Shining a Light on Depression

In addition to therapy and antidepressants, we also use “light therapy” to treat and manage seasonal depression. This means sitting in front of a specialized light box, usually for 30 minutes in the mornings, starting in September and continuing into the Spring. Light therapy provides significant relief for people who live with SAD — especially when it works to prevent the onset of an episode.

Light therapy works by re-setting people’s circadian rhythms — our 24-hour internal clocks that respond to light and dark in the environment. The clock is triggered when receptor cells in the back of the eye send light/dark signals to the brain, which then sets off cascades of responses that drive our sleep/wake cycles and energy variations through the day.

People living with depression or bipolar disorder typically experience powerful disruptions to their circadian rhythms. During a depressive episode people often have a terrible time getting to sleep at night and staying awake during the day. Energy is set to low all the time. In bipolar disorder, during a manic episode, the energy is set to high at all times. During a manic episode, they feel no need to sleep — they just keep going like the Energizer Bunny. Helping someone with mania get some sleep is a key step to shutting down the over-charged mood cycle.

Signaling the Brain to Sleep

Knowing the benefits of light therapy on depression, researchers have wondered whether “dark therapy” could calm mania. Could mimicking darkness help someone in a manic episode get better sleep, which would reduce their manic symptoms? In 2005, a researcher studied the effect of 14 hours of darkness per day on patients in the hospital with mania. The results were dramatically positive — sleep was much better compared to a control group. However, enforcing 14 hours per day of darkness was clearly not tolerable for patients.

Since then, scientists have discovered a receptor in the retina (back of the eye) that they think of as a “daylight receptor.” It responds to a limited wavelength of light — blue light in particular. When blue light hits this receptor, it sends signals to the brain’s “master clock” which then communicates the “time to be awake” message to the rest of the brain and the body. When this light is absent, the master clock signals the brain and body that the time to rest and sleep has arrived.

Blue-Light Blockers

Knowing about this receptor has led to the creation of “blue-light-blocking” lenses, which prevent blue light from reaching the “daylight receptor,” so that the master clock stops signaling the brain that it’s time to wake up. Essentially these glasses create “virtual darkness,” which delivers nearly the same benefits as keeping people in the dark for 14 hours a day without the drawbacks of actually doing so.

Now, researchers in Norway have published a paper looking at the effects of “virtual darkness” on the sleep of people in a manic episode. (Henriksen, T. E. G., Grønli, J., Assmus, J., Fasmer, O. B., Schoeyen, H., Leskauskaite, I., … Lund, A. (2020) “Blue-blocking glasses as additive treatment for mania: Effects on actigraphy-derived sleep parameters.” Journal of Sleep Research, 29(5). https://doi.org/10.1111/jsr.12984.) It was a small study, including twenty people who were hospitalized with mania. They divided patients into two groups. One group wore blue-light-blocking (BB) glasses from 6 PM to 8 AM, for seven nights, while the other group (the control group) wore clear glasses during that time. They removed the glasses only when they were in bed for sleep, with the lights out.

The results were encouraging. By the fifth night, the group in the BB group experienced more sleep time while in bed and more restful (less active) sleep than did those in the control group. The BB group also needed less sleep medication than did the people in the control group. The difference was noticeable and happened relatively quickly. More hours of darkness helped people in a manic episode sleep more efficiently and more soundly.

More studies need to be done on larger groups of people, and many more questions need to be explored, but the idea and the initial results are intriguing. Treating mania typically relies on powerful medications, which this would not replace, but can “dark therapy” play a role in helping symptoms resolve more quickly? Could it help people with bipolar disorder re-route or mitigate a potential manic episode if they use them as soon as they notice any sleep changes? Does it help us think about how to design living and sleep spaces for psychiatric inpatients experiencing manic symptoms?

For now, those of us living in four-season locations are heading into actual darkness for many more hours of our day. Looks like we have scientific explanations for feeling so tired as the days get shorter, especially until we adjust to the time change. For us, it’s not too soon to bring on the holiday lights! But those whose mania is commonly triggered by the holidays may hope for a pair of blue-light blockers in their stockings, instead.

Blech’s wealth grew with the industry as he served as the initial financial force behind more than a dozen biotech companies that continue the fight against many diseases including Parkinson’s, cancer, and AIDS. These companies include Celgene, Alexion Pharmaceuticals, Ariad Pharmaceuticals, and Icos (developer of Cialis). At his peak in 1992, he alone was worth more than $300 million, securing his place on the Forbes 400 list. He became known as the King of Biotech, and his influence on the market came to be described as “The Blech Effect” — any business he was associated with became sizzling hot.

But Blech struggles with bipolar disorder and a gambling addiction. Overleveraged, his financial world collapsed around him when banks called in their loans. In a single day called “Blech Thursday,” his net worth crashed from $200 million to negative $50 million.

