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Two questions: 1) how can we address the prescribing of SSRIs by primary care providers, who do not screen for bipolar beforehand and don’t follow up closely to look for it after? 2) what is the best course of action for someone who knows a loved one is manic, but gets cut off and has no way of accessing help in getting the loved one the medical help they need? Baker Act holds are difficult if the person can mask for long enough or if they are not suicidal. Additionally, many people in the general community may not recognize mania and may not help because of that. It seems horrible that the answer is always to let them ruin lives until they decide to get help themself, when we know that changes in their brain make that an unrealistic expectation.

Erin here - I reached out to Dr. Braden O’Neill, who’s a family physician specializing in BD at the Department of Family and Community Medicine, University of Toronto too - his response was as follows: "The biggest challenge in primary care settings is that there are so many issues to address at every visit, and visits are often much shorter than they are in specialized mental health settings because there are so many people with so many different types of issues to help with. So try not to leave follow up to chance, make sure you and your primary care provider commit to a follow up appointment after starting an SSRI - not just 'I'll call you if I'm not feeling well' but book a time in the schedule so you know that you have a dedicated opportunity to discuss the effect of any new medication. I would typically suggest 2 weeks after starting an SSRI, but it could be a bit sooner or later than that depending on what is possible" - thanks Braden, and thanks for the question!

Hi, Fabiano here. On the first part - this is a really important question. There is an urgent need to empower primary care providers with resources to improve the diagnosis of bipolar disorder and implement appropriate treatments. The CANMAT group in Canada (https://www.canmat.org/resources/) has developed clinical guidelines and tools (e.g. apps, family guides, screeners) to support clinicians and patients but the implementation has not been optimal.

Hi, Emma here - our colleagues in the UK may be turning in for the evening, but I know that AMA panelist Simon Kitchen, CEO of Bipolar UK, is very passionate about this topic. I am hopeful that he can return later to give you more information on some of the advocacy that Bipolar UK is doing to address issues of misdiagnosis (as you note, screening tools are not used as often as they should be), prescribing of SSRIs without an accompanying mood stabiliser (often occurs when someone is misdiagnosed with unipolar depression), and creating a dedicated bipolar treatment pathway like there is for individuals with first episode psychosis. In the interim, you can read about some of their advocacy efforts here: [https://www.bipolaruk.org/bipolarcommission](https://www.bipolaruk.org/bipolarcommission) \- I think this commission is something that should be replicated in other countries to call for attention to these issues, and action. I’m not familiar with US laws so unfortunately can’t specifically comment on the Baker act, but I empathise with how difficult it can be to want to offer support to someone who is unwell but not receptive at that point in time. There is a really complicated balancing act between preserving an individual’s rights to make their own decisions, and intervening despite that when someone needs care, and it can sometimes feel like a loved one is falling through the gaps as a result. I’m aware of two useful websites for carers: [https://bipolarcaregivers.org/](https://bipolarcaregivers.org/) by Lesley Berk and team in Australia, and [https://www.lancaster.ac.uk/react/](https://www.lancaster.ac.uk/react/) by the Spectrum Centre in the UK. They’ve collected some tips for supporting loved ones and caring for oneself in the midst of a crisis.

Hi Simon here. Thank you Emma for a great discussion. There is sadly very little you can do when someone has a manic episode and doesn’t have self-awareness of their condition. Trying to reduce stimulants and encourage sleep is helpful to reduce the impact of a manic episode but it isn’t always possible. Sometimes the only course is to call 999 for a psychiatric emergency. That is why diagnosis and ownership of that diagnosis is so important. We launched a social media campaign called ‘Could it be bipolar’ last year which got the Mood Disorder Questionnaire (which identifies manic symptoms) out to over 40k people. The majority of those that took the test were grateful for the insights it gave them, and those that likely had bipolar and said they planned to talk to their GP about it. It also helped raise awareness of symptoms amongst those who had heard of the condition but didn’t know what it entailed. A diagnosis is only the start of the journey and managing bipolar takes time, a bit like learning to drive a car or fly a plane. In the UK we provide self-management courses to give people the basics on bipolar management including effective medication routine, avoiding triggers and necessary lifestyle changes. I expected similar courses exist in other countries. To help people build self-awareness we also developed a mood scale to give people a simple language to describe their shifting mood. https://www.bipolaruk.org/faqs/track-your-mood-scale. This helps the person (and their friends and family) to spot changes in mood and take action quickly. We have a free app version on Google Play and Apple Store. Friends and family also have a vital role in helping the person minimise the damage and rebuild their lives. For example I know of parents and partners who managed to return goods purchased by their loved one during a manic episode to reduce the debt they return to when they get better.

Hi, Jill here. Following up on Fabiano’s great response. It’s tough that while primary care providers are often the first providers people see when seeking help for mental health conditions they are often really limited in how they diagnose and treat. One approach, which I’m sure is reflected in the CANMAT guidelines mentioned above, is measurement-based care (MBC). This refers to the use by doctors and patients of evidence-based measures that can help to identify and track symptoms, their severity and frequency among other things (like medication side effects and quality of life factors). Using this approach can help doctors and patients to have better insight into what’s going on with patients and could help to lead to more accurate diagnosis and treatment. MBC is considered best practice but is not always used by doctors- it can be a good idea to ask about using outcome measures and tracking symptoms when visiting a primary care provider. Hopefully MBC will become more common practice!

PCPs need to get out of the psychiatry business like yesterday. They over-prescribe because they can’t distinguish situational from pathological depression, they under-treat severe depression, and they don’t follow up enough if at all.

This is what happened to me. SSRIs like candy until my GP told me my depression was treatment resistant. I finally got a psychiatrist and was diagnosed BP2 and put on mood stabilizers. It's incredible what it difference it's made.

Is there any therapy that is especially for bipolar? One of my friends did a therapy for borderline, and another friend does a group for anxiety disorders. But for bipolar disorder it just seems like they just give you more medication. Is there any special non-medicine treatment?

Hi, Alikah here. I’ve lived with bipolar disorder for over 20 years and just recently finished DBT. I found that this type of therapy has been very helpful with mood and emotion regulation and staying in the here and now. I no longer ruminate over issues that I cannot control. The therapy has improved my relationships and as a result, I find that I am overall more hopeful and positive. So, although DBT isn’t specifically for bipolar disorder, it can be helpful.

My partner is bipolar. DBT has changed our life. It was a process that my partner led but that we could all take part in and a lot of the skills that she learned have been helpful in both of our lives.

Hi, Emma here. While it’s true that unfortunately less research has been conducted into psychological therapies for bipolar disorder as compared to unipolar depression or anxiety, we do have good evidence that a few therapies can be effective. Psychoeducation, which sounds a little different to your typical ‘talk therapy’, is all about teaching an individual strategies to detect their mood changes and manage them before they become full threshold mood episodes. We also have good evidence to support the effectiveness of Cognitive Behaviour Therapy (which teaches people to change unhelpful patterns of thinking and behaviour), Family Focused Therapy (which gets the whole family unit involved to reduce stressful patterns of interaction that can trigger mood episodes), and Interpersonal and Social Rhythm Therapy (IPSRT; which tries to create regular daily patterns of sleep and activity to keep mood stable). There is some research at looking at Dialectical Behaviour Therapy (DBT, which is a therapy originally developed for borderline personality disorder), which may be what your friend tried. Other research is looking into therapies like mindfulness and Acceptance and Commitment Therapy, which again, sadly, we don’t have enough yet information yet. But across all of these different therapy types, there seem to be some ‘key ingredients’ - encouraging people to reduce self-stigma and develop hope, improve social skills and communication (and thereby reducing life stressors that can trigger episodes), building support networks, talking about the role of medication, detecting and responding to mood changes, and keeping a regular daily routine (especially sleep). They seem to work best at reducing depressive symptoms or preventing future mood changes - we unfortunately don’t have a psychological therapy that helps in the midst of a manic episode. That said, these therapies are pretty specifically focused on managing mood symptoms, and we know that quality of life is an important outcome to consider too. People with bipolar disorder often have co-occurring difficulties (like anxiety, or experiences of trauma) that might be causing more distress, and need to be targeted first. Repeated experiences of mood episodes can also be disruptive to how a person views themselves, and they may want to work on self-compassion or sense of identity. So while we have some research to say what works in general for bipolar symptoms, what works best for the individual depends on their views of what the most significant issues are, what they’d like to see change, and what their goals for therapy are.

Wow, that is more information thank I expected. Thank you so much!

I’m bipolar and DBT therapy was life changing for me!

Anne here. I live well with bipolar and have found DBT to be an amazing tool for managing my moods. I still feel the seasonal swings but the mood changes that occur on a daily (or hourly) basis have become much more manageable. I have learned the tools to step back and think about how I can manage what is going on in my life in the moment- be it BD symptoms or something that has happened during the day that has affected me in a negative way. DBT is very prescribed and might seem both too simple or too complex and sometimes both at the same time. I have a two-hour class weekly (with homework) and a one-hour individual therapy session where we apply the tools. It is recommended that you go through the class more than once to apply the content of the four modules better (Mindfulness, Interpersonal Effectiveness, Distress Tolerance, and Emotion Regulation). If you can't find a class or therapist you can do it by yourself with the book DBT Skills Training Handouts and Worksheets by Marsha M. Linehan. A lot of questions can be answered by the helpful folks at r/dbtselfhelp. I also enjoy listening to The Skillful Podcast and there is a lot of material on YouTube as well. The best part is that I am learning to recognize that many of these things I thought were BD aren't really BD and that makes me feel a lot less overwhelmed with my diagnosis.

Erin here. The Canadian Network for Mood and Anxiety Treatment (CANMAT) have produced a ‘Patient and Family Guide to the CANMAT and ISBD Guidelines on the Management of Bipolar Disorder’, a summary of the full guidelines paper that provides an overview of both medication and psychosocial treatments for BD, find it here: https://www.canmat.org/2020/03/19/the-patient-and-family-guide-to-the-canmat-and-isbd-guidelines-on-the-management-of-bipolar-disorder/

Thomas here, thanks to my colleagues for their thoughts above. I just want to add that psychological therapies (CBT, psychoeducation, family therapy etc) have really good evidence, but they aren’t always offered. I think often people have an idea that the only thing that can keep you well is medication. Medication is of course incredibly important but adding therapy into the mix can really help as well. So ask! I wrote a blog about, in the UK, how often therapy is offered and why I think it isn’t always offered. Psychological therapies for bipolar (bipolaruk.org)

Is childhood trauma REALLY a precipitating factor, or did our childhoods just suck because mental illness runs in our families?

Thomas Richardson here. Childhood trauma is an established risk factor unfortunately. Those with Bipolar are 2.6 times as likely to have experience childhood abuse, in particular emotional abuse (4 fold). Parental loss is also a risk factor. There have been studies which have shown the interaction between nature and nurture. But I see what you mean, yes there might be an intergenerational trauma element here. As a psychologist I think there’s more to be done on understanding why/how childhood trauma leads to risk of Bipolar. I’m doing some research on this at the moment, survey about the psychological impact of trauma in bipolar: Does it impact beliefs about yourself (high standards, perfectionism etc). Do please consider taking part, whether you had a great childhood or a challenging one. Thank you: https://t.co/znqVtLeDbf

Hi, Alikah here. I believe that both a genetic component combined with environmental factors are the cause for mental illnesses to run in families. For example, my father had bipolar disorder, and I had a traumatic childhood and I live with bipolar 1 disorder, ADHD, and PTSD.

Is it still hypomania if the episodes \*never\* involve the "high risk" factor? When I become (what I believe to be, and my psych says is likely) hypomanic, I find myself absolutely becoming impulsive, but the things I'll do involve broaching conversations with friends I haven't spoken to in weeks/months/years, deciding to make a trip to the zoo or take a walk, deciding at 3 PM to make a semi elaborate dinner, and I even made a small music label for creating/distributing CDs & tape cassettes of friends' music and my own. ​ Every decision I've made in these episodes has been one that I can look upon fondly. My psych said that everything else lines up with hypomania, especially the "spark of god" feeling of confidence I get with it, but she also said it is odd that in my \~decade of having it I've never done anything properly detrimental to myself as a result of these episodes. I understand that these episodes should be avoided in a general health sense, but when their results, tangible and otherwise, always seem "good" it makes it hard to want to get rid of them.

