Mental illness is a medical illness, like high blood pressure or heart disease, but mental illness is often misunderstood by people, even by some physicians.
One of the more severe mental illnesses, bipolar disorder or manic depression, affects about 2.3 million adult Americans, or about 1 percent of the population. It is one of the more misunderstood of mental disorders. "The whole concept of bipolar is an elastic one," said Dr. Stephen Kowalski, a psychiatrist with Bowen & Kowalski in Birmingham. "The disorder creates a mindset of the mad scientist, like Dr. Jekyll and Mr. Hyde. There's a sense of hopelessness and dread associated with it, but it's eminently treatable if it's recognized and if the patient is willing to comply with the treatment."
Bipolar disorder involves episodes of serious depression and mania, and the affected person will experience wide mood swings with periods of normalcy in between. Manic periods typically involve heightened energy, unusually creative thinking, irritability and self-confidence, alternated with depressive episodes characterized by hopelessness, sadness and low energy.
To effectively treat bipolar disorder, it is crucial that a physician recognize the symptoms and makes the correct diagnosis. Kowalski said doctors must be astute clinicians and think like a detective. "You can't blame physicians for having some misconceptions about this illness, because we're realizing now that it's not just a black and white issue," he said. "There's a rich spectrum to bipolar that we're just beginning to grapple with and trying to reclassify."
Kowalski said he sees people with symptoms like chronic anxiety, insomnia and depression but may not see the bipolar disorder right away. "People with a low grade aspect of the illness may be up a few weeks then down. We call that 'type 2,'" said Kowalski. They also see people who are irritable all the time for no reason and people who are depressed and have gone through rounds and rounds of antidepressant treatment with no improvement. "The problem we have as a profession is there is no standard textbook way to diagnose bipolar," Kowalski said. "We are correctly diagnosing classic manic disorders but we're not fully appreciating the spectrum of bipolar disorder. I wouldn't be surprised if 5 percent of the population has bipolar but no classic features other than treatment failures."
Dr. Ed Logue, medical director of the geriatric psychiatry unit at Baptist Princeton and author of the book "Fly Me to the Moon — A Bipolar Journey through Mania and Depression," said physicians need to always keep an open mind for underlying psychological problems in their patients. "Doctors need an index of suspicion for any illness and should look for everything," he said. "We tend to go in with our own mindset for what we think the problem is." As a result, he added, children in early stages of bipolar disorder are often misdiagnosed with attention deficit disorder, and some personality disorders in adults may be misdiagnosed as bipolar and vice versa.
Another clue to bipolar disorder may be the patient who tries to self-medicate with alcohol or drugs, Logue pointed out. He said many patients don't like the stigma or side effects of the bipolar medications and turn to these substances to treat their symptoms. "Once the patient is hooked on one of these substances, we tend to see the addiction as the problem without looking for the root cause of the problem. As a result, we're treating only the addiction," he said.
Because bipolar disorder has no single cause, physicians must rely on patient evaluations to arrive at the diagnosis. Specialists generally use the following to diagnose bipolar disorder:
· Psychiatric questionnaires, oral and written;
· Medical examination to eliminate other causes of mood swings, such as thyroid disorders;
· Medical history;
· Discussions with family members;
· Family history of mood disorders.
Researchers have determined that genetics does play a role in the illness, so a patient's family history can help in the diagnosis. Logue pointed out that a patient's family members don't necessarily have to have bipolar disorder, just the genetic predisposition for the illness. "If one parent has the genetic deficiencies for bipolar, 25 percent of their offspring can be expected to have the genetic deficiencies," he said. "If both parents have it, you're looking at about a 66 percent chance for their offspring."
Logue added that even if the genetic predisposition is present, the disorder may never reach clinical visibility. However, an episode can be triggered by such things as major stress, a major life event, chronic illness, substance abuse, or sleep deprivation.
Untreated bipolar disorder can have detrimental effects on relationships, work and school. People with the illness often have higher rates of divorce and many lose their jobs. The suicide rate is also high among sufferers. "Bipolar is one of the most lethal mental illnesses," said Logue. "A person with depression can usually weather that illness until it gets better, but a bipolar person can be triggered into a depression from any kind of stress and won't know why they're depressed. It's a recurring depression that makes them feel like they don't want to live."
Kowalski said that because primary care physicians are the front line for most patients, they will treat 80 percent of all depression symptoms. If they try typical drug therapy on a patient and nothing works and the family history is there, they should consider bipolar disorder.
Logue said the best treatment for the disorder is education about the illness — both for the patient and the family — combined with medication. "A mood stabilizer may be mixed with an antidepressant or a typical psychotropic," he said. Logue added that most bipolar patients should be referred to a psychiatrist for treatment unless the primary care physician has a real interest in the disorder and experience in treating it.
Lithium generally is used to treat bipolar disorder, but Kowalski said new medications are being researched continuously and anticonvulsants are becoming the state-of-the-art treatment for the illness. "The drug Lamactil® has come on the market in the last two years and is effective in keeping people stabilized and helps with depression," he said.
According to product studies, lamotrigine (Lamactil) is frequently more effective for patients who don't respond to antidepressants or mood stabilizers and has relatively benign side effects such as skin rash.
Kowalski said that in addition to the medicines, psychotherapy can be helpful for both the bipolar patients and their families. "There is a need to build relationships in these families," he said. "Psychotherapy helps because these issues accompany bipolar, but you need to get the medical issues solved first."
