Pushing the Mood Swings.

Social and psychological forces sway the course of manic depression 

Manic depression, also known as bipolar disorder, has a well-deserved reputation as a biologically based condition. Wayward brain chemicals and genes gone bad seem to bully people back and forth between weeks of moderate-to-intense euphoria and comparable spells of soul-deadening depression. A few weeks of relative calm often separate these disparate moods.

Manic depression, however, may nurse a more sensitive side. Its intense mood swings increasingly appear to reflect a variety of social and psychological influences.

Research finding such relationships raises hopes that new forms of psychotherapy may improve the treatment of bipolar disorder. "This illness wreaks havoc with what makes us most human--our attitudes, our relationships, how we feel about ourselves, and our ability to trust our judgments about those closest to us," remarks Thomas A. Wehr, a psychiatrist at the National Institute of Mental Health in Bethesda, Md. "Even though it's tough to go through, psychotherapy makes sense as a way to understand this condition."

Until recently, treatment hopes largely rested on biological investigations. When tools for genetic analysis emerged around 15 years ago, making it possible to link signature pieces of DNA to specific illnesses, researchers quickly took aim at manic depression. Its tendency to run in families makes it a promising target. Although investigations have yet to identify genes that contribute to this mental condition, the search area has narrowed considerably.

Whatever its biological basis, manic depression shows remarkable tenacity. Only a small minority of bipolar patients who improve on psychiatric medications avoids a return of mania or depression in the ensuing 5 years. As many as one-fifth of the estimated 3 million people in the United States who develop bipolar disorder eventually find the emotional ride intolerable and kill themselves.

Treatment with lithium chloride or any of several other drugs helps to even out the emotional peaks and valleys for about two-thirds of people with bipolar disorder. Ironically, the leavening of intense feelings causes up to one-half of these drug responders to stop taking medication at some point. None longs to plunge back into depression's cold waters. Yet many crave mania's intoxicating pleasures, such as heightened creativity and a sense of unbridled potential.

Repeated forays into both mania and depression, however, lay waste to marriages, friendships, and other social ties. Moreover, people with bipolar disorder frequently observe that the quality of their close relationships affects their moods. In many cases, whether or not medication helps, bipolar sufferers seek psychotherapy in hopes of gaining insight into their volatile lives.

"Lithium ... makes psychotherapy possible," says psychologist Kay Redfield Jamison of Johns Hopkins Medical Institutions in Baltimore in An Unquiet Mind (1995, Alfred A. Knopf). "But, ineffably, psychotherapy heals."

Jamison speaks about manic depression from an insider's perspective. She has personally struggled with the condition since adolescence.

Investigators are now beginning to explore the impact of intimate relationships, social stress, individual styles of thinking, and psychotherapy on the course of bipolar disorder.

Pople who suffer from bipolar disorder have perhaps more frequently oted the sensitivity of their moods to social influences than have mental-health clinicians. Still, case reports published decades ago described how stressful events and disturbed relationships sometimes trigger episodes of mania and depression.

Over the past decade, several studies have found that bipolar patients released from psychiatric hospitals more often climb back on the emotional roller coaster if they encounter a lot of daily stress. Living with a hostile, critical family ranks high among such strains.

In contrast, social circumstances that contribute to healing have received scant attention from researchers. A new investigation finds that people treated for an episode of mania or depression recover within about 8 months if they have supportive families and friends, reports psychologist Sheri L. Johnson of the University of Miami in Coral Gables. Bipolar patients who lack these helping hands have a recovery time of more than a year.

However, the benefits of positive personal relationships fade in the face of the death of a loved one, job loss, or other major setbacks. These can extend recovery time to more than a year, Johnson and her colleagues reported in the November 1999 JOURNAL OF ABNORMAL PSYCHOLOGY.

The cruel slap of an unexpected loss or growing friction in a cherished relationship usually signaled the imminent return of depression, but not mania, according to the study.

Any of a variety of social, psychological, and biological mechanisms may provoke depression, the scientists theorize, but only a single brain network inspires mania. That network, involved in positive emotion and striving for rewards, responds to a narrow spectrum of external influences, they suggest.

Johnson's team studied 59 adults diagnosed with bipolar disorder, most of whom entered the study during an episode of either mania or depression. Of that total, 36 took lithium or other prescribed medications, as they had before the trial. The findings held regardless of whether participants received drug treatment.

A related investigation, published in the same journal issue, indicates that some people with manic depression prove more psychologically vulnerable to stressful events than others do.

Psychologist Noreen A. Reilly-Harrington of Harvard Medical School in Boston and her coworkers used questionnaires to probe the thinking styles of 49 people who had previously been diagnosed with bipolar disorder, 97 individuals who had suffered from major depression (which recurs without periods of mania), and 23 who had never been diagnosed with a psychiatric condition.

Most participants in these three groups weren't receiving any mental-health treatment.

Over a 4-month period, depression increased only among those individuals with either bipolar disorder or major depression who displayed negative thinking styles and reported a death in the family, divorce, or other stressful experience. Negative thinkers blame themselves for personal misfortunes and consider themselves incompetent.

Such a mix of negative thinking and stressful events also heralded rises in manic symptoms for volunteers with bipolar disorder, the researchers say.