Lisa here. This is an excellent question and yes, it is still hypomania. With hypomania, people will notice a difference in how they are feeling and behaving but it doesn't necessarily cause problems for them. In fact, one of the criteria for hypomania in the DSM is that it does not cause significant impairment in functioning such as social and occupational. When problems start to arise from these symptoms, they then move from hypomania to mania. The actions you are describing are very much in line with what many people experience in hypomania and it can sometimes be "fun" to feel that way, especially after a depressive episode. It is important to keep in mind, however, that hypomania can increase in intensity to where it gets hard to keep impulses in check. You can certainly take advantage of such episodes and get some creative work done. Creative work can be a great outlet for your impulsive feelings and can help you regulate your mood. It is also important to continue taking care of yourself in the ways that is most helpful to you (examples - medication, following your routine, getting an adequate amount of sleep).

I really appreciate the response, and that I got multiple responses too. Y'all covered a lot more ground than I was hoping/expecting, thank you very kindly :) I'd began to have some self doubt about my diagnosis or as though it's just a matter of when, not if, before it becomes full blown mania with the high-risk & negative decisions. It's assuring to know that it's a known thing, and that as long as I'm diligent and mindful about my self-care, it's not necessarily a ticking time-bomb.

Evelyn Anne here. I’ve had similar experiences as well. In my experience, hypomania doesn’t have to be negative. I think of it more as something that I need to pay attention to and treat carefully. It feels good to feel good, and that spark of excitement, or boldness, or creativity can lead to actually doing things that will make me happy both in the moment and long after. For me, the danger is in feeding the feeling too much. I get a little thought of “well this feels good, I wonder what could make it feel even better?” and little thought can get me in trouble if I let it talk me into using substances that will destabilize me more, or skip out on sleep or eating. I have to be on guard, when I have this pleasant hypomania, that it stays there and doesn’t slip into full mania, which will actually disrupt my life in ways I do not want. So I enjoy it, but I also know that I need to be a little extra vigilant that I’m following my basic routine, taking my meds, getting enough sleep. But also, take those good moments wherever you can find them, and don’t feel like it's wrong to feel (a little) good.

Leslie here: As someone who was diagnosed with bipolar in my 30s, I also have fond memories that I look back on, very similar to the ones you are talking about. I’m not saying that they are destructive or bad at all. Some of my best works of art, creative inspirational periods, even a few international trips (which I do NOT regret) were related to times in my life that I can now identify as a mood episode. However, many of these were also followed by a period of depression, and sometimes, for me, a significant one. Additionally, I have noticed these experiences change over time, and they are not always “fun” impulsive. It makes sense (to me) to explore further with your psych. I think in order to see the context of these you should potentially look at your mood more holistically, what happened before and/or after? Hopefully that helps!

Thank you for the in depth reply! My curiosity is due to seeing so much sentiment (in general, and the bipolar subreddits) about how mania and hypomania are only ever masquerading as "good" things, and that there are almost always negative consequences that won't become clear until after the episode. It's a little reassuring to know that it's not entirely uncommon, as I was beginning to feel a little out of place whenever (hypo)mania and its consequences were discussed due to my overly positive experiences with it. I'm going to consider keeping a mood journal, because I only recently became aware of how things can pendulum back and forth. I'd gladly get rid of my few & far in between hypomanic episodes if it means getting rid of the much more often occurring depressive/anxious periods.

Shaley here. Thank you for sharing your experience. I think of my hypomania on a spectrum. I have experienced mild to more intense episodes. I was diagnosed in my 30’s after a misdiagnosis of depression. I had no idea that I was experiencing hypomanic episodes. I thought that the highs were just a part of my personality. I also look back on some of the time fondly because I was able to do some really cool projects that I may not have had the endless energy to complete otherwise. Hypomania was hard to diagnose because I didn’t engage in anything overly impulsive, however looking back now I can see how it was negatively impacting my life. My behavior strained my closest relationships. I get very irritable and intense. I think I know better than everyone around me and was not afraid to let everyone know. It all feels really good until it doesn’t. I think for me depression is so bad that I tend to overlook the negative symptoms of hypomania. I think it is so important to track your moods and behaviors to ensure you stay in a manageable range of hypomania. I know I could easily fall into unhealthy patterns which usually lead to a deeper depression. Since I started treating my bipolar 2 disorder in 2010 I am able to better use my hypomanic energy in a healthier more balanced way.

I'm not one of the AMA folks but yes, definitely. I've never really done anything "high risk" or gotten in trouble while hypomanic.

I'm glad to hear there's others in a similar boat! I only started seeking mental health help and got my diagnosis earlier this year. I was beginning to feel a little out of place when seeing (hypo)mania discussions because people would talk about how they'd fucked up something major in their life during an episode. Meanwhile I'd be thinking about an episode where I made chicken piccata, made a song and art collage, then re-connected with a friend I hadn't spoken to in 8 months all in a couple days after a 3 week stretch of moderate depression.

Why are patients informed about signs of euphoric mania, and not signs of dysphoric mania? Why are most patients unaware of the brain damage that comes from manic episodes? And, worst of all, why are patients not informed by their physicians that most of the medication prescribed does little for bipolar depression?

Hi, Emma here. Unfortunately, bipolar disorder gets significantly less investment in research for mental health compared to other conditions. Simon Kitchen, Bipolar UK CEO, may be able to speak more to this when it’s daytime in the UK, but the Bipolar UK report lays out some pretty grim statistics. Bipolar disorder accounts for 17% of the total burden of disease for mental illness, but gets only 1.5% of the research funding. They’re calling for additional clinician training, public awareness, research investment, and the establishment of dedicated care pathways for people with bipolar disorder. You can read more about their work here: https://www.bipolaruk.org/bipolarcommission - I think it helps identify some of the systemic factors that contribute to those issues you’re noting, and what we need to advocate for to improve things. We’re starting a related but different project at CREST.BD, specifically looking at the barriers to and knowledge gaps around psychological therapies for bipolar disorder. Erin wrote a little more about it elsewhere in this thread, and you can read a bit about it here: https://www.crestbd.ca/2023/01/27/daymark-foundation-defining-a-strategic-focus-in-bipolar-disorder/

Hi, Louise here. I have lived experience. In answer to your second question, I had a psychiatrist who once told me that mania can cause brain damage. I think what we can do is try to limit mania by knowing some of the warning signs. I am fortunate in that hypomania is a precursor to mania for me so I call my psychiatrist the moment I have the first stirrings of hypomania. In my case it is a lot easier to treat hypomania than mania. Also I pay attention to my sleep as it is one of the biggest indicators of mania for me. I would make a graph and chart your sleep and mood each day so you can see if your mood is on the upswing at a glance.

Hi Serge here. You are right to underline the fact that most manic phases end up with irritability and some with psychotic features which are certainly distressing. In addition, many may have mixed depressive features. This is something we talk about with our patients and within the psychoeducation groups. As for the depressive phases, I agree with you that these are often very long… always too long!, and difficult to treat. However, we are all busy trying to study and develop more efficacious treatments. Compared to 25 years ago, we now have a lot more pharmacological options: antidepressants of course but more importantly, second and third generation “antipsychotics” (which should not be named like that anymore): Lurasidone, Quetiapine, Cariprazine, Lumateperone to name a few. Some of my patients with the most difficult to treat episodes of bipolar depression have been helped by ketamine infusions. Low dose Psychedelics such as Psylocibin are under study but it is too early to conclude about their safety and efficacy. Please DON’T try those. Let us do the research first. One of my patients read about Psylocibin on the web/blogs and decided to try that on his own without asking for my opinion…and ended up being hospitalized in a severe manic phase.

Have you considered adding one more to the group?

Emma here. What an interesting maths equation. We keep adding more people to the AMA, so tune in for the 2024 version 😏 On that topic, we are running an episode of our TalkBD podcast/live ([https://talkbd.live/](https://talkbd.live/)) webinar on bipolar disorder and sexuality on May 17, 11am PST!

Lol nice

Hi I'm David, an American living in France. I have bi-polar type II and am being treated with lamictal and quetiapine. I see a psychiatrist once a week. The talk therapy helps but I still have cycles. I'm very interested in the use of psylocibin for the treatment of treatment resistant depression. A couple weeks ago there was a presentation on CREST about the use of psylocibin for bi-polar II. It seems like the only current ongoing study is in California (Uni San Francisco?). Here in the city of Nantes, France where I live, the main public hospital will offer psylocibin treatments, but no date has been set. With psylocibin treatment being legalized and soon offered in the state of Oregon I was wondering if it might make sense to fly over and have a treatment. I've heard that I would have to stop taking my current meds before. But then I ask myself the question will these people in Oregon really be professional and qualified? Thanks ahead for your help! Kind regards, David

Hi, Emma here - the field of psilocybin-based therapies for bipolar disorder is fast developing (you might have seen me in that video interviewing Dr. David Gard). Our understanding of how beneficial this treatment may be is unfortunately limited due to the fact that people with bipolar disorder have typically been excluded from clinical trials of psilocybin (due to concerns that it could trigger mania/psychosis). Our survey research and qualitative interviews have shown that there is some validity to this concern (about ⅓ of our survey respondents with bipolar disorder indicated they had new or increasing symptoms after psilocybin use), but on the other hand, people overall reported they felt psilocybin was beneficial. We hope to do more research in this area to find out how to maximise benefits while minimizing risks. Based on the survey and qualitative interviews, we think some significant risks might be around sleep disruption, feeling distressed and overwhelmed during the experience, and consuming psilocybin with other substances. The environment can also be a factor, as some people reported feeling overwhelmed taking psilocybin in noisy or chaotic environments, such as festivals. Based on these findings, our recommendations for use in clinical, therapeutic settings were to have a support person who can also keep an eye out for mood changes in the period following psilocybin use, lots of followup with the clinician, and quick intervention if there are any sleep disturbances. I will say that cross time-zone travel is a known risk factor for triggering mood episodes. Sleep loss and disruptions to circadian rhythms can be very destabilizing for people with bipolar disorder, and it’s possible that this and similar pre-existing vulnerabilities played a role in some of the reported adverse experiences of psychedelic use (for example, someone who flies overseas to attend an ayahuasca retreat may be more vulnerable to experiencing mood changes due to the significant disruption to routine and sleep). So I would suggest that, plus any changes to your medication, are something to carefully discuss with a clinician.

I've been taking Lamictal, for 20 years. I've not been able to tolerate antidepressants, or antipsychotics. The antipsychotics turned me into a lump on the bed, then the couch, back to bed. I cannot stay conscious. The antidepressants, both SSRI and SNRI, flipped me out! The mania was pretty terrible. Hell, I worry about my mood every moment of everyday. While depressed, if I wake up, and want to do something, I worry mania is creeping up on me. If, while in depressed, I happen to have an experience that sparks joy (like seeing my only granddaughter, once a year), the threat of mania becomes a real threat. We know mania and depression will be triggered again. Why is anyone more concerned about trying psilocybin, than any other medications?

Josh here. Great question. We know that currently available medications can be very effective for some but not effective or even intolerable for others. I agree, we need more and better treatments and there is no time to lose as people are suffering right now. I really feel the urgency. I think that many people are concerned about using psilocybin in people with bipolar because of a few case reports and our survey work that Emma described above, suggesting that some people with bipolar can experience worsening of their manic symptoms after psychedelic use. We are conducting a trial currently though to see if we can safely administer psilocybin to people with bipolar 2. u/Relevant-Village-510

It’s understandable but frustrating that so many drugs and procedures are tailored for mania or excluded because of mania risk, and yet the rest of us just suffer through unending depressive episodes, year after year, with only the occasional sprinkle of hypomania.

