Abstract
The author discusses bipolar disorder, symptoms, causes, and various treatments. There is a focused discussion on two studies, one about genes implicated in circadian clock rhythms and mental illness, and one about antipsychotics and cognitive impairment. A proposal is suggested for an experiment comparing the effects of two possible treatments for bipolar disorder.
Bipolar Disorder
Bipolar disorder is a relatively common mental illness, with incidence rates of about 4% among the general population. People with bipolar disorder exhibit manic episodes, depressive episodes, and mixed episodes. Symptoms of manic episodes include increased energy levels, decreased need for sleep, racing thoughts, and poor executive control. Gambling sprees and spending sprees are common during manic episodes. Delusions and hallucinations are possible, and may be indicators of psychosis. Symptoms of depressive episodes include anxiety, change in sleep patterns, fatigue, and social withdrawal.
Background Information
There are several types of bipolar disorder: Bipolar I, Bipolar II, and cyclothymia. Bipolar I is diagnosed with the same criteria as major depression, plus a manic episode. Bipolar II is diagnosed with the same criteria as major depression, plus a hypomanic episode. Cyclothymia is diagnosed with the same criteria as dysthymia, plus a hypomanic episode. Schizoaffective disorder's diagnostic criteria are noticeably similar to Bipolar II's diagnostic criteria, with psychotic episodes added.
This could lead to a refutation of the Kraepelinian dichotomy. The Kraepelinian dichotomy is an artificial division of mental illnesses into two categories, mood disorders and psychotic disorders. Bipolar disorder and depression fit into the mood disorder category, and schizophrenia fits into the psychotic disorder category. Mental illnesses such as bipolar with psychotic features and schizoaffective disorder seem to falsify the notion of there being a clear demarcation between the two categories. Mania and psychosis are closely linked. Dopamine malfunction is implicated in bipolar disease, especially during manic episodes, as well as psychotic episodes of the various mental illnesses that feature psychotic episodes, such as schizophrenia, schizoaffective disorder, bipolar with psychotic features, depression with psychotic features, and many more mental illnesses.
Antipsychotics are commonly used to treat bipolar disorder, as well as many other mental illnesses, so a discussion about antipsychotics is imperative. Antipsychotics, which block dopamine receptors (with later generation antipsychotics blocking more dopamine receptor subtypes), are used to treat bipolar disease, as well as schizophrenia, which is related to bipolar by incidence of psychotic symptoms. The efficacy of long-term antipsychotic use is in dispute. A longitudinal 15-year follow-up study showed that schizophrenic patients who had stopped taking antipsychotics had better outcomes than those who continued taking antipsychotics. According to the study, successful cases were a subgroup of the general population diagnosed with schizophrenia with attributes of higher cognitive reserve such as an internal locus of control, higher educational attainment levels, and more favorable personalities.
There are several possible reasons suggested in the paper why antipsychotic dependency can lead to unfavorable outcomes. Antipsychotic dependency is associated with unfavorable outcomes because antipsychotics are tranquilizers and hypnotics, commonly used to sedate patients into compliance. Thorazine is commonly used to sedate convulsing or otherwise violently moving patients. When coming off antipsychotics, the dopamine receptors are no longer being blocked by the antipsychotics, and therefore symptoms of mania and even psychosis can occur. Furthermore, prescription of antipsychotics can lead to a perception of external locus of control, in that patients might believe that they are not responsible for their behavior, their psychiatrist or therapist is. Even worse, prolonged use of antipsychotics may lead to cognitive impairment.
It is important to note that many patients placed on antipsychotics try to get off them, and that the ones who are successful in getting off them may have other, confounding traits that predict a better prognosis, such as higher cognitive reserve, than patients who are unsuccessful in getting off antipsychotics. Thus the patients who got off antipsychotics are a self-selecting group, and might have had better prognoses even if they stayed on antipsychotics, though that is impossible to conclude. Patients who attempt to come off antipsychotics and face relapses might suffer blows to their self schemas, and perception of an internal locus of control. There are a few patients who manage to get off antipsychotics with the help and support of their psychiatrist, but such patients are relatively rare. (Harrow, Jobe, 2007)
Four changes in lifestyle are commonly recommended to people with mental illness: more sleep, a better diet, exercise, and more social involvement. It's possible that some of the symptoms brought about by bipolar disorder come from the mania, which involves a lack of sleep.
