Dr Patrick McKeon - Bipolar Disorder: what it is & what to do (July 2015)

okay so um then you will talk on bipolar disorder many of you are familiar with the condition but of necessity which to start at the very Basics because there are many people here who are attending a lecture like this for the first time the purpose behind this talk is to give you a practical understanding of what the condition is how it can be recognized how you can become familiar with the signs and symptoms knowing how often and why the diagnosis is missed how it best can be treated what sort of things people have to do

in connection with lifestyle management at a practical everyday level and what are the final comments on staying well so the first thing we start with is well what is bipolar disorder formerly it was known as manic depressive illness bipolar in its own way captures a certain essence of it but in another way so did the word manic depressive illness because what manic means is actually speed it up the word depression derived from the Greek means slow down so in essence that is the uh the core thing of what bipolar is about so in other words

that if you imagine that for a moment that we all operate mood-wise between these two lines we can be excited about something and maybe other times down in the dumps about something but it's only when you get down to this level that you experience depression of a clinical nature in other words it's about the severity of the symptoms and up here where a person would be in a later or manic state so we we have a certain degree of variation and it's only when a person's mood is going down here for prolonged periods of time

are being up here for prolonged periods of time that one meets the criteria of bipolar disorder so in essence it's a mood swing problem of a certain severity and in essence the severity of that is relatively disabling maybe not for the person themselves at that point in time but maybe for people around them in other words that it's not just the impact it has on people so for example the depression has to be present for circa two weeks and be pretty much there all the time the Elation or Mania needs to be present for four

days for what's called hypomania in other words little Mania and for a full-blown episode of mania it needs to be present for at least one week we've come back to the signs and symptoms in a moment how frequently does bipolar disorder occur it depends on the way you define it and certainly over the years what's tended to happen is that our understanding of how frequent minor degrees of bipolar disorder are present in society has expanded enormously and this is important because as we'll see shortly that if a person is going through periods of slight highs

but their complaint is of depression in other words as far as the person may be concerned they suffer from a depressive condition if you don't spot those little highs you can't actually switch off the depressions because they're linked with one another so in other words that for certain types of bipolar the more severe forms of it what's called bipolar one which I'll Define in a moment it has been said over the years that about one percent of the population in the course of their lifetime will experience this but the point is that lesser degrees of

bipolar disorder are extremely frequent and overload they're overlooked because the person who is a little high they're not going near a doctor to tell them they're in good form in other words if for the person it's a painless experience it's only maybe when the person gets very agitated or is in trouble at home or at work or with the law because of their mood disturbance that maybe the penny drops that there is something seriously wrong from a mood point of view and then it gets properly diagnosed so let's look at some of the symptoms and

signs of bipolar disorder many of you are familiar with the standard symptoms of depression where you have a disturbance of feeling where the person is feeling low or the person's energy is reduced where the person has difficulty with sleep and where the person's thinking is slowed down so in other words what we call the festival symptoms thank you so mood in other words feeling low e is for energy s is for sleep and T is for thinking so they're the core symptoms that you will experience in depression and elation feeding down energy down sleep broken

or oversleeping and thinking quite slow down at having impaired concentration now inhalation you get the complete opposite the person feels euphoric couldn't feel any better tremendous tremendous energy the person has great trouble sleeping at night getting off to sleep and the person is having racing thoughts jumping from one topic of conversation to another and thus being impulsive and very much all over the place so what we now need to do is to look at some of the core aspects of a model that would help you get a handle on bipolar disorder and a useful model

is this that if you imagine that within the head we have a thinking wheel we don't but just imagine we have we think at a certain rate and we accept that rate of thinking but one of the first things that happened when a person gets depressed is that this thinking wheel slows down words won't come to mind the person has fewer thoughts they say less in conversation and they have difficulty projecting their thoughts out into the future now what do I mean by out into the future if I ask you what are you doing for

a break during the summer what are you doing next weekend presuming you're not too depressed something will come up on the visual display unit in your mind that very process is weakened or absent during depression so the person looks at the screen and you ask them well what's there it's Bleak it's blank or there's nothing there there's the the absolute three terms that are that people use to describe it now because there's nothing there on the screen the person then has very little energy because energy is a figment of our imagination we see something out