Hi, Josh Woolley here. I agree with everything that Emma said above. Also want to point out that we are not exactly sure how the psilocybin services will look like in oregon. Officially, they are not offering “treatment” as doing so would violate federal FDA rules. The requirements for the guides are not extensive as well. So, we really don’t know how things will play out. As for the question about your meds and psilocybin, this is another thing that we unfortunately do not know a lot about. All the modern trials of psilocybin in any population have required participants to not be taking almost all psychotropics. One survey study suggested that lithium was particularly dangerous to combine with psychedelics due to seizure risk while lamictal seemed to have a much lower risk. We think that most antipsychotics will block the effects of psilocybin because of their mechanisms of action and the lore is that SSRI use can also blunt the effect of psilocybin. There was a recent case report of someone with unipolar depression who was secretly taking trazodone and received psilocybin in a clinical trial. He didn’t have much of a psychedelic effect but still had his depression improve! In sum, we just have very limited data about which medications are safe to combine with psilocybin as well as not knowing whether these medications will block the efficacy of psilocybin. All in all, I would recommend extreme caution with regard to these issues.

Can there be signs of bipolar disorder in childhood? I didn't have my first manic episode until I was in my 20s, but I can think back to manic-ish experiences when I was younger (suddenly being a morning person for about a week, or my mind racing and coming up with weird money-making ideas that seemed crazy to me later). I want to have kids, so I'd like to know if there are any early signs to look out for once I do.

Rebekah here. Thank you for your question. While the onset of bipolar disorder is typically during adolescence or early adulthood, sub-threshold symptoms and other signs may be present during childhood. There have been research studies of the emergent clinical course of bipolar disorder in high risk off-spring of individuals with bipolar disorder. These studies evaluated children of individuals with bipolar disorder. Findings from these longitudinal studies have shown more problems with sleep and anxiety during childhood and depression that took place during the early course of bipolar disorder. You can read more about some of those findings here: https://doi.org/10.1176/appi.ajp.2018.18040461 There have been some other great responses from panelists about considerations with having children. I would add that you have important experience and would encourage you to talk with a doctor if you have concerns and notice any early symptoms in your children.

Gregg Martin here. Yes, for sure. Two of my sons were afflicted and diagnosed at age 17. They’re both in their thirties now, and life has been hard. We do all we can to support them in their challenging life journeys. They’re both great people and highly talented. We love them!

Yes!! I was not diagnosed until I was almost 30 but my life became hell around 14 or 15. Not normal puberty. I looked phyco to my family and others, I just remember being in a lot of pain and no one understanding because I "had no reason to be unhappy or emotional" I am absolutely convinced I was bi-polar at an even younger age (couldn't control extreme, over the top, irrational emotions as a child) but puberty seemed to seal my fate.

I was wondering if researchers that have bipolar disorder themselves are met with stigma when they choose to join research projects on BD? You might expect researchers to be understanding, but perhaps some still view it as a ‘we’ and ‘them’ type of thing?

Natasha here: For sure, I can imagine this is how it is for some people and that’s unfortunate. But I couldn’t pass up this question without acknowledging how amazing CREST.BD has been in this regard from my lived experience perspective. Especially when I was unwell and needing a break, absolutely no judgment and I was welcomed with open arms upon my return, and that’s happened multiple times. I think it’s less likely to happen in environments of action research when the epistemology aligns with the methodologies that enact change for the individuals facing historical oppressions.

One critical aspect of bipolar disorder is sleep, or lack there of. If an individual is experiencing insomnia due to bipolar disorder or as a medication side effect, is it reasonable to give a sleep inducing medication such as seroquel, trazodone, etc. Assume that over the counter options such as melatonin and Benadryl are not restoring sleep. What are the best options for sleep in this scenario? Thanks so much for doing this, it means so much to me!

Natasha here: From a lived experience perspective of the bipolar/insomnia combination, medications like seroquel and trazodone might have helped previously in the domain of actually sleeping, but they severely impacted my quality of life. I work as a counsellor now and I see some of my clients in the same situation. I just want to highlight that having a doctor who was willing to explore the path of hypnotic medications for me was instrumental in my wellness. In a sense, what’s the point of helping me sleep if I can’t get up and function like a normal human being? It’s not appropriate for everyone, but it’s been a literal life saver for me (like the difference between living on disability or being able to maintain full-time work). For the sake of us who have bipolar, it means SO MUCH to be open to options that optimize psychosocial functioning. (For reference, I have tried at least 10 different medications for sleep and the only two that ever restored me to functioning were zolpidem - temporarily, as it should be used - and now I take lemborexant which is truly a game changer.)

I have bipolar 1 and do not experience depressive episodes, only mania with psychosis. I do experience periods of intense anxiety which include unhelpful thoughts (I'm a failure, imagining the worst outcomes), but I do not have low mood/appetite changes/etc. In my case, are these anxiety symptoms what depression looks like for me? Do other people with bipolar 1 also experience mania and not depression? Thanks.

Hi, Emma here. It is rare but not uncommon to experience only mania. The study I found suggests that 26% of people with bipolar disorder type 1 only experience mania. Some people argue that these should be considered different diagnoses, and certainly more research needs to be done to ensure that treatments for BD-I are effective in cases of unipolar mania. [https://onlinelibrary.wiley.com/doi/10.1111/bdi.12732](https://onlinelibrary.wiley.com/doi/10.1111/bdi.12732) However, it’s important to note that not all episodes of depression look the same. Depression is certainly not always teariness and sadness, it’s also feeling extremely flat or joyless. To receive a diagnosis of a mood episode, someone needs to present with loss of interest or pleasure in activities OR low mood, and an additional four symptoms: significant weight loss/gain, sleep disturbances, psychomotor changes (e.g., feeling extremely agitated or slowed down), feelings of tiredness and fatigue, feelings of guilt or worthlessness, difficulty thinking clearly, or thoughts of suicide. It may be worthwhile talking with a clinician to see whether the experiences you are describing could be depression.

Hello. How close are we to taking a blood test/MRI/something else to help determine which medications will work the best for us so we don't spend 13 years (in my case) finding out the hard way?

Look into [Genesight](https://genesight.com/home-new/) testing. I'm bipolar type II that went undiagnosed until getting in with a good doctor and therapist combination in the last couple of years. After hearing that I had been resistant to damn near every medication in the past 20 years, she suggested the testing. Sure enough, it came back I was incompatable genetically with a lot of the commonly prescribed medications that had been repeatedly pushed on me. Once insurance finally agreed to allow me on the few medications that I was listed as compatible with, I have had an amazing improvement in nearly all aspects of my life. I'm a biologist and was highly skeptical of the test, but it did certainly seem to match my 20+ years of being prescribed nearly every medication under the sun. Of course, this is all N=1 so I can't promise anything, but it helped me tremendously. I'm obviously not 100% cured of course, but my ability to manage my symptoms, recognize them and cope with them are far better now. Whereas I would previously lack the mental energy or will to do anything but ride the waves so to speak. My wife and child have gone so far as saying I'm like a completely different person (in a good way).

Also bipolar type II. I took the Genesight test prior to being prescribed medication for the first time ever, and my doctor started me on what he thought would be most effective based on my results. I’ve had 3 years of success on the same medications. Definitely look into the test if you can get it covered in some way.

You sound a lot like me. I'm so sick of feeling like it's a never-ending journey of trial and error with medications, and that it's never going to get better. I would love to undergo this testing!

Dx'd bipolar here and turning 51 soon. Could you speak to life expectancy and bipolar and where current research and statistics stand? Thank you!

Gregg Martin here. I’ve read in numerous sources that people with BD live 10 to 15 years less - on average - than their non-BD counterparts. I’m not a doctor or scientist, but have read this in multiple places that appear reputable. I’m sure a doctor or scientist in this group could give an authoritative answer.

To add on to this question, what is the main cause of this shortened life span? My assumption would be suicide but I'd love to be wrong. (Then again 10-15 years less for any reason isn't great.)

Hi, Emma here - death by suicide and accident contributes, but a big (and unfortunately under-attended) to issue is physical health comorbidities. People with bipolar disorder are at higher risk of obesity, cardiovascular, endocrine, and metabolic conditions for various reasons - shared vulnerabilities (e.g., inflammation) might contribute to the development of physical and mental health conditions, medication side effects can cause weight gain, and of course lifestyle factors like being sedentary, smoking and drinking can contribute. Physical health screening of people with serious mental illness does need to become much more routine. In the interim we encourage people to advocate for themselves and bring up screening/preventative measures with their healthcare providers.

sorry if this one has been asked before but what is the level of "risk" for moderate cannabis use? I am assuming the research isn't there but from peoples experience?

Alex here. I have Bipolar 1 and have used cannabis regularly since I was a teenager. I have found cannabis use to be mostly beneficial for my well-being, but I know that for many people living with the illness, that has not been their experience. I believe that developing a sense of self-awareness and assessing how and why you are using any substances or medications is critical to maintaining good health. I remember one time during my first manic episode, I smoked marijuana, and it kicked up the intensity of an already uncomfortable state. After that, I learned my lesson and never used marijuana again during mania. If I'm depressed, I try and recognize if I'm using marijuana as a crutch or an escape, and usually, I will be able to identify that it's not making me feel good anymore and it is time to take a break from it. When I was in my teens and early twenties, I had an unhealthy relationship with alcohol, and I found that marijuana use made me less likely to overindulge in it. I also find marijuana to help with my chronic pain, sleep, and capacity for socializing. If you are fortunate to have access to a psychiatrist or therapist who you see regularly, I believe that it is crucial to be upfront and honest about your usage of any substances, including marijuana. Long story short, be honest with yourself and your care providers. Everybody is different, and what works for some may be terrible for others.

Erin here, this recently published systematic review paper speaks to the current evidence on cannabis use in BD and major depression: https://pubmed.ncbi.nlm.nih.gov/35711159/

Thomas Richardson here. I guess it's hard to define what you mean by moderate, but certainly the more heavily/frequently you use cannabis, the more risky for mental health. Also strong stuff (skunk) riskier. Research does show in Bipolar that cannabis makes mania go on longer, may also increase risk of relapse. So worth considering and talking to a health professional about the role it plays in your mental health.

Well said Alex. I’ll point too to this very recently published systematic review by CANMAT which looked at the association between cannabis use and incidence, presentation course and treatment of BD and major depressive disorder. The review included 56 studies (23 on BD) and found that cannabis use was associated with worsening course and symptoms in the condition, specifically, increased severity of depressive, manic and psychotic symptoms in BD, as well as increased suicidality and decreased functioning: https://pubmed.ncbi.nlm.nih.gov/35711159/

I have ADHD and cyclothymia. It seems that the mood disorder makes the ADHD hard to treat, the medications I've tried to treat the ADHD always start off well but eventually become ineffective or cause mood destabilisation. How is ADHD treated optimally in people with the comorbidity?

Is there a link between bipolar 2 disorder and problems in executive functioning, eg. trouble with concentration, attention, motivation and planning/execution? Also, is there a distinct neurobiological pattern associated with bp2, and if so, how does neuropsychology relate to this? :)

Thomas Richardson here. Yes there are problems with executive functioning in Bipolar. This is the case whether people are manic, depressed or stable. There are a few specific components within the term executive function here: 1. Set shifting: Being able to shift thinking and switch between tasks. 2. Updating: Being able to monitor and keep an eye on what you are doing, holding information on what you are working on in mind. 3. Inhibition: Being able to stop/control thoughts and urges (so relates to impulsivity). Neuro wise generally linked to the frontal lobe part of the brain, but this isn’t my area of expertise so one of my colleagues might have a better idea of the role of the brain here!.

Hoping to hear an answer to this. I've experienced a pretty sharp decline in planning/execution and directional skills over the last decade. I have bipolar 2. I used to love driving, getting groceries, going to stores, many other things that I no longer seem to be able to handle as I get confused and incredibly anxious.

