Diet, Exercise and Sleep in Mood Disorders

Depression, and its flipside, mania, is truly dreadful, a curse on the soul. It is so awful as to be indescribable to the person who has not gone through it.

Nor is kind enough to be rare. In fact, Thomas Insel, MD, director of the National Institute of Mental Health, claimed in 2007 that depression is the "leading source of nonfatal medical disability among people ages 15 to 44 in developed countries like the U.S. and Canada. It is the leading cause by far. Nothing else is even close. In the whole world it is the second or third greatest cause of disability." (See http://www.ama-assn.org/amednews/2007/04/02/hlsb0402.htm)

So how do we even begin to deal with an illness that is so prevalent, so life-draining--and, at times, so difficult for others to see?

One of my favorite British poets, Stevie Smith, wrote a poem "Not Waving But Drowning." I copy it in full below because it speaks to me--and, I believe, will to others--of how the person suffering from depression calls out for help--and, it seems, the response is all wrong:

"Nobody heard him, the dead man,
But still he lay moaning:
I was much further out than you thought
And not waving but drowning.

Poor chap, he always loved larking
And now he's dead
It must have been too cold for him his heart gave way,
They said.

Oh, no no no, it was too cold always
(Still the dead one lay moaning)
I was much too far out all my life
And not waving but drowning."

All too often the depressed person feels her cries for help are seen as just so much more meaningless attempts to interact.

It seems like every quarter drug companies come out with a new medicine--or re-invent an old one, so they can put it on patent again--to assist those suffering from depression and bipolar disorder, and the choices now are manifold [even though I begin to suspect so many of them are fundamentallly similar]. But still, I've found in my practice that many people are helped by these drugs, and thus antidepressants, mood stabilizers, and the atypical antipsychotics can be life-altering.

But what of those who aren't significantly helped by their anti-depressant medication, perhaps aren't helped at all? It's not as uncommon as you think.

Dr. Maurizio Fava's article "Diagnosis and Definition of Treatment-Resistant Depression" in the April 2003 publication of Biological Psychology defines treatment-resistant depression rather loosely, with a patient qualifying after lack of response to only one antidepressant trial "of adequate doses and duration." [Others assert a person cannot be diagnosed as treatment-resistant until a second med has been tried and failed, as the FDA did when approving Symbyax, defining treatment-resistant patients as those who "have not responded to two separate trials of different antidepressants of adequate dose and duration in their current episode." Symbyax is another re-working of old meds into a new and money-making patent through the genius move on Eli Lilly's part of putting zyprexa and prozac into one pill--and charging plenty for the service.]

Dr. Fava, of Harvard medical school, notes that treatment-resistant depression "is a relatively common occurrence in clinical practice, with up to 50% to 60% of the patients not achieving adequate response following antidepressant treatment."

As disheartening as it is to the depressed patient to 'fail' an antidepressant trial, and to the manic one to fail to be stabilized as mood continues to elevate, l, s/he should keep in mind that there are more options out there. There are the numerous medications, in various permutation.. Transcranial magnetic stimulation is holding much promise, as is vagal nerve stimulation. And, as much as it scares people and reminds them of Nurse Ratched herself in her "One Flew Over the Cuckoo's Nest" incarnation, I've seen tremendous turn-arounds with ECT.

But I wanted to address the lesser-touched-upon issues of diet, sleep and exercise, and how they can make a radical difference to the bipolar or depressed patient.

(adapted from a blog entry)

I mean, sure, if you asked me would I want to sleep only 3 hours a night without feeling tired, finish my first novel in 10 ten days, start training for a half Iron Man with no ill effects, and ramp up my personality until I was the scintillating center of every social moment, I'd definitely consider answering in the affirmative. Really, who wouldn't? (Maybe Snow White's little friend Dopey, I suppose, but I don't take answers to hypothetical questions from cartoon dwarves--everyone must have their standards.)