there and we pursue it obviously it's in our mind in other words I have to do this I have to do that I have to do the other I have to pack the case I have to do this and we we pursue it so when a person doesn't have something there or we see a mountain ahead of us on the visual display unit it has a fatiguing effect so here you have a person who's thinking is slow down who has difficulty taking in information from the world around them in other words it can't its thinking

process is moving so slowly that it can take up the individual pieces of information from the world and put one in there the next one in there and so on it can't string things together so the person can't actually focus on what they are reading the next point about depression is that when people are depressed they tend to not when they're not able to project out into the future in that way they tend to become introspective and the two aspects of that being introspective a person can be introspective psychologically where there's an increasing awareness of

everything they do they feel maybe just self-conscious about their thoughts are self-conscious in the presence of others for other people it's a self-consciousness and awareness of their body in other words their skin the color of their eyes the size of their ears and a headache that then maybe get from time to time and now grows into in the person's Mind's Eye a tumor in other words something very serious so in other words what happens is that with this introspection you've got this hypersensitivity to things the next thing is that the person tends to go back

and think about the past because they're not really going to the Future and people go back into the past and they will resurrect negative things from their past now normally when we look at the past curiously enough if we're in good form we actually talk about the good old days how things were better how people were more polite how there were fewer cars on the road etc etc but you know there were neither good nor bad Shakespeare says but thinking makes it so so in a sense when a person goes back and sees things in

a negative way what will tend to happen is that with that negativity the person will often attribute the mood they're in to their memory of the past in other words to say I am depressed because of something I did in my past and that is where the give feelings come from but as soon as that depression lifts lo and behold that disappears and you say to the person well you were saying that you got involved in something in the past when you were depressed and now that you're out of depression can we talk about that

what are you talking about the you know it's gone as far as the person is as concerned and it has little meaning for them now the point is then when you move to the Elation you get the complete opposite what's happening now is the thinking wheel is going very quickly and because it's going quickly the person will often have a sensation of pressure in their head as if their head is about to explode they will have a thousand to one thoughts and not alone do they have a visual display unit on which are interesting things

the person will have plenty of visual display units and as you're looking at the person they're looking at this one and then their mind hops to this one and then to this one so in contrast to the person who's depressed when they're looking at the visual display unit they're looking vacantly into the future and it's as if the world is empty to them whereas this person in the high state sees one thing then another then another and you see their eyes glisten and dance literally shifting over and back even as you're talking to them and

thus it's hard for the person to take on board what you're saying because their mind is going so quickly they just can't absorb further information they have tremendous energy because there are things here that want to pursue they will chop and change in conversation be impatient impulsive often then they can only see things that are positive here we have in the depressed state pressing maybe can only see what's negative so the person's thinking is much more in the future and it's about positive things and this is what leads to poor judgment because in a sense

when we come to a decision point with our thinking we have a choice of is this overly is this um overall a positive move or a negative mood and what happens then is that if the person only sees a positive thing they come again to another one and it's just positive so for example a person might say I think I'll go on a holiday I'd really like a holiday the negative side there just doesn't get a look at the next positive thing is I really like this brochure I think I'll bring my family next thing

is I think I'll bring all the family John down the road hasn't had a holiday for a long time and on we go so it's it's that sort of anatomy of judgment that slips when a person's mood is Disturbed now you get the converse when somebody's depressed they can't get beyond the first thing so in other words maybe less money is spent on food maybe the yeast is turned down maybe stock isn't ordered for the shop animals are sold off farmers and stocked so on so you can see how these contrasting pictures suddenly begin to

make sense and probably can all be tracked back to one Central phenomenon okay so in other words that the treatments that are used are often focused on trying to Quicken the wheel or slow it down depending on the state the person is in now having looked at it from that perspective we need to go and look at the symptoms then at another level and what what what's necessary here is to look at first of all the different grades of depression and elation so we just call it severities so starting with depression the first is that

when a person is mildly depressed they feel tired have difficulty concentrating they're often anxious and often the symptom of anxiousness as a feeling precedes any feeling of depression for a lot of people and they may even have a panic attack even before they feel depressed and the other one then is self-conscious when a person is that's mild moderate and severe so in a mother depression a person is all of the symptoms that are described the withdrawn State being quiet little to say difficulty concentrating and finding everything a bit of an effort everything is uphill everything