It's possible that in bipolar disorder, manic episodes serve as a psychological defense or counterpunch against a relentless propensity for sinking into depression, Reilly-Harrington and her colleagues propose. Psychoanalytically inclined clinicians have long articulated this position.

Reilly-Harrington's group suggests that along with negative thinking and personal misfortunes, disruptions of a person's daily routines or sleep-wake pattern appear to promote mania.

This view is supported by a 1998 study directed by psychologist Susan Malkoff-Schwartz of the University of Pittsburgh School of Medicine. Her group found that bipolar patients tended to become manic within about 2 months of having their daily routines rearranged, even temporarily. These alterations included air travel across several time zones and losing a full-time job without immediately starting another.

In fact, evidence is building that efforts to initiate a steady pulse of daily activities and sleep can tame manic depression.

Using a treatment dubbed interpersonal-and-social-rhythm therapy, psychologist Ellen Frank of the University of Pittsburgh School of Medicine and her co-workers are trying to dampen bipolar extremes by stabilizing social routines.

In this approach, psychotherapists help bipolar patients recognize the interplay between their moods and the inevitable ups and downs of everyday existence. Counseling sessions also focus on how emotional turmoil in relationships can disrupt a person's daily routines and bring on a bout of mania or depression.

Bipolar patients then learn to plan and hold to a daily routine, adhere to prescribed medication doses, and work on relationship problems as they arise.

At the halfway point of a 2-year study, Frank's team has observed that this form of psychotherapy helps prevent recurrences of bipolar-disorder symptoms. Unexpectedly, though, they found that patients benefited most from staying in the same treatment program throughout the first year of the program, even if it wasn't interpersonal-and-social-rhytm therapy.

The researchers randomly assigned 82 people diagnosed with bipolar disorder to regular sessions of either interpersonal-and-social-rhythm therapy or clinical management (consisting of advice and support from a concerned therapist) or to a 1-month period with one of those therapies followed by a switch to the other method for the remainder of the year. Participants who changed therapies retained the same therapist.

Most patients who stayed in either type of therapy for 1 year managed to avoid return episodes of mania and depression, Frank's group reported in the November 1999 JOURNAL OF ABNORMAL PSYCHOLOGY. Those who switched from one therapy to another fared considerably worse.

The ongoing study may eventually reveal specific benefits attributed to the social-rhythm treatment, Frank predicts. Still, even modest changes in the nature of psychotherapy appear to throw bipolar patients seriously off-kilter, she says.

For example, a person who improves with clinical management and then changes to interpersonal-and-social-rhythm therapy abruptly confronts instructions to explore sensitive areas of conflict with loved ones. This may undercut the sense of stability achieved in support-oriented discussions that didn't probe emotional sore spots.

Moreover, Frank notes, 25 bipolar volunteers who changed therapists but not treatments during the study--due to a clinician's maternity leave or departure from the clinic--maintained their initial improvement after the switch.

"It appears that the consistency of routines, including the routine of the patient's psychosocial treatment, is a protective factor in the course of [bipolar] disorder," remark David J. Mildowitz of the University of Colorado at Boulder and Lauren B. Alloy of Temple University in Philadelphia. The two psychologists wrote a comment on Frank's, Johnson's, and Reilly-Harrington's studies in the same issue of the JOURNAL OF ABNORMAL PSYCHOLOGY.

A dose of stability--in the form of extended nightly bed rest and sleep--may help prevent mania as well as a particularly severe form of bipolar illness, according to Wehr.

He and his colleagues prescribed 10 hours of nightly bed rest in the dark for a 51-year-old man diagnosed with bipolar disorder. The man had begun to shift from full-blown depression to relatively severe mania every 6 to 8 weeks, with no calm period in between. Psychiatrists refer to this speedy mood turnaround as rapid cycling. Lithium and other medications had provided no relief.

The man's condition dramatically improved after several weeks of enforced night rest. During nearly 4 years of adhering to this routine, his sleeping pattern and mood largely stabilized, Wehr's team reported 2 years ago.

Staying up late night after night under the glare of artificial lights, an unheard-of activity until quite recently (SN: 9/25/99, p. 205), may worsen some forms of bipolar illness, Wehr theorizes. Under these circumstances, the timing of the body's sleep-wake cycle appears to come unhinged from the outside world's daily cycle of light and darkness, he suggests.

Swiss researchers led by Anna Wirz-Justice of the Psychiatric University Clinic in Basel had similar success in treating a 70-year-old bipolar woman with 10 hours of nightly bed rest for several months. An extremely rapid cycler, going from severe depression to mania within 1 week, the woman had been hospitalized on and off for 24 years.

Along with prescribing the lengthy night rest, the scientists administered 30 minutes of bright light to the woman each morning after she awoke. Wirz-Justice's case report appeared in the April 1999 BIOLOGICAL PSYCHIATRY.

Although Wehr suspects that sleep critically influences bipolar disorder, other features of his intervention may help corral wild moods. Increased activity during the day and consistent timing of behaviors, as well as the quiet, isolation, and darkness at night, represent possible agents of improvement.

Whether or not larger studies carve out a place for sleep therapy, people with bipolar disorder will continue to clamor for psychotherapy, Wehr and others hold.

"If nothing else, psychotherapy has an important role in helping people to accept that they have this illness and need ongoing treatment," Frank says.