The film begins with David Blech eleven million dollars in debt, trying to keep his family afloat and awaiting a possible jail sentence for securities fraud, Blech places his last hopes on the only asset of value he still owns — Intellect Neurosciences, Inc., which is in a race to develop a potential cure for Alzheimer’s Disease that could reverse his fortunes and rebuild his legacy.

The Blech Effect is a nuanced human tragedy captured on screen — a protagonist who is fully aware of his illness and his personal shortcomings, yet still unable to control his worst impulses, a devoted wife and mother, and a beloved child heartbreaking in his beauty and disability. It is perhaps best described by David Blech himself as “a cautionary tale about manic depression, a cautionary tale about using leverage in business, and a cautionary tale about putting money over family.”

The film is compelling, and I think it delivers a valuable message to people living with bipolar disorder and their families on the importance of getting proper treatment and, as Blech says, “You’ve got to put up the roadblocks that will stop you from repeating patterns.” I wonder how the outcome might have been different if Blech had received effective treatment early on and put effective roadblocks in place, such as having a third party providing some sort of checks and balances. Of course, such roadblocks are effective only when the person who has bipolar cooperates, which can happen only when everything else is working — medication, therapy, self-help, support from family and friends.

Perhaps most importantly, The Blech Effect reminds us of the potential value of people with bipolar disorder — their intelligence and drive, which can do so much good in the world — and what we stand to lose as individuals, family members, and communities when we come up short in our efforts to help them control the illness.

The Blech Effect is out today on iTunes, Amazon and all digital/HD platforms. View the trailer below.

After a month or more of stay-at-home orders — with daily onslaughts of news about the coronavirus pandemic and the fraying economy — almost everyone is reaching new levels of frustration, fear, and grief. With no clear endpoint or idea of what comes next, uncertainty is becoming a constant in our lives, which drains a lot of personal bandwidth. “Not knowing” keeps our nervous systems on high alert. Fear of the unknown is a built-in survival instinct — but one that’s built for instant challenges like a bear in the bushes, not for the 24/7 news cycle. Chronic elevation of our alert system is exhausting, and it’s often running in the background, so we don’t even realize what’s making us so tired and cranky.

The current level of disruption and uncertainty puts particular kinds of pressure on the nervous systems of people living with bipolar disorder. It also turns carefully crafted life skills strategies upside down. Living with bipolar disorder, managing it, usually focuses on maintaining some degree of predictability. But routines and rhythms have unraveled, and social distancing and staying at home all the time run counter to many of the recommended day-to-day interventions for managing bipolar symptoms.

So, what options are available? What can be done to mitigate the risks during these unprecedented times? You’ll find so many recommendations and ideas that they can begin to feel overwhelming and seem like “more of the same.” Living with bipolar, you already have some ideas about skills and strategies for mental health, such as mindfulness and routines, but they’re harder to do now.

What I recommend is to keep it simple. In this post, I present four simple strategies for managing bipolar disorder when the stay-at-home orders disrupt your routines.

First: Be kind to yourself.

Over the last couple of months, I have repeated one sentence over and over to myself, my family, my patients, and my friends: “Be kind to yourself, no matter what.”

Self-compassion — kind words to yourself — helps save bandwidth and keeps you a step away from a negative spiral. It’s a powerful tool.

So if you feel like you can’t get anything done — if you can’t follow routines, if you are sleeping too little or too much, if you are irritable,  if you hide from phone calls, if you eat comfort food all day, if you cry a lot, or whatever you feel like you are doing wrong that you’re beating yourself up for — try talking to yourself like you might to a friend. Try words of forgiveness, acceptance, and encouragement. Remind yourself that, no matter what, you still deserve to be loved and respected by yourself and others.

Second: Stop comparing yourself to others.

All those people on Instagram with their exercise routines and daily walks and meditation — they are struggling too, in their own way. Everyone struggles. No one has it all figured out. No one. We don’t know their full story, and no one knows yours.

One of the most common “thought errors” that comes into play in treating depression and anxiety is that “Everyone else has it together except me.” This has always been a tough one to get rid of — and it has become even more difficult in an era of Instagram and Facebook and YouTube. It seems like everyone’s life is all happy and put together. But those are curated stories made to present the happy/good stuff. It’s a bias — people don’t usually post the ugly crying in the car moments. Or the screaming at the TV or the computer moments. Or the hiding in the couch in pajamas for three days moments.

Your story is complicated — and human and no less than anyone else’s. Living with bipolar disorder is a challenge that many people will never experience. Other people have whatever challenges in their lives; we don’t know them. But people don’t know yours either.

Third: Start very small.

Do tiny amounts of things that help — do the smallest things if you can. One minute of a big body stretch. Count five breaths — (in fact — do that now). Stand up for a minute or two. Turn off your screen — for a few minutes. Connect with a friend — even for a moment — even a text if not a call. Take a nap if you are tired. Eat if you are hungry. Listen to a song that you love.

Last: Ask for help.

Your care team, your family, your friends — they want to support you, but they need to know that you need help. Don’t try to tough this out.

