Treatment of Bipolar Depression: The Missing Piece

Treatment of bipolar depression is no different than treatment of major depressive disorder with but the one exception that antidepressant treatment is generally contraindicated for those with bipolar depression. Beyond that important distinction, there is little difference between treatments needed to help someone recover from a major depressive episode vs. bipolar depression. However, because bipolar illness is typically viewed as a neurochemical brain disorder, we often don't give enough consideration to the role that individuals childhood development can have upon their adult vulnerability towards depressed mood.

Depression is a very significant part of the bipolar clinical picture. Those with bipolar type II experience depressed mood approximately 65% to 70% of the time. With bipolar I we see less depression, though episodes of mood elevation tend to be more acute than for those with bipolar II. Despite the more popular notion of bipolar II as being less acute or less serious than bipolar I, I really don’t perceive one form of the disorder as being any easier to live with than the other. They both carry their own unique challenges. And in each, the functional impairment brought about by depressed mood is one of the more difficult aspects of living with bipolar disorder.

When we think of depression in a general sense, as opposed to that which specifically occurs in bipolar disorder, we should first consider the difference between situational depression vs. endogenous depression. If you lose your employment or you break up with a love partner – or worse – if both occur concurrently, your emotional experience will be painful. You’ll feel bad, sad, and hurt. You’ll likely experience some degree of interpersonal withdrawal, low energy, low motivation, lessened self-esteem, impaired concentration and negative thinking. If the experience is painful enough, suicidal ideation may also become part of the picture. To put it bluntly, you’ll feel like crap.

If you weren’t depressed before the precipitating event(s) we could rightfully imply that your depression was brought about by the specific painful situation(s) in your life. This is what is referred to as situational of exogenous depression – one that was brought about by external circumstances.

In contrast, endogenous depression is more indicative of an underlying illness. With regard to bipolar disorder we’re referring to the brain’s deficient capacity to maintain stable mood. Depressed mood is sometimes brought on by a shift in neurochemical functioning in the absence of situational stresses. An example would be the individual who is feeling fine. Mood is generally positive or what we’d call euthymic. But gradually over the course of a couple of weeks, his or her mood becomes progressively more depressed. In the absence of precipitating stresses the depressive onset is caused by a shift in brain chemistry rather than by the events of life. Essentially sometimes our brain chemistry is out of balance and sometimes our life is out of balance. Clear enough?

No. It shouldn’t be; at least not yet.

Let’s assume the worst and imagine the person in the situational example was fired from his dream job and his fiancé called off their wedding on the same day. He had a really, really bad day ... AND his brain chemistry was significantly different after his bad day than it was before his bad day. Would we say he’s feeling depressed because his brain chemistry has altered, or is he feeling depressed because life has treated him badly? The answer here is both.

Whenever we notice a shift in our emotional experience, this corresponds with an accompanying shift in brain chemistry. In fact, the role of brain chemistry is impacting our mood and emotions during each and every moment of our lives. The same neurochemical processes occur whether we’ve had a very bad day or taken a depressive dip for no clearly identifiable external reason. When we look through this biologically oriented lens the distinction between endogenous vs exogenous causes of mood becomes fuzzy. The best we can do is to ask if shifts in emotional experience coincide with impact from the external world or if they seem to have more to do with unstable neurochemistry in the absence of external precipitants. But in either scenario, the role of neurochemistry in relation to emotion and mood are the same.

The one problem I see with the neurobiological perspective is that sometimes, the underlying psychological causes of depression for the individual with bipolar disorder can be overlooked. The depressive episode is too easily chalked up to be a manifestation of bipolar illness with treatment efforts being directed mostly towards medication and behavioral changes that will facilitate a gradual shift in mood.

The kinds of interventions I’m referring to are listed below. They are the standard fare of most clinical work with individuals experiencing bipolar depression.