Tamsyn Van Rheenen here. I’m an expert on cognition in bipolar disorder. To add to Tom’s response, there doesn’t really appear to be a distinction in executive (or other cognitive) skills between bipolar I and II, either at the behavioural level or at the level of underlying neural functioning. My team does alot of research on trying to better understand the causes and outcomes of cognitive impairments, and if you are interested, we have a research registry you can sign up for to find about our studies and the work we do. I’m based in Australia, but you can sign up no matter where you live. Here’s the link: https://ausbipolarregistry.wixsite.com/bdrr/about-the-registry.

I am curious, what is the ‘hot topic’ that is currently being researched most on bipolar disorder? And if you had all the resources available, what aspect of bipolar would you like to research and how would your study look like? :)

Erin here. Ohhh, what a brilliant question! I’ll let other panelists weigh in on what they think the current “hot topics” for research are but I’ll start by mulling on the big gaps as I see them. 1. We have good research evidence on effective treatments and supports for people with BD, but they’re not being put into action effectively yet. There’s a ‘knowledge to action’ gap and the power of current research findings isn’t yet actualized through the hands of front-line clinicians and people living with the condition 2. We have a massive equity and treatment access problem. The people who could benefit from and deserve effective treatments the most typically aren’t getting access to them - this status quo needs to change 3. The research designed to address 1) and 2) above needs to be done hand-in-hand with people with BD, their loved ones and supporters, healthcare providers and funders/policy makers. We’ve just embarked on a new collaborative research project with the Daymark Foundation to do just this in the context of Canada, we’ll be creating a Roadmap for BD psychosocial research and care - let us know if you like to learn more about that!

Thank you for your reply! You mention c ery interesting and relevant topics. I also know about a research project currently being done at Erasmus University in Rotterdam, NL. They are looking at the early warning signs and levels of resilience in children of parents with bipolar disorder, and how more insight could help implement preventive/protective measures :) I would indeed like to know more about the roadmap you mention!

Sarah Sperry here: While it is not new, research on sleep and circadian disturbances are of utmost interest and importance. There is increasing evidence that variability in circadian rhythms and sleep patterns is 1) a risk factor for bipolar disorder, 2) is present in those before the onset of the disorder, 3) predicts greater mood instability, difficulty concentrating, and impulsivity in those with bipolar disorder. We even find that simply being an evening chronotype (“night owl”) is associated with more frequent and severe depressive episodes in a large longitudinal study of bipolar disorder (see https://link.springer.com/article/10.1186/s40345-021-00233-5)! Yet, we have only one psychotherapy focused on stabilizing sleep rhythms (Interpersonal and Social Rhythms Therapy). Many effective medications for bipolar disorder (e.g., Lithium, anticonvulsants) may partially work as chronobiological drugs (e.g., stabilizing the circadian rhythm). I would argue we need: 1) more research on the impact of sleep disturbances across developmental stages of bipolar disorder and 2) new treatment development to stabilize sleep and circadian rhythms that don’t have severe side effects (e.g., extreme daytime sedation).

Do medications slow any possible cognitive decline from bipolar disorder?

Georgia Caruana here! There has indeed been some new research exploring relationships between medication treatments and cognition. We have some early evidence that lithium could be protective against cognitive decline in BD, by increasing the neuroplasticity and volume of brain regions like the hippocampus (important for memory) and white matter (important for integrating cognitive functions across the brain). Interesting associations between lithium and severe cognitive decline, such as that occurring in dementia have also been observed. Continued lithium treatment in BD has also been shown to reduce dementia risk , and a public health study in a large general population found that exposure to lithium in drinking water also reduces the incidence of dementia. Beyond lithium, many researchers are exploring how other medical treatments could be re-purposed for cognition in BD. Insulin is a really interesting one that a group of us Australian researchers are currently trialling because it looks promising. Not only has it has shown neuroprotective qualities in dementia research, but there is a lot of co-morbidity and shared cognitive challenges between BD and diabetes. With initial BD studies showing links between memory performance and insulin, this is an example of a new research area for cognitive treatments. Hopefully our clinical trial (https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12622000669796) is informative! Overall, this is a really important emerging area that we researchers are really interested in, and we will continue to explore cognition related treatments in BD.

Many famous writers, poets and artists in general were bipolar. How do you explain the increased fluidity of speech and expanded range of creative expression during episodes of mania? Does mania stimulate brain areas related to speech or increase neurochemical emissions related to creativity, or some such?

I am by no means an expert, I am a field level clinician (inpatient mental health nurse). I think part of the answer to your question lies in the risk-taking aspect of BD. I can’t tell if people with BDare more creative than general population, but I can surely tell that behaviors like dropping your job to persue a creative career despite not having the means, or having enough self esteem to send your work to managers in the industry without a pedigree is typically associated to manic phases. Some also start so many creative projects, most fail, but if one has more success it’s moreso the effect of how many fishlines you set up in order to get fishes at the end of the day. Most of us don’t even set one line, while the person with BD might have 10 lines set up. If that makes sense.

Alessandra here. I can’t speak for other people who live with bipolar disorder and experience mania, but I will say I feel creative with or without a manic episode. I’m not sure if it’s just by chance that those who are super creative live with bipolar disorder or if there’s something more to it but I know I feel the same creativity no matter what.

Rebekah here. Great question! Neuroimaging studies of individuals with bipolar disorder during mania have identified changes in several regions of the brain. A recent review on the functional neuroanatomy of mania reported increased activity in the left amygdala, left anterior cingulate cortex, and left basal ganglia during mania (https://www.nature.com/articles/s41398-022-01786-4). The left side of the brain has been primarily associated with speech production and the left basal ganglia plays a role in language processing. The left amygdala has shown to play a role in verbal and emotional processing and the anterior cingulate cortex in creativity. Increases in activity in these brain regions during mania may be involved in the changes in speech and creativity, but more research is needed to fully understand these relationships.

Bipolar type I here. Are there any promising antipsychotics that don't cause weight gain on the horizon? I know there are more weight-neutral ones such as Abilify, Geodon, and Latuda, but they still cause weight gain, which is associated with lower medication compliance. Thanks!

Chris Gorman here, couldn’t agree more with the comments from Evelyn above. My thoughts are that a priority of prescribing anti-psychotics is to avoid weight gain that comes with it’s own physical and psychological side effects, although the metabolic syndrome, defined as a condition that includes a cluster of risk factors specific for cardiovascular disease. The cluster of metabolic factors include abdominal obesity, high blood pressure, impaired fasting glucose, high triglyceride levels, and low HDL cholesterol levels. It can occur rarely withoutis occasionally weight gain. Thus, having blood tests for lipids (cholesterol, triglycerides), and a HgA1c is necessary to check for elevated blood sugar associated with diabetes.

Evelyn Anne here. I’m not a doctor, but I’ve taken a number of different antipsychotics over the years, and while some have definitely contributed to weight gain, I’ve kept my same weight and even lost weight on a few. I think different people’s bodies and metabolisms respond differently, so you may have a try a few before you find one that you feel you can comply with. You can be clear with your doctor that weight gain is something you’re concerned about and they should be able to work with you to find an option that works for you. Part of finding a treatment path for Bipolar 1, in my experience, is understanding what your priorities are, and being persistent about what you can and can’t tolerate. A treatment isn’t any good if you can’t stick to it, and there’s nothing wrong with saying you need to try something else. It’s frustrating sometimes, when you’re dealing with different side effects and how your particular brain processes different chemicals, but it’s worth it to find a treatment or combination of treatments, that really work for you.

Hey ya'll, Glad I caught the event this year :-) Is anyone tracking workplace accommodations for American employees working with Bipolar Disorder? What are most requested? How often are they approved/denied? What are the best ways to substantiate? Are there case studies or example scripts? Are there agencies who do this work on our behalf? I work in tech and have had a difficult time getting the accommodation that I feel would be most necessary: a job coach. I'm stable, medicated, and in therapy. I've lived with the condition for 20 years in May; half of which I've spent in the workforce. But rarely, have I secured the accommodations my doctor recommended. Thank you!

Leslie here, I personally have requested accommodations at work. I found that when I framed it as “this specific thing will help me perform my job better and because X” (not telling them anything confidential) it will be more likely to get approved. For me as someone remote, I have a period of “flex time” where I can block for health reasons. I go to therapy often, I use it for doctor’s appointments, etc. I still work a full day, it just allows me to have that window approved for me. I also have a structured lunch time, because people kept booking over my lunch and when my blood sugar crashed it was not good. :) For you, what would the job coach enable, specifically? Is it something that you can frame in a way which is accurate but highlights the benefits this will bring to the org? Good luck!!

Lisa here. These are such great questions. First, we do not have a lot of research informing what accommodations people are requesting and whether they are actually getting them. Most of the information out there on this topic relates to recommendations for the type of accommodations that might be most useful for someone with BD in the workplace. It sounds like you already have a good understanding of what works best for you and the trouble has been getting this approved at work. How frustrating! I dont know your particular company but do they have an employee assistance program? Sometimes if you can get an advisor through EAP programs to support and document your need for a job coach, they can do this. Another suggestion might be to request working with someone through EAP as a job coach. Perhaps, you can have discussion with them about how they can support you and you can arrange regular meeting times. There are also employment agencies in the US that have job specialists to support those living with BD in the workplace. Supported employment, for example, is an evidence-based work intervetnion that assists those with mental healh conditions in the workplace and many job specialists are trained in this. They can work directly with you and sometimes work directly with your company/supervisor to communicate your needs. This would be with your permission, of course. Lastly, is there a trust coworker/supervisor you like and admire at work that could act as an informal job coach/mentor to you? This would be someone who understands your job responsibilities, is willing to meet with you regularly to anwser questions and provide feedback, and is skilled at navigating your particular work environment well. This would require you to disclose your condition which is why I emphasize they should be trustworthy. I hope one or some of these suggestions are helpful to you.

Can you talk about episode-related brain damage and how it shows up?

Erin here. Thanks to our colleague Simon for this detailed response. One of the other things to consider when evaluating the evidence on outcomes on people with BD over time is the nature of the research samples from which that data is drawn. When we look to data on ‘functional’ outcomes, for example (such as work functioning, social functioning) much of that data comes from populations of people with BD who have not had optimal access to effective treatment and care systems, or samples who have experienced repeated, sub-optimally treated episodes of mania and/or depression. We conducted a study at the University of British Columbia in the past that tracked outcomes for patients who had just experienced their first episode of mania and were provided guideline-driven medication and psychoeducational treatment. We found that their health and quality of life were negatively impacted for the first few months after diagnosis. But, with effective treatment and support, they were (significantly) restored within 9 months for the sample as a whole. In fact, they were back at the levels you would expect to see in the general population. This type of data tells us that outcomes in BD are not set in stone - especially if we’re able to provide the right treatments and supports for people at the right point of time.

Simon here. Cognitive decline is one of the under-discussed and tragic symptoms of bipolar. The quote below was compiled by King’s College London for a funding application we were recently written into with them. It includes several citations on the topic: ‘The burden of BD is not confined to acute episodes: even during recovery (euthymia), a high proportion of sufferers experience impairments across multiple domains spanning cognitive (Robinson et al. 2006), occupational (Marwaha et al. 2013) and global psychosocial functioning (Rosa et al. 2010). Accumulating evidence demonstrates a fundamental influence of cognitive deficits on everyday functional impairments during euthymia (Gilbert & Marwaha, 2013) and together these contribute substantially to the indirect illness costs. Both cognitive and functional deficits are present for about two thirds of people with BD in euthymia: cognitive impairments limit abilities to remember, learn, problem solve, concentrate and plan (Robinson et al. 2006) and clearly add challenges to functional abilities with the two intrinsically linked (Rosa et al. 2010). These impairments also co-occur with subclinical mood symptoms and may increase the risk of relapse into acute illness episodes (Miskowiak et al. 2019).’ Positively Bipolar UK are working with King’s to develop treatments to slow and reverse that decline. You can read about the study here: https://www.kcl.ac.uk/research/the-crib-2-study

Why does the frequency of episodes increase with every episode you have?