If you can’t go to the pharmacy, and you are running out of meds, let someone know. If you aren’t sure about your doctor or therapist appointments, call or email them and find out what’s happening — maybe they are doing telemedicine.

If you’re struggling financially — reach out to someone. There are resources and help but they can take time and energy that you may not have right now, so let others help you.

You have nothing to be ashamed of — asking for help is a key skill in managing bipolar disorder. It’s not something you have to do alone.

Just to let you know, I will be delivering a webinar called “Back to the Basics: Bipolar Disorder 101” hosted by the International Bipolar Foundation this coming Monday, March 30 at 4:00 PM EST. Register for the webinar here.

Disruptive Mood Dysregulation Disorder (DMDD) is a childhood condition characterized by ongoing irritability and frequent temper outbursts (verbal or behavioral) that are inappropriate for the given situation and excessive to whatever provoked the outburst. This is a relatively new diagnosis introduced in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which was published in 2013.

Prior to the DMDD diagnosis, many children with these symptoms (ongoing irritability and anger) were being misdiagnosed as having bipolar disorder. Follow-up research showed that these children often grew up without developing the manic or hypomanic episodes that are essential for a diagnosis of bipolar disorder. The DMDD diagnosis was developed, in part, to provide children who exhibit these symptoms the psychiatric and psychological treatment they need without over-diagnosing bipolar disorder and without subjecting them to powerful pharmaceuticals that could do more harm than good.

DMDD Symptoms

According to the DSM 5, a diagnosis of DMDD requires that the following conditions be met:

• The child must exhibit a pattern of “severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocations.
• The outbursts must occur, on average, three or more times per week.
• The mood in between episodes must be persistently irritable or angry most of the day, nearly every day, and be observable by others. (In contrast, in bipolar disorder, mood episodes are clearly distinct from the person’s baseline or typical mood, as I explain later in this post.)
• Symptoms must persist steadily for at least 12 months and in at least two of the following three settings — home, school, peers.

DMDD was added to the DSM 5 to try to capture the many children whose primary emotional/behavioral difficulties are related to frequent and severe “meltdowns” in response to minor triggers. They struggle to regulate their emotional and behavioral responses demands or stimuli. While all children are developing these skills over time, these children’s emotional and behavioral modulating systems are not developing the same way as their peers. They can’t self-soothe or de-escalate effectively when their emotional “circuits” light up.

Frequent and severe tantrums, along with irritable mood are some of the most common reasons children are referred to child psychiatrists. The symptoms disrupt their lives and interfere with their development. And yet tantrums and irritability are not specific to any particular psychiatric diagnosis. These patterns can be seen in depression, anxiety, bipolar disorder, borderline personality disorder, attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), trauma, and autism spectrum disorder — just to name a few.

I think of these symptoms as a “final common pathway” for many different psychiatric and neurodevelopmental conditions. Just as a cough is a “final common pathway” for many conditions such as asthma, pneumonia, influenza, bronchitis, emphysema, and many more. The symptoms tell us broadly that something is wrong and we need to start looking — but they aren’t themselves a diagnosis.

Differentiating Moody from Manic

When kids have emotional reactivity and dysregulation, they are often referred to as “moody” — or as “having mood swings.” This characterization of these children led to a decade’s long debate among child psychiatrists as to whether or not irritability and dysregulation were childhood expressions of mania — which would mean that these children would be diagnosed with bipolar disorder. This has been an energetic discussion in my field, because trying to help these children and their families is so much of what we do. Calling these kids “bipolar” seemed to capture something about them, and gave some diagnostic clarity — at least initially.

Unfortunately, this thinking led to a massive increase in the number of children diagnosed with bipolar disorder. It became clearer over time that while many adults with bipolar disorder had emotional dysregulation and irritability as children (and continue to have them in adulthood), most children with emotional dysregulation and irritability did not eventually develop bipolar disorder. Those children often develop depression and anxiety, and a variety of other psychiatric illnesses, but only a small percentage develop bipolar disorder.

In the DSM 5, the bipolar type 1 diagnosis requires at least one manic episode. The symptoms include elevated or irritable mood, high energy with a decreased need for sleep, big and grandiose ideas about themselves and about what they are thinking and doing, increased levels of activity, decreased judgment and increased impulsivity, rapid speech and racing thoughts, and sometimes psychosis. Most importantly these symptoms must occur in an episode that looks significantly different than the person’s baseline — everyone can see it — and it lasts a minimum of seven days (shorter only if it results in an inpatient hospitalization). Bipolar type 2 requires an episode of hypomania — which includes some similar symptoms to mania but much less severe. Hypomania must last four days and must also be a change from baseline.

DMDD, on the other hand, presents with chronic irritability and regular, frequent, and severe outbursts. There is not a sustained change in mood, energy, thinking, or activity — except during the outburst itself. These occurrences are part of the child’s baseline; they happen all the time. This is moodiness on a scale of minutes to hours rather than days. The diagnosis of DMDD is not made if other conditions can be identified as the primary cause of the outbursts — such as depression, PTSD, autism spectrum disorder, separation anxiety disorder, or obsessive compulsive disorder — and many others. However, if there are major dysregulation patterns not explained by the other disorders, these diagnoses can go together. For example if a child has separation anxiety disorder, but their outbursts don’t occur only in the context of separation from a caregiver, they could receive both diagnoses.

