Mental Health Prescription: Nature

I love to travel. It satiates my curiousity about the world and it disrupts the monotony that can accompany daily life. And when I travel, exploring the natural world is always on my agenda; whether it is an urban garden or outlying areas of unspoiled nature.

Travel also serves as a way to de-stress because I disconnect from the usual demands of my home base. One of my favorite ways to stay healthy on the road and at home - both physically and mentally - is to go for a hike. Walking in nature is a powerful mood stabilizer with great side effects. Instead of the long litany of negative side effects that often come with taking medications for mental health, walking outside comes with a great list of benefits: reduced risk of heart disease, hypertension, diabetes and some forms of cancer and is a great way to reach and maintain a healthy weight.

A recent study* by Stanford researchers published in the Proceedings of the National Academy of Science (July 2015) found that walking in nature served as an anti-depressant. The study wanted to explore why it is that people who live in urban areas have a much higher risk of mental illness. This has been a consistent finding but the cause/effect relationship is unclear. For example, city dwellers have a 20% increased risk of anxiety and a 40% increased risk of mood disorders as compared to people who live in rural areas**.

The study assigned one group of people to walk in a grassland area with trees and another group to walk along a busy 4-lane urban road. They found little to no impact on physiological conditions but marked differences in the brain. Those who walked in nature had a lot less activity in the area of the brain that is active when people focus on negative emotions.

So the takeaway for people with bipolar disorder: Take a hike! Get your mind and body healthy by going outside and enjoying the positive benefits for your mind and your body.

*Bratman, GN, Hamilton, JP, Hahn, KS, Daily GC, & Gross, JJ. (2015). Nature experiences reduces rumination and subgenual prefrontal cortex activation. Proceedings of the National Academy of Science, 112 (28), 8567-8572.
**Jordan, R. (2015). Stanford researchers find mental health prescription: Nature. Stanford News, June 30.
Photo credit: I took this picture on a recent trip to Glacier National Park with my daughter.

Mental Health Awareness Month 2016: Stories and Resources

May is Mental Health Awareness Month and so mental health issues have been front and center in many publications. I have been featured in the Women's Health magazine mental health campaign and been cited in a Vh1 article. I include links to these pieces below, along with links to other articles and websites.

My Bipolar Disorder was misdiagnosed as ADHD, Women's Health, May 2016

Here's what Hollywood gets wrong about bipolar disorder, Vh1, May 5, 2016

Women's Health magazine feature on mental health awareness, May 2016

Mental illness is not a "white person disorder", Mater Mea, May 2016

National Alliance on Mental Illness

Diagnosing the Difference Between Depression and Bipolar Disorder

Featured article:
Hirschfeld, R. M. (2014). Differential diagnosis of bipolar disorder and major depressive disorder. Journal of Affective Disorders, 169(S1), S12-S16.

Summary & Overview
In this article the author - a leading scholar of bipolar disorder - discusses the challenges of differentiating between bipolar disorder and major depressive disorder. Prevalence of unipolar depression is almost four times that of the range of bipolar disorders (including bipolar disorder I, bipolar disorder II and sub-threshold bipolar disorder).

The major challenge is that people with bipolar disorder tend to experience more depressive symptoms than symptoms of mania or hypomania and are much more likely to seek help when experiencing the lows of depression than when they are experiencing the highs of mania or hypomania. Several studies referenced in this article found that many people suffering from depression have undiagnosed bipolar disorder.

Therefore, if someone is seeking help for the first time it is important to differentiate between bipolar disorder and depression because anti-depressants alone are not helpful for people with bipolar disorder and are best used in combination with mood stabilizers; even then anti-depressants are not very effective. Furthermore, there is considerable debate about whether or not anti-depressants can cause destabilization or manic symptoms in people with bipolar disorder.

Symptomatic and Experiential Differences
The possible indicators of bipolar disorder in depressed patients include: earlier onset of symptoms, a family history of bipolar disorder, seasonality (with depression more likely in the winter months), mixed states, history of hospitalization, history of treatment-resistant depression, numerous past episodes, mood reactivity, switching on anti-depressants, more likely to experience psychosis and cognitive impairment, and are more likely to have a history of suicide attempts.

Screening and Diagnosis
The most popular screening tool for bipolar disorder is the 15-question Mood Disorder Questionnaire (MDQ) that takes approximately 5 minutes for the patient to complete. However, it is a screening tool and not a diagnostic instrument. The MDQ measures lifetime symptoms of hypomania and mania. It has been translated into 19 languages and has been cited in more than 600 publications. It correctly identifies 75% of people with bipolar disorder and screens out 90% of people without the illness.

The Hypomania/Mania Checklist (HCL-32) has 34 self-report questions that are completed in less than 10 minutes and assesses lifetime symptoms of mania and hypomania and will correctly identify 80% of patients with bipolar disorder and screen out 51% of people without the illness.

Another self-report instrument is the Patient Health Questionnaire (PHQ-9) which has 9 questions -  that can be completed by the patient in less than 5 minutes - that assess current depressive symptoms. It correctly identifies 88% of cases of major depression and screens out 88% of people without symptoms. The author suggests that this is the best tool to measure depression among general patient populations because it is so short and so widely used.

The Beck Depression Inventory (BDI) is a widely-used 21-question (in the main version) instrument that screens for symptoms of depression and takes less than 10 minutes to complete.

