Following #bipolar on Twitter for the last few years, I am often dismayed. So many people seem to spend so much time struggling with their medications and so little time focused on anything else that could help.
Don't get me wrong. Medication is an important tool for managing bipolar disorder. But it can't do the whole job. Education and life style changes are crucial for getting off the roller coaster of constant med adjustments to address the episode du jour.
I decided it was time to revisit my 2011 review of Ellen Frank's Treating Bipolar Disorder. It was a four-part review. The last three posts describe the treatment itself, Interpersonal Social Rhythms Therapy, IPSRT.
Part II outlined Frank's Social Zeitgeber Theory and the treatment that proceeds logically from it, a process of establishing regular daily rhythms that set our interior clocks and keep them running on time. (Zeitgeber means timekeeper.)
Part III explained how work on interpersonal issues helps people reduce stressors and prevent disruptions to their social rhythms.
This last post will pull together my appreciation, my reservations and my hopes for future directions.
Social Zeitgeber Theory
Frank builds IPSRT on the theory that people with bipolar are more vulnerable than others to disruptions in our circadian rhythms. When our interior clocks get screwed up, we do, too. Daily events, like getting up at a certain time, seeing people, going to work, set our circadian rhythms. The core of the therapy is to help keep our rhythms regular.
The best brilliant part of Treating Bipolar Disorder is this theory.
A good theory accounts for as much of the data as possible, and then provides a way to solve problems.
The old theory is bipolar is a chemical imbalance in the brain. The advantages of the old theory is that it is simple, it suggests a way to solve the problem, and it is earning the pharmaceutical companies billions and billions of dollars. The disadvantages are that decades after it was first offered, it has offered false hope and subsequent despair to millions of sufferers, focused blame on those who won't take the drugs that make them sick and/or don't work, and for a majority of people who receive the best pharmacotherapy possible, simply failed to fix the problem. It also neglects a lot of data.
The chemical imbalance theory comes from the data of clinical experiments -- that symptoms go away when you change the chemical stew. Or at least, they go away enough to get FDA approval for marketing claims. It does explain a piece of the puzzle.
But another set of data has to do with what was going on before the symptoms developed. Frank and company turn to circadian rhythms to account for how the chemical imbalance developed. And here there is a wealth of data. For example, study of circadian rhythms reveals that lack of sleep causes depression as often as it is caused by depression. This suggests a whole other way to solve problems.
Treating Bipolar Disorder documents this evidence in support of the theory. Most of the book then describes the therapy that derives from the theory.
People With Bipolar Who Are Doing Well
The Social Zeitgeber Theory accounts for the data of those with bipolar disorder who are managing their symptoms, working, thriving over the long haul. There are almost no studies done from this angle -- what people are doing to stay well. John McManamy reports on two of these studies at mcmanweb.com. Healthy lifestyle is the top strategy for these people, particularly maintaining good sleep. Most, 85% take medication, but do not make medication the center of their self-care. None rely entirely on medication to stay healthy.
Medication, Medication, Medication
My chief reservation about the book has to do with its assumptions about medication.
Let me put it this way. It is a bold move to list the uses of specific medications in a hard copy printed published book. Chances are that such a book will report positively on a medication for which the manufacturer then settles a class action suit in the same year as publication. Zyprexa/olazapine is just one example of how quickly the chapter's information became debatable and/or dated.
Frank assumes that IPSRT is an add-on to pharmacotherapy. She notes that lithium, the miracle drug that was supposed to have solved the problem of bipolar has turned out not to have done so in near as many cases as people think. She acknowledges that there are problems with side effects and efficacy for anything that is currently in use. But just barely.
Unfortunately, it is only a minority of patients with bipolar disorder who can comfortably take the medications that seem to control the symptoms of the illness and who are willing to submit to this control. Especially early in the course of the illness, before it has wrought complete havoc in the patient's life, there is denial that there is anything permanently wrong and a longing for the highs that the medications take away.
Yup. There it is. Ellen Frank, too. They miss their highs. I won't go there right now. It's just too tiresome. But stay tuned...
Okay, on a positive note, Frank pays more attention to side effects than other clinicians, repeatedly urging that the therapist and prescribing clinician work in partnership, and that medication problems be addressed.
On a very positive note, Frank spends a lot of ink on the issue that people with bipolar I or II spend way more time depressed than manic and hypomanic. And our depressions are far and away the part of the illness that disables us.