DMDD overlaps significantly with the diagnosis of oppositional defiant disorder (ODD). If symptoms of both are present, then only the DMDD diagnosis is used. (I almost never use the diagnosis of oppositional defiant disorder — and that is another blog post for another day.) If a child or adolescent develops full blown symptoms for mania or hypomania, then the bipolar diagnosis steps in and DMDD is not used.

It is notable that many — if not all — children with a DMDD diagnosis also have ADHD. While many children with ADHD have short fuses, DMDD is at another level in terms of mood responses. And while kids with ADHD may be impulsive all the time, impulsivity during an emotional/behavioral outburst is not quite the same. When someone is in the midst of a rage or meltdown, they say and do things that they wouldn’t do if they were thinking clearly. Emotions have hijacked their impulse control. This is the same with children during their dysregulation episodes.

A Developing Story

The DMDD diagnosis was developed and put into DSM 5 in an effort to capture children with significant emotional dysregulation — chronic mood outbursts and irritability – who don’t meet criteria for a manic episode. The concept of irritability as an important symptom on its own — different from sadness or fear or mania — is becoming more well-developed by child psychiatry researchers. It is not a diagnosis — recall the cough discussed earlier in this post. But it is a symptom that we need to observe and find out more about when we see it.

There is a growing body of research using brain imaging — functional MRIs — to understand what happens in the brains of children with high levels of irritability compared to control children with more typical levels of irritability. For example, an interesting finding is that the brains of children with high irritability levels seem to respond differently to perceived threats in the environment. Some researchers are looking at differences in brain responses between DMDD and bipolar disorder. This area of research is just beginning, so we don’t know what we will ultimately find. But understanding these phenomena at the level of the brain and central nervous system can help us begin to develop targeted psychotherapies and other approaches to treating and helping these children and their families.

Although people who live with bipolar, depression, or other psychiatric illnesses often are relieved to receive an explanation for why they are feeling the way they feel, they rarely, if ever, appreciate being “labeled.” In fact, we go out of our way not to label people as “depressed,” “bipolar,” or “schizophrenic,” because these labels can be stigmatizing. Instead, we use “people first language” to describe people as “having” or “living with” these conditions, in an effort to reduce stigma. The question then becomes why are such labels even necessary?

In medicine, the terms used to reference diagnoses serve a valuable purpose. The intent is not to label patients but to label illnesses, so we can discuss specific conditions, diagnose them more accurately, and formulate targeted treatment plans. Having an accurate diagnosis expedites the process of getting the patient the most effective treatments available.

ADHD without Hyperactivity?

Unfortunately, sometimes diagnostic terminology creates more confusion than clarity. For example, in my practice, when a child or teen presents to me with symptoms of inattention, but not hyperactivity or behavioral impulsivity, patients and families are often surprised when they receive a diagnosis of attention deficit hyperactivity disorder (ADHD). Parents and/or children/teens rightfully wonder why we would include “hyperactivity” in their diagnosis if that doesn’t describe them at all. The reasons for this awkwardly worded label are based on scientific research about ADHD that has shown the two patterns to be much more similar than they are different.

In 1994, the Diagnostic and Statistical Manual 4th Edition (DSM IV) dropped the ADD diagnosis. Rather, the diagnostic term became ADHD, divided into three different types: predominantly inattentive, predominantly hyperactive/impulsive, and combination. In the most recent DSM, (DSM 5), these distinctions have become even less clear-cut, and we refer to ADHD as having a current presentation of inattentive, hyperactive/impulsive, or combination.

A major reason for this evolution grew out of research showing that impulsivity — problems with the “stop” or “off” systems in the brain — is part of the big picture of ADHD, even when someone is not physically impulsive. For example, we often think about kids who are inattentive but not hyperactive as daydreamers, and we frame this as “difficulty maintaining focus.” However, “off” switch disruptions are part of inattention. Kids with ADHD are unable to turn off their attention to one thing (the ever present squirrel in the window) and shift their attention to the teacher’s words and actions. Other ADHD symptoms include not paying attention to details and making careless mistakes by misreading or mishearing instructions. These are also impulsivity challenges — trying to squash the impulse to attend to something shiny or more interesting rather than to maintain focus on what the teacher is saying or on the reading in front of them.

Another part of shifting our language away from strict categories of inattentive or impulsive is that treatments do not seem to have different effects based on the subtype of ADHD. That suggests the existence of common underlying brain signaling problems in all types of ADHD that respond to similar types of interventions.

A further component of the change in thinking about “types” of ADHD to “presentations” of ADHD at any given time is because people often present differently at different points in time. One of the most common shifts is very hyperactive, physically impulsive young children who seem to mature out of those symptoms into a primarily “busy brain” presentation, which looks more inattentive than hyperactive/impulsive.