is a problem maybe being off their food generally the person feels worse in the morning than they do later in the day typically the person's sleep will be that they're waking up repeatedly during the night and or oversleeping and are sleeping during the day when a person comes to a severe depression what they often have are very negative thoughts where the negative thoughts take over and produce what we call delusions and our hallucinations now it's important to remember that in a depressed state those fixed false ideas which delusions are they're fixed false ideas which have

no best in reality they're nothing more than the negative thinking that is part and parcel of a mild depression in a mild depression a person might feel they're not a very worthwhile person not a very good mother or father or maybe they'd be better off if they left the company they work for but to do nothing about it moderate depression it's more intense the person might start making remarks to other people about these thoughts but here when it gets more severe the person actually is firmly convinced of it they'll feel their useless worthless people will

feel the world will be better off without them or they may actively ask people around them would they help them get out of this life on the other hand the person may feel they've got some terminal illness um and just see that as a release now very often the hallucinatory experiences where a person is having voices or visions they may in extreme cases just be part and parcel of that picture but it's very important for people who have these experiences just to be open about them because they are something that is very treatable and again

it's nothing more than an extension of what's there in the mild and moderate form so when we look at relation again it's the same phenomenon now you will know that when I mentioned mild depression I didn't see say the person felt depressed because that's the Curious Thing about depression see depression isn't actually a great word to describe depression and it has different meanings for different people often a person from an emotional point of view feels more anxious than depressed and so in a way that when a person is going into a depression what often tends

to happen is they're very anxious at this point and then they're anxious on the way out again but down here it's almost as if the anxiety switches off in other words it's the brain's way of shutting down the awfulness of depression now curiously enough it's actually here at these points that the person is more distressed and it's often at those points the point of entry and exit from depression the people that are more at risk of harming themselves so when we look at the different grades of severity with Elation again it's it's pretty much the

same so for a mild Elation the person might be feeling great never felt better confident foreign energy now generally in at this phase nobody will know that there's anything a Miss with the person other than their immediate family generally work colleagues extended family won't spot it it's only people who are living with the person can see the contrast between the person they knew and what's there now moderate illness the person is overactive over talkative says things to people that are out of order quite disinhibited in what they say what they do maybe the clothes they

wear sexual activity the amount of alcohol street drugs they might engage with have often very little sleep and the absence of sleep then fuels the problem because one of the things you'll find about bipolar disorder if you want to start a manic episode just stop the person sleeping because two or three nights without an adequate night's sleep is is often enough to to trigger it so in the severe phase of the illness what happens is the person again has these delusions and hallucinations and or hallucinations in other words the person may see themselves as all-powerful

or feel that they're going to live forever or they can cure anybody or come up with great inventions or sort out the world's political problems and be quite convinced of this now again it's important to remember that those features are just as treatable as these in fact in in many ways more treatable because what tends to happen is that when a person is that severely unwell it'll be evident to everybody and they're more likely to get help fairly quickly often people with mild forms of it accumulate enormous debts will often have given away an awful

lot of their possessions and maybe the possessions of others um and that causes a lot of heartache next thing I want to deal with is where there's a diagnostic difficulty and this is with what are called you'll often hear the term mixed mood States when a person is going through a high like this foreign if not everybody in a high state has periods of time where they're a bit weepy a bit agitators distressed feeling hopeless and if you ask them at that point how are you feeling they will use the term I'm depressed to describe

it but any casual Observer looking at well you know 10 minutes ago he was talking his head off everything seemed fine delighted with the world and the vast majority of time in this that is the symptom or the way the person is so the question is how do you distinguish these types of conditions because what tends to happen is that if that person really is convinced they're depressed and they go to their doctor and say I'm depressed how can the doctor distinguish it that from a depression proper and this is one of the big problems

in treating or recognizing bipolar disorder because what tends to happen is that for a certain percentage of people in fact it said that up to 30 percent of people who are in Highs are in these mixed mood States in other words the person is saying categorically they're depressed what's the difference between this depression and that depression and the reason it becomes important is this that it said that something like 30 percent of people who have recurring depression have actually bipolar disorder that's gone undiagnosed simply because they're so vehemently depressed and it's hard very often for