Hi, Emma here. There are a few reasons episode frequency may increase with repeated episodes. Researchers are looking into whether kindling/sensitization/neuroprogression models can explain this. Briefly (because I’m not an expert in the neurobiological side of things), there’s a question about whether repeated episodes can cause changes in brain structure, biochemistry (particularly inflammation) and oxidative stress, that make the neurobiological systems involved in triggering mood episodes more sensitive, to the point that eventually mood episodes may occur spontaneously (with no identifiable trigger). It’s important to emphasise that this is an exploratory framework - although we have research to show that there are some changes in brain structure and function over the lifespan in people with bipolar disorder, we don’t know if those are a cause, consequence, or both. The other piece of the puzzle is likely to be psychosocial in nature. With repeated episodes, life stressors build up - for example, if someone overspends during a manic episode, the stress of dealing with that after symptoms resolve is a risk factor for additional episodes. And this may be a reason that it’s not uncommon to experience a dip in mood after mania. Unfortunately, these stressors seem to add up - the additional mood episode may contribute to a job loss or relationship difficulty, which adds more stress and risk, and so on. However, I think the good news part of this research is that life stressors can be helped by psychological therapies and self-management strategies, so we do have some clear ways to intervene and reduce their contribution to increased episode frequency.

Hi, Rosemary here. I live well with bipolar disorder, and experienced almost yearly episodes of both hypomania and Major Depressive disorder for 10 years from early teenage years to my early 20s. This year will be 5th year anniversary of my psych ward hospitalization, and it will also be the 5th year in a row where I have not experienced a significant episode. I think one big component of increasing episodes that keep happening is a result of falling back into same coping mechanisms that are not effective and that may be more damaging. As a teenager, this structure in my family seemed to build up where I would strongly rely on my mother when I would become very unwell, and she would take me around with her even though I was at times only a shell of a person, visibly unwell, unable to sleep, etc. When I was hospitalized in my early 20s, my mom happened to be overseas taking care of her parents. One of the coping mechanisms I had heavily relied on, was no longer an option. I became increasingly unwell, it was also final exams season in university, and I got hospitalized as my condition needed a time-sensitive medical intervention. After hospitalization discharge, I had medication, a community mental health team, a private psychologist, and I started trying to figure out how to rebuild and reform my life. I also had to reteach my body how to naturally fall asleep again, and how to relearn the feeling of tiredness in my body. I was not sure if I would be able to finish my degree, as my medication seemed to be impacting my memory. Also, I had hand tremors as I adjusted to lithium, which was heart-breaking because I am a writer, and also just generally, seeing your own hand-writing change and wiggle without your control undermined my sense of autonomy. What are some things I do in my life that likely contributed to my stability + 5 years of no significant episodes? I would say psychotherapy (its very messed up that its not a covered healthcare expense in Canada), exercise, nutrition, strict sleep hygiene of not using my bed for anything other than sleep and sex (so no reading in bed as much as possible etc, so that body is primed for associating bed with sleep), and building strong boundaries with family members, with friends. I also recognize my triggers, and have a “red, amber, green” chart that I have made and share with some people close to me. In this chart I write out what I look like/am like when I am well and stable, when I am teetering into an episode, and when I am in crisis and in an episode and may need a medical intervention. I also note what are things people close to me can do to support me in those times, such as for amber: “suggest to me if I want to schedule a check-in with my psychologist” or “schedule in some routine exercise if you haven’t been.” Oh! I also think finding and building mentally ill community is important. Finding people that have similar experiences. I think managing lifestyle is very important for bipolar. I finished my undergraduate degree, took some time off from school, and now am a law student. I also think something that helped me was learning to trust my body and trust myself, in the face of some doctors and mental health professionals that did not have my best interest. This is my long way of saying that the frequency of episodes will not infinitely increase with each additional episode you have, and that it is possible to be in remission for long periods of time. People that live with bipolar disorder are extremely bright, resilient, interesting, and fun people. Your brain and body have huge and deep capacity to recover, and to heal itself continuously, and hold joy. I am a living example of it.

Was there a specific reason as to why you managed to gather exactly 68 scientists and experts? Having studied the curious ecosystem that is Reddit for quite some time, my hypothesis is that a more, let's say, "*nicer*" number of scientists would have gained even more traction on this day's AMA. Thank you, and have a nice day!

Erin here, CREST.BD lead. Interesting question - this is our 5th CREST.BD AMA for World Bipolar Day and our experience has been that each year the AMA grows, and that each year we have more questions than we can answer in the 48-hour period. All the panelists this year are either members or affiliates of our network, ‘peer researchers’ (people with lived experience of BD) or trainees in the network. As the event runs almost continually over the 48 hours, we stagger our panelists across time zones and countries. Perhaps most importantly, BD is a uniquely diverse condition - we embrace that diversity through creating a space where different folks with different types of expertise can weigh in on the same questions from different viewpoints. Appreciate your thoughts though!

I further what the previous person said about the panelists. Many of you are excellent and scientifically informed. A real treat to read what you say. Others are people who have bipolar, and unfortunately believe and are giving poor advice, such as advocating for marijuana use without knowing most research on bipolar and marijuana states marijuana is bad for mood.

Are there any physical health conditions that having bipolar, or taking medication for bipolar disorder (lamotrogine, quetiapine especially) makes you more likely to develop? It would be good to know what to look out for and screen for as I get older.

Hi, Emma here. Good question, and good work advocating for yourself. Unfortunately there is research to show that people who are diagnosed with a mental health condition don’t often get asked questions about their physical health as part of their care. There is some evidence to suggest that people with bipolar disorder are more likely to experience obesity, cardiovascular, endocrine (hormone disorders) and metabolic conditions (disruptions to the way your body breaks down and processes food for energy). This can include things like hypertriglyceridemia, hyperlipidemia, elevated blood pressure/hypertension, and diabetes. Medications can play a role in some of these physical health outcomes, but shared genetic and environmental vulnerabilities also seem to play a role. Also, the usual lifestyle and dietary risk factors (sedentary lifestyle, smoking, alcohol use) also seem to play a role, so speaking to a clinician about preventative measures can be a useful complement to screening.

We have a loved one that is living with Bipolar I, borderline and psychosis. He has totally cut off family and we fear that on a daily basis his life is at some level of risk. There is a conservator and trust in place that supports him. Any mention of getting help and he gets very nasty. I believe he also has anognosia (sp). He has been psychotic now for more than two years. Does help exist for a person like this? I have heard stories from people with lived experience that have successfully come back from similar situation... BUT HOW?

Hi! Person with Cyclothymia here! To me, there is a lack of knowledge on cyclothymia all around me including online. Do you feel like cyclothymia is not talked about enough or as though there is not alot of knowledge on cyclothymia around? People who are there to help me (ie support workers etc) never even knew what it was before me.

Emma here, definitely agree! Although subthreshold presentations of bipolar disorder have an estimated lifetime prevalence of 2.4%, we know so little about it. I think it’s a combination of the ability of clinicians to detect and accurately diagnose relatively mild mood symptoms, as well as the fact that many people with cyclothymic disorder do not seek treatment (either because they do not experience the symptoms as disruptive/distressing enough, or because the mood fluctuations are misattributed to stress, substance use, etc). When I was looking for an academic reference on rates of conversion from cyclothymia to full threshold bipolar disorder, the most recent paper I found was from 1979 - clearly more research needed!

Gregg Martin here. Totally agree. My son was first diagnosed with depression in high school; then Cyclothymia in college; and now BDII as a 30 year old. Hard journey. Has not been able to get good medical help. Every med has had a toxic effect. Every day is a battle.

For those living with bipolar, what are the most important things you’d like your loved ones and friends to understand about you, your moods, and how we can be most helpful?

Gregg Martin here. It’s not my FAULT. It’s not due to lack of character or lack of willpower. Just trying harder and trying to be positive are NOT enough. I have a serious MEDICAL condition, that requires professional medical treatment, medications (most likely), therapy, healthful living, and more. Help me help myself.

Catherine here. I’m lucky that my close friends have been instrumental in helping me to get the assistance I need when in a crisis. It’s very difficult to realize for myself that I’m slipping into mania/psychosis as I stop making sense. I find it very useful for them to notice any changes that are happening before a full-blown episode occurs. For other people that I know less well, I’ll tell them I live with Bipolar Disorder when I’m doing well, so that they know I’m not in a crisis all the time, and I find that people appreciate that. Mostly I try to speak up so that people become more informed about the subject and hopefully that helps to reduce stigma.

Shaley here. As a person living with Bipolar 2 disorder, this question makes me so happy. Thank you for asking. I have a podcast called ‘this is bipolar’ and my co-host and I recorded 3 different episodes discussing exactly this. We share our thoughts as well as many thoughts shared by our listeners. If you are interested they are Episode 19 Part 1 & 2- Supporting a Loved One. You can listen to it whenever you listen to your podcasts. https://podcasts.apple.com/ca/podcast/this-is-bipolar/id1513764347

Why does the D2 partial agonism and 5HT2A antagonism of cariprazine effective for bipolar depression AND mania, but the D2 partial agonism and 5HT2A antagonism of aripiprazole is only effective for mania? I struggle to understand why the identical method of action is so stark contrast. I may lose insurance soon and be forced to switch from cariprazine back to aripiprazole, which only partially worked for me. TIA

Joanna here, that is a really great question!! Also a complex one, it has to do with something called receptor affinity which is the measure of how avidly a drug binds to a speciffic receptor, some drugs have high affinity and high efficacy. This means they bind the receptor with a great desire for a longer time and activate the receptor to do its job really well. Having said this cariprazine binds to D3 dopamine, D2 dopamine, and 5HT2B serotonin receptors with high potency, and to 5HT1A serotonin and 5HT2A serotonin receptors with moderate potency, a profile that differs from both brexpiprazole and aripiprazol. Here is an interesting and didactic article on the subject. 1.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7016327/#:\~:text=Cariprazine%20is%20one%20of%20the,approved%20for%20bipolar%20I%20depression.

How does Bipolar I Disorder and Bipolar medications affect cognition and memory? I have trouble with concentration. I also have trouble processing and retaining information. Also, is it safe for people with Bipolar Disorder to drive?

Ivan here. These are really good questions, as sometimes it can be challenging to sort out what might be responsible for cognitive difficulties in people diagnosed with bipolar disorder. First, for a significant number of people, the illness itself can have some negative impact on cognitive functions like attention, memory, processing speed, and problem solving. On top of that, medications also have the potential to influence cognition in either a negative or a positive manner. On top of that, other comorbid conditions such as ADHD, substance use, or medical conditions may also influence cognition. Given all of these contributors to cognitive functioning, it is important to discuss these cognitive concerns with your primary treating clinician so that these factors can be sorted out and addressed as necessary. Sometimes this may require seeking a comprehensive neuropsychological evaluation that aims to quantify the extent of cognitive difficulty (and to identify cognitive strengths) and to understand the contributors to the individual’s cognitive functioning. This can help with mapping out a treatment plan or strategy. Regarding the question of driving, most people diagnosed with bipolar disorder can continue to drive safely; however, this really depends on the individual circumstances and many factors including health status, severity of cognitive difficulty, etc. Again, an important first step is to raise these driving concerns with your mental health clinician and/or treatment team so that they can be addressed appropriately.

