Scientific Update: Exercise, Mood, and Bipolar Disorder

Exercise is well-known to influence both physical and mental health. The articles reviewed in this post are specific to the impact of exercise on mental health and the symptoms of bipolar disorder. These articles show that people living with bipolar disorder are more likely to be overweight and to have poor eating habits. The implications of these studies is that people living with bipolar disorder must develop good eating habits and a routing habit of physical activity.

Kilbourne, Amy M., Dana L. Rofey, John F. McCarthy, Edward P. Post, Deborah Welsh, and Frederic C. Blow. 2007. "Nutrition and exercise behavior among patients with bipolar disorder." Bipolar Disorders 9, no. 5: 443-452.

Objectives: There have been few comprehensive studies of nutrition and exercise behaviors among patients with bipolar disorder (BPD). Based on a national sample of patients receiving care in the Veterans Affairs (VA) health care system, we compared nutrition and exercise behaviors among individuals diagnosed with BPD, others diagnosed with schizophrenia, and others who did not receive diagnoses of serious mental illness (SMI). Methods: A cross-sectional study of patients who completed the VA's Large Health Survey of Veteran Enrollees section on health and nutrition in fiscal year (FY) 1999 and who either received a diagnosis of BPD (n = 2,032) or schizophrenia (n = 1,895), or were included in a random sample of non-SMI VA patients (n = 3,065). The groups were compared about nutrition and exercise behaviors Results: Patients with BPD were more likely to report poor exercise habits, including infrequent walking or strength exercises than those with no SMI. They were also more likely to self-report suboptimal eating behaviors, including having fewer than two daily meals. 

Piri, Mohsen, Shirin Zardoshtian, Shahrzad Khazaee, and Roghieh Piri. 2012. "The Effect of Eight Weeks of Aerobic Training on Reducing Mood Disorders, Depression And Mania in High School Students High School Boys." International Journal Of Academic Research In Business & Social Sciences 2, no. 1: 267-273.

Abstract: The aim of this study was to consider the effect of eight weeks of aerobic training on the reduction of mood disorders, depression and mania in boys' high school in Ilam-Iran. This was a quasi-experimental and field research taking the experimental and control groups into consideration. In this study, 60 students were randomly selected as the sample. In order to measure students' Depression and mania, multifaceted Minnesota questionnaire (MMPI-2) and depression and mania sub-scales were used. We applied both descriptive and inferential statistics using SPSS software for statistical analysis of data. The results showed that eight weeks of aerobic exercise had a significant effect on students` depressive disorders and mania. Eight weeks of aerobic exercise reduced depression and mania in experimental group of students. [Edited from the abstract written by the author]

Eriksson, Sebastian, and Gunvor Gard. 2011. "Physical exercise and depression." Physical Therapy Reviews 16, no. 4: 261-268.

Objectives: The objective was to review studies which used physical exercise as an intervention to treat major depression, focusing on methodology, mechanisms of action, types of physical exercise and treatment outcomes. Methods: A literature review from PsycInfo and PubMed databases from 2000-2010 using the key words 'major depression', 'exercise', 'outcome', 'physical activity' and 'aerobic training' as search terms. Results: Eight studies met the inclusion criteria. Seven of the eight studies showed significantly improved mood and reduced depression. Three studies measured an increase in aerobic capacity, two with correlated mood improvements. One showed a correlation between increased muscle strength and reduced feelings of depression. Conclusion: Physical exercise can be an effective treatment against depression. A mood enhancing effect of exercise was identified in the interventions regardless of the mechanism of action.  [Edited from the abstract from the author]

Bipolar Medications and Grapefruit & Citrus Juices

Although citrus juices including grapefruit juice are very good for you with their high levels of vitamin C and other nutrients, they have been known to have negative interactions with certain medications and some medications taken for bipolar disorder are included on that list. 

Certain nutrients within this family of fruits interact with medications that treat bipolar disorder (such as olanzapine) and this must be taken into consideration when deciding what fruit juice to drink. Olanzapine comes with a warning associated with the ingestion of grapefruits or grapefruit juice while on the medication because it impacts the way the body processes the active ingredient in the medication. Grapefruit juice has been known to impact the uptake (the rate of absorption) of certain substances and/or the bioavailability (how much is available to the body) of others.

