Have you heard? You can choose to be happy. That’s right. If you’re sitting around right now all depressed and unhappy it’s just because you’re not choosing the right path. You’re not choosing to be happy.
I find this concept to be absolute hokum and incredibly insulting to anyone with depression – an actual brain disorder.
Every day I fight bipolar disorder. I have to because every day my bipolar disorder requires fighting. Every day, bipolar disorder is at the forefront of my mind. Every day, I have to do all the things that are required to improve (or at least maintain) my mental health. Every day, I have to fight the bipolar depression that makes me exhausted and upset. Every day, I have to focus on medication and schedules and sleep. Every day, every day, every day.
And my reward for all of these fighting and fighting and fighting of the bipolar disorder? If I’m lucky, it’s the reward of not being sick. If I’m lucky, my reward is feeling like one of the normals for one day – a way that other people feel without putting any work into it at all.
And if I’m not lucky? My reward is just another day with illness, with me expending hopeless amounts of energy in a seemingly-impossible fight to stay alive.
Would you like the short answer or the long answer? In short, if you have bipolar disorder, no, you shouldn’t be taking an antidepressant – even if you’re depressed – in many, if not most, cases.
The long answer is, naturally, more complicated.
Depression is many things to many people. The common perception of depression is that you’re “just” really sad all the time, and while this is true for many who suffer depression, this is not a universal norm. Some people don’t feel sad, per se, they feel nothing; they feel dead inside.
I’m always going on and on about how there are only two medications approved to treat bipolar depression (quetiapine and a fluoxetine/olanzapine combination) and about how we need new, novel ways of treating depression in bipolar disorder.
Well, this might not be novel, but it is new.
Lurasidone (Latuda) has now been approved both as monotherapy and as adjunct therapy (with lithium or valproate) in the treatment of bipolar depression by the Food and Drug Administration (FDA). Lurasidone was tested and approved for people with bipolar I.
The Diagnostic and Statistical Manual of Mental Disorders (the DSM) is frequently called psychiatry’s “bible.” I, however, would not pen it that way. I would suggest that the DSM is simply a guideline for the diagnosis of mental illness. It lists the criteria one has to have in order to be diagnosed with a mental illness.
And, as the name of this post suggests, the DSM is releasing its fifth major version – the DSM-5 – in just a couple of weeks.
Now, the DSM-5 has been controversial from the get-go and I have said that much of this controversy is overstated, but some of the changes do have fundamental nosological implications. In other words, some of the changes in the DSM-5 can change how people fundamentally think of certain mental illnesses.
The DSM-5 Cuts the Chord between Depression and Bipolar
And one of the changes in the DSM-5 is the separation of major depression and bipolar disorder into their own chapters. No longer is there a chapter called “Mood Disorders” with both disorder types listed (Can we still call them mood disorders?). Now they each represent a separate category.
This may seem like a small change, and I’m not going to have a fit over it, but I will say that I think it was the wrong move.
There’s a lot to know about bipolar and bipolar depression. How do I know? Because I’ve written about bipolar depression so many times it would make your head spin.
And what I try to do is either present the human side of bipolar depression or the evidence-based side. Here are a few of the articles I’ve written on bipolar depression:
- Atypical Depression More Common in People with Bipolar Disorder
- How to Handle Treatment-Resistant Bipolar Disorder
- Bipolar Disorder – When to Get Off Antidepressants
- Five New Bipolar Depression Treatments You Don’t Know About Part 1 (and Part 2)
- What is Treatment-Resistant Bipolar Disorder?
- Treatment and the Prevention of Bipolar Depression Part 1 (and Part 2)
- And on and on…
Well now I, and you, have the (FREE) chance to get a genuine look into bipolar depression from an evidence-based approach through the words of a leading psychiatrist.
Free Webcast on Managing Bipolar Depression
Here is the information on a FREE webcast by doctors (technically, for doctors) and Global Medical Education on an evidence-based approach to treating bipolar depression. I believe there will be a lot to learn here.
N-acetylcysteine, also known as N-acetyl-L-cysteine or just acetylcysteine is a supplement that shows promise in the treatment of bipolar depression. This is really big news because there are very few drugs, supplements or anything else that show promise in the area of bipolar depression. But N-acetylcysteine (NAC) is even better than most because:
- N-acetylcysteine is an over-the-counter supplement
- N-acetylcysteine is cheap
- N-acetylcysteine has very few known side effects
What is N-Acetylcysteine (NAC)?
Don’t be scared by the fancy name, just think of NAC as a supplement like omega-3 or vitamin D.
N-acetylcysteine is the N-acetyl derivative of the amino acid cysteine, and cysteine is an amino acid required for you to live. Your body uses it in your brain, for digestion and many other things.