clinicians who mightn't be experienced in this area to actually recognize it as such now this has enormous consequences because if you treat this with antidepressants that's what you get in other words you worsen the situation very significantly and so let's just look at the way we separate these things out now this is also known as dysphoric meaning unpleasant feeling Mania they said speed it up or hypomania foreign so in other words What's Happening Here is this if you as long as you remember that the core aspect of depression is that it's the slowed down thinking

and physical state it's like a flat battery syndrome in a non-pleasant high state or a mixed mood state or a dysphoric State these are all interchangeable terms key thing is that the person's mind is still overactive so in other words even though the person says they're depressed when you look at them very often you can't get a word in Israel it might be an angry state it might be a hostile state it might be a very frightened state but you still can't get a word in edgewoods the person typically has trouble getting to sleep at

night whereas somebody with depression generally doesn't have trouble getting to sleep at night in other words if somebody with depression has marked trouble getting to sleep at night the first thing you need to think about is what is a depression the second thing is the person's eyes are Lively whereas the person in a depressed state they're vacant and staring into space so let's just from a symptom point of view that from your own point of view how would you distinguish the two because they're very very important so it's relatively easy in some senses so What's

Happening Here is this if we just draw it in in this way that if they're all the symptoms of depression and there all the symptoms of the unpleasant mood state the almost overlap one another totally so I'm just going to tell you what the distinguishing symptoms are between the two so the first one is trouble getting to sleep anger and if you don't like that word irritability number three is worse in the evenings depression tends to be worse in the mornings so in other words this is the unpleasant High State we're talking about worse in

the evenings so trouble getting to sleep having anger or irrigibility tending tending to feel worse in the evenings and tearfulness now this one isn't too reliable the tearfulness bit the reason I'm putting it in is that just to emphasize the point that frequently when people are clinically depressed with bipolar depression during the depressed mood State the person's um is is not generally cheerful uh you see in this unpleasant High State it's an anguish State it's a torturous State it's a very very unpleasant state the risk of somebody harming themselves in the state is actually much

greater than in Enterprise state and in fact probably a lot of the suicidal attempts associated with bipolar disorder are in these states mistakenly called depressive States depression States for years and years uh the amazing thing about this is that this condition as such was recognized back in 1910 the lady and the early part of the 20th century and towards the the close of the 19th century and surprisingly it just got overlooked within clinical practice and it's only now recognized for what it is and the reason why it's important is this that frequently with people with

recurring depression what you'll find is when they describe it they will say I get depressed for X period of time and then I'm okay for a few days weeks or months and the same thing happens and again when you ask the person do you ever get too well do you ever go through periods of time where you seem to need little sleep do you ever go through periods of time where you're overactive over talkative no sometimes when you bring in the family and interview them they'd say well no generally not you can't you can't blame

the person being in particularly good form of the commercial for depression the deserve a period of Wellness but when you actually get the person to start documenting it what you find is actually substantial enough so each time the depression ends there is this high now it's this high that seems to contribute to this the next one in other words that upswing in mood seems to be associated with this so if you didn't see those upswings and just treated it as a depression you'd be missing the point totally because what you'll be doing is this you'd

actually be exaggerating the whole phenomenon what happens is that if you put in a mood stabilizer here and stop the antidepressants overacting at this point eventually what happens is that the mood pattern goes like this over a period of time the hype once the high stops happening what you'll find is then the depressions begin to get they just fade out over time now that can take months even up to a couple of years but the whole thing is trying to find this particular phenomenon as part of what's called bipolar II mood disorder in other words

um it's it's really a diagnostic problem bipolar one and this is where the person has a large High frequently followed by a large load now by definition that is a high that's bad enough to land the person in hospital it's just a rough definition of it but it's where the person has symptoms for of an extreme degree for at least one week but that's just from a definitional point of view very often these phenomena go on for weeks and months untreated bipolar II is where the person has a lesser degree of high and then a

low in other words that's what we call a hypomania in other words it's something that's much shorter and much less disruptive and maybe overlooked and all we may hear about is the depressive aspect because the person is relatively unaware of the high now bipolar 3 refers to pattern similar to this maybe where the person is getting high after the low but it's happening because the person is on an antidepressant in other words they were depressed they were commenced on an antidepressant and their mood picked up and went over the line so you might say well

