Risk taking and suicide

Twenty percent of people with bipolar disorder commit suicide. I myself have had suicidal thoughts, but luckily have never been so low as to attempt anything. Suicide attempts usually happen during depressed episodes, or mixed episodes where the person experiences both mania and depression. It is thus important to be aware of the risks and to put strategies in place to reduce the risks.

First of all, here are some factors that can help protect from suicide:

Family and friends

Future plans

Feeling useful- investing yourself in work, volunteering or family

Having good self esteem

Being able to handle stress

Strong cultural or spiritual links

Good physical and mental health (though this is of course easier said than done)

Risk factors include:
Mental illness (of course)
Isolation
Having previously  made a suicide attempt
Unemployment

Misuse and abuse of alcohol and other drugs
Access to lethal means

Suicide or other risk taking can take many forms. People with bipolar are particularly at risk of attempting suicide when depressed, but are also likely to take risks when manic, as they will feel invincible  and can lead to unusually dangerous behaviour, whether the risk be for their life, their health, their social position, their job, their family or their money. This may include driving too fast, undertaking dangerous dares, risky sexual behaviour, or breaking the law.

So what should you do if you're depressed and worried about feeling suicidal? Here are some preventative strategies:

Make a list of future plans

Write a list of supportive friends and family

Write a list of things that you love

Write a plan for what to do if you start feeling suicidal

Make your home safe

Avoid triggering situations

Avoid taking alcohol and other drugs

Learn to identify the danger signs

If you start actually feeling suicidal, it is very important to talk to someone. There are many hotlines available for this, but if you feel in immediate danger the best idea is to go to hospital, where you will be looked after and prevented from hurting yourself. Please know that however bad you're feeling, things will get better, and life will not be better without you in it.

Substance Addiction

This is luckily not a subject that affects me (the only things I'm 'addicted' to are sugar and Facebook) but a high percentage of people with bipolar disorder are addicted to substances, whether they be cigarettes, alcohol, cannabis, cocaine, or other drugs, and unfortunately these addictions up the risks of both depressive and manic episodes and/or prevent medication from working so effectively.

Cigarettes

People with bipolar disorder are two to three times more likely to start smoking than people without psychiatric disorders and may be less able to quit. People with bipolar disorder die an average of twenty years before their counterparts from the general population, and while some of these deaths are due to suicide or accidents, the

most frequent causes of death are due to cancer, cardiovascular, cerebrovascular, and respiratory diseases, which are all conditions for which tobacco use is a known cause of early mortality. Cigarettes also make some medications such as lithium less effective, and a higher dose is needed in order to reach the desired effect, which in turn increases risks of side effects like kidney damage.

Alcohol

Many people drink but it is considered excessive if a woman drinks more than three drinks on any day or more than seven per week or if a man drinks more than four drinks on any day or more than fourteen per week. Excessive doesn't equal addiction though. Drinking is considered an addiction if the person feels unable to function normally without alcohol. Studies have shown that people with bipolar disorder have a 60% chance of developing a drinking problem at some point in their lives, which is a frightening statistic! Alcohol is dangerous for people with bipolar disorder, as it reacts badly with medication, and can fuel both mania and depression.

Cannabis 

Almost 70% of people with bipolar disorder use marijuana during their lifetime and 30% are dependent on it.  This is problematic because the risk of psychotic disorders increases with cannabis use and its use is linked to a younger onset of bipolar disorder. It can worsen both manic and depressive symptoms and suicide attempt rates in people with bipolar disorder are higher in those who use marijuana than in those who abstain.

Cocaine 

A large amount of people with bipolar disorder also use cocaine and 5% to 30% of cocaine users have bipolar disorder compared to 1% in the general population. However, it is difficult to prove causality- do people use because they have bipolar or do they have bipolar because they use? Either way it's bad news because cocaine causes big boosts in mood, often accompanied by hallucinations and fears, and then a crash accompanied by depression and a feeling of loss. These shifts in mood are similar to those experienced by people with bipolar disorder, and one on top of the other is a recipe for disaster. There is a high suicide risk for people with bipolar, and about 20% of people who commit suicide have some form of cocaine in their bodies, which makes taking cocaine a double risk for people with bipolar.