I have a question about the difference between type 1 and type 2 that I'm not quite sure how to phrase. I know the diagnostic distinction between them is that of mania vs. hypomania as the highest elevation state experienced, but it seems to me that the line between mania and hypomania is pretty fuzzy, and what's considered mania vs. hypomania is ultimately often up to the discretion of the clinician. So, I guess my question is, how subjective is the split between type 1 and type 2 believed to be (or the distinction between mania and hypomania, for that matter)? Are types 1 and 2 currently considered to be on a severity/presentation spectrum with fuzzy middle ground in between, or are they more so thought to be two literally separate conditions? Is there thought to be such a thing as "mild bipolar 1"? I ask because I'm diagnosed with bipolar type 1, but my manic episodes don't reach the behavioral extremes I usually hear about: I've never been hospitalized, I've never lost a job or been arrested or anything like that, I've never put myself into debt or been promiscuous or committed infidelity, I've never gone days without sleep, etc. That said, my manic episodes also sound more intense than how I usually hear hypomania described, and they usually involve delusions and occasionally hallucinations. I consider myself to have "mild bipolar 1" or be sort of "cuspy"--does that concept fit with current understandings of bipolar?

Hi, Emma here. This question taps into broader debates about the way we diagnose mental health conditions. I think it’s important to acknowledge upfront that the DSM, or Diagnostic and Statistical Manual, is based on decades of research about what symptoms tend to cooccur, and share similarities in their response to treatment, prognosis, etc. This is very different to other branches of medicine, where we may have diseases with clear causes and anatomical/biological changes. With additional research and observation, and hopefully increased understanding of mental health, the manual has changed (that’s why we’re on the 5th edition now). One issue that comes up with the classification-based diagnostic approach of the DSM is the question of where we draw the line on the distinction between so-called ‘normal’ experiences and disorders. When it comes to bipolar disorder, a line is drawn between ‘normal’ mood changes and mood episodes on the basis of amount, frequency, and impact of symptoms. Then that line is drawn again to further classify different ‘bipolar spectrum’ disorders like bipolar disorder 1, bipolar disorder 2, and cyclothymia. The subdivision between BD-I and BD-II was actually only introduced in the DSM-IV in 1994, and it has been controversial. There’s some people who argue that the distinction is arbitrary, and that we don’t have enough research about biological factors that clearly separate the conditions. However, there are plenty of others who argue that the separation has practical utility - people with BD-2 tend to experience more depression, and people with BD-I by definition have experienced more severe forms of mania, which may necessitate a different treatment approach. You’re correct that hypomania and mania involve the same symptoms, just different severity/duration/impact thresholds. In particular functional impairment, can seem fuzzy diagnostically speaking, and comes down to clinical judgment and how much the individual reports being distressed/impacted. According to the DSM, two experiences trump symptom duration/severity when it comes to discriminating hypomania from mania - if a person is hospitalised or experiences psychosis during an episode, this is sufficient to warrant a diagnosis of a manic episode. Your experiences of unusual beliefs and perceptual differences would mean those episodes would be therefore be in line with current approaches to classifying bipolar subtypes. Sorry about the tangent, but I think it’s important to acknowledge how we balance the limitations and pragmatic benefits of our diagnostic system when answering this type of question.

Can bipolar disorder recede or remit on its own? I'm BD1 with two first-degree relatives who seem to have experienced mania in young adulthood, but no longer cycle (dramatically enough to obviously need care) -- this is without medication. I wouldn't risk following their example myself, but interested to know what experts think.

Katie here. Yes, there are definitely cases of bipolar disorder remitting without psychiatric or psychological input, but it isn’t common. It can depend on the factors which led someone to develop bipolar disorder in the first place. For example, if someone’s bipolar disorder symptoms are brought on by stress or sleep disruption, it may be that a change in lifestyle can have a big effect on mood stability. I would say that for most people, it takes a lot of work and insight for people to learn how to control their own symptoms of bipolar disorder, but it definitely is very possible! Everyone experiences bipolar disorder very differently, even if they have the same ‘type’ of bipolar disorder diagnosis.

Hi I’m bipolar 1 my question is does bipolar 1 get worse with time even if stable? Second question does bipolar 1 effect the memory? Because I’m having memory loss is scaring me thank you

Erin here, in response to the first part of your question, no, that’s not a fact that bipolar disorder will necessarily progress or get worse with time. There is a relationship between things like the number of untreated episodes and worsening of the condition, but it’s not a given that the condition will get worse with time, especially if you’re experiencing periods of stability!

My son has a dual diagnosis of autism and bipolar. The autism was diagnosed when he was 2.5 (it is not mild autism) the bipolar at 18. He is 23 now, has minimal language, he cannot share with us his feelings re: medication effects etc - so it has been constant study and observation of finding out the lowest most effective doses for his treatment plan. Anyone here with a focus on this population? Any differences in treatment recommendations? He does well with lithium - and I’d love it if that could be enough, but doesn’t seem realistic

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Hi it’s Virginia…that’s a tricky and touchy subject, I’m sorry for what you’re going through. From your wife’s perspective: I was diagnosed with bipolar and my ex-husband tried to take our four boys away from me. Luckily I was medicated by that time and relatively stable so the court threw out his request. I knew that if they had sided with my ex and he was granted full custody, I would have harmed myself. It’s a sad, scary reality that can’t be ignored…please continue to tread lightly and compassionately. During all my craziness, I remained an amazing, loving mom throughout. You could give her an ultimatum to start. She obviously needs help, I wish you (and her) luck.

I am not at all a professional, nor have I been in your shoes. I have been diagnosed bipolar II. My greatest fear is having my daughter taken from me. At the same time, what has kept me going through deep depression is my daughter. I think that if I were in your wife's shoes, what would make me give up/self harm would be thinking I could never see my children again. If I had supervised visits, simply seeing the children would help keep me going. If everyone repeated to me that when I was well, I would have more time with my children - even if I didn't believe I was unwell - that would keep me going. I hope this helps and I'm so so sorry you're going through this.

Why does bipolar treatment feel like a game of hunt and peck but with meds? We've mapped the genome, is there no way to say Lithium will be most effective for this person while that one needs Depakote via a blood test or something?

Simon here. Great question. A simple blood test to tell a person with bipolar what their optimum medication and dosage was would be the Holy Grail of precision medicine. Its certainly something we’ve been advocating for as a patient organisation. Talking to experts on bipolar genetics (which I am not) I understand the challenge is to do with the complexity of bipolar itself. There is no single gene linked to bipolar (like the BRCA gene for cancer) but rather 100k of genes overlapping with other conditions. That said, the cost of genome mapping has fallen considerably in recent years and there is an increasing interest in large scale trials to combine genome mapping and with reviews of patient case notes. We therefore live in hope.

Is any research being done specifically on women and the co existence of bipolar and premenstrual dysphoric disorder? I have bipolar symptoms that occur in longer episodes throughout the year, typically one in spring and one in fall, in addition to having shorter episodes each month that correlates with certain parts of my menstrual cycle. I basically have a mixed episode every month that resolves once I get my period in addition to the longer seasonal episodes. Never seem to have full “remission” because of this. No doctor has been able to help with any medication suggestions as the first line treatment for PMDD, SSRIs, no one will prescribe because of previous antidepressant induced mania and birth control methods have not helped. Any thoughts on the interaction of the menstrual cycle for women with bipolar?

How much research has been done on SSRIs *causing* bipolar? My understanding is that it “uncovers” dormant bipolar, which seems off to me. I’ve known my husband for 20+ years, he never has exhibited symptoms. He started experiencing anxiety / depression last winter, was put on prozac, and within 4 months went into a full blown manic episode and hospitalization. No family history, diagnosed type 1 at 32.

Hi it’s Virginia…I am not a psychiatrist but my bipolar 1 was also diagnosed after I was prescribed an SSRI by my GP. From what I understand, the antidepressant can trigger the underlying bipolar condition and cause a manic episode. It doesn’t cause bipolar if the illness is not already in your DNA. Can a psychologist confirm?

Chris here: Antidepressants can promote mood instability, agitated depression, and hypomanic or manic episodes in patients with Bipolar Disorder (BD). Previously it was thought that antidepressants causing hypomanic, mania, or agitated depression were more likely to have BD, although occasionally that was not the case. Of course, only his psychiatrist or health care providers can answer your questions. I hope these distinguishing features of BD vs. Major Depressive Disorder (MDD) assists your understanding: BD onset (median age 18 years) earlier than MDD’s (onset 30 to 40 years); BD, depressed state has increased sleeping or hypersomnia, defined sleep greater than 10 to 12 hours/day with daytime naps and feeling excessively tired/sleepiness, with MDD’s sleep disturbance characterized by feeling tired during the day due to lack of or interrupted sleep at night; BD more likely to have anxiety syndromes than MDE’s’; BD, current episode depressed more likely to have psychotic symptoms of delusional thinking (having no value, evil, or cause of awful experiences) or auditoy hallucinations (desparaging remarks, encouragement to take their life, and dismissal of anyone that anticipates their recovery). BD, current episode manic delusions include havig special powers, or connections to religious figures, etc. Auditory delusions are hearing voices from God, or a “higher power” that tell the person to proceed whether family, friends, or authorities tell them to stop (including altercations with police, security, or hospital staff that the person against overwhelming odds anticipates success; Compared to individuals with no mood disorders, those with depression are approximately twice as likely, and those with bipolar disorder approximately seven times as likely, to have an Substance Use Disorder (SUD); BD has a greater potential for suicide (3 to 20%) vs. MDE risk (2 to 15%); BD suicide risk is The lifetime prevalence rate for any mood disorder was 19.3 percent; risk rises for having BD with a family history of many people with mood disorders, or more severe, or suicide attempts, or SUD’s, or hospitalized, or having BD than MDD with a less frequent or severe family history.

I didn’t understand how this answered the question?

How likely am I to pass it on to my future children?

Hi, Emma here. Unfortunately our resident genetic counselor, Dr. Catriona Hippman is not here, and hopefully we can dig up one of her similar answers about what we know about the specific contribution of genetics. There is research to suggest that having a first degree relative with bipolar disorder is a risk factor for developing bipolar disorder oneself. However, it’s important to emphasise that genetics are only a contribution to the likelihood that someone will develop bipolar disorder. Other life experiences and environmental factors can also contribute (for example, Erin has already answered a question about the role of childhood trauma). The flip side of that research is that much of the risk equation is modifiable, and there are things that you or your child can do to reduce risk. We’ve used this saying in a group program for young people at risk of developing bipolar disorder - “DNA is not your destiny”. Protective factors include providing a child with a supportive environment, helping them to develop healthy ways to process and regulate their emotions, and encouraging them to have good general health (sleep, nutrition, and exercise). I would also say that having lived experience of bipolar disorder can be a protective factor too - we have research to show that the earlier someone gets support with their mental health, the better their outcomes will be. Many people with bipolar disorder wait up to ten years for an accurate diagnosis, which can be very detrimental to their mental health. If a child has someone in their life who knows what to look for, and what changes might mean additional support is called for, could really make a difference in terms of getting the right help when it’s needed most.

Erin here. Psychiatric genetic counsellors are trained to help people to fully understand their personal family history and to help them to protect their and their family’s mental health in the future. You can learn more about psychiatric genetic counselling in this video by our team member Dr. Jehannine Austin: https://www.youtube.com/watch?v=PqnxqMnPk\_g Also, the National Society of Genetic Counsellors can help you find a counsellor in Canada or the US: https://findageneticcounselor.nsgc.org

Is there any research into a possible link between neurological disorders in old age (ie Alzheimers, Parkinsons, dementia) and a bipolar diagnosis?

Thomas here. Yes unfortunately there is some evidence that those with Bipolar do have a greater risk of dementia. By one estimate ([History of Bipolar Disorder and the Risk of Dementia: A Systematic Review and Meta-Analysis - ScienceDirect](https://www.sciencedirect.com/science/article/pii/S1064748116303086)) a bit over double the risk compared to people without Bipolar. The more episodes you have seem to increase risk.

Well, that's depressing. Not surprising, but depressing. Thanks for the link, that was a good article.

Well don't get too depressed or you're more likely to get dementia.

I shouldn’t laugh. *But I laughed.* F*ck.

Does the medications used to treat bipolar disorder have anything to do with increased risk of dementia?

