APRIL 15, 2006
VOLUME 3 NO. 7

PATIENTS & PRACTICE

'Spring madness' in bipolar patients

Longer days bring manic episodes.
Diaries reveal patterns


What causes the seasonal symptoms of bipolar disorder?

"We don't really know what causes it," says Dr Anthony Levitt. "There are many theories, some of which are very compelling. But there's clearly an interplay between three things":

1) Biological disposition "There's something in the patient's genetic makeup that makes them susceptible to seasonal changes. There could be a genetic disturbance to the clock genes which regulate circadian rhythms."

2) Environmental triggers "This means big things, not what direction the wind is in, but some sort of geoclimatic variable — day length and exposure to light, rate of change in day length, barometric and temperature changes."

3) Thermal comfort "Everyone's got their own personal reaction to weather. I'm from Australia where we basically only have two seasons, wet and dry. I just met someone from Australia who's been in Canada just a couple of months. He asked me, 'How am I ever going to get used to Canadian winters?' That's exactly the way I felt when I first arrived, but I adapted, but still if there's a slight chill in September I have my hat and mittens on. The thermal comfort of people with bipolar disorder is likely set at a fairly intolerant level, and they don't adapt well to changes in temperature, etc."

Northern spike? Since there appears to be a daylight component, one would think seasonality would be more prevalent in countries like Canada which have shorter days in the winter and longer days in the summer. Not so, says Dr Levitt. "We did a study that looked at latitudes in Ontario and we found there was no change, he says. "Actually, the difficulty improves the further north you go, probably because people who can't cope move south. There have been studies that have compared say Finland to Florida and found more [cases] in Finland — but ours was the only one to actually look at latitudes and what we found was the opposite to what everyone expected."

Some places are better than others, however. "At the equator, where there are no seasons, there's no seasonality. We found that at 43-44° it's at its peak, where there are four seasons."

"April is the cruellest month," wrote T S Eliot in his modernist masterpiece The Waste Land. For bipolar disorder (BP) patients with seasonal symptoms, he had it exactly right. Springtime is the high season for manic episodes in these patients, though nobody's exactly sure why.

"The admission peak in Ontario is April for mania," confirms Dr Anthony Levitt, psychiatrist in chief at Sunnybrook and Women's in Toronto. "In fact, this week was exceedingly busy for my emergency colleagues here at Sunnybrook." Many patients go straight from winter depression to spring mania.

Although some of the symptoms feel good, most are as debilitating as depressive symptoms. "Mania is a very unhappy, disruptive experience," says Dr Levitt. "Patients may feel elated, high or abnormally happy, energetic, but they may also feel intensely irritable, be extremely talkative, have an inflated sense of self-worth and have grandiose ideas."

All of this can tailspin out of control. "They can behave dangerously — speeding, overspending, taking drugs, engaging in dangerous sex. They're often not sleeping and not feeling tired," he says. Some of the time they're feeling really good during a manic episode, but "there are brief moments of lucidity where the patient realizes what's going on and they'll often seek help."

THE CHAOS CYCLE
Dr Levitt is one of Canada's few experts on seasonality and BP. He says while seasonal depression is well-known, within BP seasonal symptoms often get muddled up with other cycling the patient experiences. "Symptoms are entrained in cycles," he explains. "Some people have diurnal changes — changes across the day — typically down in the morning and high in the evening. Others, especially women, have monthly changes that tag on to their menstrual cycles. Then there are those who have weekly and annual cycles."

"But these can combine," says Dr Levitt. "I have a patient we discovered had daily cycles superimposed on annual seasonal cycles. So in the winter he would be even lower in the mornings and in summer he'd be even higher in the evenings."

To the treating physician, this can seem like complete chaos. "Patients like these seem impossibly unstable," says Dr Levitt. "That's where you get what we call 'therapeutic nihilism' — where it just seems too complicated."

FOOL ME ONCE...
All of this makes the symptoms extremely difficult to treat. "For example, someone will feel high so the treating physician will give them something to bring them down — it might seem to work, but it had nothing to do with the drug. They actually spontaneously recovered because the seasonal symptom passed," explains Dr Levitt. "But the physician thinks it was the drug so they'll keep the patient on it indefinitely. The danger is we can actually be making the condition worse."

Dr Verinder Sharma, a psychiatrist at the Mood Disorders Unit at the University of Western Ontario, says he's seeing a lot of BP patients misdiagnosed with seasonal affective disorder (SAD) by both family physicians and psychiatrists. "They're given antidepressants for SAD and this worked initially and then there's a relapse in spite of continued treatment," he explains. "These patients had hypomatic symptoms that weren't picked up. I think what was happening is they were focusing on the seasonal depression and not looking at family history."

This can lead not only to missed treatment opportunities, but worsening of symptoms. "Antidepressants can definitely also bring on mania," he says. "We're seeing more of this."

DEAR DIARY
So what's a physician to do? First of all, try to establish whether or not the patient has seasonal BP, although this can be extremely difficult when other cycling is involved. "You can do this by observation, careful history taking, input from family," he adds. Both Dr Levitt and Dr Sharma swear by mood diaries. "I encourage patients to keep a mood diary," says Dr Levitt. "We find mood diaries very useful," agrees Dr Sharma. "Some patients will say to me, 'Look, this is happening to me every winter.' But when most patients present with depression, it affects what they report, so it's better to do a longitudinal recording of their moods." The diary allows the physician to track changes in their symptoms over time — to put the whole thing in context and get the big picture. Making out the patterns isn't easy, though. "The pattern can be very subtle, changing daily and yearly," notes Dr Levitt. "It's very time-consuming."

When a physician has established the patient has seasonal BP, they can try to work out a medication schedule that follows their symptom patterns. "You can adjust the treatment, prescribe light therapy in the winter and increase the anti-manic medication in the summer," says Dr Levitt. For instance, for his patient who has diurnal cycling and annual seasonal symptoms, he's worked out a regimen where the patient gets a mood stabilizer in the winter and an anti-epileptic in the summer.

"It's very challenging to treat," says Dr Sharma. "There are some patients who may require a slightly higher dose of the medication they're using."

"This is not commonly done by psychiatrists — very few look at seasonal fluctuations," notes Dr Levitt. "I'm speaking from the lofty vantage point of someone who's interested in this. Very few people get managed properly."

 

 

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