Some researchers suggest that the pharmacokinetics (or intereactions) with medications is very complex and in one literature review almost 200 studies were found that studied grapefruit juice interaction and interactions were published for 40 drugs (Saito, Hirata-Koizumi, & Matsumoto et al, 2005). Another study found that due to the complexity involved in measuring intake and magnitude of interactions it was challenging to predict the extent of grapefruit product-drug interactions (Seden, Dickinson, Khoo, & Back, 2010). 

Some people with bipolar disorder  take hormone substitutes such as levothyroxine due to thyroid dysfunction, which can be a side-effect of lithium. It appears that although there is some effect of grapefruit juice on absorption of the hormone it does not impact the availability of the hormone to the endocrine system (Lilja, Laintinen & Neuvonen, 2005).

These articles and the warning labels on some medications would suggest that people taking medications for mental illness should avoid grapefruits until science can give firm recommendations. To be safe it is best to read the documentation that comes with your medication, especially the sections that describe possible interactions and side-effects. Discuss with your medical provider any risk of citrus/grapefruit interactions with any medications you are taking.

Lilja, J. L., Laintine, K., & Neuvonen, P. J. (2005). Effects of grapefruit juice on the absorption of levothyroxine. British Journal of Pharmacology, 60(3), 337-341

Saito, M., Hirata_Koizumi, M., Matsumoto, M, Urano, T., & Hasegawa, R. (2005). Undesirable effects of citrus juice on the pharmacokinetics of drugs: focus on recent studies. Drug safety: an international journal of medical toxicology and drug experience 28(8): 677-694.

Seden, K., Dickinson, L., Khoo, S., & Back, D. (2010). Grapefruit-drug interactions. Drugs, 70(18): 2373-2407.

Circadian Rhythms and Bipolar Disorder: Scientific Update

It has been some time since I wrote a post on scientific research, which was to be the focus of this blog but I expanded it into many things bipolar while staying on the science side. This post is one way to indulge my hypergraphia.

In selecting articles to review for this blogpost, I first find articles I understand as many neuroscience articles can be highly technical. Second, I find articles that have some practical utility to people living with bipolar disorder. So I tend to avoid articles that are related to mice or other animals. 

The first article is about the circadian rhythms. According to the National Institute of General Medical Sciences (NIGMS), which is a part of the National Institutes of Health (NIH), circadian rhythms are the physical, mental and behavioural patterns that closely follow a 24 hour cycle. These patterns are found in most living things including animals, plants and even microbes. Chronobiology is the study of circadian rhythms. Produced by natural factors in the body, circadian rhythms are also affected by factors in the environment with light being the most important as it controls the genetic switches that influence these patterns. Circadian rhythms influence many bodily functions such as body temperature, hormone releases and sleep/wake patterns. 


Circadian rhythm characteristics in mood disorders: Comparison among bipolar I disorder, bipolar II disorder and recurrent major depressive disorder. Chung, JK, Lee, KY, Kim, SH et al. (012) Clinical Psychopharmacology and Neuroscience, Vol 10(2), Aug, 2012. pp. 110-116.

Summary of Findings
This Korea-based study used factor analysis to study data on how people experience the rhythms of day and night and found that people with mood disorders were more likely to be evening types than people with no mood disorders. Those with bipolar disorder I were more likely to have evening tiredness than those with bipolar disorder II. Those with bipolar I scored higher for morning alertness than people with recurrent major depressive disorder (RMDD).



The second article is highly technical and the practical implications are not as explicit but the findings are worth a mention because they reinforce the link between abnormal circadian rhythm patterns and bipolar disorder.

