psychiatrist who suffers from manic depression, gives a rich amount in her autobiography, The Unquiet Mind (published by Picador in 1995) of the precariousness of many of her work and personal relationships, engendered by her illness. Reactions ranged from shock and disappointment to disapproval and outright hostility, when she disclosed her illness to certain colleagues and friends. Although these caused her a great deal of pain, she acknowledges that having bipolar disorder can confer advantages on both the individual and society. In Jamison’s study of the illness, entitled Touched with Fire, she examines the apparent correlation between bipolar disorder and the creative temperament. It is widely supposed that madness is a requirement for creativity.
Someone suffering from depression should not be thought of as “crazy”. Rather, bipolar disorder is an illness, just as “flu and heart disease are illnesses. Possible causes or precipitating factors of bipolar disorder include: a chemical imbalance in the brain; heredity/genes; changes in biological rhythms (including sleep, seasonal and hormonal changes) and psychological stressors.
The first thing to do is to contact a mental health professional. Your physician, or a psychiatrist, community mental health centre or self-help and support groups can also be helpful. It is essential that you consult someone who is knowledgeable about bipolar disorder and that you, your family and significant others learn as much as possible about the disorder, through reading books, attending lectures and talking to specialists. The more you know, the more control you have over the illness.
For further counselling, referrals or information, contact the Depression and Anxiety Support Group, open 8 am to 7 pm Monday to Friday, and 8 am to 5 pm on Saturdays (011) 783-1474/6 or 884-1797