 I'd like to welcome everybody to today's presentation on bipolar and depression. Bipolar one and bipolar two are obviously both bipolar, but what makes them different? The biggest defining feature of bipolar one is there has to be at least one full-blown manic episode. If someone hasn't had that, then they qualify as bipolar two. Bipolar one, the people can have major depression or persistent depressive disorder in addition to the occasional manic episode. It's important to remember that bipolar episodes don't go one for one. People with bipolar two have depressive episodes about 30 times more often than manic episodes or hypomanic episodes. People with bipolar one have depressive episodes about four times more frequently than they have full-blown manic episodes. So it's important to remember that you're not gonna have a one for one correlation and somebody may be presenting for a depressive episode before they've even ever had their first manic or hypomanic episode. So always be alert to that. Bipolar disorder is episodic, which means you're gonna have periods where they've got symptoms and then you're gonna have periods where they're in remission or asymptomatic. And that's good. We wanna increase the duration of asymptomatic periods and increase the frequency of them. It is a lifelong illness. It's not gonna go away, but we can help reduce the frequency and intensity of their episodes. The first episode a person has can be manic, hypomanic, mixed or depressive. It can be anything. Now a mixed episode has a person who's depressed but also has a ton of energy and can't seem to settle down at the same time. So just kind of put yourself in there ahead for a minute. Mixed episodes can be really daunting for people to work through. Patients may experience several episodes of depression before their manic episode. So just keep an eye out, even if you're treating someone who's had depressive episodes for 10 years, you could be surprised and have a hypomanic or manic episode just pop in there. It's important to ask about a history of depression accompanied or followed by manic or hypomanic symptoms. A lot of patients aren't going to report their hypomanic symptoms because they don't realize there's anything wrong with them. They may assess, it's important to assess for substance use disorder and other general medical conditions or medications the person may be taking. Substances can mimic manic episodes as well as depressive episodes. So can medical conditions and prescribed medications. Some of the medication, medical conditions associated with manic-like symptoms or secondary mania include multiple sclerosis and lesions closely linked to the limbic system. Now this is not something I'm gonna tell my patients because most of the time, the majority of the time it's not this. It is bipolar disorder. So I don't wanna freak them out but it is important for clients to go and get a full workup from their physician just to rule out anything that might be causing it and there can be simpler things that are causing it like hormone imbalances, the thyroid, hypothyroid can look like depression, hyperthyroid can look like hypomania. So it's important for them to just kind of rule out anything that might be a easier fix, if you will, than bipolar disorder. Some medications associated with manic-like symptoms include L-Dopa. This is a medication that people who are on antipsychotics may take to handle some of their Parkinson's-like symptoms and people who have Parkinson's disease may be on. Corticosteroids, the drugs that they give you to reduce inflammation after a really bad accident or surgery sometimes can trigger manic-like symptoms. High-dose decongestants. Now, if you take it as prescribed, it's probably not gonna have any effect on you more than just feeling like you drank a bunch of coffee. But if the person is taking excessive amounts of decongestants, then they may have manic-like symptoms. And for some people, antidepressants can even trigger a manic episode. Now, substances can cause manic-like symptoms, especially your stimulatory drugs, your cocaine, your amphetamines, your ADHD medications, your dex-methylphenidate and your methylphenidate. Diet pills, especially the prescribed diet pills can cause manic-like episodes. Depressive-like episodes can be caused by any of your sedatives. Your anti-anxiety medications, your sleep aids, your alcohol. So those are the things that we want to look for and rule out to make sure someone's not under the influence of some sort of medication or substance that could be masking or masquerading as mania or depression. Substances can be used by people who have bipolar, either one, bipolar one or bipolar two, to help them self-medicate. So if they are hypomanic and they want to sleep, they may look towards using or abusing sedative-type medications. If they're depressed and they wanna have energy and feel better, they may self-medicate with your more stimulatory euphoria-producing substances. Again, be aware. If somebody is self-medicating, you wanna evaluate them during a period where they are clean, they don't have the substance in their system to figure out what their unmedicated mood is like. Patients with bipolar often seek treatment during