stay away from antidepressants yes relatively speaking but the point is if you do that the person remains down there so the issue here is that we need to keep this within the Spectrum we now talk about the bipolar Spectrum to acknowledge the fact that there are different severities of this condition somewhere the high is very mild but at the same time of great clinical importance because if it's overlooked the point is the person's mood remains in in free fall yes we do tend to use as little antidepressants as we possibly can when treating bipolar depression

because it increases the chances of the person's mood going up and down but what we've got to do is first of all deal with this try and prevent this recurrence of mood of recurrence of the high and bit by bit it fades out if you stop the antidepressant the person just goes down and stays there so it's often a matter of trying to get two Powers equally balanced one is the antidepressant helping the person up and then something here that blocks it going Beyond a certain point now the other point is that there's a subgroup

of people within bipolar one who have highs only but it's still by definition called bipolar disorder even though there aren't at this stage two poles in the condition very often this is a condition uh or what we call you recurring uniportal Mania it's where the person often has a very severe illness quite disabling other manic nature that will be quite disruptive in the person's life but when they come down out of the high they dip ever so slightly below the line and all they might complain of is tiredness but you will frequently notice that the

word depression is Never uttered by the person as far as they're concerned it's just a high now the reason why this condition is so difficult to manage is that because the person doesn't have much pain from this phenomenon the difficulty the person has is of heating treatment recommendations sticking with advice taking medication whatever it may be somebody's had a good whack of depression behaves otherwise because they've a very big vested interest in doing whatever they can to stay well now as a result for people with this it can have quite a disabling effect often people

lose their employment marriage house any finances so just let's look at treatment for a moment when a person is going through a big highlight this and coming out this side and there are a variety of different medications used to try and help contain contain this and they often come under the general term of anti-manic medications but often on the market as anti-psychotic medications basically they're the focus is on trying to slow down the person's rate of thinking such that they can contain themselves and their increased energy and dynamic nature that is beginning to get them

into trouble now very often what these compounds do is they take the top off the condition and very often there's a sort of a an aspect of it still there beneath it um the other class of tablets are medications that's used are called anticonvulsants so amongst these antimonic things would be things like Zyprexa Circle I'm using trade names here because you may or may not know the other names Risperdal serenes so the second group are anti-convulsants now what the anti-convulsants do and things such as epilimp and Tegretol and Trileptal they seem to have a calming

effect on this and probably epilim is probably the most effective one for the severe relations the final mood stabilizer for this condition is lithium and it is by far the most effective treatment because it has lost its reputation uh uh as a compound over a period of years simply because it wasn't being marketed and is very cheap um costing pennies as opposed to uh hundreds of Euros um nobody was promoting it or doing research on it but research over the past five years has shown that it's actually not alone Superior to these but also has

fewer side effects many of these compounds are although effective produce a lot of weight gain increase people's cholesterol and blood glucose whereas lithium has its own issues maybe around renal function but by and large if that's carefully managed over the years and people do extremely well on it and have a longer lifespan better quality of life and a more by far much more stable mood what lithium tends to do if You observe it carefully is that when the person starts on it almost over a period of two weeks if they're on sufficient lithium their mood

comes down like that almost you could set your watch by it now it doesn't work for everybody but it does work for the vast majority of people with a severe straightforward elation and very often what happens is the person is put on some of these antimonic medications while waiting for the lithium to kick in because it's very difficult for people who are high to be patient and take medication and maybe stay in hospital at a time because their mind is going so quickly they find it hard to cope with it the problem with episodes of

elation is that almost always they're followed by episodes of depression even in people with uniport Romania that are referred to later if you follow up people like that over the course of their lifetime that may be in their teens 20s maybe early 30s it's mainly Highs but as they get into the middle years it's surprisingly more depressions than they begin to emerge so when that depression ends and is treated the person may be well for X period of time in days gone by it used to be said that the chances of a person having a

second episode was about 50 we now know that it's actually much higher than that and probably 70 80 even 90 percent in some studies so this is why a preventative approach is needed for the next episodes and the choices are generally between those three categories the antipsychotic agents the anti-convulsant agents and lithium generally the treatment of choice in this instance where you have a high followed by a low the treatment of choice is lithium now for people who have what we call the bipolar 2 pattern whereas a big low and a certain amount of high