Can We Ever Crack This Medication Nut?
This medication debate never seems to get anywhere. Like abortion or the Palestinian issue in US politics, nuance is not allowed. You're either pro-med or anti-psychiatry. And I can feel myself drawn into the blogosphere's quicksand. So let me do the down and dirty on Frank's position and get out of here.
Frank's assumption that everybody who has bipolar I and not on meds is a train wreck waiting to happen -- maybe that is a necessary evil to maintain her professional credibility; maybe more of the usual professional wishful thinking:
Frank's concern to take side effects seriously and her criticism of the standard practice of medicating people with bipolar into a permanent state of mild depression, treating anything approaching a normal feel-good state as a danger sign of impending mania:
Clinical Language Alert
I have spent the last several years reading books and articles written not for me, but about me. It is a perilous business. Prozac Monologue readers occasionally are on the receiving end of my efforts to manage the consequences of this endeavor. It is getting less perilous, as I learn some skills, the first of which is simply to acknowledge the intended audience. So...
Treating Bipolar Disorder is written for clinicians and about people with bipolar. I am not a clinician; I am a person with bipolar. Therefore, Treating Bipolar Disorder is not for me; it is about me.
If you are like me, you need to take this into account when reading this book.
Having said that, this book is less perilous than others.
Yes, there are a couple bumps in the road: the bipolar temperament, the attitude of entitlement and they miss their highs. For the record, Frank never uses those exact words. Her exact words are above.
On the other hand, this book is exceptional in its tone of respect and genuine partnership between clinician and patient. Absolutely exceptional. Props to Ellen Frank.
The Future Of IPSRT
Like I said, this book was written for clinicians, who are addressed directly. It was not written for people who have bipolar disorder, nor for a general audience. There is no book, no pamphlet, no article, no website, no youtube that describes IPSRT for a general audience. Prozac Monologues is as close as you get. Not enough for a do-it-yourself-er. But a start.
Frank and company keep track of those they have trained. She says maybe she should develop a website. A lot of people think maybe they should develop a website. Most of them have many other things to do. I wouldn't hold my breath. I would write her directly and ask. And then come up with a do-it-yourself strategy. I have one outlined below.
Frank has the support of NIMH's STEP-BD study giving IPSRT the magic label of evidence-based. So she has a therapy, a book, a training. And 5,700,000 people who could benefit from this treatment. She needs to develop the market for her training the same way pharmaceutical companies develop their markets -- go directly to us 5,700,000 people with bipolar.
There's a whole world of people out here who get our mental health care from Facebook friends and [Name Your Diagnosis and/or Treatment] for Dummies. We need an IPSRT for Dummies. We need a workbook. Once we get started, we'll ask for help, and our care providers might get interested.
Here is my story: The meds don't work. I have been stalled in Cognitive Therapy for some co-morbid trauma issues. I don't have the capacity to interview a bunch of therapists who might deal with my bipolar, even if I could find them. I lose my voice when I talk with therapists -- back to those trauma issues. So I went back to my CBT therapist. We are renegotiating to do more interpersonal work and I am experimenting on my own SRT/Mood Chart. Here's a post describing it. Here's the chart itself. I will do the SRT part on my own. My therapist and I can talk about my grief for the formerly healthy self.
You have to really have it together to do therapy this way. I am not starting from a position of crisis. I have good insurance and a lot of resources. My wife tells me, if I have lost half of my cognitive functioning, that still makes me smarter than 80% of the people in the room.
So this might work for me and maybe another 100,000 high functioners out there. 5,600,000 more to go.
On July 14, 1990 Ellen Frank knew with absolute certainty that [she] needed to dedicate the next decade of [her] life to doing better by these patients and family members. It was a decade well spent. And then another. I hope she keeps going into the third.
If you are a person living with bipolar disorder, cut the author a break for the inevitable mental health provider mentality. The medication issue is a minor, minor piece of an otherwise helpful, hopeful book.
Treating Bipolar Disorder offers hope. Read it. Talk to your therapist about it. Get yourself a schedule that includes enough sleep at a regular time each day. Talk with your therapist about whatever keeps you from doing that.
If you are a therapist, read this book. Give its techniques a try. There's now an eight hour online training available here.
If you are a doctor, read this book. Stop promising more from meds than meds can deliver. There is more help out there for your patients. Help us find it.
If you are Ellen Frank, get this stuff out to those of us who can't find or afford a therapist whom you have trained. And God bless you.