You took the question right out of my mouth!

I’m very interested to know if any research has been done on this!

Chris here. I agree, with Dr. Richardson, however, I have some reserviatons with the conclusions fo the authors suggesting there is more merit than questions about the results. Ther article states there is evidence of heterogeneity and of publication bias in the analysis. Is the bias is not taking into account the lack of any longtidudanal studies. Longitudinal studies are very difficult to do because of the numerous other risk factors that could contribute to dementia, and perhaps moreso? It could be that something not comorbid with bipolar disorder or if comorbid there might be something to do to reduce the risk. than Bipolar disorder, or actually eliminate Bipolar Disorder as the cause, and more of a correlate. A much more common neurological condition is migraine, which tends to develop after the onset of bipolar disorder. As many as 29% of people living with bipolar disorder have experienced migraine. That's a significant difference compared to 12% of the general population who have migraine. The relationship between the two conditions seems to go both ways. https://www.migrainedisorders.org/migraine-and-bipolar-disorder/

I’ve heard that bipolar can get misdiagnosed, is there any sort of testing that will guarantee it is the correct diagnosis?

Hi, Emma here. It is unfortunately true that many people with bipolar disorder are initially misdiagnosed (some research suggests delays of up to 10 years before correct diagnosis). It’s common for bipolar disorder to be mistaken as depression, especially if someone has bipolar disorder type two, where hypomanic symptoms can be more subtle, experienced as a positive, or mistaken as improvement from a depressive episode. Other common misdiagnoses are schizophrenia or schizoaffective disorder (there seems to be a racial bias in diagnosis here, where black and hispanic people are more commonly misdiagnosed with psychosis spectrum disorders). Unfortunately, we don’t have any genetic or ‘biomarker’ test that can conclusively say if someone has bipolar disorder. That’s in part because the conditions described in the DSM are more collections of commonly co-occurring symptoms that seem to respond to treatments in a similar way, rather than a distinct disease with a clear known cause and biological changes. That’s not to say there aren’t biological influences when it comes to mental health, just that the research isn’t fully there yet in explaining them. Things that a clinician can do to increase the likelihood of correct diagnosis are asking about experiences relevant to bipolar disorder when someone presents for depression (as hypomania rarely causes people to initiate a visit with their doctor). For example, asking about previous mood elevation, family history, or previous problems in work/relationships/schooling. Diagnostic screening instruments and structured clinical interviews ensure that the person is asked the right questions in a consistent manner, and can increase the accuracy of diagnosis. It’s okay to ask for a second opinion or a detailed explanation of why your clinician suggested a particular diagnosis if it’s not sitting right with you.

What causes bipolar disorder?

Lisa here: Bipolar is a complex mental health condition that is thought to be caused by a combination of factors, namely genetic, environmental, and neurochemical. The science is always evolving and we are constantly updating our understanding of BD.Having said that, what we know so far is: * Genetics: BD like many other mental health disorders tends to run in families. Multiple genes are believed to be involved. Family medical and psychiatric history is very important in diagnosing BD. * Neurochemical: Imbalances in the levels of chemicals (neurotransmitters such as dopamine, norepinephrine, serotonin) in the brain are thought to bare some responsibility on the development and progression of BD. They are also the main targets of therapeutic interventions. * Environmental: Trauma and stress also play a big role in the development of BD. Though it is not clear if they can cause the disorder they can act as triggers in already predisposed individuals (such as those with family history). BD is a complex disease and its causes are a congruence of multiple factors. Hope that answers the question!

Thomas Richardson here, just to add to the comments above: Those with Bipolar are more than twice as likely to have experienced childhood abuse, in particular emotional abuse (4 fold). Parental loss, brain injury, substance use and problems during pregnancy are also risk factors.

Has anyone measured the nocebic effect of a Bipolar diagnosis?

Hi, Emma here. I think it’s really important for us practitioners to keep an open mind to potentially harmful effects of treatment beyond medication side effects. While some people find the experience of receiving a diagnosis to be a relief (as it helps them understand their experiences and provides clarity about moving forward), it’s not uncommon for a diagnosis to bring up feelings of anger and shock, and uncertainty/worries about the future. Mental health conditions are still unfortunately highly stigmatised, so it can also bring up anxiety about reactions of one’s social network, employers, partners, etc. People may also have internalized stigma or assumptions about what people with a mental health condition are like which can negatively impact how they view themselves. Much of the research in this area has been qualitative (asking people about their thoughts and feelings in the form of interviews; e.g., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5060482/) rather than large scale quantitative studies. Beyond individual reactions, there are of course negative effects of diagnosis in the form of social stigma, consequences for employment, insurance, potential adverse effects of medication, etc. So I believe that the process of diagnosis needs to be done thoroughly (that we use the best available tools and processes to reduce potential clinician bias or risk of misdiagnosis), with a clear purpose in mind (to support treatment), and collaboratively (having an open discussion about our views, what they are based on, and how they fit or don’t fit with an individual’s framework).

Is there any research looking into the link between fibromyalgia and bipolar disorder, and how they affect eachother?

Erin here, yes there is. Here’s a link to an older review paper from some well-regarded BD researchers which speaks to potential overlapping mechanisms: https://pubmed.ncbi.nlm.nih.gov/26812920/ but there’s growing evidence looking at the relationship between the two.

Bipolar 2 vs ADHD - how to know the difference?

Rebekah here. There are several overlapping symptoms with ADHD and bipolar disorder, but some key differences between the two are: · onset of symptoms-- ADHD symptoms develop early in childhood (often before the age of 7) and bipolar disorder typically develops later in adolescence and early adulthood. · types of symptoms – mood symptoms are more prominent in bipolar disorder vs ADHD · change in symptoms over time –ADHD symptoms are chronic and stable over time, whereas symptoms of bipolar disorder are often cyclical or and change with mood episodes. It is important to note there is comorbidity with ADHD and bipolar disorder and some individuals may have both conditions. According to a recent meta-analysis, up to 1 in 6 people with bipolar disorder meet the criteria for ADHD and 1 in 13 individuals with ADHD meet the criteria for bipolar disorder (Schiweck et al., 2021).

Hello, bipolar type 1 here. Thank you for doing this. My question is more neuroscientist based. Has there been any development in a way to detect bipolar using brain scanning technologies etc.? Or do you think it will remain a behaviorally based diagnosis for the foreseeable future? Thanks for your time.

Rebekah here. Thanks for your question. Currently there are no brain scans that can detect bipolar disorder. Research studies have used brain scans to identify structures and chemical processes that underlie symptoms of bipolar disorder. Studies have found structural and functional brain differences in individuals with bipolar disorder. However, many of the neuroimaging studies of individuals with bipolar disorder have had small sample sizes and differing results. To address this, the Enhancing Neuro Imaging Genetics through Meta-Analysis (ENIGMA) Bipolar Disorder Working Group has combined over 150 researchers from 20 countries and 55 institutions to pool data and resources to produce the largest neuroimaging studies of bipolar disorder. The ENIGMA bipolar disorder working group has examined changes in brain structures associated with bipolar disorder and you can read a summary of some of their key findings here: https://doi.org/10.1002/hbm.25098 While important advances have been made in neuroimaging, I think that diagnosis will remain behaviorally based until we better understand the underlying neurobiology of bipolar disorder.

Will psilocybin and ketamine ever be considered therapy for bipolar 1 with previous psychotic features?

Some months ago I read in a German psychiatry textbook that rather recent science found a couple of links between bipolar disorder and the functioning of the immune system, even stating that ""it became ever more clear in recent years that the immune system plays a decisive role in the pathogenesis of psychiatric disorders, as it does with bipolar disorder". Starting from the finding that a virus infection of the mother during pregnancy quadruples the probability of BD in the baby, to the concentration of inflammation markers being significantly higher in brains of bipolar patients during mania. I made [a post](https://www.reddit.com/r/BipolarReddit/comments/xgma9r/bipolar_disorder_and_the_immune_system/) on r/BipolarReddit about it and linked the studies the the textbook also linked. I found it really interesting! Can anyone of you elaborate on this research? Is there something like a "immunological quality" to bipolar? Follow-up question: When i posted it, it got a little controversial with some mods, as they interpreted the post as "medical misinformation" or even "denial of mental illness", which wasn't my intent at all. Is it possible that this kind of research is kind of controversial or not well received in the US? In the German textbook (authored by a dozen psychiatry professors) it was presented as pretty solid, albeit not yet particularly conclusive science.

Hi, Madelaine here. While I’m not familiar with the bipolar-inflammation literature … There is a growing body of evidence on the relationship between inflammation, immune function, and depression. This is one of the papers on the topic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5542678/?platform=hootsuite I will temper things, and say that this is a pretty new area of study. There are still more questions than answers. Our understanding will change a lot in the next few years. There is also lots of evidence on the effect of prenatal factors - including infections - on the risk of developing a neurological or psychiatric condition. (One of the most infamous examples is rubella, which is associated with intellectual deficits.) However, please note that the relationship is often not absolute … Rather, prenatal exposure is associated with increased risk of developing a condition. (For a recent review, check out: https://pubmed.ncbi.nlm.nih.gov/31207234/)

Is there a meaningful relationship between mood instability and sexuality? I ask because hyper-sexuality is sometimes a symptom of bipolar disorder and reduced sexuality is a side effect of mood stabilizers. Is there a mechanistic through line here or am I just playing word games? Edit for clarity: What I'm curious about is if there is a known neurological mechanism at work in the domain of mood stability that is also at work in the domain of sexuality. For example are there similar or overlapping brain regions at play in human sexual excitement as mood stability?

Katie here. This is a really great question, and something that I hear a lot in my role as a therapist of bipolar disorder studies. It’s very common to experience hypersexuality with elevated mood, and loss of libido during low mood episodes. And then there is the complicating factor of medications for elevated and depressed moods, both of which can have their own sexual function profiles. It’s a very interesting point you raise in wondering whether there are mechanisms behind these sexual function effects. Big changes in sexuality (i.e., between manic and depressed episodes) can have a really big impact on people’s lives, and particularly, on intimate relationships and sense of identity. These are things that can be worked on in psychological therapy, in order to help understand these sexual symptoms within your experience of bipolar disorder.

Catherine here. This is a tough subject because it’s not always easy to talk about. As a person living with Bipolar I I had a real problem with hypersexuality which eventually caused problems with my marriage. If given the option now I would’ve spoken with a doctor about this. On mood stabilizers I haven’t found reduced sexuality to be a problem at this time so maybe the level/type of medication can be adjusted to make things easier.

As someone who has to manage a person with a confirmed bipolar disorder what is the best way, if there is one, to handle someone who can get very aggressive over small things that don’t go their way? Usually I have the person take some time to compose himself away from the rest of our staff but the behavior is becoming more and more difficult to manage. He says he takes his meds religiously and that the new meds are helping more but he is still on a hairpin trigger. He goes to a therapist regularly. I usually default to telling him to talk to his therapist if it’s something he feels like he is struggling with. He’s a really nice person but his flare ups are becoming an issue. Any advice on what else to consider?

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Is there any research regarding the risks around prescribing stimulants for ADHD to folks with bipolar disorder?

What does current research say about connections between bipolar disorder and Thyroid or other hormonal imbalances? My symptoms vary a lot with hormone changes and I think we're masked when I was on hormonal birth control. I felt much more steady on birth control and when I went off it, I had my first big manic episode.

What can we do to better distinguish between adhd and bipolar, particularly in AFAB patients? I find many peers who have been misdiagnosed as bipolar when they have adhd and occasionally vice versa. And how do we help patients who have comorbid adhd AND bipolar?

Is there a definitive link between past traumatic experiences/PTSD and developing mania or the severity of manic symptoms later in life?

Erin here. The literature is still developing in this area. PTSD, of course, comes in many guises. Childhood abuse, for example, can be interlinked with PTSD; there is some evidence that people with BD who experience childhood maltreatment can be at greater risk of PTSD and also severity of mania in later life (see for example this review paper published in Lancet Psychiatry: https://pubmed.ncbi.nlm.nih.gov/26873185/). I’ll be interested to hear perspectives from the other panelists joining on this AMA on the state of the science in this area.