And more interesting for people with bipolar disorder, cysteine is a precursor to glutathione, which is a precursor to glutamate – a neurotransmitter in the brain. Like the neurotransmitter serotonin is made more effective by using selective-serotonin reuptake inhibitor (SSRI) antidepressants, glutamate is increased by taking NAC.
The Research on N-Acetylcysteine (NAC) and Bipolar Disorder
I have been watching the research on NAC and bipolar depression for a while and it looks very promising.
Note that NAC is always used as an add-on medication for bipolar depression and is not used alone.
- A recent open-label trial found statistically significant reductions in bipolar depression scores over the course of eight weeks. Improvements in functioning and quality of life were also seen.
- A randomized double-blind placebo-controlled study found significant reductions in bipolar depression scores. Reduction in depression was seen by week eight but further (“medium to high”) benefits were seen by week 20.
N-acetylcysteine has also been used to treat compulsive behavior (like hair-pulling, trichotillomania and gambling), cocaine craving and cigarette smoking.
How is N-Acetylcysteine (NAC) Dosed? What is the Cost of NAC?
This is always a call for your doctor but the double-blind placebo-controlled study mentioned above dosed at 1000 mg twice daily. Some studies have gone higher than this.
I pay about $25.00 per month for NAC and I get it from a vitamin shop.
What are the Side Effects of N-Acetylcysteine (NAC)?
This depends on who you ask. In the double-blind placebo-controlled study no side effects were noted as statistically significant but side effects are, of course, possible with any medication. Long-term data is not available on NAC’s safety.
It’s worth noting that in very high doses (much higher than is used in humans) mice were found to develop damage to the heart and lungs.
Natasha Tracy’s Opinion on N-Acetylcysteine (NAC)
In my non-medical opinion, this medication is worth a try for people who have unresolved bipolar depression. Again in my opinion, it is a low-risk option for treatment that really appears to have no downsides.
And on a personal note, I, personally, have found it effective.
Learning More About N-Acetylcysteine
If you’re interested in NAC I encourage you to click on the studies I have linked to and read Dr. Phelps’ write-up on NAC as it contains more detail than I have provided. You may need to provide this information to your doctor as many doctors don’t know about NAC and bipolar depression.
This is an informational article and nothing is intended as medical advice. All medications, including supplements should be taken under the care of a doctor only. Please and thank you.
Including the Dangers of Using St. John’s Wort to Treat Bipolar Depression
Nevertheless, St. John’s wort is the most well-known alternative treatment for depression and many people take it. However, there are absolutely some dangers in taking St. John’s Wort that you should know about, especially if you’re bipolar.
Warning – the following is information provided by me, a non-doctor. Please check all information out with an actual doctor if you’re at all concerned. Thanks.
St. John’s Wort is not “Safe”
One of the problems with herbal remedies is that people think they are “safe” because they are “natural.” Well, so’s lithium and I wouldn’t recommend chomping on that without a doctor’s supervision either.
Herbs do things. If they didn’t, people wouldn’t take them. St. John’s wort may not be FDA-regulated (a whole other problem) but it is, for all intents and purposes, a drug. This means it should be treated with the same caution as any other drug.
As I mentioned, people with bipolar type II spend 35X more time depressed than hypomanic, and yet there are very few treatments available.
As we discussed last time, the neurotransmitter glutamate and the inflammatory complex are two new, badly-needed areas of bipolar depression treatment research. Here are three additional bipolar depression treatment areas you probably don’t know about: diet, antioxidants and modafinil.
Diet, Insulin and Bipolar Disorder
There are quite a few people talking about diet and bipolar disorder, and diet and depression. And for all the words they say, the one thing we actually know through study is: no diet is known to treat bipolar disorder. Period. We know an unhealthy diet will possibly make you worse, but the only thing science can recommend is to eat a healthy, balanced diet.
Diet and Insulin
[push]The only thing science can currently recommend is to eat a healthy, balanced diet.[/push]
That being said, insulin interacts with many parts of the body responsible for much of the brain functioning. For example, insulin regulates the concentration of neurotransmitters and monoamines in the central nervous system; and these chemicals are thought to impact mood disorders, Alzheimer’s and schizophrenia. It appears a lack of insulin can produce mental illness symptoms.
This area is in extremely early development but there is currently testing of insulin increasing drugs in treatment of bipolar disorder and depression. And yes, other dietary issues are being studied (more carbohydrates and less carbohydrates are being studied) but as of yet, there is nothing concrete.