Bipolar disorder is complicated enough without adding drugs as these promote relapse and make the disorder harder to treat. Help is fortunately at hand, whether it be from your GP, Alcoholics Anonymous, Nicotine Anonymous, Narcotics Anonymous, or a hotline. Help is also available to those with addictive behavioural problems, such as gambling. For those in France the association SOS Addictions can be contacted for any type of addiction problem.

Comorbidities

So what are comorbidities? Comorbidities are conditions that have been found to often overlap a primary condition. Unfortunately there are quite a few for bipolar disorder.

The percentage of people with bipolar disorder who also have an anxiety disorder is very high: 43% to be precise. These include panic disorder, generalised anxiety disorder, social anxiety disorder, agoraphobia, other phobias, PTSD and OCD.

Eating disorders, which are also a form of mental illness, have a high rate of comorbity with bipolar disorder. Between 6 and 18% of people with bipolar have anorexia nervosa, bulimia nervosa, or hyperphagia (compulsive eating).

Addiction, whether to substances or behavioural, also has a high comorbity with bipolar disorder. Many people with bipolar disorder are addicted to alcohol, cigarettes or cannabis, which I will explore further in my future post on addiction.

People with bipolar disorder suffer from migraine more often than those without; 31% compared to 6% in the control group. Migraines are also linked with more frequent and severe depression among those with bipolar disorder.

Other physical comorbidities include thyroid illness, high blood pressure, obesity, type II diabetes, and cardiovascular disease. Some of these may be impacted by a sedentary lifestyle due to depression, and emotional overeating or overeating due to medication.

There are a lot of both physical and mental comorbidities with bipolar disorder, but luckily they can mostly be treated, whether with medication or with therapy, or they can be prevented with a healthy lifestyle.

Treatment

Medication is a critical part of bipolar treatment. It is treated primarily with mood stabilizers, of which there are three types. These are Lithium, antipsychotics, and anticonvulsants. Patients can take up to one medication from each category, depending on the severity of the case. Other medication may include anti-anxiety drugs, sleeping pills and antidepressants. The latter present a risk of provoking mania, and are only used during a severe episode of depression, and only in conjunction with mood stabilisers.

Lithium is the oldest mood stabiliser and is one of the most widely used. It works well but also has many side effects, including possible kidney damage, so for less severe cases other drugs may be preferred.

Antipsychotics do what it says on the tin. They prevent hallucinations and other symptoms of mania that stem from psychosis. They help to balance the brain's thinking mood and perception, though scientists are yet to understand why. One of their main disadvantages is that they stimulate appetite, which may lead to weight gain. I myself have struggled with this and have put on more weight than I would like. Doctors tend to downplay this side effect, maybe to avoid patients being reluctant to take the medication, but it is important to be informed in order to be able to make healthy choices.

Anticonvulsants were initially created to treat epilepsy, but were found to treat bipolar as well. There are a high amount of people with both epilepsy and bipolar, and some even believe them to be two sides of the same coin. This may be why ECT (Electro Convulsive Therapy) is so effective in extreme cases. ECT introduces an electrical current to the brain which induces a seizure similar to those in epilepsy. Despite its bad rep in the media (think: One Flew Over The Cukoo's Nest), ECT is non-violent (it is done under general anaesthetic) and is the most effective treatment, but it does have side effects like headaches and memory problems.

Talking of side effects, it is important not to read the list before taking the treatment, as this may provoke the nocebo effect, which means that you will have negative side effects because you think that you're going to have them. With ECT though, doctors are legally obliged to tell you about the possible side effects, so it's a bit of a catch 22 situation.

All this being said, medication only does 40% of the work, so let's move on to non-medicinal treatments. The main ones of these are psychoeducation, CBT, family focused therapy, mindfulness, and then of course there's having a healthy lifestyle. I'll come back to the latter two in later posts.