A survey of genetic studies supports association of circadian clock genes with bipolar disorder spectrum illnesses and lithium response. McCarthy, MJ, Nievergelt, CM, Kelsoe, JR, & Welsh, DK. (2012), PLoS ONE, 7(2) 

Summary of Findings
This study acknowledges the relationship between abnormal circadian rhythms and bipolar spectrum disorders and that this has inspired the search for genetic sources for this abnormality. However, to date there have been no significant findings from this research that would link genes to these abnormalities. The researchers list 3 factors that could be a reason for this lack of significant findings: 1. complex traits usually involve more than one gene; 2. circadian rhythms may be more complicated than they first appeared; and, 3. genetic risk for bipolar disorder could be spread among many illnesses. Without going into technical detail, the major finding was that their analysis revealed previously unrecognized links between bipolar disorder and circadian rhythms.

Circadian rhythms and bipolar disorder. Murray, G. (2010). Bipolar Disorders, 12(5), 459-472

Summary of Findings
This accessible article is a review of existing literature on the relationship between abnormal circadian rhythms and bipolar disorder. It does not present anything particularly new but does reinforce what is already known.

Sleep and the Bipolar Mind

The list of symptoms for bipolar disorder as it appears in the DSM IV states that people with bipolar disorder are more likely to have problems sleeping and lack of sleep is both a cause and a symptom of bipolar disorder symptoms. Sleeplessness is a symptom of mania and although feeling tired is a symptom of depression, so are changes in sleep, which might result in sleeplessness or in sleeping too much. Not being able to sleep is also symptomatic of a mixed bipolar state.

Before or early in a bipolar episode you may experience a change in your sleep patterns, whether in quantity of hours, or the quality of your sleep – not feeling rested or frequent waking – that allow you to make the changes necessary to prevent an episode or mediate its length and severity through changes in behaviors that influence sleep. Being aware of these changes and recording them and the behaviors that accompany them will help you and your healthcare provider take the necessary steps to bypass an episode.

Once bipolar disorder has been treated people are less likely to have sleep problems. Having insufficient sleep can cause hypomania, depression and mania. Sleep loss is also a symptom of depression, mania and hypomania and thus is a significant issue for mental well-being that should be monitored by people living with bipolar disorder.  Even if you need medications to sleep you can have a better quality sleep by taking the following steps which may even help you reduce your reliance on sleep medications.

1. Develop a sleep routine to keep your circadian rhythms in order. This means going to bed and waking, and taking any medications at the same time every day, including weekends. This gets your body in a pattern of knowing when to feel sleepy and when to wake and allows you to get the amount of sleep your body needs for you to feel rested in the morning with the energy you need for your day.
2. Sleep in a cool, dark, quiet room on a comfortable bed. If there are lights or noises that annoy you then sleep with an eyeshade and/or earplugs. Or perhaps you want the soothing noise of a particular sound or music collection. Make sure your bed, pillow and linens are comfortable.
3. Exercise regularly to give your body a reason to be tired. Complete your exercise at least 2 hours before bedtime so that your body is not overheated or have an elevated heartrate near bedtime
4. Avoid caffeine, nicotine and alcohol. Caffeine and nicotine are stimulants and alcohol may help you fall asleep but interferes with sleep patterns to make your sleep less restful.
5. Relax before going to bed. Do relaxing activities before going to bed such as meditation or reading or knitting and avoid doing anything in bed but sleep and intimacy. 

Monitoring your sleep patterns may help you know what factors are helping you sleep and what factors are keeping you from a good night's rest. For a sleep log: §  http://www.helpguide.org/life/pdfs/sleep_diary.pdf

Other sleep resources: 

'Sleep Matters: The Impact of Sleep on Health and Well-Being' which is downloadable from http://www.mentalhealth.org.uk/publications/sleep-report/.

'Your Guide to Healthy Sleep' and it is available free at http://www.nhlbi.nih.gov/health/public/sleep/healthysleepfs.pdf. 

National Sleep Foundation (www.sleepfoundation.org)

American Academy of Sleep Medicine (http://www.sleepeducation.com/)

National Minority Mental Health Awareness Month

July is National Minority Mental Health Awareness Month.

So instead of creating original content for this entry, I will simply add links for sites where information and resources can be found about mental health issues among minority communities.