The Inventory of Depressive Symptomology (IDS-SR) is a 30-item self-report questionnaire and the Quick Inventory of Depressive Symptomology (QIDS) is a 16-item version. Both instruments measure symptoms of depression and can be completed by a clinician or by the patient.

Included in this article is a table (Table 3) that compares all of the above instruments and 2 other clinician-rated scales. The Hamilton Depression Rating Scale (HAM-D) has 21 questions that are completed by a clinician and takes less than 20 minutes to administer. It assesses current depressive symptoms and has several different versions. The Montgomery-Asberg Depression Rating Scale (MADRS) is a 10-question scale that takes less than 10 minutes for a clinician to assess current depressive symptoms.

The PHQ-9, BDI, HAM-D and MADRS do not distinguish between bipolar and unipolar depressive symptoms.

Conclusion
Understanding the difference between instruments can help inform your discussion with clinicians about assessing symptoms and making the correct diagnosis.

Depression, Men and Suicide

This is a repost of an excellent article on depression among men.

Suicide and Silence: Why depressed men are dying for someone to talk to
by Owen Jones, The Guardian, Friday 15 August, 2014

How Much Exercise is Enough to Fight Depression?

The article below is reposted from PsychologyToday.com and explores the science behind the challenges and benefits of getting the 'right' amount of  exercise to get the most from its anti-depressant properties:

Dose Matters: Exercise as Anti-depressant by Dr. Victoria L. Dunckley - a board-certified psychiatrist.

Quotes:
"Interestingly, in a recent study in which patients were assigned to antidepressant medication, exercise, or combined medication plus exercise, the combination treatment did not appear to provide any additional benefit than exercise alone—which was equivalent to the medication effect (sertraline, brand-name Zoloft was used). In fact, when researchers looked at 6-month relapse rates, the exercise-only group did better than the combination group. (only 9% had relapsed compared to 30% in the other two groups.)"

"...based on other research regarding the beneficial of morning bright-light exposure on mood and sleep quality, that an outdoor workout in the morning will augment exercise’s effect even further."

Social Support and Bipolar Disorder

The following is an excerpt from the book, Preventing Bipolar Relapse (New Harbinger, 2014)

Several studies have shown that social support from friends and family is important to preventing bipolar disorder. Studies seem to be biased towards the impact of social support on depression, probably because people with mania are less likely to seek help. The onset of symptoms can be accompanied by social behaviors such as irritability, anxiety and anger that impact social relationships and negative social relationships can exacerbate or trigger mood changes creating a downward spiral. Some studies of the link between social support and bipolar disorder is discussed below to demonstrate the evidence for making a case for seeking and maintaining a social support network that will improve your overall mental health and prevent and reduce the impact of symptoms of both mania and depression.

A study of social support and social strain (Eidelman et al, 2012) compared people living with bipolar disorder and people without a mental illness (control group) for 28 days using journals. The bipolar disorder group had lower measures of social support and more social strain that the control group. Manic and depressive symptoms in the bipolar disorder group were increased the more social strain they experienced. Social support was also associated with more stable sleep in people living with bipolar disorder.

Another study of social support and mood symptoms (Pratchett, 2010) among high-functioning people living with bipolar disorder showed that lower levels of perceived social social support was related to more severe symptoms of lower mood and higher mood, and to persistence of these symptoms 6 months later, regardless of age, marital status, income or gender.

Unsupportive social networks have also been found to increase the likelihood of medication non-adherence (Sajatovic et al., 2011). A study of unipolar and bipolar disorders found differences in the functioning of social networks between the two groups but found that stabilizing supportive relationships should be a goal of psychotherapy because both groups had minimal social networks and relied on one primary person for all their social support (Poradowska-Trosz, Dudek, Rogoz and Zieba, 2009).

Self-esteem has also been shown to be a mediating factor through which social support is expressed. This means that people with higher self-esteem are more likely to seek out social support and to have more friends. It also means that people with higher self-esteem are more open to the social support that a strong network of friends provide.

For adolescents with bipolar disorder it appears that family relationships are important to onset and continuation of symptoms (Sullivan et al, 2012). Family conflict, adaptability and lack of cohesion are predictors of adolescent mood symptoms. The authors suggest that family conflict be a focus of psychosocial intervention in early onset bipolar disorder.

REFERENCES

Eidelman, Polina, Anda Gershon, Katherine Kaplan, Eleanor McGlinchey, and Allison G Harvey, "Social support and social strain in inter-episode bipolar disorder." Bipolar Disorders 14 (2012): 628-640.

Poradowska-Trzos, Magdalena, Dominika Dudek, Monika Rogoż, and Andrzej Zięba, "The comparison of social networks of patients with unipolar and bipolar affective disorder." Archives Of Psychiatry & Psychotherapy 11 (2009): 43-50. 

Pratchett, Laura.  "Social support in bipolar disorder: The relationship between social support and mood symptoms." US: ProQuest Information & Learning, 2010.

Sajatovic, M., M. Valenstein and F. Blow, “Treatment adherence with antipsychotic medications in bipolar disorder”, Bipolar Disorders 8 (2006): 232 – 241.

Sullivan, A. E., C. M. Judd, D. A. Axelson, and D. J. Miklowitz, “Family functioning and the course of adolescent bipolar disorder”, Behavior Therapy, 43 (2012): 837-847.