Serious side effects from lithium administration are rare, but minor complaints such as gastrointestinal discomfort, nausea, diarrhea, polyuria, weight gain, skin eruptions, alopecia, and edema are common. Over time, urine concentrating ability may be decreased, but changes in function do not result in significant nephrotoxicity. In a small subset of patients in whom excessive polyuria occurs (>3000 mL per 24 h), dose or schedule adjustments or the adjunctive use of diuretics should be considered. Lithium exerts an antithyroid effect by interfering with the synthesis and release of thyroid hormones. Approximately 5 percent of patients taking lithium for 18 months or longer develop hypothyroidism, with women more likely to be affected than men. Iatrogenic hypothyroidism should be ruled out in any patient who experiences recurrence of depressive symptomatology during lithium treatment. More serious side effects include tremor, interference with concentration and memory, ataxia, dysarthria, and incoordination. Electrocardiographic (ECG) changes of T wave flattening and conduction delays may occur. There is suggestive but not conclusive, evidence that lithium is teratogenic, inducing cardiac malformations in the first trimester.

In the treatment of acute mania, lithium is initiated at 300 mg bid or tid, and the dose is then increased by 300 mg every 2 to 3 days to achieve blood levels of 0.8 to 1.2 mEq/L. Because the therapeutic effect of lithium may not appear until 7 to 10 days of treatment, adjunctive usage of lorazepam (1 to 2 mg every 4 h) or clonazepam (0.5 to 1 mg every 4 h), may be beneficial to control agitation. Antipsychotics are warranted in patients with severe agitation and who respond only partially to benzodiazepines. These agents should be discontinued in the transition to maintenance lithium therapy. Patients using lithium should be monitored closely, since the blood levels required to achieve a therapeutic benefit are close to those associated with neurotoxicity. Risk factors for neurotoxicity include concomitant medical illness, decrease in salt intake, or concurrent use of medications that may increase the serum level of lithium (neuroleptics, diuretics, and calcium channel blockers).

Valproic acid is an alternative in patients who cannot tolerate lithium or respond poorly to it. Valproic acid may be better than lithium for patients who have a rapid-cycling course (i.e., more than four episodes a year) or who present with a mixed or dysphoric mania. Valproic acid is usually started at 500 to 750 mg/d bid or tid. The dose is increased every several days to achieve blood levels in the range of 50 to 100 ug/mL, which typically are achieved at a dose of 1000 to 2500 mg/d. The most serious adverse effect of valproic acid is hepatoxicity, which may be fatal. Such cases are fortunately rare, but regular monitoring of liver enzymes, particularly during the first 90 days of treatment and periodically thereafter, is indicated.
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Carbamazepine, although not formally approved by the Food and Drug Administration (FDA) for bipolar disorder, has clinical efficacy in the treatment of acute mania. Carbamazepine is initiated at 400 to 600 mg/d in divided doses, and the dose is increased to achieve a blood level of 4 to 12 mg/L. Carbamazepine may induce a benign leukopenia, but the risk of aplastic anemia is minimal. Nevertheless, it is wise to obtain a complete blood count (CBC) periodically.

The recurrent nature of bipolar mood disorder necessitates maintenance treatment. Maintenance of at least 0.8 mg/L blood lithium levels is important to achieve optimal prophylaxis. Antidepressant medications are sometimes required for the treatment of severe breakthrough depressions, but their use should generally be avoided during maintenance treatment because of the possible risk of precipitating mania or accelerating the cycle frequency. Loss of efficacy over time may be observed with any of the mood-stabilizing agents. In such situations, an alternative agent or combination therapy usually restores the therapeutic benefit.

Perhaps what it is really all about is simply learning to be present, to be here now, as they say. It seems trite, but once you’ve really learned that, everything else becomes so much easier. Just to be present with yourself, with how you really actually feel in the moment, seems to be what makes us most alive.

Shambhala Sun - Six Kinds of Loneliness

The experience of certain feelings can seem particularly pregnant with desire for resolution: loneliness, boredom, anxiety. Unless we can relax with these feelings, it’s very hard to stay in the middle when we experience them. We want victory or defeat, praise or blame. For example, if somebody abandons us, we don’t want to be with that raw discomfort. Instead, we conjure up a familiar identity of ourselves as a hapless victim. Or maybe we avoid the rawness by acting out and righteously telling the person how messed up he or she is. We automatically want to cover over the pain in one way or another, identifying with victory or victimhood.