National Alliance on Mental Illness

American Psychiatric Association

National Network to Eliminate Disparities in Behavioral Health: Webinar

National Latino Behavioral Health Association

Black Mental Health.net

National Asian American and Pacific Islander Mental Health Association

HYPERGRAPHIA - the compulsion to write in bipolar disorder

It was not easy finding a 'reputable' definition of hypergraphia so I will accept the one from About.com as it is comprehensive and consistent with other definitions found in various more reputable sources.


A Definition
About.com definition (not the most scientific of sources):
Hypergraphia is a condition in which a person feels an overwhelming compulsion to write. People with bipolar disorder, especially during mania or hypomania, may find themselves writing for hours at a time, not necessarily realizing that this is unusual. It may take the form of journalling, creative writing, or copying page after page of a book. Hypergraphia may also be associated with temporal lobe epilepsy and schizophrenia, as well as certain brain injuries. 


The Experience of Hypergraphia
I realized that my hypergraphia was associated with both  hypomanic and depressive episodes but in different ways. When I am hypomanic I get creative and write all sorts of things - poetry, magazine articles, blogs, academic articles, abstracts, and long emails to friends. I also find myself entering notes into my blackberry, when I dont have access to paper or a computer. When depressed, I write dark poetry but have no other creative productivity. When I am hypomanic I have no desire to write poetry. My brain is just not so inspired. So in my search to understand this pattern, I found some interesting information I wanted to share with you and I would love to hear your stories.


What the Scientists Dont Say
It was not easy to find information on this condition. It did not show up in a search on the Merriam Webster online dictionary. A search on the website of the National Institutes of Mental Health (NIMH) and the Mayo Clinic also resulted in no entries. No books could be found in my school library database but In the PsycInfo and Medline databases it is primarily associated with temporal lobe epilepsy.


However there are some well known experts in psychiatry and neurology who have been writing about the behavior from personal and scientific perspectives.


What Some Scientists Say
The Midnight Disease - is a book by Alice Flaherty,  a neurologist at Massachussetts General Hospital. She found herself writing compulsively both after the death of premature twin boys and the birth of healthy twin girls later diagnosed herself with hypergraphia. She believes that this behavior is attached to extreme moods that are found in people with manic depression and other people with brain disorders and brain injuries. 

Peter Whybrow, MD, Director of the Semel Institute for Neuroscience and Human Behavior at the University of California in Los Angeles and a specialist in mood disorders, was reported in the The Guardian (March 17 2004) as saying that manic depressives with a predisposition to chronicling their lives or composing poetry are likely to engage in voluminous writing in their darkest hours.disorders.

Dr Kay Jamison, a professor of psychiatry at John Hopkins University, was quoted in The Guardian (March 17, 2004) as saying that "Two aspects of thinking are pronounced in both creative and hypomanic thought: fluency, rapidity and flexibility ... and the ability to combine ideas or categories of thought in order to form new and original connections."

Mood Disorders and Creativity

In a conference at the Library of Congress (Depression and Creativity, Feb 3, 2009 - click link for video), both Dr Jamison, Dr. Whybrow discussed the controversial and long-standing (pre-Grecian) conversation about creativity and mood disorders. The symposium also included Dr. Terence Ketter who is chief of the Bipolar Disorders Clinic at Stanford University, whose research focuses on the relationship between creativity and madness. Though most artists and creatives do not suffer from mental illnesses but many creatives, especially poets, suffer a disproportionately high rate of mental illnesses, particularly depression and bipolar disorder. Dr Jamison refers to Mendelssohn, Virginia Woolf, Van Gogh as creatives with mood disorders. She argues that during periods of depression people are less productive and are more productive when they are manic or hypomanic.


The Advantages and Disadvantages of Hypergraphia

The great thing about hypergraphia for an academic is the productivity. However it is frustrating that there are often so many ideas that cannot all come to fruition. It inspires insomnia. But the indulgence to these intense desire to write is that it compensates for depressive episodes where dark moods interfere with the discipline to complete ideas.

Manic depression has its advantages and disadvantages and though hypergraphia is both blessing and curse (depending on its expression), in a world where productivity is valued, I have no cause to resist its lure or try to medicate it away. There is beauty in seeing words that come from my brain. And one can only hope that others share the same view.

Note: This was written in a hypographic period during a hypomanic phase.