Lack of sleep causes other problems too. Problems with judgment, also known as central executive function, can result from lack of sleep. Lack of sleep may induce mental states similar to inebriation in people suffering from many mental disorders, including but not limited to bipolar disorder, depression, schizophrenia, anxiety disorders, and ADHD.
Hypnagogic hallucinations are common symptoms of people with many psychiatric disorders, and even functioning members of society with no diagnosed mental disorders. According to a study in the United Kingdom, in which a survey known as the SLEEP-EVAL index was given to the general population, hypnagogic hallucinations have a prevalence of around 15% in the general population of the UK. The study took place over non-institutionalized members of the UK's population, suggesting that hypnagogic hallucinations are common even in people without diagnosed mental disorders, though it's important to note that the prevalence of hypnagogic hallucinations among people with diagnosed mental disorders is even higher than the prevalence of hypnagogic hallucinations among the general population. (Ohayon, 2000)
Psychosis is related to hypnagogic hallucinations and lack of sleep. The delusions and impaired insight are related to the loss of central executive function, or judgment, and the hallucinations may be explained as related to hypnagogic hallucinations that come from lack of sleep. For people with mental illness, quality of sleep directly affects their quality of life. Maintaining a good sleep schedule is the most important lifestyle change related to improving the prognosis of bipolar disorder.
A good diet is also important for people with mental illness. Sugar is implicated in many mental illnesses. Many people with mental illness have comorbidities with substance use disorders, so staying away from drugs is important. Alcoholism, especially, has a high rate of comorbidity with many mental illnesses. Incidence of mental illness is higher in rural than urban areas, and diet, exercise, and sleep probably play roles in the difference.
Exercise is important for people with mental illness because exercise helps release dopamine effectively, maintaining a healthy level of dopamine in the brain. Exercise also increases serotonin levels, which helps with depression. Finally, exercise helps with other components of a healthy lifestyle, such as sleeping in particular. To wit, if patients are very tired, going to sleep will be easier.
Literature Discussion
The two studies discussed will be McCarthy et al's study published in 2012 about lithium's use to fix circadian clock disorders in people with bipolar disorder, and Pålsson et al's study showing cognitive impairment in patients treated with antipsychotics.
“A Survey of Genomic Studies Supports Association of Circadian Clock Genes with Bipolar Disorder Spectrum Ilnesses and Lithium Response” was the first study. The authors of the study looked at different genes, and noted the ones affecting circadian clock rhythm and bipolar disorder. They compared the circadian clock rhythm affecting gene's co-occurrence with genes associated with bipolar disorder to a control group of randomly selected genes. The main conclusion drawn from the study were that the core clock genes, genes most strongly correlated to circadian rhythm functioning, were more likely to be linked to psychiatric illness and lithium responsiveness or both than random genes. The authors also suggested that more research should be done regarding mental illness and circadian clock genes. (McCarthy et. al., 2012)
“Neurocognitive function in bipolar disorder: a comparison between bipolar I and bipolar II and matched controls” was the second study. In the study, there were 2 groups, one group of 120 Swedish people diagnosed with bipolar disorder, and one control group of 86 people not previously diagnosed with any mental disorder. The 2 groups were both subjected to a battery of neuropsychological tests, including 5 tests from the Delis-Kaplan Executive Function System, designed to measure executive functioning in the subjects, the Claeson-Dahl learning and memory test designed to measure working memory, and the Rey complex figure test, designed to measure several components of brain functioning, like memory and visuospatial ability.