• Psychotropic medication prescriptions:
  • Lamictal – a mood stabilizer – has antidepressant properties. Can be energizing/activating.
  • Lithium – a mood stabilizer - helps to stabilize mood, decreases mood elevations and diminishes suicidal thinking.
  • Abilify – an atypical antipsychotic with antidepressant properties - can be energizing/activating. Seroquel – an atypical antipsychotic with antidepressant properties.
  • Latuda – an atypical antipsychotic with antidepressant properties.
  • Seroquel - an atypical antipsychotic with antidepressant properties.
• Several times weekly physical exercise – preferably aerobic in nature – can have potent antidepressant effects.
• Regular exposure to morning or mid-day sunlight. If access to good sunlight is limited (i.e. – during winter months) then the regular use of light box (phototherapy for depression) can sometimes be effective in boosting mood. This needs to be monitored closely due to risks of evoking rapid onset mood elevation.
• Stabilization of sleep cycle with emphasis upon regular sleep wake times and relatively early morning awakening (not spending excessive time in bed when depressed).
• As an adjunct to psychotropic prescriptions, daily use of vitamin supplements can be helpful. Those shown to have some efficacy with bipolar depression are listed along with supporting information from different internet links:
  • Omega-3 fatty acids (fish oil), (link 1) (link 2) (link 3)
  • N-acetylcysteine, (link 1) (link 2) (link 3)
  • Vitamin D, (link 1) (link 2) (link 3)
  • Folic acid, (link 1) (link 2) (link 3)
  • There is also a prescription drug named Deplin that can be taken for the purpose of increasing concentrations of L-methylfolate in the body (see the embedded link to an article about Deplin in the Wall St. Journal).
• Cognitively oriented psychotherapy for depression – becoming aware of and learning to modify the distorted negative thinking that typically accompanies depressed mood.
• Mindfulness practices with strong emphasis upon observing/identifying mood states as well as practicing self-acceptance, gratitude and appreciation (learning to see the cup as half-full rather than half-empty).
• Dietary practices with emphasis upon low carbohydrate consumption – becoming successful at avoiding or limiting dietary intake of high concentration carbohydrates which can lead to brief mood elevations followed by sharp declines in mood.

I want to be quite clear in stating that there’s nothing wrong or inappropriate about any of the above. The list represents the bedrock of what we typically see with contemporary approaches to the treatment of bipolar depression. My point is that sometimes the work doesn’t go far enough in assessing the causes of an individual’s depressive episodes or the possible reasons why a depressive episode appears to be intractable. What about the individual’s unique unresolved psychological issues that may contribute to or exacerbate depressed mood?

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In order to improve depressed mood, the person’s history and their pathogenic developmental issues may need attention in treatment, just as much as they may need exercise, sunlight, medication, vitamin supplements and mindfulness.

Below are two case examples to further illustrate:

Vignette #1

Michael is a 48 yr old single male with bipolar II disorder who had previously been employed in a biotech company. He had an undergraduate degree in chemical engineering and an MBA. About a year ago he experienced a hypomanic episode that included elevated energy combined with a high degree of interpersonal irritability and aggression. Since Michael’s mid-20s this mixed-symptom picture was how his hypomania presented, as opposed to more typical hypomania involving high energy with positive mood.

Partly as a function of his extended hypomanic episode (lasted a total of approx. four months), Michael found himself experiencing recurrent conflict with his co-workers. He didn’t handle the interpersonal differences well and wasn't able to keep his cool during board meetings or other situations where there were differences of opinion among his company’s leadership. He was eventually asked to resign from the company and was given a relatively generous severance package. After another month or two of intense anger and energetic agitation, he fell into a deep depression. He was unemployed in a depressed job market and increasingly aware that he brought about his own demise as a result of his poorly managed hypomanic irritability. Michael came into treatment approximately four months following his employment termination and, despite several medication changes made by his psychiatrist, his depressive symptoms showed little to no improvement.

The immediate causes of his depressed mood were obvious: 1) A major loss within his career, 2) his own guilt and remorse regarding his employment loss and 3) the neurochemically-based depressive crash that typically follows an extended period of bipolar mood elevation. All three components interacted and greased the downward slope of Michael’s depression. The basic elements of Michael’s road to recovery were fairly straightforward – attention to healthy lifestyle (sleep, exercise, diet), directing strong efforts towards maintaining productivity during his unemployment, actively engaging in a job search and paying closer attention to quality of his relationships with friends and family, which had declined over time due to his workaholic lifestyle.

There was also a much less apparent component to Michael’s depression that required just as much attention as the bipolar and situational issues identified in the previous paragraph. Michael’s personality style reflected a narcissistic personality structure. His overall behavioral patterns were not maladaptive enough to meet DSM5 criteria for a narcissistic personality disorder diagnosis. However, he was someone who had always placed strong emphasis upon his own sense of potency, power and acheivment. Being seen by others as “impressive” was very important to him. The problem with his psychological investment in being impressive was that it served as a defense against underlying feelings of inadequacy and weakness. These painful aspects of Michael’s self-image reflected years of aggressive dominance from two older brothers as well as the adverse impact from his relationship with father, a career Army colonel, who repeatedly criticized Michael during childhood years for not being strong or tough enough to warrant father’s approval. Essentially the problems Michael faced reflected the interaction of his bipolar depression, the situational stresses of job loss and the collapse of his narcissistic defensive system.