depressive episodes and will rarely volunteer information about manic or hypomanic episodes. Hypomania is often not seen as a problem. People are feeling like they're making up for lost time that when they were depressed, they couldn't get out of bed. They couldn't get stuff done. Now they're energetic and able to do all this stuff. Mania often is seen as a problem, but a lot of times people don't wanna give that up because they really like the high feeling when they're in that manic state. So we wanna inquire about it. We wanna be alert to it. If you can get information from secondary resources, like significant others, that's always helpful. It is important to remember that for people with bipolar, the completed suicide rates are between 10 and 15%, especially when they're in a depressive episode or they have depressive features with a mixed episode. So if they're really depressed but energetic, they may just want to make it all go away. The other time that is dangerous is when people are coming out of their depressive episode. They have a little bit more energy. They feel like they can get out of bed and they may have just enough energy to try to do something to make it stop so they don't have to feel that bad ever again. So we do wanna be aware of it. Also, when people are coming out of their depressive episodes, they may experience something called euthymia, which obviously dysthymia is feeling flat and low and poor. Euthymia is feeling happy. Feeling happy is okay. It feels like a weight has been lifted off of them when the depressive symptoms start to lift. It's not characterized by extreme goal-driven activity or excess energy or lack of a need for sleep. It is just feeling better, feeling good for once and being like, ooh, this is awesome. So euthymia, not a problem. I'm happy to see it. But again, when people are in that kind of euthymic state, it is also a risk factor because this is when they start having more energy and can have enough energy to commit suicide if they made that decision when they were deep in their depression. Factors associated with increased risk of suicide, if people have means, everybody has means. There may be a preferred means if somebody says, if I'm gonna commit suicide, I am going to use a gun or I'm gonna overdose or I'm gonna hang myself or whatever it is and they have that available. Obviously, that's a greater risk factor. But in reality, if somebody wants to commit suicide, they have the means available. They have kitchen knives. They can go out into traffic. There are things they can do. So don't delude yourself into thinking that someone is safe just because they don't have their preferred means of committing suicide available to them. You wanna look at their level of lethality, both the lethality of the means. If they're talking about overdosing, you may have time to get there, shooting themselves a lot less time. You wanna look at a family history of suicide. If family members have committed suicide, there is an increased likelihood that this person may attempt and or complete suicide. If they have pervasive insomnia, as people lose sleep and become more and more exhausted, even if they're revved, they become much more of a risk to themselves. Again, think about being revved but being majorly depressed at the same time. You know, you're awake and you just can't make it go away. A lot of people when they're depressed sleep a lot because they're trying to make those feelings go away or to escape from them for a little while. When you can't sleep, you can't escape. Impulsiveness, obviously, may be a risk factor. So again, looking especially towards mixed episodes. If there's psychiatric comorbidity, people can have bipolar disorder as well as PTSD and generalized anxiety all at once. So if there are other conditions going on, that's an increased risk factor. If they're in a psychotic episode, increased risk. If they have a personality disorder, increased risk. And if there's a lack of social support, there's an increased risk. Other things that you wanna listen for, if they've started tidying up loose ends and saying goodbyes to people, if they're not talking about future plans, if they don't wanna make an appointment for next week, if they aren't talking about what they're doing tomorrow, that's a huge warning sign. Sometimes when people have made the decision to commit suicide, their mood actually seems to improve and they seem calmer and more at peace because they've made that decision. So again, don't assume just because somebody went from being super depressed to seeming like they're getting better, don't assume you're out of the woods yet. So keep your eyes open for those things. Hospitalization is often required or a good idea for patients who pose a serious threat of harm to themselves or others who are severely ill. They can't take care of themselves or their impulsiveness is putting them in harm's way. They lack adequate social support. A lot of times it's really helpful to have someone who can remind the person with bipolar disorder to take their medications and to not sleep all day and to talk them through some of their stuck moments. If they demonstrate significantly impaired judgment, have complicating psychiatric