Bipolar Screening - People with Bipolar Know It When We See It

Psychiatrists and people with bipolar both have told me that my book captures what the manic experience is like.

Reviewers tend to say either, She must have written it when she was manic. Too bad her editor didn't fix it. One star. Or: She must have written it when she was manic. So glad her editor didn't fix it. Five stars.

Which gets me thinking: Doctors say bipolar is really hard to diagnose. But if people who have it know it when we see it, what if we wrote a screening tool? Bear with me here. I'm thinking something like this:

They say: A distinct period of abnormally and persistently elevated, expansive, or irritable mood.

What we hear is: Are you abnormal?

To which we answer: No. I mean, duh.


So what if they said: Has there ever been a time when everybody around you just didn't understand why the world was so great or why you felt so good? Or has there ever been a time when everybody around you was massively irritating?

That is the core symptom of mania. Moving on to the others:

They say: 

  • Increased self-esteem or grandiosity.
  • Decreased need for sleep.
  • More talkative than usual, or pressure to keep talking.
  • Flight of ideas or subjective experience that thoughts are racing.
  • Distractibility (attention too easily drawn to unimportant or irrelevant external stimuli)
  • Increase in goal directed activity (socially, at work or school, or sexually) or psychomotor agitation
  • Excessive involvement in pleasurable activities that have a high potential for painful consequences

How about instead, the way we would put it: 

  • Despite how shitty you feel right now, have you ever understood just how special you really are?
  • Yeah, the decreased sleep one works okay.
  • Has there ever been a time when you had to keep trying to get your point across because others were too dense to get it?
  • Has there ever been a time when others couldn't keep up with your ideas? Has there ever been a time when your ideas flowed like out of a spigot?
  • Has there ever been a time when you recognized that nothing is unimportant, when everything needed your attention?
  • Have you ever worked so efficiently that you were your boss's favorite employee or your teacher's favorite student? Have you ever had so much to do you couldn't waste time sitting?
  • Has there ever been a time when you knew that life is a banquet and most poor suckers are starving to death?

I mean, it's a matter of perspective, isn't it?

People with bipolar go seven and a half years on average from first manifestation of symptoms to an accurate diagnosis. A third of us are misdiagnosed for ten years or more. Would somebody like to turn my list into a research project, find out if it does indeed produce better screening results than what they do now? Go for it. Just mention my name.

Suicide is Not a Mystery - Get Beyond the Romance to Get to the Work

Suicidal people have not been quiet this year during Suicide Prevention Month. Most years we are the topic of conversation, not the source of the content of all these campaigns. But Twitter, at least, has been filled with our own voices this year. I have always shot my mouth off, and seldom taken the party line. Which means my voice is never included in the campaigns of the typical mental health organizations.

The following is an example, a post from a previous Suicide Prevention Month, edited with my more current thoughts on the matter.

This is Suicide Prevention Week - from September 8, 2011

When I started Prozac Monologues, I didn't know there was a Suicide Prevention Week. I spent a month writing about suicide in June, 2009. I chose June because it is the month when the highest number of suicides take place. So I wonder why the officially designated week is in September. Maybe because when everybody else is so happy about the sunshine in June, they wouldn't give any thought to the darkness? Maybe because they didn't ask those who are suicidal?

If you want to know my take on suicide prevention, here is the link for those original posts. Among the Labels in the right-side column, you will find links to other posts tagged suicide, suicide prevention, and the like.

Looking back at these posts, I wish I had less to say about suicide. But having this much to say, and frankly, a lot more, I think it's best I go ahead and say it. That was my POV for The Suicide Monologue. And I'm sticking to it. I urge you to take the same approach. If you have something to say about suicide, go ahead and say it.

You know, all those years we never talked out loud about cancer, our silence never saved a single life.

Several years ago, John McManamy, author of McMan's Depression and Bipolar Web, gave the day on his blog over to an excerpt from Nancy Rappaport's book, In Her Wake: A Child Psychologist Explores the Mystery of Her Mother's Suicide. Rappaport wrote about how even psychiatrists sit around and wonder how a person comes to the conclusion that he or she wants to die. Most of us want to live. Even those of us who want to die, for the greater part of our lives, we want to live. Her mother's diaries are full of her struggles to survive. What happens in somebody's mind to make that change? Rappaport says it is a mystery.

