Recovery Issues in Bipolar Disorder

Dr. Emanuel Severus, is a research fellow in psychiatry at Harvard Medical School where he works with the Bipolar and Psychotic Disorders Program. His research consists of new treatment options for bipolar disorder, schizophrenia, and other psychotic disorders.

David HealthyPlace.com moderator.

The people in blue are audience members.

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online conference transcript

David: Good Evening. I'm David Roberts. I'm the moderator for tonight's conference. I want to welcome everyone to HealthyPlace.com. Our topic tonight is "Recovery Issues in Bipolar Disorder." We have an excellent guest tonight. Dr. Emanuel Severus, M.D., is a research fellow in psychiatry at Harvard Medical School where he works with the Bipolar and Psychotic Disorders Program (New and Experimental Psychopharmacology Clinic/Lab). His research consists of new treatment options for bipolar, schizophrenia and other psychotic disorders. Dr. Severus won the 1999 Glaxo Wellcome Research Award.

Good evening, Dr. Severus and welcome to HealthyPlace.com. We appreciate you being our guest tonight. Before we get into the meat of the conference, can you tell us a bit more about your expertise in Bipolar Disorder?

Dr. Severus: Thank you for the invitation! Since 1995, I have been interested in new treatment options for bipolar disorder. In 1995, Dr. Stoll and I came up with the idea of using omega-3 fatty acids.

David: Can you expand on that a little more? Maybe explain what omega-3 fatty acids are and how they are used?

Dr. Severus: Omega-3 fatty acids are essential Polyunsaturated Fatty Acids (PUFAs). They are found in flaxseed oil and fish oil, and of course, fatty fish. Some examples include salmon, herring and mackerel.

Those fatty acids seem to share similar properties with the established mood stabilizers, with regard to signal transduction at the postsynaptic membrane.

David: In non-technical terms, what is the impact, then, of ingesting these fatty acids?

Dr. Severus: Down-regulating of post-synaptic pathways, resulting in improved membrane stability.

David: Since you are in the research field, what is the "best" treatment for bipolar disorder available today?

Dr. Severus: It really depends on the individual, and it also depends whether you are just focusing on pharmacological treatment options, or not.

David: Let's start with bipolar medications, or natural remedies for bipolar, and then we'll progress from there.

Dr. Severus: Okay. We can start with natural remedies for bipolar. Omega-3 fatty acids are definitely a good choice for patients with bipolar depression, however, they also seem to have mood-stabilizing properties.

Another benefit, is the beneficial side-effect profile. Apart from gastrointestinal distress, there are practically no adverse effects. In fact, omega-3 fatty acids seem to protect individuals with myocardial infarction from sudden cardiac death. And as you might know, patients with affective disorders are at an increased risk of developing Coronary Artery Disease and myocardial infarction.

David: I have not heard of many doctors recommending omega-3 fatty acids as a first line treatment. Usually, they start with medications like Lithium, etc. Would you suggest that some with bipolar disorder try omega-3 fatty acids first, before turning to some of these other medications?

Dr. Severus: It is true that Lithium is the most established mood-stabilizer. It seems to have potent anti-suicidal properties, apart from its mood-stabilizing properties. On the other hand, it seems to prevent manic episodes more effectively than depressive episodes. Some patients also complain about the side-effect profile, like increased thirst, cognitive dulling, weight gain, acne, tremor. I think it really depends on the individual.

KcallmeK: How does the use of omega-3 measure up in regard to anti-suicidal properties?

Dr. Severus: We don't know yet. There are some data from Finland which suggests that it also has anti-suicidal properties.

erycksmom: Can you try the omega-3 if you are currently on Lithium and still not stable?

Dr. Severus: Sure. I think adding omega-3s to Lithium or Valproate is a very good option. You also don't have to be concerned with drug interactions.

David: How much omega 3 is recommended, and what is the "best" form to take it in?

Dr. Severus: Good question! There is alpha-linolenic acid, which is found in flaxseed oil, and there is EPA (eicosapentaenoic acid) and docosahexaenoic acid (DHA). Double-blind controlled data exist for fish oil (EPA and DHA) with a ratio of EPA/DHA:3/2. During the last few years we have got the impression that DHA alone is not very helpful. So, we suggest that you start with a high EPA fish oil.

Other characteristics you should look for are:

• High concentration of omega-3 fatty acids per capsule.
• No fishy aftertaste.
• Quality brands of fish oil manufacturer use nitrogen to produce the fish oil.
• No fish liver oils due to high levels of vitamin A and D.
• No cholesterol.
• Start with a high EPA brand, approximately 3 grams of EPA.
• If you are a vegetarian, use flaxseed oil (1 to 2 tablespoons is a good starting dose).
• Using a lignan rich flaxseed oil might have some advantages. Barlean's offers such a flaxseed oil.
• You should always keep it refrigerated.

