Missing link in bipolar

About 2.2 per cent of the population has bipolar disorder, a life-long mental illness marked by depressive and manic episodes. Researchers have found talking therapy has huge benefits – but for many it remains elusive. Cate Broughton reports.

From 11 years old, Sarah* began feeling worthless, and thoughts of suicide flooded her mind. The administrative executive, now 27, spent her teenage years cycling through inexplicable and extreme moods that seemed completely outside her control.

Just when her parents were at their wits’ end, she would ‘‘come right’’ and tell them to ignore the previous period of desolation.

‘‘I would say, ‘I was just being dramatic, I’m fine now’ – and I’d believe that too. And it would happen over and over again.’’

Cushioned between long periods of depression were the highs. The naturally subdued teenager would become overwhelmed by ‘‘so much energy’’, chatting constantly, staying up all night, skipping meals.

‘‘[You have] so much energy and just [feel] really confident and just think you’re amazing and everyone else is amazing.’’

Friendships were bruised when she failed to follow through on expansive plans made at the height of a manic episode.

Sometimes the highs would become laced with darkness, morphing into the worst possible combined mood state.

‘‘It would go from being good to then being agitated by everything. Everything is heightened – it felt like being on drugs. Things felt weird, everything sounded loud.’’

When she was 18, a GP prescribed anti-depressant medication, but Sarah says it made no difference. In her second year of university she returned to the GP and was referred to Canterbury’s specialist mental health service.

A diagnosis of bipolar disorder came as a relief, but hope for an effective treatment soon evaporated.

Sarah was prescribed medications including lithium, which made her feel like a zombie. But staff insisted she continue taking it, suggesting it was the only option.

Staring at a future life swamped by a foggy brain and depression, Sarah paid to see a private psychiatrist, with help from her parents. The psychiatrist changed the medication and told Sarah about a clinical trial testing therapy for bipolar.

As a trial participant, Sarah saw psychologist and researcher Maree Inder regularly for 18 months and learned she could take back some control over her moods.

The trial, by clinicians and researchers at Otago University and the Canterbury District Health Board (CDHB) mental health service, compared two types of therapy in 100 patients aged between 15 and 36.

One group was assigned to Interpersonal Social Rhythm Therapy (IPSRT), designed specifically for bipolar by a team at the University of Pittsburgh, with a focus on managing a ‘‘fragile body clock’’ and social relationships.

The other group attended specialist supportive care where the patients could discuss issues concerning them.

For most participants in both groups, symptoms of depression and mania reduced. The research team has since conducted a second trial comparing IPSRT for people discharged from the specialist mental health unit and care from their GP. The results are being analysed.

Seven years since starting her sessions with Inder, Sarah is almost free of medication. ‘‘If I hadn’t done the study and if I didn’t have my parents, I don’t think I’d be here.’’

She emphasises the positive results did not come quickly. Just six months into the trial she was admitted to hospital after a suicide attempt.

Even now she can still have periods of depression. But the times of ‘‘wellness’’ lengthened as she came to recognise and manage signs of a relapse.

Inder says IPSRT helps people understand their sleeping, eating, and activity routines and the effect on mood. ‘‘It’s about having a framework that can help them make sense of what is going on for them . . . that they can then make changes and have a sense of having some control or mastery . . .’’

Patients are also able to explore relationships with the people in their lives and the disorder itself. ‘‘We can’t take away bipolar disorder – that’s part of what people have to make sense of. And it’s not an easy process. No-one wants it, no-one puts up their hand and says, can I have bipolar.’’

Through therapy, patients can address the strain of the disorder on relationships, Inder says. ‘‘Because, absolutely, having bipolar disorder has an impact not only on the individual but those around them, so that can lead to conflict in relationships, it can lead to a person not getting support or help, so you focus on that.’’

But despite internationally recognised guidelines for evidence-based talking therapy – in conjunction with medication – many bipolar patients are missing out, believes mental health clinical research unit director and CDHB psychiatrist Richard Porter.

Patients diagnosed with bipolar disorder at the health board are assigned a psychiatrist and a case worker, receiving 120 days on average of follow-up care.

But Porter is unsure what that care involves and if it is recognised, evidence-based therapy. ‘‘I think patients with bipolar are not currently, anywhere, by and large, getting a recognised therapy for bipolar disorder and that is recommended by guidelines.’’

The Royal Australian and New Zealand College of Psychiatrists recommends one of four evidence-based therapies, including IPSRT.

One analysis suggests psychological therapies achieve a 40 per cent reduction in relapse of bipolar symptoms compared with standard treatment alone.

Porter says CDHB case workers have recently

‘‘If I hadn’t done the study . . . I don’t think I’d be here.’’