Violence and Mental Health Stigma

The Headlines

Gunman: a life full of rage, a shocking final act

This was the headline in the Seattle Times on Wednesday May 30, Ian Lee Stawicki shot and killed 5 people in 2 locations in Seattle and then turned the gun on himself. As the news reports became one never ending roll of updates, and spread around the world, it was soon discovered that Mr. Stawicki had been showing signs of mental illness and his father suspected he had untreated manic depression (aka bipolar disorder). Once again violence and death became linked with bipolar disorder even though these events are relatively rare. 

The Other Face of Bipolar Disorder and Mental Illness
Most people who have bipolar disorder are like me and so many people I know: they  are employed, have successful careers and families. We are the face of bipolar disorder and mental illness but this is not the face we see in the public sphere. National organizations like the the National Alliance on Mental Illness (NAMI) - which has more than 1100 local chapters in all 52 states,  and the newly founded Seattle-based Professionals Affected by Mental Illness (PAMI) include members that represent a wide variety of jobs and careers and levels of education.

For some reason, we who have a mental illness have not joined the 'anonymous' movement (perhaps Mental Illness Anonymous - MIA). Perhaps if we went to meetings where we would stand up and own our issues we would get praised and supported for staying symptom free. And when we went out in public we could talk about getting our 1 year medal and be supported for our efforts.

The Stigma of Mental Illness
Instead we hide in closets of society's making with our own support. So that when people talk about the mentally ill they think of people who are homeless shouting at the moon or just another mass killing; but most people do not think about their boss, friend, neighbor or cousin. The TV shows such as Law and Order, Criminal Minds or CSI do not help our image any. But if our image is to change we have to change it.

Because the public links 'danger' to those of us with mental illness, many who are affected with mental illness often refuse to seek help because of the stigma that is attached to being ‘one of them’. We have to step out and show the world that with available, accessible and high quality care we can manage our symptoms and function well, just like those with diabetes do. 

It is also a sign of stigma that we say ‘mentally ill’ to describe someone with mental illness as we do not say ‘cancerous’ to describe people with cancer. We are much more than the parts of our brain that do not function as they should. The reality is that mental illness is physical – unless my brain is not part of my body.


Mental illness is also stigmatized within the health professions because if someone with a mental illness is receiving health on the public dime (Medicare or Medicaid) then it is most likely that they will access care only when they are "a danger to self or others" and the kind of care that could prevent or ameliorate symptoms before a crisis is simply not available or if available, it is only for the lucky few. Feeling mentally unwell is not enough to get care because healthcare is such a precious commodity in this country - whether public or not.

Why We Should Step Out of the Stigma Closet
If women had not stepped out of the secrecy and shame of losing a breast we would not have the movement for research, support and for public education. They had to let everyone know that breast cancer affected women of all colors, classes, creeds, nationalities etc. 

If our only view of the mentally ill is one of limited achievement or of rare violent episodes that end up on the front pages, then the newly diagnosed are at risk of not achieving their full potential because they have no idea of what that may be. Nor do their families or their employers.

Who Are the Mentally Ill
We are a diverse group of people whose biochemistry has gone awry, just as it has for people who suffer from other biochemical disorders. Why stigmatize me because of my brain when my brain works well in so many other ways (such as compassion, humour, and complex problem-solving?

We are friends, family, colleagues and even your healthcare providers. Just like any other illness, it does not discriminate and everyone has a unique experience that is not summarized by scary headlines.

As more people ‘come out’ as mentally ill we can reduce the fear, change stereotypes and give hope to people who are affected by a mental illness. Employers can also see that we can be productive employees who have illnesses that can be treated effectively with the right support.

Coming Out
To those of you out there who are dealing with mental illness, take a brave step and tell someone. The more diverse the faces and lives of the mentally ill, the less shame and stigma we will experience and the more resources will be put into helping to understand and treat one of  the most debilitating health conditions.

For more  information on bipolar disorder and other mental illnesses and ways to advocate for mental health services contact: Depression and Bipolar Support Alliance, National Alliance on Mental Illness, the American Psychological Association and the National Institute of Mental Health