Additional Complexity with Bipolar Disorder

The bipolar disorder diagnosis has undergone its own evolution that can be traced back to Hippocrates in the fourth century BCE. Much later, in the nineteenth century, it was first referred to as “manic depressive insanity” — a term that was incorporated into the first DSM and lasted until DSM III, when episodic mood dysfunction started to be described as “bipolar disorder.” (Brittany L. Mason, E. Sherwood Brown, and Paul E. Croarkin. (2016). “Historical Underpinnings of Bipolar Disorder Diagnostic Criteria.” Behavioral Sciences, 6(3): 14.)

For people with bipolar disorder, more layers must be addressed when considering an ADHD diagnosis. Hyperactivity and impulsivity — both physical and mental — are core symptoms of a manic episode. Someone who has ADHD with an impulsive/hyperactive presentation struggles with these problems most of the time, even when not experiencing mania. For mania to be diagnosed, the level of activity and impaired impulse control must be clearly more than at baseline. For people with bipolar disorder and ADHD presenting primarily as inattentive, their baseline typically includes getting distracted from tasks, or starting things but having trouble finishing them, for example. These are also symptoms that can be part of a manic episode. Like impulsivity, in a manic period these symptoms would look more severe than the person’s day-to-day ADHD.

For more about the differences between bipolar mania and ADHD hyperactivity, see my previous post, Manic or Hyperactive: What’s the Difference?”

Request Clarity

Diagnostic terms are important only because they help us to identify and understand a problem we are trying to solve and to develop an effective treatment plan for that problem. The evolving semantics of the DSM are not really important except in helping us communicate and making sure that we (physicians and other providers) are using language that makes sense to our patients and their families. Unfortunately, when a term’s meaning evolves, it may lead to more confusion than clarity, as in the case of ADD and ADHD. Just remember that if a doctor is speaking in language that doesn’t make sense (or seems not to apply to you) don’t hesitate to speak up and ask about it.

As cannabis has become legal for medical and recreational purposes in many states, discussing risks and benefits of cannabis in relationship to health and illness has become part of routine medical care. Physicians are fielding questions about marijuana prescriptions for many different illnesses. Products containing the cannabidiol (CBD) component of cannabis, have exploded onto commercial platforms as over-the-counter products with claims of health benefits for every type of symptom. Our job as physicians is to try to present treatment options and balance the risks and benefits. Unfortunately, for now, too little information is available about the effectiveness of “medical” marijuana for me to offer an opinion informed by any scientific evidence in these areas.

In psychiatry, we have historically been more focused on the negative effects of cannabis use on psychiatric conditions. The correlation between cannabis use disorder (heavy use) and higher rates of depression is well established. Similarly, many studies show an association between cannabis use and onset of psychosis, and the higher the level of cannabis use, the higher the risk of psychosis occurring. These relationships have been well studied and found in many replicated studies. Although these studies have yet to confirm any causation in these relationships, but the correlations are robust.

The story is similar for bipolar disorder. The scientific research so far shows that cannabis use increases the risk of manic episodes, and that it may be related to earlier onset of first manic episodes. At least one study showed that people who quit using cannabis after a first manic episode did much better in terms of their recovery than people who kept using cannabis. Those who still used had more frequent recurrence of mood episodes and more difficulty with functioning.

In My Practice . . .

In my practice, over the last two years, I have had several young people present to me with new onset of manic and psychotic symptoms, and they were all heavy users of cannabis. Three were women, and one was a young man. They were all in their early to mid-twenties. Three out of four were heavy recreational users and had been for a long time. One was not a recreational user, but had been prescribed medical cannabis, with high THC content, through a local clinic, for back pain. They all had suffered with depression from earlier in life — childhood/early adolescence — but none had experienced mania or psychosis before. At least one had a family history of bipolar disorder.

All of these young people had good response to medications, including mood stabilizers and antipsychotics. However, those who continued to use cannabis still had a much harder time getting back into their school or work life. Those who were still using had a harder time staying on their psychiatric medications and with maintaining their sleep and wake cycles. They became more depressed and still had breakthrough delusional symptoms at times, which did not occur with the patients who stopped smoking marijuana.

I can’t say with any clarity how the cannabis use related to their manic episodes in my patients. It was definitely notable to me that this was a pattern that I was seeing and that their patterns of recovery were at least somewhat related to their continued use or their abstinence from cannabis. These four young people experienced patterns of bipolar symptoms and cannabis use that have been well described in the scientific studies about this combination.

Does Cannabis Help Any Psychiatric Conditions?

The flip side of this discussion is whether any evidence suggests that cannabis could be used to treat any psychiatric conditions. And this is where our research becomes much scarcer. From basic research, we do know that our brains have cannabinoid receptors. A brain system referred to as the “endocannabinoid system” is at the center of many complex interactions that regulate mood, thought, and behavior. The endocannabinoid system also has interactions with our immune system and inflammatory responses.