Antioxidants and Bipolar Depression (N-acetylcysteine (NAC))
We know something unfortunate about the brain and mental illness: mental illness shrinks the brain. (Mental illness decreases neuroplasticity, technically.) And we know that some drugs protect or reverse this effect (SSRI antidepressants, lithium, electroconvulsive therapy (ECT)). [pull]We know something unfortunate about the brain and mental illness: mental illness shrinks the brain.[/pull]
And one of the possible causes of brain shrinkage currently being considered is oxidative stress. Oxidative stress represents an imbalance that prevents detoxification and repair within tissues. (It’s complicated. See Wikipedia.) Some amount of oxidative stress is normal (and important) but this stress combined with cell abnormalities is implicated in bipolar disorder. Evidence suggests lithium and valproic acid protect neurons against oxidative stress.
(Still with me? Good. It’s going to get easier. Just hang on a bit longer.)
This oxidative stress can be caused due to decreased levels of antioxidants. One in particular, glutathione, is known to have abnormal levels in bipolar disorder. And in order to make enough glutathione, a body must have enough of an amino acid, cysteine.
Increasing cysteine levels using N-acetylcysteine (NAC) has been reported to be neuroprotective and impact glutamate (which we think is good, see here). NAC has been able to alleviate depressive symptoms in people with bipolar disorder in a double-blind placebo-controlled study as an add-on medication.
The good? NAC is cheap, over-the-counter, and from what we know, safe.* The bad news? NAC can take up to five months to work and study on it is limited. (See bipolar disorder type 2 depression and NAC notes by Dr. Jim Phelps.)
In a completely non-medical, Natasha-only-based opinion, NAC seems like something you could talk to your doctor about adding. There doesn’t seem to be a downside other than waiting for five months to see if it works. This doesn’t mean try it on your own. It means talk to your doctor.^
Modafinil and Bipolar Depression
Last, but not least, is the research into modafinil treatment of bipolar depression. Modafinil is a “wakefulness promoting agent” prescribed to people “with excessive sleepiness.” This is not an amphetamine but is a stimulant. Basically, we don’t understand this medication but it increases monoamines like norepinephrine and dopamine, which we generally like.
Modafinil has been shown effective in treating bipolar depression (without inducing mania or hypomania) by week two of treatment. In the study, modafinil decreased depressive symptoms and increased remission rates.
This medication is one some doctors are already using off label for the treatment of bipolar depression.
Summary of Bipolar Depression Treatments You Didn’t Know About
Basically, under all of this, the message is: we’re working on it. It’s long and slow and frustrating for us crazies but the doctors have their lab coats out and they’re thinking up stuff all the time. Will any of these help you? I don’t know. But what I do know is these five areas should be a reason to hold onto hope, even if what you’re doing right now isn’t working.
The information in this article is primarily from: Novel Treatment Avenues for Bipolar Depression By Roger S. McIntyre, MD and Danielle S. Cha. Clinical Psychopharmacology. April 19, 2011.
See the article for all the nitty gritty details about the above.
* Safe in this case means no known drug interactions (to the best of my knowledge and according to a doctor). In the drug database used by doctors up here in Canada it reports no side effects. In the study they note it as “safe” but report change in energy, headaches, heartburn and joint pain as possible side effects – these being basically the same in the placebo and NAC group. Keep in mind though, so little study has been done on this there may be all sorts of gotchas we haven’t seen.
^ Remember: your doctor should know about all medications, vitamins and supplements you take. Just because it’s over-the counter doesn’t mean it’s harmless.
People with bipolar disorder 2 spend 35 times more time depressed than hypomanic. As a person with bipolar type 2, I can tell you how true this is. Bipolar type 2 is more like a depressive disorder than a bipolar one. However, this doesn’t mean bipolar disorder 2 can just be treated like unipolar depression. If only life were that simple.
Bipolar disorder type 2 depression treatments must not induce hypomania or mania, and antidepressants used alone often do that. For this reason bipolar 2 depression treatment is generally like happy hour (full of cocktails). And many of us are very frustrated with the fact no new medications are being developed for our mental illness.
So here’s some hope. Here are five bipolar depression treatment areas you probably don’t know about.
Ah, depression. Sucking, vaporizing, numbing black hole. A void where feeling used to be.
Last night I went out on a date. It was a girl I had connected with through a site online. Lovely girl. Smiling. Happy. There’s a picture of her taking another girl’s bikini top off with her teeth. Playful happiness.
And in person, she was, in fact, happy. Enthralled and entertained by me. She wanted to hear story after story. Captivated. Charmed. Her gaze burned into my flesh.
Most Notable Feeling in Depression is Nothingness. A Lack of Want.
And I’m a depressed girl. I felt, nothing. Nothing. I had gone out determined to hunt a female. But. I couldn’t. Sure, part of that might have been the girl in particular, but it’s mostly me. Mostly bipolar, depressed, lack of feeling, lack of want me. I just don’t feel anything about, well, anything. (Except tired. I am tired.)