Psychoeducation is the name for the workshops that I'm currently doing. In fact, all of my posts so far, excepting the poetry, have been themes that we've covered.  Psychoeducation involves educating and providing information to patients with mental illnesses and to their family members. Patients are given information about the causes, symptoms, prognosis, and treatments for their condition. Learners find out not only what to expect, but also what they can do or avoid to improve their condition. 

CBT stands for Cognitive Behavioural Therapy. This is a type of therapy that I've experienced myself to treat depression. It involves learning to challenge and transform negative thinking and behaviour and often involves writing down negative thoughts, then writing down alternative, more positive ones. For example, if a friend who systematically wishes you Happy Birthday doesn't do so one year, instead of thinking 'They must not care about me anymore' the patient learns to think 'Maybe they have a lot going on at the moment. I should get in touch and see how they are.'

Family-focused therapy was  developed especially to treat bipolar disorder. It was designed based on the theory that a person's relationship with their family is vital to the success treatingof managing their  illness. In FFTs family members are included in therapy sessions  in  order to improve family relationships, which has been found in several studies to help stabilise the person with bipolar and prevent relapses. FFT mainly focuses on educating the family about bipolar disorder, building better communication skills in order to deal with stress, and solving problems together as a family.

Treatment of bipolar disorder is varied and a symbiosis of medical and non-medical treatment is necessary in order to best treat the illness and help the person with bipolar to achieve stability and avoid relapses.

Euthymia

I am currently euthymic. What does that mean? It means that I'm stable; neither depressed nor manic. However it is important to note that euthymia is a phase of bipolar disorder, and the illness is still there even when the person is stable. One does not get cured of BD but one can be stabalised and live normally for decades. However, if the treatment is stopped the patient will relapse, with a 50% chance of relapse within the three following months.

During euthymia it's still possible to suffer from symptoms such as anxiety, hypersensitivity, feeling depressed, having trouble sleeping, and cognitive difficulties (problems with memory, concentration and organisation). However in general the person feels well during euthymic phases. And it's precisely during these phases that there is the most work to do to put into place a healthy lifestyle. Medication only stabalises the person at 40%, the rest is therapy and lifestyle. This includes Cognitive Behavioral Therapy, eating well, sleeping well, and exercising. That is not to say that doing all these things will prevent a relapse, as life events can provoke one, but doing these along with taking medication can greatly reduce the chances of relapse and the severity. It's important to note however that these need to be put in place while the person is stable, as no-one who is experiencing a depressed phase is going to be able to start going jogging, and equally no-one experiencing a manic episode is going to be able to start getting a good night's sleep.

So euthymia's all good, right? Well, not for everyone. After the bright rainbow highs of (hypo)mania, euthymia can feel dull and grey. Some people feel nostalgic about hypomania and may actively seek it out. Stephen Fry has talked about this, as per the illness he is at his most creative and productive when hypomanic. Seeking it out often means stopping medication however, and this is dangerous. People may also stop taking medication because they feel well, but this inevitably leads to relapse, and the more a person relapses, the more likely they are to relapse again, and the more severe those relapses will be. There is also the fact that medication will be less effective after starting it up again after having stopped it.

So basically euthymia is a desirable state, but achieving it doesn't mean that you are cured and it certainly doesn't mean that you can come off of your medication. It can be maintained through medication, but that alone isn't enough and therapy and a healthy lifestyle are also necessary. It's all about balance. 

Mania and me

Mania is both scary and exciting. When I'm manic I am bubbly, more so than usual, until the pressure in the bottle rises and the bubbles fizz up, out of control, leaving the bottle suddenly empty. It's hard to explain to someone who hasn't experienced it, but the closest I can get is being drunk, and getting drunker and drunker until you completely lose control and then waking up with the worst hangover ever, that lasts for weeks, if not days.