In Her Wake is a powerful memoir of the aftermath of suicide. People who struggle with suicide need to read such accounts to fortify them in their struggle. But I think she has misidentified the mystery.

I think every person is a mystery. 

We have our joys, sorrows, strengths, dreams, fears, failures. We have capacities and weakness that sometimes we tell to others, and sometimes they divine. But the core of the person remains a mystery.

I am a Christian, so I believe there is One to whom we are not a mystery, One who knows our true name and calls us by it. And we ourselves don't even know that name until we hear that One call it. And when we do, then we know ourselves for the very first time. 

But I don't think suicide is a mystery. 

Suicide is simple. Each of us wants to live. That is how our brains and bodies and souls are constructed, for life. And each of us dies anyway, when our brains and bodies and souls give out. Suicide is one way that we give out. We don't give up. We give out. We reach the limit of what we can survive, whether it be a tumor, lack of oxygen, or a knife that turns in our chest, whether figuratively or literally.

I learned this perspective from David L. Conroy, who learned it from his practice and from his own experience. And I confirm it in my experience. He says, and I repeat it from time to time in this blog, 

Suicide is not a choice; it happens when pain exceeds resources for coping with pain. 

After a suicide, the survivors are indeed immersed in mystery. It is the mystery of the heart of the person who died. It is the pain of questions we cannot answer. We never know the sum total of the pain another had to bear, or was able to bear, or not, nor who or what was available to help, or not. I don't know that psychological autopsies ever satisfy. What we really want to understand is the core of a person. That is the mystery.

But we can understand suicide. We can recognize its broad strokes. And we can prevent it, not every time, but most of the time, the way that suicide crisis lines do it, by relieving pain and by providing resources for coping with pain. If we can help shift that balance, between the pain and the resources, then the person at risk will be able to do what he or she really wants, to live a life worth living.

45,000,000 Suicides Prevented 

Fifty million people who are alive today in the United States have or will at some point struggle against suicidal pain. I am one of them. I have a disease with a 15-20% mortality rate. Someday I will die of something. It is my fervent prayer to be one of the forty-five million who survive suicidal pain and die of...

something else.

It doesn't improve my odds for me or you or psychiatrists or anybody else to ponder the mystery of suicide. You can't prevent mystery. You can provide resources to prevent suicide.  Here is a list to get you started.

It's a long list. It comes from David Conroy's book. Unfortunately, in its attempt to be thorough, and perhaps in the limitations of the voices consulted, certain things get glossed over.

I am thinking in particular of the major components of suicidal pain list, the items bunched into one: loss of: esteem, security, health, talent, job status, job, money, relationship, home. Let me expand. Major components of suicidal pain include shame, discrimination, job loss, crushing debt, chronic untreated health issues, solitary confinement, police harassment, white supremacy, domestic abuse, bullying, homelessness...

Why don't we have a suicide prevention month that talks about this sort of stuff? You can't medicate these pains away. You can trace their effects on suicide statistics.

This graphic is based on the research by Jasmin Brooks, et al., in that last link:


What can you do to prevent suicide? Justice. No, you can't fix it all. So pick an issue. Do something to make this world a less sucky place to live.

If you want to focus on one person, pay attention to these issues in that person's life. Make a difference in their life situation.

I expect that strategy would work for all of us. If you struggle with suicide, is there one thing you can do to make your life or somebody else's life less sucky? It's a place to start.

Meanwhile, if your suicide needs preventing right now, tell somebody. Tell somebody who cares about you (and is not an idiot). Or call 1-800-273-TALK (8255) in the US. The Trevor Project at 866-488-7386 is particularly for young people, lesbian, gay, bisexual, transgender or questioning, and the people trying to help them. There is a link at the top of this blog called Suicide - Resources to find numbers outside of the United States and other help. They can't pay your rent. But they may have some ideas that get you through that dark hole where all your own ideas disappear.

I want you to die of something else, too.