or general medical conditions or if not responded adequately to outpatient treatment, hospitalization may be a really good option. It's important and most of you are probably in an outpatient setting. So it's important to remember to reevaluate the treatment setting regularly. If your patient seems to be not progressing or worse yet moving backwards, you may need to consider an increase in intensity. And you don't have to go from once a week outpatient to hospitalization. There are intensive outpatient or partial hospitalization programs where clients go during the day and then they go home at night. So there are a lot of different options. You need to check with your patient's insurance provider to see what might be covered and look at what resources are available in your community. We do need to educate clients about bipolar disorder. We need to introduce facts about the illness and its treatment, help them understand this isn't something like a common cold that we're going to give you medication for and you're gonna get better and never have another episode. Bipolar disorder is lifelong and it's episodic. There are a lot of things you can do to reduce the frequency and intensity of the episodes. Most of that is proper self-care and stress reduction. But it's important to recognize that they may need to be on medication mood stabilizers for the rest of their life. Use printed verbal and videotaped material, especially if the client is not asymptomatic, which they're probably not. If they're presenting in our office, they're probably in a depressive episode. Printed material can help them because they're probably not remembering everything you say. So that can let them go back and review it. It's also handy because if they have it, they can share it with their significant others who very often don't come to treatment with them. You wanna talk about it though, make sure they understand. Don't just hand them something and go, here, read this. Talk about what's in it, explain it to them. Some people are visual learners, some people are auditory learners. So it's important to kind of present both. And if you can videotape material that they can watch that will help them learn about it. So they're seeing somebody talk about it and kind of like watching TV. Present the information in an ongoing, gradual and consistent process. So don't dump everything on them in the first session. The first session, you may start saying, okay, this is what your diagnosis is and this is maybe what causes it. Now, let's talk about times when you haven't had these symptoms, when you've been asymptomatic, what's different then or what helps you manage your depressive symptoms when you start feeling them. So encourage them to use a strengths-based approach and a solution-focused approach to starting to address the presenting symptoms that they're experiencing right now as well as start learning about the disorder. It's helpful for a lot of clients to participate in psychoeducational groups because then they start hearing other people say, oh yeah, I had this experience with that medication or this is what triggers my episodes or this is what I do when I start feeling like I'm becoming manic. So they provide each other social support. It reduces that sense in patients that they're the only one with this problem. And it really helps put out ideas because clients never cease to amaze me. There are always new suggestions from clients on ways to handle manic episodes, depressive episodes and stay healthy and asymptomatic that I haven't thought of before. I learned something from clients pretty much every group. So psychoeducational groups are really helpful for a lot of reasons. They can also be helpful in assisting a new patient in identifying early warning signs of an episode. It is important to remember that stressors commonly precede episodes. When someone gets really stressed out either emotionally or physically for some reason, it can trigger a depressive or a manic episode. Disrupted sleep wake cycles may specifically trigger manic episodes. So this is especially problematic if you have someone who does shift work, who's bipolar. Now it doesn't mean that they can't do it. It doesn't mean they can't be a nurse or whatever. But it is important to be aware of and it's important to be aware of if you've got a new parent, not just a mom, a new parent who has bipolar disorder because the baby crying throughout the night is going to likely disrupt the sleep wake cycles for both people and can trigger manic episodes. So we want to promote regular patterns. If you've got a family member, a parent, that has bipolar disorder, it's important to make sure that that person has every opportunity to try to get a regular sleep pattern going and maintain that even if there is potentially, for example, a new baby in the house. Maybe the non-diagnosed parent can take the overnight feeding in order to let the parent with bipolar disorder sleep through the night. So counselor activities, what can we do? We can help clients pre-plan, help them plan for impairments and functioning. If they've already had depressive episodes, they know what happens when they're depressed and they know what they need help with. They know