David: Just a note here: I received a couple of messages from people who are concerned that we may be advocating dropping your bipolar medications and taking omega-3 fatty acids instead. That is not the case. As I said at the top of the conference, any information presented here is for your information only. If you find it useful, I suggest you talk it over with your doctor. But please, do not stop taking your medications based on what is presented here.

Pjude9: How long before one would notice any effect from omega-3?

Dr. Severus: You might notice beneficial effects within the first two weeks, however, you should take it for four weeks to be sure whether it is helpful for you, or not.

I would also like to support what David just said: We don't encourage people to drop their current bipolar medications. In addition, omega-3 might be a good option, if you are not stable on your current medications. Furthermore, always talk to your Primary Care Physician or psychiatrist before changing any medications.

L.Lee: I am Bipolar II, and am on 400 mgs. Topamax (Topiramate) and 400 mgs. Wellbutrin. Lately, I've been having a problem with rages. Is this due to medication? I have always have been passive.

Dr. Severus: Well, any antidepressant may worsen the course of the disease and trigger manic or mixed episodes. On the other hand, Wellbutrin is the one which is very well tolerated in general. The side effect profile of Topiramate does not include rages as a common side effect.

David: One of the things we get a lot of email about is people who are prescribed antidepressants, when they really needed mood stabilizers. How does a person know which type of medication would be right for them?

Dr. Severus: I agree. Mood stabilizers should be the first-line treatment. And it might be a good option to add Lamotrigine instead of an antidepressant, because Lamotrigine seems to have mood-elevating and stabilizing properties.

sadsurfer: Dr. Severus, if mood stabilizers and antidepressants are used, and a patient achieves some degree of stability, does this necessarily confirm the diagnosis of bipolar disorder, even if the patient has never had a "true" manic episode?

Dr. Severus: The diagnosis should not rely on a treatment response. Bipolar 1 disorder requires a manic or mixed episode, Bipolar 2 disorder "just" hypomania. Sadsurfer, if you click on this link you'll find the criteria for diagnosing bipolar disorder.

e: I'm concerned with the idea of my bipolar illness being hereditary. I was diagnosed after my son was born, and have been told the pregnancy might have triggered my illness to surface. I am Bipolar and have Obsessive Compulsive Disorder (OCD). My question is what chance is there that my son will suffer from a mental illness?

Dr. Severus: It is hard to tell, but you should remember: Even if the genes are involved in bipolar illness, environment also plays an important role. So don't get discouraged.

webbsspyder: How can psychotherapy be helpful in managing and treating bipolar?

Dr. Severus: Sure, there is a new psychotherapeutic approach called: Social rhythm therapy. This sound very promising to me!

David: Can you explain more about that?

Dr. Severus: Yes, social rhythm therapy focuses on restoring and maintaining personal and social daily routines to stabilize body rhythms (especially the 24 hour sleep-wake cycle).

David: Also, webbsspyder, we've had many conferences here where the doctors talk about the importance of therapy in dealing with your personal issues, feelings, and thoughts. The medications can stabilize your moods, but they don't resolve psychological issues. That's what therapy is for. Here are the transcripts from those conferences.

victory: How does improved membrane stability affect bipolar disorder?

Dr. Severus: Well, we think that it translates into increased mood stability. It may also decrease the stimulation threshold, however, this is a hypothesis.

rwilkins: I have been on Lithium for over twenty years. I do pretty good for myself. Christmas holidays are usually the hardest, but not all the time. My levels are always good. My question is would Omega 3 possibly be a plus?

Dr. Severus: You can try it, but you should start then pretty soon. Another, and maybe better option, might be to invite friends for Christmas, if it is possible.

ripley: I was on Lithium for two years, and can no longer take it due to a goiter in my thyroid. How can I get back on it? It has helped me greatly otherwise.

Dr. Severus: You could take a thyroid supplement. Have you developed the goiter under Lithium?

ripley: Yes.

Dr. Severus: Are you hypothyroid, or do you have elevated T3/T3 levels?

ripley: I'm not sure, I wasn't told.

Dr. Severus: You should find out. Taking a thyroid supplement might be good option for a "hypothyroid" goiter if you developed it under Lithium.

Pjude9: Could you explain why anti-psychotics such as Zyprexa and Seroquel are used in treating bipolar?

Dr. Severus: Zyprexa has acute anti-manic properties. We don't know yet whether these drugs also have good mood-stabilizing properties in the long term.

techie: Would you recommend medicines like Depakote and Celexa along with the omega-3 fatty acids?