the treatment of choice here is first of all to try and get the person up out of the depression with an antidepressant and if the high is significant to use an antidepressant plus a stabilizer now in this instance the anti-convulsant stabilizers do seem to be more effective in other words things like epilium Tegretol Trileptal are particularly good at sorting this out now it means number one reducing the antidepressant number two putting in a mood stabilizer and trying to work out a balance between those two forces until the person is on a sufficiently low dose of

antidepressant or no antidepressant plus a stabilizer in other words if a person was on a stabilizer on its own that person may be depressed or another person mightn't be so you've got to vary the doses of the stabilizer and the antidepressant until the pattern of swinging begins to settle there is another pattern called rapid cycling and this is where a person is having four or more of these episodes in the course of 12 months for some people though it's even more rapid than that Ultra Rapid Cycling now frequently you'll see this pattern postnatially or if

somebody is on an antidepressant and they're very sensitive to the antidepressant it can bounce the person's mood around quite a lot if a person is on certain drugs such as steroids or if a person had we say a woman had her ovaries removed that so it seems to be some hormonal phenomenon that leads to that greater instability in mood that person may have had a relatively straightforward mood pattern that was relatively treatable but hormonal changes seem to have an impact on it um and again it's it's more often the anti-convulsive mood stabilizers that are helpful

here lithium will work for some people maybe for 30 of people with this so there's often a lot of work over a period of time trying to find out um the the best compound for these main causative factors in bipolar disorder are genetic such that we know that on average that if it takes if this bar represents 100 percent on average 70 percent of the contribution is genetic and the other 30 is environmental we know this from twin studies adoption studies twins rare together twins reared apart that this statistic seems to hold true uh right

throughout the research done over a hundred year period really but that average is made up of all sorts of different figures uh it might be the other way around for some people where it's 70 Environmental and 30 genetic and this may be where a person has a very vague hint of bipolar disorder in the background maybe somebody in previous generations who got a lot of depression we don't even know if they had a high or there might have been a binge drinker but in that person's environment there's been a lot of trauma in their past

and probably more so in their present life uh for somebody else it might be 90 genetic and 10 environmental in other words in this instance the person became ill when little or nothing had gone wrong in their life but they were very very very strong family history of bipolar disorder so you get all of these variations when we look at the genetics of it we don't have any clear understanding of what genes were involved what we've come to discover is that it's wildly complex it's more complex than diabetes blood blood pressure heart disease any other

phenomenon and it looks as if there are a whole lot of mechanisms from a genetic point of view in the mind that are important in this instance and we don't really quite grasp how these begin to play a part what do we know about the environmental factors well the environmental factors are the usual stress factors and stimulants and the stimulants are bucket lots of coffee high energy drinks street drugs amphetamines cocaine steroids certain medications some homeopathic remedies um different anything that is a stimulant can do can do it so in other words what might be

a mild stimulant for the average person in a pick-me-up as it were for somebody else with who is a vulnerability or a family history of bipolar disorder it can be the thing that kick-starts the illness and then the other big heading the three s's are social rhythms if we if a person who has a tendency to bipolar disorder has for some reason or other been unable to get to sleep might be prolonged pain might be sunburned might be too bright outside whatever it may be or working um alternating shifts at work that upsets the biorhythms

the Circadian rhythm in the brain which in turn creates almost a jet-like type phenomenon within a person and can totally destabilize a person's mood so these factors are actually quite amenable to intervention so for example staying away from coffee and other stimulants avoiding steroids unless you need them for something that's life-threatening getting to bed at a fixed time getting up at a fixed time um uh being careful about observing what effect shift work has on your mood and if it has an effect to bring it to your employees employers attention so fix bedtimes fix Rising

times fixed meal times are extremely important we also need to I'm afraid putting cigarette smoking amongst the stimulants it's been shown that certain aspects of cigarette smoking have a measure quite akin to antidepressants who didn't know that the first thing is to acknowledge might seem Elementary but for many people that don't get off the starting blocks because they can't acknowledge what's going on even though intellectually they might know at a certain level but at another level nobody's business this is my illness stay out of my space etc etc but a lot of that is is

the illness phenomenon itself so it can be hard for people when they're maybe a bit High to take on board what this illness is doing in their lives so being able to acknowledge it means being able to say it to family what's going on maybe to some close friends not to everyone on the street please but just keeping it in in a small circle and because again when a person does that in a public space and I mean public within the family and they're actually beginning to take responsibility for what's going on they're prepared to