And if this post has brought somebody else to mind, somebody to whom you have said, "Call me if you need to talk," then don't wait for the person who may be clinging to the edge by their fingernails to make the call. YOU make the call. Even if you don't catch them on the edge, even if they are fine, it's one way to make this world a little less sucky.

Which we all could use.

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book jackets from amazon.com
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Understanding Bipolar Disorder - A Review

On the one hand, bipolar disorder can sweep like a tornado through a family, disrupting every aspect of daily living and relationships.

On the other hand, family members can be one of the most significant resources for a person's recovery and stability.

In my own case, my wife is the one who described the symptoms that helped my psychiatrist recognize that I have bipolar, not major depression. But once that happened, what did she, as a family member, as the member of the team with day to day, hour to hour access, receive by way of help and guidance?

Nothing. Not a word. Butkus. Like, not even a pamphlet.

Nope, nothing. She worried. She worked from home to protect me at my sickest. She shouldered every responsibility. She thought through and recommitted to and excelled at "for better for worse, for richer for poorer.

Eventually she got to Family to Family, NAMI's program for education and support of people whose family members have a mental illness. And that helped. It gave her a skill set. It let her know she was not alone. It was more than a brochure.

What she needed was Aimee Daramus's new book Understanding Bipolar Disorder: The Essential Family Guide. Daramus, a clinical psychologist with over twenty years of experience in mental health, from psych units to private practice, has written the definitive guide for family members of people with bipolar. She takes you by the hand and leads you from a chaotic landscape to a steady path.

Step by step, the information is presented in the order that it is needed. It's a good book to read over the course of a year, and to reread for a refresher as time goes on.

  • Bring something to occupy your time in the ER, where mental illness is gets to wait, sometimes for a very long time.
  • Get release of information forms signed, so that the doctor can communicate critical information with the family.
  • Let people have their own emotions and opinions; share them rather than argue over them.
  • Develop emergency plans.
  • Adopt specific lifestyle measures.
  • Don't expect to get it all right all the time.

My wife and I worked out much of this on our own. And Daramus is right, ten years later, we do not get it right all the time. Weekly family meetings help. Daramus's book reminds us of pieces that we still don't have in place.

The language is clear, simple, calm. The formatting makes it easy to follow. The anecdotes are relatable.

I bought two more copies to give to friends who could use the help. How's that for a recommendation?

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World Suicide Prevention Day from a Different Perspective

Many people who are suicidal hate suicide prevention campaigns. We notice that they are not directed at us, but at would be heroes. They publish lists of risk factors, things to watch out for in those of us who would thwart their efforts. But we fail to see listed what drives us to suicide: poverty, bills, homelessness, rape, child abuse, bullying. Nor do we hear anything about addressing these issues that might actually reduce suicide rates.

What about helping parents understand their children's sexuality so that LBGTQ children don't end up on the streets? What about bully intervention programs in schools (designed to prevent bullying, not treat the victim)? What about universal health care and food security? What about a health care reimbursement structure that encourages doctors to go into psychiatry? What about treatment that isn't demeaning? What about...

Instead, we get posters of "head clutchers." Get a grip.

I could go on. I did go on a month ago in a blogpost titled A Better Suicide Prevention Month. I suggested that people with actual experience of living with suicide might come up with something better than a head clutcher. Because it turns out we do know something about preventing suicide. We do most of the work anyway, preventing our own suicides.

How would you, somebody with lived experience of being suicidal, design a suicide prevention campaign? What messages would you like to see? What do you want to have happen in the month of September to prevent suicide?

That's what I asked. Today I discovered that people really are working on this. The website says.

RE:CREATE Psychiatry is a Mental Fight Club project that emerged in 2015 from our flagship creative space The Dragon CafĂ©, a weekly arts and health pop-up in the Crypt of St George the Martyr Church in Borough.

Mental Fight Club? I have to learn more about these people!

Meanwhile, today they posted one of their projects, a suicide prevention project, a film called Living with Suicide, scripted and produced by Eve Loren. Find out more here. And watch it below:


There could be another way to live... We need to make space for truth... Redefine what is normal... Replace compensation for the dead with help for the living... It's time to change the system... Channel self-doubt into anger... Fight.