But as surely as night follows day, research and experience show that, for a bipolar person, a manic or hypomanic episode, improperly treated and managed, will be followed by a depressive one, and, from what I've seen, it's simply not worth it. For this illness, following prescribed treatment is essential, as much as you may not like it, as much as it may be unpleasant, as much as you feel you lose. Because if you don't follow treatment, you surely lose more.

As surely as night follows day, mania leads to depression.

I work with one superlative psychiatrist who tells our patients, "If you don't have mood stability, you don't have anything. Anything."

He responds to their protests, "But I feel great," "But I need the energy to. . .," "But I miss my personality," with a blank stare, and a Herman Munster-like repeat of the same words he's just spoken, that are his own personal mantra: "If you don't have mood stability, you don't have anything." He's the unmovable object--and with him, often even my most treatment resistant patients can start to improve.

For the sad truth of bipolar disorder is the following: Depression is by far the dominant disordered mood state. In fact, the ratio of time spent in depressive episodes to time spent in manic or hypomanic ones is basically an unhappy three to one--if you approach the question with rose-colored glasses.

In an incredibly un-subtly titled article, called--I really couldn't make this up--"Three Times More Days Depressed Than Manic or Hypomanic in Both Bipolar I and Bipolar II Disorder," RW Kupka et all from the Altrecht Institute for Mental Health Care in The Netherlands share the research behind the unpleasant facts. [If you'd like to check it out, it's in the August 2007 edition of Bipolar Disorders. Read it for yourself if you don't believe it--it's important that you, if you are suffering from bipolar and are attached to your "highs," understand what every "high" brings in its wake.]

Don't like that study? Still think your manic episodes aren't dangerous? Okay, there's a 2002 study by Lewis L. Judd at al from University of California at San Diego in the Archives of General Psychiatry with the exact same statistic on bipolar I--but they claim that in bipolar II it's a ratio of 1:40. It's getting ugly.

Still displeased with the information, still hoping to wish the unpleasant facts of mania's promised damage away?Just take a look anywhere, in any research journal, or, heck, take a look on the web, head off to about.com if that's where you find your in-depth information on topic (and, yes, we've all done it, just like we've all--and this is embarrassing--used Wikipedia at one point or another). I encourage you, if you're still resisting the facts in the above studies, because there you'll find the following: "depression is three times more common than mania in bipolar I disorder, and . . .over the natural course of bipolar II disorder, the amount of time spent in depression [is] up to 39 times more common than the time spent in hypomania."

I'm sorry--I really am--but it's a truth worth holding on to when you pine for your high, that you're just setting yourself up for a far-longer low.

To add bad news on to worse, the more cycles you go through, the more likely you are to cycle again. In a term borrowed from epilepsy, this is called kindling, wherein episodes--without treatment--both increase in frequency and worsen in degree over time.

I have more than a handful of patients who have gone off their medication--sometimes more than once--and an even larger number who continue to mourn their "highs" while being medically compliant.

But you allow yourself to experience your mania to the serious detriment of your emotional outlook. It's time to take matters in your own hands, and stop the cycling once and for all.

So let's address with the texts, links, youtubes, et al, that follow some ways to assist your healing from bipolar--aside from the obvious consistent use of appropriate medication--but for now, just recall the mantra.

"If you don't have mood stability, you don't have anything."

(adapted from blog entry)

My mother highly valued intelligence, and her way of putting down someone she saw as sub-par in the smarts department was saying, "He's no brain surgeon, I'll tell you that." But I, literally, am no brain surgeon, so to discuss this latest research I have to do one of those "let's start at the very beginning" Julie Andrews routines.

So, you've got a brain. So far, so good. And the brain has what is known as a limbic system. The limbic system is a set of structures that make up the inside of the cortex, which, in turn, is the tissue that is just outside [I know this is getting to be like "The House That Jack Built," but hang in there for just a few more moments] the cerebrum, which basically heads up your central nervous system. The limbic system is crucial in the experience of emotion--and memory, too, by the way.