share what they're going through and to take pointers from others and support learn the facts about the illness often for by you know diagnosed a bipolar disorder it's frightening for people that don't want to hear the word you know the biggest threat of anyone with depression did you say I was bipolar you know in other words not me please don't don't say that to me um but the point is that often a person with depression has to take that on board it might only be that size but we have to put some sort of label

on us in a way to help the person get a handle on what the treatment is about otherwise they're they're actually quite lost about it so learning about the illness number three is getting emotional support talking to others who have the condition and who've been on that road before you through support groups aware support group is a an excellent way of meeting people who know what it's about you might think they can see around corners see many people for example who come along to where support groups will find out in the course of the retentions

of the group that come along with depression and they realize yes they do actually have symptoms of being high from time to time and then once they can bring that information back to their doctor or therapist it can be factored into their treatment plan and it makes a hell of a difference of how they they're managed now once the person is on board about doing something about it this is the key thing spotting a relapse if a person is going high and they can sponsor it quickly I mean within hours of what's happening it means

they don't it doesn't intrude into their family life into their work it doesn't means that there are fewer altercations at home around it or time off work or loss of study time and so on so how do you spot it well you can take the ordinary signs and symptoms I've given you that's fine for depression but it's pretty hopeless actually for Elation because Elation is a relatively Pleasant phenomenon for the person concerned the second way to Sparta relapse within yourself is to know what your personal sign is what do I mean by your personal sign

when somebody's High everybody does something that's characteristic of them that they wouldn't be seen Dead doing otherwise wearing a certain pullover um buying certain items wanting to go out the back and saw an acre of potatoes never think about it other than one eye suddenly smoking a non-smoker suddenly taking a cigarette now the point here is that the family know from the person's previous behaviors during highs that that's what Tom or Mary does when their mood is gone in other words that is all from the first sign and it's personal in the sense that one

day it's not there the next day is there the trouble with a lot of the things like sleep disturbance and so on is it when you have a half an hour's trouble getting to sleep or in hours or two hours that you call it sleep disturbance in other words the person will say oh well I just was a bit excited that night or had too much coffee or something ultimately though not both of those things are inferior to the next one and that is picking somebody whose judgment you trust preferably somebody you're living with and

asking them to tell you if they if they think your mood has gone up simultaneously you've got to give them permission to act on your behalf that might be if you see me in that state again please take away the car keys get me to the doctor even if you got to get me into hospital I give you permission to do that okay that doesn't get abused I can assure you I've never seen it abused what tends to happen is that when a person has a safety net like that they lo and behold they don't

end up in hospital because it's spotted early treated early and dealt with very effectively the three S's better to fix time I'll put a fixed Time Regular as monks the stimulants coffee anything that you find that gives you a buzz most people know when they've taken something or yeah I need to be careful about that it's often best to keep below that level uh where you find it's it's affecting you and um obviously trying to limit stress in your life as best you can it's probably true to say that mindfulness in reducing stress in a

person's life will be shown to have a lot of effect on reducing the relapse rate where stress is a factor in a person's bipolar illness the final item is talk over their past when people are depressed but more particularly when they're high they will do things that upset others and very often that gets brushed aside when the person is on well and then the person themselves doesn't particularly want to bring up a thorny subject when they're recovering and the family don't want to do it either in case it upsets the person so it gets swept

onto the carpet but if that happens a few times somebody begins to trip over that carpet and suddenly relationships end marriage's end whereas if the person can be encouraged to bring out the hurts into the open and speak about them openly it prevents prevents that happening so what we advise people is when the person's mood is stabilized not when they're still high not when they're still low when the mood is stable to talk to the person they think they've offended and say look when I was high the last time I called you X Y and

Z or I did such and such or I spent all this money or whatever I need to apologize to you for this I take full responsibility first okay yes it may be illness-based Behavior but if the person is going to benefit from being honest about it and taking ownership of it they have a less chance of doing it again it's just facing the pain of it the relative in question or the friend might say oh no forget about it no the person that friend needs to let the person say what they've got to say if

they shut it up and it's not expressed that friend relative will hold a grumbling resentment that will eventually cause trouble thank you for your attention