If Michael had not been so invested in success as compensation for perceived inadequacy, he may have been better able to manage the depression he was experiencing. But when the self-esteem reward he derived from professional accomplishments became sufficiently shaken, he no longer had the resilience to work through the depression that followed his hypomanic episode.

Once Michael’s personality dynamics were dealt with through fairly intensive nine-month-long twice weekly psychotherapy, his depression gradually resolved and was replaced by positive mood and a more realistic appraisal of his self-esteem which had come to reflect a better integration of strengths and vulnerabilities.

Vignette #2

Julia was a 36 yr old psychotherapist with bipolar I disorder. Her bipolar illness didn’t emerge until her late 20’s when she was in graduate school. She had two hospitalizations due to mania during her first year post-diagnosis but had not experienced any further mania once she began treatment with lithium. Julia’s mother also had bipolar disorder (untreated) and throughout Julia’s childhood and adolescence Julia took on the role of mother’s emotional caretaker. She tried to minimize stresses at home when mother seemed tightly strung. She tried to become mother’s support when mother was depressed. And during periods of mother’s mood elevations, Julia tried to stay out of mother’s way and to protect her two younger siblings from the consequences of mom’s poor judgement and impulsive behavior. Tragically Julia’s mother died of suicide when Julia was 16. It’s not so much of a surprise that Julia’s choice of a profession entailed a role where she was continually trying to help others regulate and manage their emotions.

Julia had a seasonal component to her depressed moods and the months of late fall through winter often proved to be a difficult time of the year. In the fall of the preceding year Julia experienced a painful loss of her 15 yr old dog, Maggie. She did an amazing job of nursing Maggie through the later stages of cancer, but ultimately the disease took the dog’s life, and with it, much of Julia’s remaining resiliency. The combined impact of her grief and the approach of winter months took Julia into strong extended depressive episode.

Julia had received good psychiatric care during the decade she had lived with her illness. She had reasonably helpful psychotherapy during the first several years following her bipolar diagnosis, although Julia had not done a lot of in-depth work on the impact of growing up with an untreated bipolar mother. This surprised me because, given her profession, I would have anticipated her mental health providers would have placed stronger emphasis upon her personal/psychological development than had occurred. Over the course of our first five months of work together it became clear that Julia maintained a deep conviction that she had been responsible for her mother’s suicide. If she had only paid closer attention to mother’s mood state instead of becoming caught up in the high school activities which served as an important boost to her self-esteem... if only she had stayed home on the evening of her mother’s death instead going to an extended school play rehearsal… if only she had been the better daughter, able to relinquish her own adolescent needs, her mother might not have left her.

Julia’s inability to turn her depression around was but one more example of her perceived inadequacy. She could attempt to help others through her professional role, but when it came to those she was most emotionally connected with, she felt like a failure. Her dog’s cancer, her own illness and especially the tragedy of her mother’s death, all served as evidence of her inadequate caretaking. Essentially she felt that she deserved to suffer for her shortcomings.

Once Julia was able to realistically accept bipolar disorder as her genetic acquisition, as opposed to punishment for her mother’s death, she was gradually able to emerge from her depression and return to mid-range stable mood. This was no small shift. It required Julia’s acceptance of the unmet needs and emotional pain that had to be minimized so she could take on the role of the stable supportive and protective figure within the household.

What’s important to note here is that neither Michael nor Julia were cured of their bipolar disorder. Psychotherapy won’t accomplish that. What they each did accomplish was to identify, understand and begin to resolve some key pathogenic issues that added additional layers of complexity to their depressed mood states.

I also have no doubt that Michael or Julia will intermittently experience depressed mood states at different points in their futures. After all, they live with bipolar disorder. They may even find they’ll need to revisit some of the same issues they’ve previously worked on in psychotherapy. Strong aspects of "how we are" don’t just go away through one successful course of psychotherapy. However, as individuals become more self-aware and as they gradually come to terms with the influences that have helped to shape them, then the same issues will potentially exert less of a downward pull during future depressive episodes.

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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications) (www.BipolarYoungAdult.com).