There are two types of mania, hypomania and mania. During hypomania the symptoms are less intense, the person is aware that they are behaving differently from normal, and they are able to continue functioning in a somewhat normal manner i.e. going to work. During hypomania the person is more sociable, talks faster than normal, is more productive but needs little sleep, concentrates better, is more creative and is more productive at work among other symptoms. Sounds great, right? Well the problem is that hypomania mostly leads to mania, which is when things start really going out of control. The person becomes euphoric, believes themselves to be very important, spends a lot of money, speaks without stopping, has wild mood swings and becomes unaware of danger. They can even become psychotic and start hallucinating. Basically all the positives are classed under hypomania, while the negatives are pure mania. And mania is always followed by a period of depression, making it doubly negative. 

Looking back I can now see that I was at least somewhat experiencing hypomania during my month long CELTA course when I was training to be an English language teacher. Over a five day period I slept for 15 hours, and yet felt full of energy and was extremely productive, even going so far as to start going running and swimming in the little time that wasn't spent at college or prepping lessons.

I have experienced true mania twice, and was hospitalised both times, but more on that another time.

My black dog

                     Image credit: Matthew Johnstone 

Depression is often referred to as a black dog. Imagine a black Labrador lying on your chest so you can't get out of bed. Or the same dog pulling on its lead and preventing you from leaving the house. This gives you some idea of what depression is like for me. There are over forty different symptoms of depression, but some of those that I personally experience are being unable to get out of bed, feeling really tired, sleeping a lot, not wanting to socialise, not showering, feeling worthless, and losing the will to live. I have never attempted suicide or made any serious plans before, but I can't say it hasn't crossed my mind.

There is a difference between feeling down and having clinical depression, in which symptoms have to last two weeks or more. Depression is an illness, like diabetes, and not something that you can just 'snap out of'. It requires treatment, which can come in several different forms, including cognitive behavioral therapy (CBT) and medication. I was on antidepressants on and off for years, but unfortunately antidepressants are actually a very bad idea for someone with bipolar disorder, as they can make them manic. It makes sense if you think about it; antidepressants lift your mood, (I'll get into the science of this another time) but lift the mood of someone with bipolar disorder too much and they become manic. This is why antidepressants are not used to treat bipolar disorder, or at least not unless in combination with mood stabilisers, but more on that later.

All this to say that depression can be a stand alone (unipolar) illness, or part of bipolar disorder, but either way it's a shitty thing to go through and it is important to get treatment. If you do think that you might have depression, please reach out to your GP. It is important to get help and not to go through this alone.

If you are having suicidal thoughts, please call a hotline such as the Samaritans in the UK or SOS Amitié in France.

Poems

I will let these speak for themselves.

The roller coaster 

Most people roll along at an even pace
With a few occasional dips and bumps and sometimes singing crescendos:
A wedding, a birth
And sometimes devastating lows :
A loss, a death
But my life is a constant roller coaster
I am always going up or down
Bubbly barrel rolls
Or terrifying falls that leave me screaming, panting, feeling out of control.
Sometimes the downward tilt is so gradual that I don't even realize until I'm submerged in the water underneath and I
can't
breathe.
Unlike a roller coaster, the descents are never fun,
It is the climbing highs that spark joy but sometimes
too
much
And the sparks ignite a fire
And the rails are burning.
Sometimes I wish for a steady train ride like other people
But wonder if I'd miss the dazzling heights
The medication is a seat belt
Holding me in so I don't go flying and
Crumple
to
the
ground.
Sometimes it's too tight, uncomfortable
And I long for sailing heights among the stars
But with the stars come clouds
And with the clouds come rain
And I am wet and miserable, or numb from the cold.
So I dry myself with a fluffy towel
And try to take care of myself
To predict the highs and lows and
Put on
The brakes.
To wear a waterproof jacket to protect me from the icy spray, and wrap around sunglasses for the burning stars.


Self care.
Self.
Myself.
I care.
I am.
I will.