Because these cannabinoid receptors are so important to mood and other brain functions, there is hope that somehow cannabinoid compounds can be harnessed to treat some psychiatric symptoms. However, research about how this would actually work is limited. Many factors are at play in how these receptors and chemicals affect each other, and these factors make this whole body of research rather daunting. One of these factors is genetics; people’s genes affect how they respond to different cannabinoid chemicals. Another factor is a strong placebo response to cannabinoids, and the social/cultural expectations related to the use of these compounds.

Cannabis itself includes a number of different cannabinoid chemicals. The two that most people know about are tetrahydrocannabinol (THC), and cannabidiol (CBD). THC causes the psychoactive effects of cannabis; it causes the “high.” CBD affects the brain and body, but it does not cause a change in mental status; you don’t feel different in how you are thinking and experiencing the world. CBD has a range of reported effects — including reducing inflammation and, for some people, reducing anxiety. In states where you can buy recreational or prescription cannabis, you can usually purchase well defined “blends” of the two compounds. Research in this area typically focuses on cannabis, which includes at least some THC, or CBD only, which does not include any THC.

Research on medical uses of cannabis for brain illnesses shows that it can reduce pain and spasticity in conditions such as amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS). It may also reduce pain and rigidity in people with Parkinson’s disease. It has some benefits for some children with severe epilepsy that isn’t responding to typical seizure medications. However, research on cannabis in schizophrenia and bipolar disorder have not shown evidence of medical benefits of cannabis for these disorders. Heavy cannabis use is associated with worsened outcomes in bipolar disorder and it is associated with higher risks of onset of psychosis and schizophrenia. While any causal relationship remains unknown, no studies show that use of cannabis is associated with reduced symptoms. Similarly, depression rates are higher in groups of people who are heavy users of cannabis, and no solid evidence supports its use in the treatment of depression.

CBD for Certain Psychiatric Disorders

The use of CBD in psychiatric disorders may be more promising. Interestingly, some evidence shows that CBD could possibly be used to reduce some symptoms of schizophrenia. A well-done study from last year involved giving patients with schizophrenia CBD in addition to their regular medications and giving a control group a placebo instead. At the six-week mark, the patients taking the CBD had fewer psychotic symptoms compared to the placebo group. Given the challenges of treating schizophrenia, this could prove to be important in helping patients with recovery. (McGuire, P., Robson, P., Cubala, W. J., Vasile, D., Morrison, P. D., Barron, R., … Wright, S. (2018). Cannabidiol (CBD) as an adjunctive therapy in schizophrenia: A multicenter randomized controlled trial. American Journal of Psychiatry, 175(3), 225–231. )

Some research also suggests that CBD may reduce symptoms of some anxiety disorders, in particular, social anxiety disorder. CBD may also have a role in helping people withdraw from cannabis and tobacco. No real body of evidence identifies benefits or risks of CBD in bipolar disorder or unipolar depression.

Bottom Line

Right now, the evidence we have strongly suggests that people with bipolar disorder should not use cannabis; it is associated with worse outcomes. In terms of CBD, no good studies show positive or negative outcomes in bipolar disorder. Any possible use of CBD would be something to discuss in detail with your doctor. Even though it doesn’t get you high, we don’t know how it might interact with mood circuits or other medications. In the future, we might find that it offers some benefits, but for now not enough information is available to make any judgments at all.

Recently, someone posted the following on Instagram: “I am clinically #bipolar, which means that I don’t know what my mood will be like in the next 20 minutes.”

This sparked some discussion among doctors on Twitter, who noted, correctly, that mood episodes in bipolar disorder last days to weeks, not minutes or hours. The Instagram post and Twitter discussion also sparked discussion among people who live with bipolar disorder, which made me think that an expanded conversation would be helpful.

In this post, I highlight the distinctions between moodiness and bipolar disorder, and explain why these distinctions matter.

Characteristics of Moodiness

Moodiness is characterized by quickly changing moods (hour-to-hour or moment-to-moment), which is a common emotional experience that has a wide range of causes. This pattern of mood changes is also commonly referred to as “mood swings” or, if the mood changes frequently to anger, “irritability.”

Transient periods of moodiness, unrelated to any psychiatric diagnosis, are common to most people. For example, some people may become irritable when they are very tired or hungry. High levels of stress also can trigger moodiness. Longer term, but still transient causes of moodiness include puberty/adolescence, pregnancy, and menopause.

More persistent, excessive moodiness — and especially irritability — can be a symptom of a variety of illnesses across the spectrum of the body and brain. In psychiatry, irritability is a common finding in many diagnoses including ADHD, autism, anxiety, depression, bipolar disorder, and borderline personality disorder. Moodiness is like a fever; it tells us that something is happening, but it is only a symptom and not the disorder itself.

Characteristics of Bipolar Disorder

Bipolar Disorder Type 1, is characterized by periods of mania lasting at least seven days, but often weeks or months, that may or may not alternate with periods of depression. At least one manic or hypomanic episode is necessary to make a diagnosis of bipolar disorder. Bipolar Disorder Type 2 is characterized by chronic depression, punctuated by periods of hypomania — a period of time with similarities to mania, but less intense, which by definition does not cause problems in function and must last at least four days.