they may need help picking the kids up from school or keeping the house clean or making dinner or whatever it is they need. Assist the patient in scheduling absences from work if they feel a depressive episode coming on or a manic episode. They may not be a good idea for them to go to work or they may not be able to in both of those instances. So they need to be able to communicate with their employer about how they can get time off and whether they need to take family medical leave or if they have to take time off without pay versus regular time off. It's important that they know how to schedule that. Avoiding major life changes is always helpful. It's not always possible though, but if a major life change comes up, pre-planning can help to ease that transition if you've got to move or change jobs or get married or start a new career or whatever it is, it's stressful. So encouraging the person to think ahead of time and plan it out so it's less of a jolt to their routine and their system. And plan for the needs of their children while they're in an acute state. If they've got children at home that need help with homework and to be picked up from school and laundry done and all that stuff, who's gonna do that if the parent with bipolar disorder is not able to perform some of those tasks. Assist the patient who is able to work in contacting vocational rehabilitation. Most patients with bipolar disorder can get it managed with medication to the point where they're working and you're probably working next to one. About one in 50 people have bipolar disorder. So if you work in a big company, you're almost definitely working with a couple of people who have bipolar disorder and they are no less productive than any other employee. Assist patients in linking with a case manager and or needed services. So if they need additional assistance, help them link with the resources to do that. Now medications we may see in patients with bipolar disorder. If they have severe mania or mixed episodes, they may be on an anti-psychotic and Valparate which is the trade name depocote or lithium to stabilize their mood and help them feel a little bit better. Mild to moderate mania or mixed episodes, you may see the person on monotherapy with an anti-psychotic Valparate or lithium and short-term adjunctive treatment with a benzodiazepine. So while they're trying to get all the medications stabilized, the doctor may give a as needed benzodiazepine like Valium or Xanax to help them with any anxiety symptoms and to help them sleep. Mixed episodes. If someone has a mixed episode, certain drugs are preferred over lithium and atypical anti-psychotics are preferred over your typical anti-psychotics. So you're gonna be looking more at like a cerakwil as opposed to your typical anti-psychotics like trisodone or something. Just be aware when you start seeing anti-psychotic medications and mood stabilizers, there are going to be a lot of side effects that the patient is going to have to deal with if the side effects are not tenable, if they're just not acceptable. Instead of discontinuing medication, the patient needs to talk with their doctor ASAP in order to figure out what to do. They may switch medications, change the dosing schedule. There are a lot of different interventions doctors can do but it's really important that patients feel that they're able to advocate for themselves and can have a high quality of life despite being on some pretty heavy duty meds. Anti-depressants are often used earlier for bipolar two depression than bipolar one depression. Patients with bipolar two disorder have lower rates of antidepressant induced switching into hypomania or mania. It doesn't mean it doesn't happen but if they've got bipolar two, you may not see that dramatic shift. Anti-depressants can increase mood cycling though so they may have more ups and downs instead of asymptomatic periods. So the general recommendation is that mood stabilizers like DepaCote are combined with an antidepressant in order to keep the person from getting super depressed but also avoid the ups and downs of rapid cycling. Electroconvulsive therapy may be considered for patients who are severely ill whose mania or depression is treatment resistant or who are experiencing symptoms during pregnancy. During pregnancy a lot of these medications can't be taken so ECT is an option and it has been found to be safe according to the research studies for the fetus and it can help stabilize some of the mood symptoms. So the goals for treatment are really to prevent relapse and recurrence just like anything else. We wanna reduce the cycling frequency and sub threshold symptoms. So sub threshold symptoms are what I generally look at as warning signs that were headed towards an episode so if somebody goes from feeling pretty good, a three or a four on a one to five scale most days to more like a two or a three, they start feeling kind of flat and eorish. Then we wanna figure out how to address that. That should be a warning sign that something may be getting a little off kilter in their neurotransmitters and they need to figure out what's causing that. Are they not getting enough sleep? Is there too much stress? Is it change of seasons and they're