The average score of the groups was significantly different for some tests indicating problems in executive functioning and working memory in the bipolar group. When attempts were made to control for different confounding variables, it was noted that the problems in executive functioning and memory were associated with antipsychotic use, but not with other treatments for bipolar disorder, such as antidepressants, lithium, or anticonvulsants. In conclusion, the authors noted that they found a greater degree of impairment in patients treated with antipsychotics, but no correlation with cognitive impairment and psychosis. This counters the popular conception that psychosis in and of itself leads to cognitive impairment, and suggests that treatment of psychotic and other disorders (like depression, where atypical antipsychotics are often prescribed off-label, or schizoaffective disorder, and especially bipolar disorder) with antipsychotics leads to cognitive impairment. (Pålsson et. al., 2013)
Proposed Experiment Suggestion
The facts stated thus far lead to an idea for an experiment. The idea for the experiment is to have two or three groups, in a between-groups study. One group will be a group of diagnosed bipolar II subjects treated by strictly medications, no therapy, no informing the patient about lifestyle changes that could help treat the mental illness in the patient, and one group will be a group of diagnosed bipolar II subjects treated with lifestyle changes, diet, exercise, sleep, and meaningful social activities, with an optional control group of healthy subjects.
Flaws in the Experiment
Such an experiment would probably not pass an institutional review board. In practice medical institutions rarely meet the high standards expected of patients, and the the experiment might be a good thing insofar as it encourages patients to develop internal loci of control, or to be more proactive in taking care of their health. Finally, some patients who are in a mental hospital clearly need treatment much more than others, such as people in the middle of a psychotic break, and coming out of psychosis is clearly an important prerequisite to achieving full health in those patients, and from a cost-benefit analysis antipsychotics are probably a good option for such patients.
Another flaw in the proposed study is that one of the main uses of antipsychotics is to help patients sleep, and sleep as an individual lifestyle change might be difficult to adjust without resorting to antipsychotics or sleeping pills. Martin Harrow and Thomas Jobe's study showed that people who were on antipsychotics for only a short amount of time reacted the most favorably. Antipsychotics are tranquilizers and hypnotics and in practice this means that they are helpful in getting patients to rest. Also, there are many confounding factors and concurrent variables. There are 4 variables, sleep, diet, exercise, and social activity, and they can interact in at least 12 ways. The studies seem to indicate that the most important variable is sleep, but arguably all of them are important and patients with mental illness will need to have all of those needs fulfilled.
Conclusions and Future Study
As public healthcare funding is slashed and various other cost-cutting systems are imposed to theoretically make a badly functioning system more efficient that will in practice ruin countless people's lives with the mentally ill probably experiencing the greatest amount of suffering, new ways of treatment will have to be found. Patients with mental illness will have to learn how to manage their symptoms well. Promoting healthy lifestyle habits as a treatment for mental illness will have to be emphasized. Research should be conducted on how to cheaply and effectively distribute information about healthy lifestyle habits to people suffering from bipolar disorder and other mental illnesses.
References
Ohayon, Maurice M. (2000). Prevalence of hallucinations and their pathological associations in the general population. Psychiatry Research, vol. 97. 1-5.
Harrow, Martin, Ph. D., Jobe, Thomas H., Ph. D. (2007). Factors involved in Outcome and Recovery in Schizophrenia Patients Not on Antipsychotic Medications: A 15-Year Multifollow-up Study. The Journal of Nervous and Mental Disease, vol. 195. 1-9.
McCarthy, Michael J., Nievergalt, Caroline M., Kelsoe, John R., Welsh, David K. (2012). A Survey of Genomic Studies Supports Association of Circadian Clock Genes with Bipolar Disorder Spectrum Illnesses and Lithium Response. PloS ONE, vol. 7. 1-9.
Pålsson, Erik, Figueras, Clara, Johansson, Annette GM, Ekman, Carl-Johan, Hultman, Björn, Östlin, Josefin, Landén, Mikael. (2013). Neurocognitive function in bipolar disorder: a comparison between bipolar I and II disorder and matched controls. BioMed Central Psychiatry, 13:165. 1-8.