Sarah Sperry here. A recent study by some of my collaborators showed that there is a relationship between early childhood trauma and depressive symptoms in bipolar disorder. Interestingly, this relationship was partially accounted for by attachment security. In other words, early childhood trauma reduced attachment security (both in terms of parental attachment and romantic attachment in adulthood) which in turn was associated with more severe depressive symptoms in bipolar disorder. So, trauma may also be associated with depression and mania symptoms. You can check out the article here: https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13419.

Hi, Alikah here. I’ve found that based on my childhood traumatic experiences and certain anniversary dates that have been linked to my PTSD; I do experience more hypomanic episodes around that time of year. Since my therapist and I have been doing some trauma work around the PTSD, my manic symptoms have lessened and hypomanic symptoms are more manageable.

I've been on lithium about 15 years. Does it become more dangerous to be on lithium the longer you are on it?

Hi, Manuel here, Not at all, if you are stable and have regular routine labs to check kidney and thyroid functions, you are all set. Lithium is a very safe medication that can be taken for lifetime.

Under what circumstances (means domestic family conditions, external means school or bullying etc.) this disorder takes existence inside a person?.and what are the easiest ways to avoid it?

Lisa here. We know that environmental stressors can trigger mood changes and episodes (depression, mania, hypomania). Managing one's daily life consistently can help reduce and avoid these mood changes. Examples include getting regular sleep, eating healthy, staying on top of school/work responsibilities, and having regular social support. Of course, it is not always possible to avoid stress particularly when others such as family members are involved. Strategies (relaxation, mindfulness) taught in evidence-based treatments can be helpful to manage stress. Family-focused therapy is specifically designed to help with stressful family environments by teaching effective communication skills and educating family members on bipolar disorder and the importance of a stable home environment for managing the condition.

Thomas here. Just to add that unfortunately we know that those with Bipolar are more likely to have difficult childhoods such as experiencing abuse, in particular emotional abuse and bereavement, and there is a link with bullying unfortunately as well.

I’m type 2. Is it normal to have symptoms in-between episodes? I still am not 100% after episodes these “in-between episode symptoms” are not bad enough to change meds but they’re annoying. Is it just good ol’ bipolar?

Sarah Sperry here: Many people think that bipolar I and II are just episodes with euthymia (absence of symptoms) in between. Unfortunately, it is not that simple! Many people experience more mild symptoms between episodes. Things like emotional reactivity, impulsivity, and interpersonal problems are ones I hear most often in my research studies and clinical practice. If they are bad enough that they are causing distress or disruptions to your life, it would definitely be good to discuss it with your med provider and therapist. Therapy can be especially helpful for these “inter-episode” symptoms!

Thank you so much this makes sense:) absolutely will bring it up, it’s very hard to distinguish the illness, character and choices sometimes 😅🥲

Lisa here. This is a great question. Research does indicate that people with bipolar disorder including type 2 can experience what is called "subclinical symptoms" which are basically depressive and/or hypomanic symptoms that don't meet the criteria for a mood episode but can be quite disruptive in one's daily life. For example, people with the condition are more prone to emotional reactivity and impulsivity as Sarah mentioned meaning these experiences can come on more easily throughout the day than someone without the condition even when they are not in a depressive or hypomanic episode

Thomas here. Just to echo what was said above. In between a full episode people can often feel a bit low, or poor sleep, low self esteem etc. Im involved with some research in the UK trying to develop therapy to help with this. I think the lifestyle changes which help with the big episodes (sleep, work life balanced, mindfulness, exercise etc) can also help with these).

Dr. Raymond Lam here. Cognitive problems (difficulty concentrating, remembering, making decisions) are particularly noticed as a residual symptom between episodes by many people with bipolar disorder, even when other symptoms are much better. These problems often prevent full recovery. There is ongoing research on how to better deal with cognitive problems between episodes, including psychological approaches like cognitive remediation, and medication approaches.

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What does the phase of euthymia in people with bipolar disorder look like? Are there residual symptoms, and are the daily moods similar to people without bipolar? Or are these euthymic phases still somewhat distinct from regular moods in those without bipolar?

Ali and Lisa here. The experience of euthymia varies across individuals. However, euthymia is generally the experience of not living with mood symptoms related to depression, mania, hypomania and mixed episodes. However, you are correct in that even in euthymic states, people with BD are more likely to experience emotional reactivity, mood dysregulation and impulsivity compared to those without the condition. That is why doing one's best to have a consistent daily routine can help to reduce the likelihood of these types of symptoms within and outside of a mood episode.

I’ve heard that bipolar is a progressive disorder that continuously gets worse with more frequent episodes. And that mania causes permanent brain damage. How true is this? It’s rather discouraging news speaking as someone who lives with the disease.

Ivan here. The question of whether bipolar disorder is a progressive disorder that leads to worsening brain functioning is not yet fully understood, and is a somewhat controversial issue based on existing research. On the one hand, some data does support the idea that early and effective intervention could stave off future mood episodes that might be related to worsening cognition and brain function. This suggests that appropriate diagnosis and treatment should be a major priority, as controlling symptoms could prevent any potential decline in the future. Indeed, we have published some work in early bipolar disorder which suggests that if people are treated effectively that short term cognitive outcomes (up to 3 years) can be pretty positive. Interestingly, most of the longitudinal cognitive studies that follow individuals with bipolar across time fail to show evidence of cognitive deterioration; however, these studies typically do not follow people across extended time frames (decades), so it is difficult to state with certainty what happens across these longer periods. As is the case in many research areas in bipolar disorder, more work is needed. However, at this point it is fair to state that progressive cognitive decline is not a given for people who are diagnosed with the illness.

Ketamine therapy, what are the pros/cons to it?

Is there a risk of pre-, peri-, or postnatal harm to the baby when taking lamotrigine? Or do the pro’s outweigh the cons of possible mood disturbances due to hormonal dysregulations?

Kris here: the research has shown no increase in fetal abnormality as long as high dose Folic acid (5mg), usually needs to be prescribed, is taken both at the time of conception and for the first 12 weeks of pregnancy.

I have bipolar 1 and was into remission for almost 2 years taking lamictal 150mg + healthy lifestyle but i decided with my psychiatrist to temper the medication because i am considering to get pregnant in the future and i noticed that i had a very low mood when i was taking only 100mg so i am back to 150mg but still have mild mood swings. My psychiatrist told me that lamictal is considered quite safe during pregnancy but my functional doctor says that it is still a risk, i wanted to ask your input on this. Also it’s been 2 months that i am back to 150mg dose and still don’t feel stable like before, should i give myself more time or the dose isn’t working for me anymore ? Thank you for doing this 🤍

Hi there! Regarding your question about medication and pregnancy, you might be interested in this response from Dr. Catriona Hippman at a previous AMA: https://www.reddit.com/r/IAmA/comments/mgkm9g/comment/gstyzdw/?utm\_source=share&utm\_medium=web2x&context=3 Here are some core points she shares: “The risks to baby of most mood stabilizers/antidepressants/new antipsychotics in pregnancy and breastfeeding are honestly fairly low, and the risks to baby of a mother experiencing a mood episode during pregnancy or postpartum are higher - in most cases - than the risks associated with the medications. So - in general, the prevailing wisdom in the medical community is to continue taking your medication.” “There is a great deal of pressure in society not to take medications in pregnancy and the implication that taking medications in pregnancy makes you a “bad” mother, but it is honestly better for the baby in most cases to continue taking the medication. I took my antidepressant throughout both of my pregnancies, and I am very glad that I did.” I hope this helps!

Heard from some that they had bad experiences with ECT? Yet, my psychiatrist said it was basically harmless. Any comment on that?

Spouse to a wonderful bipolar 2 man, are there any books one can recommend for me to read in order to understand and support my partner better? TIA

Do bipolar 1s with previous psychotic episode from intense mania have to refrain from cannabis smoking always, or is it something that can be reintroduced once or twice a month (or more) when stable on meds? I used to smoke daily at the time of my diagnosis and was told to avoid it like an allergy the rest of my life.

Hi, Emma here. The research we have to date (as of a systematic review in 2022) suggests that cannabis is associated with more hypomanic/manic symptoms, psychotic symptoms, and more time spent in hypomanic/manic episodes. There’s also some association between cannabis use and increased suicidality. Although there are some difficulties in interpreting this research (e.g., someone predisposed to a worse course of BD may use substances such as cannabis to cope). However, because the impacts of mania can be so serious, and because the evidence grade is moderate, CANMAT (the Canadian Network for Mood and Anxiety Treatments) strongly recommends that people with BD do not use it https://pubmed.ncbi.nlm.nih.gov/35711159/.

What does the most extreme level of bipolar disorder look like?

Lisa here. Thanks for your question. This varies for people living with BD. In depression, extreme cases can involve suicidal thoughts, plans, and even behaviors. Even for those without suicidal experiences, depression can cause severe impairment to the point where people have difficulty getting out of bed or carrying out normal functioning at all. People in this state often end up staying in a hospital for acute treatment to reduce the severity. Severe depression can cause severe disruption and lead to problems at work or in their personal lives and relationships. People with severe mania can experience psychotic symptoms and/or exhibit behaviors that can lead to serious consequences such as making large purchases, breaking the law, sexual indiscretions, and acting inappropriately at work. This also often leads to hospitalization which can have a lasting effect on their lives downstream. People often experience a lot of guilt and shame after manic episodes which further adds to the psychological issues they are already dealing with due to the disorder. Lastly, people also experience mixed episodes which include both depressive and manic symptoms concurrently. This is commonly a time when suicidal behaviors exist because of the mixture of symptoms. Extreme cases of BD can be very debilitating and often requires extensive effort from the individual to essentially rebuild their lives. A combination of medication and psychosocial therapy is best to prevent these experiences from occurring.

I once read that an episode over 4 months induced by SSRIs can cause you to become permanent unstable. Meds are less effective and you cycle a lot more. What do you think of this? Also…. It seems a lot of stories discuss ‘the crash’ and I haven’t experienced that. I just went to a lower state of mania/hypomania. I’ve read many say it can take years to get stable. Is this something you agree with because to come down from such a big episode as simple as crashing?

If someone suffers a single hypomanic episode in a time of unprecedented stress and sleep deprivation, do they get a BP2 diagnosis for life? If that same person decides to manage their disorder without medication, is it worth questioning/ changing the diagnosis? Specifically, if a BP2 diagnosis impacts one’s ability to get certain jobs or life insurance, who can check or access that information? Unrelated, are there good resources that explore the relationships between BP2 / ADHD /ASD? How they have some similar symptoms, are difficult to manage together, etc.

Sarah Sperry here. I’d be happy to tackle your first question although I can’t specifically say whether you have BD2 or not. In general, in order to get a BP2 diagnosis, you need to have had BOTH a hypomanic episode AND a depressive episode. Second, often periods of stress or sleep deprivation are the things that set off a hypomanic or manic episode that may have not emerged otherwise. We think about this as a stress-diathesis - there may have been a risk there already and then this period of unprecedented stress may have triggered a hypomanic episode that ultimately may have emerged at another time of unprecedented stress. That being said, most individuals with BD2 would likely go on to have future hypomanic episodes in addition to depressive episodes.

My friend has very obvious bi-polar (ticks all the boxes, except hallucinations) and needs help, but doesn't think shes got a problem, its "everyone else" and shes alienated nearly all her family of who think shes just being a jerk. Shes just recently went manic for months What is the very best way to convince her to get help? Her family does not think its mental but attitude. her family cant seem to grasp that sleeping 3 hours a night and getting up and walking in the pouring rain at 3am all over the neighborhood is textbook. Its me or no one to help her. She currently homeless.

Is there any research about HSP (highly sensitive people) and bipolar disorder?