It's time to fight.

I have to learn more about these people.

Diagnosing Bipolar - Doing Better to Prevent Suicide

How can I be a better psychiatrist for you?

Frankly, I was gobsmacked by that question. It came in response to reading my book, Prozac Monologues: A View from the Edge. The book is a comedic memoir of misdiagnosis and a self-help book for bipolar. It is both uproariously funny and brutally frank about my suicidal episodes, usually at the same time.

There are two directions to go with that question. This particular psychiatrist cares about both.

What kind of behaviors and qualities could he display that would make the relationship more helpful? Honestly, not all psychiatrists are interested in this question. I don't do relationships; I use psychopharmacology to treat psychiatric disorders, a psychiatrist once told me. Well, that had the benefit of clarifying things.

How can I improve my diagnostic skills? Nevertheless just about any psychiatrist wants to get the answer to the puzzle right, even the ones who treat patients as no more than a puzzle.

So this week I am going with the question about diagnostic skills. Buckle up for lots of links to research articles. The links appear in a different color. Click on them and end up at reports written by the experts. Or ignore the links, if you can take my word for it.

Bipolar is hard to diagnose. And they are not getting better at it. It takes 7.5 years on average from first appearance of symptoms to the correct diagnosis. A third of us are misdiagnosed for over ten years. Over time, these numbers are not improving. It turns out, telling yourself that bipolar is hard to diagnose doesn't help you get better at it. And during all those years, we patients receive treatments (antidepressants) that make our prognosis worse and flip us into mixed episodes with their heightened risk of suicide. Our lives depend on getting the diagnosis right.

There are ways to do a better job. Research validates various techniques that improve results. Many of these are a couple decades old, but for whatever reason have not found their way into standard practice. Nevertheless, some doctors, psychiatrists and family practitioners both, still ask that question, How can I improve my diagnostic skills? So here are some techniques with links to the research studies that support them:

  • MDQ, Mood Disorder Questionnaire. This is a simple screening questionnaire using real, nontechnical language that patients and their family members fill out. It's like those screens for depression and anxiety that are becoming standard practice for annual physicals. It doesn't make the diagnosis by itself; but it tells doctors whether they need to look at the question more carefully before prescribing antidepressants to treat the presenting episode.
  • BSDS, Bipolar Spectrum Diagnostic Scale. This is a similar simple screening questionnaire in narrative form. It tells a story, while the patient decides how well the story describes his/her own experience. 
Both of these instruments have sensitivity (~70) and specificity (~90) comparable to other screening instruments. This means they catch roughly 70% of those who do have bipolar and their "false positive" rate is 10%. The screens themselves can be found here.
  • Whatever screens or questions used, it is good practice to ask family members or close friends for their input. The patient notices depressive symptoms, but often does not notice or remember symptoms of hypomania or mania that the family can see.
  • When taking a history from a depressed patient, ask about overactive behavior, whether there was ever a time that the patient was able to do a lot more things, get a lot more done than usual, before asking about a time when s/he had elevated mood. It has been demonstrated that it is easier for patients to remember episodes of excess behavior than to remember elevated mood. (It was demonstrated fifteen years ago! Why hasn't this finding been incorporated into the Structured Clinical Interview, SCID-CV?)  Asking about behavior/energy first improves the accuracy of the diagnosis.

I'll leave it there. Two simple screens, two simple changes in practice, each of them are demonstrated to improve the diagnosis of bipolar.

No, I'll add one more.

  • Every episode of depression adds a new risk of "conversion" to bipolar, throwing the patient into hypomania, mania, or mixed episode. There is no length of time that confirms a diagnosis of MDD over bipolar. Screen for bipolar again with each episode and each failed antidepressant.
It is hard to change practices that doctors were taught in medical school. But what they were taught in medical school leads to a 50% success rate, also known as a 50% failure rate, in differentiating between major depression and bipolar. The mantra, bipolar is hard to diagnose, doesn't cut it when the consequence of getting it wrong leads to years of suffering, lives that go off the rails, and lives that even end suddenly and tragically in suicide.

Doctors want to do better. And they can. Research has shown them how.

photo used under the Creative Commons license

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