By Moryt Milo
For years, Dr. Po Wang has studied and treated individuals diagnosed with bipolar disorder, a brain disease that causes severe mood swings and significantly impacts a person’s ability to function. The Stanford psychiatrist, who collaborated with Dr. Terence Ketter in establishing the Stanford Bipolar Disorders Clinic, said although the disease is defined by manic episodes—racing thoughts, distractibility, decreased lack of sleep—it’s actually the depression portion of the disease and mood cycling that are most prominent.
A study in the early 2000s noted that depression is a greater factor—32% in people with bipolar I and 50% in those with bipolar II. The psychiatrist said the question becomes how does treatment move forward when mania is the immediate issue, but depression is actually more prevalent.
The most common way to treat the problem is to prescribe medication for “whatever the doctor sees in front of them at the moment,” said Wang, who specializes in the treatment of mood and anxiety disorders. But strategies are changing, especially when the person comes in with mixed episodes of mania and depression. Most often, it’s the depression that is more precarious and harder to treat because it can last for many months.
“Racing thoughts and high energy, those symptoms don’t seem to be as problematic for people as depression symptoms,” he said. “So the better strategy is to treat mania and depression together.”
There are many different medications dating back to the discovery of lithium in 1949 that are used to treat mania. There are also anticonvulsants from the late 1960s–early 1970s that are still given as mood stabilizers. At the time, researchers thought bipolar disorder was a “mood seizure,” but several medications such as Depakote and Carbamazepine have turned out to be effective, Wang said. There are also antidepressants and more recently antipsychotics that have been introduced as options for treatment.
Wang said that certain antidepressants have not worked as well as others for individuals with bipolar disorder depression because this type of depression is not the same as “uniform” depression.
The goal should be to stabilize the movement between mania and depression and then add an antidepressant on top of that, he said.
“When I mean stabilize, I don’t mean flat-line with no emotions. We don’t want that,” he said. “I am talking about not too high and not too low. You have a mood in a range like everyone else has.”
Bipolar disorder doesn’t come and go, medications are long-term, Wang said. The goal is to stabilize and prevent future episodes. If a person is able to reach this point and wants to come off the medication, Wang said, “we can come off in a slow, safe way.”
Finding the right combination of medications is more trial than science. Sometimes, a medicine is tolerable, but it doesn’t work. Other times, it’s intolerable and also doesn’t work. Then there are times when a medicine is tolerable and works but has side effects. That’s when adjusting the dose is needed to optimize its effect and tolerability, the doctor said.
Wang hopes that future medical advancements will be targeted toward specific areas of the brain to reduce existing side effects caused by medications such as diabetes, significant weight gain, and lethargy. He said there is a third generation of medications that may be able to reduce these issues, so the science is heading in the right direction.
He mentioned Transcranial Magnetic Stimulation (TMS) as an example of treatment being done on severe depression. TMS is a noninvasive form of brain stimulation that targets a specific area of the brain. The process involves the use of a magnetic field to induce an electric current.
The key, he said, is to find those next-generation treatments. Early studies show they can help with bipolar depression, but if not done correctly a person can become manic or more depressed, he said.
“We need to find the right dosing and the right spot in all this and the timing needs to be teased out,” Wang said.
He also said that in addition to medications, there are other augmentations that can be incorporated into a treatment program such as Cognitive Behavioral Therapy (CBT) along with family-focused therapy and interpersonal social rhythms all of which help to improve medication adherence, life style, and greater family support.
“Ultimately, the current strategy is not to treat mania and depression by itself because you get sub-optimal results. Now we try to stabilize the whole picture,” Wang said.
To view the complete conversation, go to YouTube