During a manic (or hypomanic) episode, a person is not their usual self in many ways beyond their mood. A diagnosis of mania/hypomania is defined as a distinct period of:

• • Elevated or expansive mood or sometimes irritable mood AND
  • Extremely high energy
  • This period must be a change from a person’s usual function, and must last at least one week for mania and four days for hypomania.
  • During this period, the person must exhibit at least three of the following symptoms or four if the primary mood state is irritability:
    • Big grandiose thoughts and ideas; inflated sense of self-esteem
    • Little need for sleep
    • Engaging in activities that are high risk/impulsive/dangerous
    • Increased activity level for all activities, even ones that are not high risk
    • Distractibility — drawn to irrelevant details and stimuli
    • Flight of ideas (changing topics frequently) and/or the sensation that one’s thoughts are racing
    • Speaking rapidly and intensively, which is referred to as pressured speech

In mania, but not hypomania, thinking can become severely disrupted and evolve into psychosis — delusional thinking that is not grounded in reality. If psychosis occurs, the episode is, by definition, manic.

Key things to note are that the symptoms of mania show a clear difference from a person’s baseline, must include both mood and energy changes and three or four other specific symptoms, and the episode must persist for more than minutes or hours. If a person has chronic irritability and impulsivity, that irritability and impulsivity become visibly much more extreme during a manic episode, and they must remain at that level for at least seven days.

A Challenging Diagnosis

Bipolar disorder/mania is not always an easy diagnosis, because people can experience what are commonly referred to as mixed episodes — a manic episode accompanied by symptoms of depression or a depressive episode that contains manic features. If psychosis is a symptom (which can occur in mania, depression, or a mixed episode), distinguishing between bipolar disorder and schizophrenia can be difficult.

Between the specified mood episodes, people with bipolar disorder may be irritable, moody, and impulsive at their baseline. That moodiness/irritability, though, is not why they are diagnosed with bipolar disorder Having moodiness/irritability is not the same as having bipolar disorder. And some people with bipolar disorder do not have a lot of moodiness/irritability between episodes.

Ultra-Rapid Cycling Bipolar Disorder

Extreme and rapid moodiness has sometimes been called “ultra-rapid cycling bipolar disorder,” but this sub-classification has not been borne out by research to date. In other words, these symptoms have not been shown to consistently co-exist with or turn into classical bipolar disorder. Some people with bipolar disorder can have “rapid cycling” features, which means four episodes per year. But the episodes must still be full blown mania or depression, and they must last days to weeks, not hours or minutes.

If mood changes that come within moments or hours are the primary symptoms, and the other symptoms of mania or hypomania don’t occur, then it is not bipolar disorder.

Understanding Why These Distinctions Matter

The reason we care so much about distinctions among different diagnoses is that our treatments are researched and developed based on specific symptom pictures and diagnoses. Being as accurate as we can with the diagnosis helps us build the best possible treatment plan with our patients and their families.

If the diagnosis is bipolar disorder, we have protocols in place to provide the most effective treatments based on each patient’s specific symptoms. If, however, a patient experiences moodiness that does meet the criteria for a diagnosis of bipolar disorder, it is critical to look carefully for the underlying cause(s) of those types of mood changes so those cause(s) can be addressed.

In Bipolar Disorder For Dummies, I point out that a key self-help strategy for living well with bipolar disorder is to monitor your moods, and I provide a Mood/Sleep Chart to facilitate the process. I also point out that those who prefer to track their moods using a digital device can find several online mood-tracking tools, including the following:

• DBSA Wellness Tracker
• eMoods Bipolar Mood Tracker
• IMoodJournal
• T2 Mood Tracker

Another app that some younger kids have pointed me to is Dailyio, which is very simple. It uses emojis to represent moods. Dailyio offers a free version and one with more personalization options for $5.99. Dailyio is a good starting point for kids or for adults who are less familiar with technology.

Recently, a new online mood monitoring/management tool popped up on my radar that offers more than the standard mood-tracking capability. It is called KIOS Bipolar Mood Navigator. You access the tool using any standard web browser on a desktop, laptop, or tablet computer or on your smart phone. (It’s not an “app” per se, but once it is running in your browser you may not know the difference. More about that later.)

The opening screen, shown below, gives you quick access to the application’s four main features: Assess, Advice, My Data, and Journal.

Assessment

When you choose Assess, KIOS presents you with a series of eight simple questions, each of which you answer by tapping a gradient on a scale of one to seven. For example, one of the questions is “Have you felt depressed, sad, or down?” and the answer choices range from “Not at all” to “Severely.”

After you answer the eight questions, KIOS asks you to enter any recent medication changes and then instructs you to choose the positive behaviors you have practiced since your last assessment.