Dr. Severus: If you are suffering from severe depression, than this combination alone is not helpful, you might consider adding the Omega-3s. By the way, I would always recommend a daily mood chart to monitor symptoms and improvement when you change medications. I think that this is extremely helpful, especially also in retrospective.

techie: I'm on 1250mg of Depakote, 20mg Celexa and 10mg Zyprexa, but I can't seem to stay stable for more than a month. Is this common?

Dr. Severus: Unfortunately, it does occur. This is why polypharmacy (taking several medications) has become so frequent.

David: A few notes here, then we'll continue with a few more questions. Here's the link to the HealthyPlace.com Bipolar Community. 

erycksmom: I attend a bipolar support group, and there is a lady there who has been on Lithium for over 20 years. She mentioned that when she was first diagnosed, that they gave her some test that pointed to manic depression. I have been told no such test exists. Was there ever such a test, and will there ever be a definitive test to prove medically that I suffer from bipolar?

Dr. Severus: I doubt that this test was reliable, and I am a bit skeptical whether we will have such a test in the near future. However, we can diagnose bipolar disorder even without a "test" pretty well. This is why we have the diagnostic criteria.

PSCOUT: Can you please discuss the use of Neurontin as a mood stabilizer?

Dr. Severus: Gabapentin seems to be especially helpful in the treatment of anxiety in bipolar disorder. Another advantage is its lack of interactions with other drugs, however, it may cause fatigue, sedation, and dizziness. Furthermore, I am not aware of any well-controlled data regarding long-term mood-stabilizing properties.

David: Just to make sure, Gabapentin and Neurontin are one and same, correct?

Dr. Severus: Yes.

garfeld: Can this be used with children with bipolar and an anxiety diagnosis?

Dr. Severus: To tell the truth, I don't know the data in children with bipolar disorder, if there are any. Sorry.

SaxDragon78412: I have read some reports that people with bipolar should not take Melatonin supplements, and other reports that we should. Which is correct?

Dr. Severus: Melatonin might be helpful to improve sleep during a depressive episode, but it does not have anti-depressive properties. It might also be useful to treat jetlag, which is especially dangerous for people suffering from bipolar disorder.

cris7448: I was misdiagnosed and went through hell on other antidepressants, but Wellbutrin has worked very well for me. However, even on the medications, I still have some mood fluctuations. What besides medications and omega 3, can I do to try to keep my moods stable?

Dr. Severus: Here are some suggestions for maintaining mood stability:

• Exercise on a regular basis.
• Maintain a stable sleep pattern.
• Don't use any alcohol, try to avoid caffeine.
• Some people also report that white sugar makes them feel worse.
• Start some kind of relaxation technique (Diaphragmatic breathing for example seems to be helpful for some).
• Try to reduce stress at work and during your leisure time!

David: Those are excellent recommendations, Dr. Severus. I'm also getting some audience requests re: the correct daily dosage level for omega-3? Could you give that to us, please?

Dr. Severus: Sure. Start with approximately 3 grams of EPA per day, or 1-2 tablespoons of lignan-rich flaxseed oil.

David: And is there a maximum limit on that?

Dr. Severus: We don't know yet, but I would not recommend more than 4.5-6 grams of EPA or 3 tablespoons of flaxseed oil, and always closely monitor your symptoms. We have seen a few hypomanias on flaxseed oil and EPA/DHA, however, on high doses.

missdjv: My mother has been very unstable for months, so we had to move her to my home. Will this Neurotin work quickly, or should she be hospitalized while adjusting to this medication? I really want to do what is best for her.

Dr. Severus: You should talk to her psychiatrist regarding hospitalization. It really depends on her condition. In general, if there is a significant risk of suicide or homicide, you should definitely consider hospitalization.

truckdog: How can you help your loved one gain" insight" that they have Bipolar?

Dr. Severus: Good question! The best thing might be to tell him or her, is to read some books on this condition. Or to attend a meeting of a self-help group and to talk to other people with this illness.

terri/co: Does omega-3 fatty acids in combination with other medications tend to moderate side effects such as weight gain?

Dr. Severus: We don't know yet. In our study we have not seen any significant weight gain. There are some studies in obese non-psychiatric patients which point to the fact that omega-3 have beneficial effects on the blood lipid profile in that population. However, you should also get some advice from a nutritionist.

David: I know it's getting late. Thank you, Dr. Severus, for being our guest tonight and for sharing this information with us. And to those in the audience, thank you for coming and participating. I hope you found it helpful. We have a very large and active bipolar community here at HealthyPlace.com. Also, if you found our site beneficial, I hope you'll pass our URL around to your friends, mail list buddies, and others http://www.healthyplace.com.

Thank you, again, Dr. Severus for joining us this evening.

Dr. Severus: Thank you for the invitation. And to the audience, one last piece of advice: Never ever give up!

David: Good advice. Good night everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.