Ok, one of those structures in the limbic system [and this is where I really wanted to get to] is known as the hippocampus.

Essentially, it's part of the brain's mood center. And it's pretty sensitive, it turns out. In a research study examining the effects of chronic stress on rats, Fred Helmstetter of the University of Wisconsin found that the rats' hippocampal volumes shrank in response to chronic stress.

Included among chronically stressful conditions is the stress of mental illness, or, for our purposes, bipolar episodes.

For years, brain autopsies on people with bipolar illness have showed decreased density in the hippocampus. A freshly published study entitled "Hippocampal Interneurons in Bipolar Disorder," in the 2011 volume of the Archives of General Psychiatry, compared brains of those with bipolar disorder to those of healthy control subjects. The abstract results are too wonderfully arcane to deprive you of, so here goes: "the bipolar disorder group showed reduced volume of the nonpyramidal cell layers, reduced somal volume in cornu ammonis sector 2/3, reduced number of somatostatin- and parvalbumin-positive neurons, and reduced messenger RNA levels for somatostatin, parvalbumin, and glutamic acid decarboxylase 1. " Got it?

What they're really saying is that the hippocampus is smaller in those who suffer from bipolar disorder.

Despite this rather disheartening knowledge that there is brain atrophy in the bipolar nervous system, there is cause for hope. Because scientists have discovered something remarkable.

[Continue on to read of this remarkable discovery--and how it can affect your life.]

Whereas for years it was considered a given that primates were born with a certain number of brain cells, and, apparently, you spent the rest of your life finding ways to lose them, recently scientists have found that neurogenesis [that's just the process of the brain creating new neurons; it's nothing to follow compared to all that brain mapping stuff] actually can occur in the hippocampus. That's right--you can grow new gray matter--if you just know the right tricks.

In "Lithium Builds Gray Matter in Bipolar Brains, Study Shows," researchers discovered that taking lithium increased volume in the paralimbic regions of the brain, and it has since been demonstrated that consistent treatment with adequate doses of antidepressants increases hippocampal volume, as well.

And, medication aside, we now get to return to one of my favorite topics, which is- in case I haven't pushed it enough in this lens--exercise. Just to be clear--I firmly believe that bipolar disorder needs to be treated with a strict medicine regime, rigorously adhered to. I'm not a proponent of going all-natural or organic or touchy-feely, with such a serious illness.

However, in addition to whatever medicine your doctor has prescribed, exercise also holds much promise for not just slowing the shrinkage of the hippocampus cells-but actually reversing the process.

Numerous studies have found that 30 minutes of aerobic exercise three times a week will slow hippocampus volume loss in the elderly, thus working against age-related memory loss. A research study published in the Proceedings of the National Academy of Science entitled "Exercise Training Increases Size of Hippocampus and Improves Memory" found that the exercise impacted hippocampal volume so positively that it was the equivalent or reversing age-related volume loss by 1-2 years.

Under our constant stress theory of volume loss, it should be no surprise that schizophrenia is also, like bipolar disorder, associated with hippocampal shrinkage. Yet in a study of control-sample healthy men and men with schizophrenia entitled "Hippocampal Plasticity in Response to Exercise in Schizophrenia" in the February 2010 issue of the Archives of General Psychiatry, authors Frank-Gerald Pajonk et al found that cycling for 30 minutes 3 times per week increased hippocampal volume--for both groups, even the schizophrenics [and see the link there "Major Brain Similarities Found in Bipolar Disorder and Schizophrenia" at http://www.sciencedaily.com/releases/2011/08/110825090236.htm].

I may be no brain surgeon, but I can understand from the research that exercise will slow and even reverse illness-associated loss of brain volume--and, brain surgeon or no, I can get that that's a pretty good thing.

[adapted from blog entry]