Riding the wave

Riding the wave.
It's thrilling;
A roller coaster that keeps going uP
Don't let it go down
And spiral
out of
control.
Channel the energy;
thrummmming from deep withiin.
Ants in my brain,
Buzzing bees,
Harness them}
Tiny bee harnesses}}}
Harni???
Let them pulll you to
Creative
Outpourings of
organisation
planning
lists
1.
2.3.
Enthusiasm
Passion
Dyyynamism
Energgy.
But. Be careful.
Beware the Jaberwock my son.
My daughter.
Do not feed it's hungry mouth
And look into its flaming eyes;
'All the better to see you with my dear'.
Shun that frumious Bandersnatch.
O frabjous day! Callooh! Callay!
You can chortle in your joy;
But be on guard []
Batten down the hatches  i - - - i
Close that stair gate XxX
Lest your mind come
tumbling
down
Followed by your
body.
Gird your wallet.
Zzzzip it up and swallow the key.
Put that debit card
on ice.
No
shopping 'till you're
Dropping.
Your bank account will feel it later
And weep red tears.
Et voila:
Ride the wave;
But beware of sharks.

A tightrope walker being pulled up by balloons and pulled down by leaded weights
Dancing on the backs of sharks
And being pulled down by seaweed

One side of my brain is lying down
The other is jumping up
The two sides meet
Crash
My
H
E
A
D

Nurture oneself

No, it's too hard, I can't say it.
N-n-n-n-no.
Enn Oh
No-o-o-o-o
I self eface
Wipe across the steamy mirror
Am I still there?
Say it
Tongue flicking off the bottom of your mouth
Giving it the bird
What? Life
Them
The constant demands
Physical
Emotional
Work
Family
Weigh
ing
You
DOWN.
You need to stop.
Say it.
Say it with me.
No. NO.
Nuture yourself.

This blinking illness.

Blink once, manic
Blink twice, depressed
Blinking bright lights manic
Blinking dark depressed
Blinking shimmy manic
Blinking curtain depressed
Blinking blinking blinking manic
Shut my eyes depressed
Eyes
open
and
stay
open.
Stable.
For now.

Being manic is like
Being drunk
Everything is very
Very fast
Very excited
Very energetic
Very loud
Very talkative
Very open
Very honest
Too honest
Then very slow
Very tired
So
L
e
t
h
a
r
g
i
c

Very everything

So what is bipolar disorder?

As some of you know, about six months ago I was diagnosed with bipolar disorder. In fact I diagnosed myself, before having it confirmed by my psychiatrist, but that's another story.

So you may be wondering, what exactly is bipolar disorder? It's a mental illness that used to be called manic depression, where the person experiences periods of depression and periods of mania. You may well be familiar with depression. You probably have friends and family who have it. I myself was diagnosed with depression for ten years before being diagnosed with bipolar disorder. 

So what about the mania side? What's that about? To answer this question I'm going to refer you to Jim Carrey's character in the film 'The Mask'.

When wearing the mask he is hyperactive, amorous, makes a lot of puns, talks very fast, is impulsive, grandiose, and cycles rapidly between emotions. These are all mania symptoms. In fact Jim Carrey himself has bipolar disorder, which permits him to be very authentic in his representations of other eccentric characters such as Ace Ventura and The Grinch.

Anyway, I'll come back to both depression and mania in more detail later, but to summarize, I suffer from extreme mood swings. These are not your regular mood swings though, they only affect 1-2% of the population and can be lethal, with an shocking 20% of people suffering from bipolar disorder dying from suicide. Not to worry though, I take medication and see a psychiatrist, and also do not do drugs or drink to excess, which means that I'm a lot more stable than most of the people who unfortunately die due to this condition. I am also educating myself about my illness by attending a weekly seminar on bipolar disorder which is in fact what motivated me to write this blog, and so I'm becoming more and more aware of what to look out for and when to seek help.

If you think that you might have bipolar disorder I encourage you to go and see your GP, as it is a treatable condition and you can greatly improve your quality of life by getting treated.

If you are feeling suicidal please call the Samaritans on 116 123 from the UK, or SOS Amitié on 01 42 96 26 26 from France.