not getting enough sunlight and vitamin D? There can be a lot of reasons for it. We wanna reduce suicide risk, obviously and improve overall functioning. Have them identify instead of looking at just eliminating these symptoms, accept the fact, help them accept the fact that, okay, they've got bipolar disorder. What does that mean? How do you envision a rich and meaningful life despite bipolar disorder? Because you can and I encourage them to learn about people who are famous because the average Joe is not gonna be on the internet talking about it, but people who are famous, who've had really successful careers who also have bipolar disorder because there's a lot of them and it will help people start seeing that, you know what? I can do whatever I wanted to do. It may just have to approach it a little bit differently since I have bipolar disorder. Psychosocial interventions. We wanna address illness management, making sure that they have support to make sure they get their meds and people that can identify early warning signs of impending manic or depressive episodes. Address interpersonal difficulties, especially those that may be caused by their rapid cycling or by cycling at all. A lot of people who don't understand bipolar and even those who do understand bipolar can get really frustrated with patients when they start to become symptomatic again. It's like, oh, here we go again. So helping them learn how to effectively communicate what they need and try to manage any interpersonal difficulties that are caused by symptomatic periods. And encourage them to develop support. Everybody needs support, but people with bipolar disorder sometimes need a little bit more support because it is a different diagnosis than most people are used to. They're used to the depression, but they're not so used to the mania. A lot of people still, even if you educate them, have a difficulty grasping that the person may go back and forth between the different types of moods. Postpartum period is associated with increased risk for relapse into mania, depression, and psychosis. The rate of postpartum relapse is as high as 50%. Think about it. When somebody's postpartum, not only do they have emotional stressors going on, new baby and big life change, but their body is readjusting after having a baby and they're probably not getting enough sleep. That sleep wake cycle is disrupted. So the rate of postpartum relapses is really high for women. But also, again, if dad is the one who has the bipolar disorder, because of the disruption in sleep wake cycles and the increased stress of having a new life to take care of, it can trigger a relapse in the partner of the mother. Prevalence in children and adolescents is about 1%. So one in every 100 children and adolescents has diagnosable bipolar disorder. An additional 5% to 6% have mood symptoms not otherwise specified. So they don't meet the threshold for full-blown bipolar disorder yet. Children with bipolar disorder often have mixed mania, so depressive symptoms with a lot of energy and irritability, rapid cycling, and psychotic features. It is often comorbid with attention deficit and conduct disorders. So we talked about that comorbid psychiatric diagnosis. ADD, so inability to focus, sometimes lack of organization, all the things that go with ADD combined with bipolar disorder and conduct disorders to boot. So we wanna look at when these things occur and what is driving them. People with ADD will often have the symptoms pretty consistently. It's not an episode and then asymptomatic and then an episode. So if somebody seems to have ADD symptoms consistently, but they also have the highs and the lows, then they may have both diagnoses. In patients over 65 years of age, the prevalent rates of bipolar disorder range from about 0.1% to 0.4%. So the prevalence goes down as age goes up and most manic symptoms are due to a general medical condition or medication. So what we're talking about here is a patient over 65 years of age getting diagnosed with bipolar at that point in time. The rate goes down a lot. So if you see someone who is over 65 experiencing manic symptoms, it's definitely important to get a medical evaluation because a lot of times those symptoms are not bipolar, but they're due to something medical going on with them. So bipolar can be diagnosed in children, adults and even the elderly. There are a wide range of medications that are effective in treatment, including antidepressants, mood stabilizers, atypical antipsychotics, antipsychotics and even electroconvulsive therapy. Psychosocial interventions need to focus on minimizing stress and increasing routines for the people with bipolar disorder in order to increase the duration of the periods that they're asymptomatic and reduce the intensity of their mood symptoms. If you haven't already signed up, please remember that on-demand addiction and mental health counseling and social work continuing education credits are available for this presentation and are accepted in most US states, Canadian provinces, Great Britain, Australia and South Africa. Go to allCEUs.com slash counselor toolbox and click on the counselor toolbox CEU spreadsheet to easily locate the course based on this presentation.