Light therapy (or in this case, dark therapy)

Light therapy clearly works as an antidepressant.  It has much less likelihood of triggering mania, as the regular antidepressants do (as you've probably heard me rant about elsewhere on this website).   But to get a mood stabilizer  effect, you need to consider "dark therapy".  This has much less research to support it, compared to light therapy, but it's worth knowing.  Here's the story on "dark therapy" (it opens in a separate window so you can come back here easily -- just close the window).  

What is the role of exercise in bipolar disorder treatment?

Exercise clearly has antidepressant effects,^Phelps  even being shown recently to be equal to Zoloft^Blumenthal -- and perhaps better, 6 months after the end of treatment!^Babyak  It would be one of the most widely used antidepressant approaches, but for people’s ability to stick with it.  Even people without mood problems have trouble getting regular physical activity! Unfortunately this is not a joking matter: though Oregonians are more active than almost all other states in the U.S., still half of the state’s population gets no regular physical activity^{CD summary}. So expecting people with severe mood disturbances to get regular exercise is extremely unrealistic. However, my patients with the worst symptoms seem actually to have more regular exercise regimens. They seem to have learned from experience that it helps, and they are looking desperately for any help they can get.

One patient in her late 20’s, who has had extreme agitation and racing thoughts, described exercise as very effective for anxiety as well. She said that after about 20 minutes of vigorous aerobic effort she would feel something shift. As she "came down" from the workout, her anxiety would seem to "come down" with it. Another patient with an extensive history of self-harm (cutting, burning) found that weight work-outs seemed to provide the same kind of benefit: it would keep her from dissociating, or feeling like she was "flying apart".  

For another extensive "testimonial" direct from a patient herself, read this strong endorsement of exercise as a treatment in itself (includes my reply to her initial statement, and her follow-up). 

As you can imagine, routine physical activity is an important part of an overall mood-stabilizing "lifestyle", but I warn patients that maintaining such a plan is extremely difficult and will require great effort on their part.  Here is an essay about making exercise part of your life.  The more severe your symptoms, the more beneficial exercise may be. If your illness is bad enough, it may actually help motivate you to stick to the exercise.

What is "Social Rhythm Therapy"?

Bipolar disorder somehow disturbs how your body "clock" keeps time. Some people lose their "anchor" to real time (when the sun actually comes up and goes down). They can have their energy turn "on" in the middle of the night and be unable to sleep, often finding their mind extremely active. Or they can try to get up in the morning and feel as though their body is still completely asleep ("somebody give me some caffeine!") This led researchers to wonder whether "anchoring" a patient’s circadian rhythm might have mood stabilizing effects.  Click for a stunning example. 

The Western Psychiatric Clinic has been testing this idea with treatment for bipolar disorder they call Social Rhythm Therapy^Frank, which is added on to the regular medications used. Daily routines such as time of awakening, time of rising, time of first meal, time of going to bed, and time of going to sleep are kept very regular in this treatment.

Early results show some benefit, especially after months of keeping a very regular schedule of daily activities. If you have found that your activities are highly irregular, there may be value in looking for sources of this irregularity. Staying up late to work or play is one of them. Working irregular shifts is another.

Is ECT effective in Bipolar II?

Electro-convulsive therapy (ECT) has efficacy in bipolar disorder at least equal to medications, in the 60-70% range (improved or much improved).^Kusumakar Most experts agree that ECT should stand high in treatment algorithms (e.g. UTMB bipolar algorithm^Texas). However, these judgements are based on efficacy in bipolar I, as most of the studies of ECT in bipolar disorder preceded the formal recognition of BPII. To my knowledge there has been no published trial of ECT for BPII per se. Several of my BPII patients have had ECT with positive responses. Six patients with very rapid cycling have been presented, with the authors concluding that length of illness prior to ECT has tremendous impact on efficacy (longer time ill correlates with lower likelihood of response, and high likelihood of relapse after treatment). ^Wolpert

Unfortunately, in all forms of bipolar disorder one must think about long-term prevention as well as acute treatment, and "maintenance ECT" (repeated single treatments at regular intervals, as prophylaxis) has been much less studied, even for bipolar I. Rapid transcranial magnetic stimulation (rTMS) using a hand-held but very powerful magnet (similar in power to an MRI magnet) has been shown to have antidepressant effects^George, but exactly where to stimulate, how long, with what intensity and frequency, have yet to be worked out. Mark George’s group in South Carolina (the same group which recently demonstrated that retrograde stimulation of the vagus nerve has antidepressant properties!) has a randomized trial of rTMS for bipolar depression underway. This treatment holds some promise: though it requires repetition about every two weeks in most people, there are no significant side effects and almost zero risk.

Update 2004: You may have heard the news about people having an MRI study done and feeling better afterwards, which was recently studied at Harvard.^Rohan  Since they used a much different magnet, much less specialized than is used in rTMS, all of a sudden the question of how to use magnetic fields to treat depression is even more complicated than before!

Can diet do anything?

There is reason to think that a "ketogenic diet", which is basically what happens with the Atkins Diet approach (very few carbohydrates), might have mood stabilizing properties, because it sometimes helps limit the frequency of seizures, and there are some remarkable similarities between epilepsy and bipolar disorder.  Dr. Robert Belmaker in Israel has tried this (personal communication, 2004) but the patient did not become "ketogenic" (which can be measured very easily with a urine test) . It was also proposed by a research group in Kentucky,^El-Mallakh but so far we do not have research evidence on this approach. 

The ketogenic diet is very nearly the opposite of common American eating, which can include very high quantities of refined carbohydrates (read "sugar").  And the American diet is very clearly associated with "metabolic syndrome" (one recent study indicated as many as one quarter of the entire U.S. population has this condition Ford).  And there is just a hint of evidence that metabolic syndrome may have its own mood consequences.  Thus it becomes plausible to see the ketogenic diet as an extreme in one direction, while the refined carbohydrate/metabolic syndrome approach to eating represents an extreme in the opposite direction, dietarily -- and perhaps even in their mood effects.  A patient's wife sent me a "case report" describing her husband's mood changes on and off the Atkin's Diet.