Usually we regard loneliness as an enemy. Heartache is not something we choose to invite in. It’s restless and pregnant and hot with the desire to escape and find something or someone to keep us company. When we can rest in the middle, we begin to have a nonthreatening relationship with loneliness, a relaxing and cooling loneliness that completely turns our usual fearful patterns upside down.

There are six ways of describing this kind of cool loneliness. They are: less desire, contentment, avoiding unnecessary activity, complete discipline, not wandering in the world of desire, and not seeking security from one’s discursive thoughts.

I’ve written a previous post about celebrity lives and why they predispose people towards problems with their mental health. In it I mention Britney Spears, who has been regularly described in the press as ‘troubled’ for some time now. Things took an altogether more serious turn when on Thursday she was taken to a psychiatric hospital under a 72-hour detention. This was the second time she has been taken to hospital in recent weeks, the first was after she refused to relinquish her children who were to be taken into the care of her ex-husband. On this occasion, in a pantomime show some 30 cars trailed her ambulance, twelve of them belonging to the police. By way of contrast, here in London it can take a week to get one police car to attend a section.

Recent news is that Ms Spears period of involuntary stay in hospital has been extended to 14 days. Not that I have given it a great deal of thought, but I’d always considered that Spears’ problems were likely to be personality based, that is to say as the result of learned behaviour, rather than because of a serious mental illness. Even if I am right, it appears that her problems have become much more severe than just throwing her toys around when someone refuses to pick out the blue M&Ms.

Her behaviour certainly has been bizarre, Associated press report that

Since her breakup with Federline, Spears has been seen at public events in short skirts and without underwear, has shaved her head bald, run over a photographer’s foot with her car, left the scene of a fender bender, flogged another car with an umbrella and abandoned a car in traffic when it had a flat tire. Recently, she was seen sitting on a sidewalk, holding her pet dog and crying

elsewhere it is said that before she was admitted she had not slept for five days.

It’s impossible from this vantage point to know what’s wrong with Spears. The diagnosis of mental illness requires a period of assessment and often is only settled with response to treatment. Emma Forrest writing in the Guardian seems to have decided that she’s got bipolar disorder and writes an article sympathetic to Spears detailing her own experiences. Biopolar has become quite a fashionable diagnosis these days - I’ve been toying with the idea of doing a survey where I ask people whether they think it’s okay to be bipolar now that Stephen Fry says that he has it.

Let me finish on a confession: I’m more than a bit disgusted with myself for writing a post about Britney Spears when the best medicine for her is for us all to leave her alone. But that won’t happen.

Britney’s perfume still selling well - Britney and the Sweet Smell of Distress Laura Barton Guardian 25 February 2008

Lisa Appignanesi’s Out of Control Guardian 10 March 2008 - an excellent article discussing her mental health problems in the context of how differently she would have been treated were she a man.

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Genetic findings converge with previous research to reveal what goes wrong in the nervous system of bipolar patients. A large genomic study suggests that defective sodium and calcium channels in neurons may explain an important part of the physiological mechanism of bipolar disorder.

Click for full article

Despite being very famous, Heath Ledger had somehow passed me by until a few weeks ago when I watched ‘Monster’s Ball’ and ‘Brokeback Mountain’ within a few weeks of each other. It seems likely that his death was caused by an overdose of sleeping pills, either mistakenly or intentionally. As a psychiatrist I was struck by something Ledger said in his last interview with Sarah Lyall, published in the Observer.

‘Last week, I probably slept an average of two hours a night,’ he said. ‘I couldn’t stop thinking. My body was exhausted and my mind was still going.’ One night, he took an Ambien sleeping pill, which didn’t work. He took a second one and fell into a stupor, only to wake up an hour later, his mind still racing

Obviously there’s not much to go on here, but I wonder if Ledger is suffering from hypomania, although I note that there is no mention of elevated mood in the article. It is also worthy of note that Ledger had been flying between Manhattan and the UK, as he had been filming ‘The Imaginarium of Doctor Parnassus’ in London. According to NICE guidelines, if a person has a predisposition towards bipolar disorder, relapses can be triggered by ‘night flying and flying across time zones, and routinely working excessively long hours, particularly for patients with a history of relapse related to poor sleep hygiene or irregular lifestyle’

There’s also been press speculation about Hedger’s history of drug use. In 2006 he was the victim of a paparazzi sting operation during which time he was filmed admitting to smoking ‘five joints a day for twenty years’; in the background of the film were unidentified persons snorting what is presumably cocaine. At the time the tape was not shown due to legal threats, but now Ledger is dead no such restriction aside, of course, from decency.