KIOS recommends that you take this assessment at least three times a week. You can adjust your account settings to have KIOS notify you via email when the time has come for a reassessment.

Advice

Based on your answers, KIOS conducts its assessment and presents the Advice screen. The initial assessment merely presents your KIOS Score along with additional information about how to use the application. It does not provide specific advice. You can expect to receive specific advice after the next assessment and more and better advice the longer you use KIOS.

Over time, KIOS identifies any changes that may indicate a shift toward depression or mania or back to your baseline. When KIOS identifies a warning sign, it provides specific advice to get back on track. On the other hand, when KIOS identifies a positive shift toward a healthier, more balanced mood state, it lets you know that, too. You can think of KIOS as your personal bipolar coach, warning you when your moods are wandering off track and cheering you on as you progress toward a healthier state of mind.

My Data

At any time, you can select My Data in the menu bar to access various charts, including Today’s Results, My Progress, KIOS Factors, and Symptoms. These charts provide a visual representation of the data, which is easier to grasp, especially when checking your long-term progress.

One of the options on the My Data screen is Download Report. When you select this option, KIOS generates a report in PDF format that you can send to your doctor or therapist or print to take to your next appointment. Even better, with your permission, your doctor or therapist can download reports between visits to remotely monitor any mood changes.

Journal

KIOS also features a journal, where you can record your own observations, including how you feel, stressors or triggers, specific concerns you have, or what you have found helpful for maintaining balance.

Where to Get KIOS

To try KIOS free for 30 days, visit kiosbipolar.com and click Sign Up Now! KIOS is not a smart phone app, so you will not find it on iTunes or in the Google Play Store. However, you can open it in any web browser, and you can create an icon on your smartphone’s home screen for quick access to KIOS. (See the KIOS FAQ at kiosbipolar.com/faq for details.)

If you decide to continue using KIOS past the 30-day free trial period, the cost is $29/month or $319/year ($26.58/month). However, your provider (doctor, insurance company, Medicaid clinic, etc.) may offer the tool for free or for a reduced cost. The fee structure for providers will differ substantially, and because the tool can improve outcomes and may save the provider money, they may offer it to their customers for free.

Although KIOS is no substitute for medical treatment, professional therapy, a support network, or having a trusted friend or relative watching your back, one of its key benefits is that it enables you to answer questions about how you are feeling honestly and obtain objective feedback without feeling judged or pressured in any way. In addition, if you choose to share the data with your doctor or therapist, it can provide valuable guidance for discussing and evaluating treatment options.

I like KIOS and will recommend it to patients, especially those who want and are able to use a more substantial online mood management tool. I think there are a sub-type of people who will want to/be able to use KIOS given the complexity and detail (which are both good things), but when very depressed, people may struggle to use something that takes a lot of mental and physical resources.

I was recently interviewed by Meredith Carroll for her article in Redbook, “My 6-Year-Old Is Obsessed with National Tragedies — and I Doubt She’s Alone,” which is based on the author’s experience that “it’s practically impossible to go outside, online, open a newspaper, or turn on the TV and not have to pick your jaw up off the floor over an international crisis, natural disaster, or a national tragedy.” The article specifically discusses how to talk to young children about tragedy or disaster in the news, especially in the context of recent events that have dominated the news cycle.

The gist of the article, and comments from me and another child psychiatrist, encouraged parents to try to limit exposure to the news, reassure children of their safety, identify their own feelings as a way to help children label and process their emotional responses, and talk together with children about ways that people can help each other.

The discussion and the article got me thinking about how adults respond to an onslaught of death and destruction in the news, especially adults who live with depression, anxiety, and histories of personal trauma. Bad news can trigger feelings of fear, sadness, hopelessness, and powerlessness. Finding the right balance between awareness/knowledge and the care and support of your mental health can be a challenge.

Following are four suggestions to establish the right balance:

• Manage your exposure to the news. With 24-hour news cycles and social media feeds endlessly scrolling on all of our devices, we can have constant input of news and commentary. Self-dosing is important; shut off the television, phone, and computer well before bed time, and resist the urge to check your Twitter feed or Facebook account when you first wake up. Give yourself time limits for how long you spend online or watching TV news.
• Load up on more positive, optimistic stories. You can Look for “good news” stories and talk about those with others. Spread those stories.
• Look for “helpers” — people who respond to bad events with kindness and generosity. This is advice that Mr. Rogers said his mother had given him when he was a child. In other words, look at bad news with a wide-angle lens that captures the goodness and generosity in people. This is an especially wonderful strategy with children, and it’s easy for them to understand.
• Build your own life with compassion for yourself and others. Participating in activities you enjoy and spending time with people you love are the best antidotes for bad news. Working to make positive change in the world and engaging with others to be a helper can feel good and bring more goodness into the world. When things are not in your control, keeping your brain and body grounded (through mindfulness) and creating your own life worth living are keys to resilience and to improving your sense of well-being.

You may not be able to control the world around you, but when bad news is the news of the day, you may be able to tune some of it out and strive to bring more goodness to your corner of the world.