If you enjoyed this post you can buy me a coffee!

The influence of inconsistent moods and the opposing realities they attempt to create and then perpetuate within a single mind are daunting. Identity becomes a confusing mess of contradictions played back in memory and your vision of the future continually shifts as your inconsistent mood continues to influence the atmosphere of your mind. Freedom begins to haunt you as you begin to realize your only choice in life is to continue choosing while not fully trusting your judgment, even though in every moment that judgment feels right. Identity becomes split into three modes of functioning: manic, normal and depressed. You identify differently with each identity and although your overall identity remains the same, each different mode transforms you into something far different than the other. Parts of your life can’t function properly together and things start to become a mess and fall apart. You do things in one mood that you would never do in the other and you have to somehow find a way to reconcile this conflict during of your fleeting moments of stability.

Left alone to your sense of freedom, you see the world around you happening and you try to understand how you fit into it. You find things to surround yourself with to tell you who you are, to reassure your insecurities that inevitably present themselves in every choice you make so that you think you understand the reasoning behind your choices, but as time goes by the things you surrounded yourself with lose their effect and influence and you’re lost once again to your sense of freedom and the unpredictability of who you will be in the months to come.

The difficulty in all of this is how real your mood driven behavior and thoughts become. You don’t see them as mood driven behavior or thoughts because you become them and you can’t see through their influence because you become the influence. It’s not until your mood shifts along the spectrum and pauses somewhere where a different perspective can take place that you realize that you’ve been deluded once again. The scary thing though is that most of the behavior that happens during these mood driven phases is far from passive and usually has far reaching impacts on your life and the people close to you, which inevitably increases your stress and anxiety once you’ve realized that you lost control once again and have to deal with the consequences, which usually sets you off once again.

Now making sense of it all is so difficult because of the way we’ve been taught to rationalize and understand our world. My behavior and thoughts don’t make sense all the time in a logical linear fashion. They don’t always neatly add up in a rational way. My behavior and thoughts are filled with contradictions and opposing view points. One month the world will reveal itself one way and I will attempt to derive conclusions and insights from it and the next month it will appear in another way that opposes the conclusions and insights formed from the month before and I never really know which view point best represents the world around me because the feelings behind the view points keeps changing so dramatically. I can only imagine how confusing it must be for the people in my life to comprehend and predict who I am.

I guess I am making some progress though in understanding and making sense of it all because I am able to occasionally separate myself from these extremes and see things in a more overall context that includes the extremes and everything in between. I sometimes feel blessed by my disorder because it allows me to have access to these extreme realms of human experience that I don’t think everyone has access to, but once again I also feel cursed by my disorder because this access can also lead you into the most horrible places imaginable or places where you really shouldn’t have been. I guess all the parts of my life don’t neatly add up to something that creates an easily understandable conclusion, I don’t think anyones life does, but I do think I am beginning to accept what life includes for me and I’m trying to find ways to channel these extremes into elements of my life where I think they can be more useful. The catch now is to remember this perspective once an extreme takes hold of my mind.

In my defense, I’ve been finding it nearly impossible to do anything productive in this apartment at all. It is simply too fucking small. It feels more like a cell than an apartment and in the 11 months I’ve been here, I haven’t opened the windows once because the gratings on the windows just make it feel even more like prison.

On the other hand, productivity is supposed to be a mental thing, so there’s that other part of me that just blames me for it. I doubt I would have been any more productive elsewhere. Of course, I’m hoping I’m mistaken on that count and that the new, much larger apartment I’m signing the lease for tomorrow will prove me wrong.

Christmas presents I got this year:

• 1 fleece throw.
• 2 books; Designing Web Usability and a Photoshop book I can’t quite remember the title of. I think it had “Web” in the title, though.
• 3 apparel items.
  1. A black shirt with a patch that reads, “Damn, I’m good.”
  2. Northface items, two of them; a cap of some kind, and a sweater-vest-thingy.
• 1 power tool. A first! Now I can call myself a man.
• 2 pillow cases, intended to be shared with Danica.
• I might be missing something, but the allure of Christmas gifts and gift-giving has long since lost its excitement.

Article provided by Medical News Today