Bipolar Disorder

Difficult Choices Following Bipolar Destabilization

Facing the realities of medical withdrawal from university enrollment

Posted Jul 05, 2015

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At the time of this blog post it’s early July, approximately six weeks beyond the end of spring semester for most universities across the country. A small percentage of enrolled students with bipolar disorder will have had to medically withdraw due to poor academic performance as a result of mood and behavioral instability. The choice to take a medical withdrawal usually reflects needs to lessen situational stressors, return to a supportive environment and avoid adverse impact upon one’s academic record. A medical withdrawal also leaves individuals without any accrued credits from the semester in which they were last enrolled.

This past spring I saw two university students within my own practice who were too depressed to complete spring semester. Both withdrew. A third was referred after being hospitalized at the end of the semester due to a manic psychosis. It happens. And when it does, the young adult often feels a great deal of shame, embarrassment, failure, and not so surprisingly, depressed mood.   

Students with bipolar disorder already feel they’ve got a couple of strikes against them. The choice to exit before the end of the semester has them feel like they blew it. Their fears of not being able to function like their neurotypical peers have materialized. And now they’re out of the game, sidelined, wondering what’s next.

Getting back up on the horse is no simple endeavor. Perhaps the worst strategy is for the student to conclude that he just needs to dust himself off, take firmer hold of the reigns and hold on more tightly. Instead, the student needs to learn to ride differently. But before talking about recovery, let’s look at two very different examples of medical withdrawal due to bipolar destabilization.

Jonathan was mid-way through fall semester when he began to experience strong hypomanic symptoms over the course of several days. After three days of minimal sleep, elevated mood, racing thoughts and high productivity he progressed into manic psychosis. He could no longer sustain rational linear thought, his perceptions of reality became delusional and his behavior was increasingly disorganized and chaotic. Jonathan was hospitalized for five days while being treated with an atypical antipsychotic.

His mania did resolve but upon discharge from the hospital he returned home with a whopping depression that lasted nearly three months before he began to improve enough to glimpse the potential of resuming college enrollment. By the summer months he felt ready to test his recovery by taking a couple of on-line classes.  Having done relatively well in both he went on to return to his university. He also wisely chose to enroll in only nine credits in order to keep his stress level relatively low.    

Heather’s experience was very different. She was diagnosed with bipolar II in her high school senior year due to a series of brief hypomanic spikes following the initiation of antidepressant medication. Her mood and sleep cycle began to smooth out after discontinuing the antidepressant and replacing it with a mood stabilizer.

During the summer following graduation Heather’s hypomanic symptoms returned but more gradually than when she was on Prozac. She was definitely elevated, but there was little that felt alarming or out of control. A few weeks into her elevation, her positive mood elevation switched to strong and persistent irritability. During late July she felt constantly on edge, enough so that the thought of coping with her first semester of college was daunting. She just wanted to be left alone. But the end of August did arrive, as did the beginning of her first year at college.  By mid-September Heather’s irritability transitioned to mostly depressed mood, low energy, low motivation, and difficulty with attention and concentration. Her capacity to handle academics was significantly compromised. She had withdrawn interpersonally and she perceived that she had missed the boat on the first year experience. By early November she made the decision to withdraw from school and return home.

Heather experienced much more rapid recovery than did Jonathan. Rather than becoming depressed, she was much relieved once the academic demands and social complexities of college were off her plate. Within a couple of weeks she returned to feeling like her normal self and by early December she thought she was ready to return for winter semester. She also falsely concluded that she didn’t need to take her medications because there were no current symptoms requiring treatment.  

Heather knew she’d be entering second semester with a lot of catching up to do. She knew she’d need to work hard to develop a friend network. She felt driven and she didn’t want to get too far behind with her academic progression. Some of what being home had accomplished was that it reconnected Heather with her memories of high school success, of which there were plenty. She became convinced that if she could just establish enough self-discipline and commitment, then maybe her last six months of instability could become events of her past rather than something she’d carry into her future.     

At first glance, the reader may perceive this low-acuity-rapid-recovery situation as preferable… and from the perspective of milder vs stronger symptom acuity, it is. After all, the longer-term prognostic picture is more positive when the early course of bipolar disorder doesn’t entail high acuity symptoms. But a low-acuity episode can actually entail greater risk of relapse, as the young adult can be more prone to minimize the role bipolarity plays in contributing to the medical withdrawal outcome.

In previous blog posts I’ve addressed the ways that bipolar II can actually be more challenging to manage than bipolar I. Mild to moderate mood instability knocks things out of balance just enough that academic performance is adversely impacted. Stress and anxiety make the situation worse. The student can’t save the semester and subsequently withdraws from enrollment. Once the storm has passed, relapse potential is minimized in the service of denial and the student approaches the next semester with naïve expectations. But the good news here (or maybe the bad news – depending how you look at it), is that the naiveté or the wishful thinking that we see in Heather’s story won’t likely survive future bouts of relapse. If Heather does return to second semester only to repeat what she hoped to avoid, it will be more difficult for her to revive the same strategy of wishing herself back to non-bipolar wellness.

Painful experience is a powerful teacher and once bipolar disorder arrives on the scene it tends to not go away, unless it’s not bipolar. The illness usually does a good job of reminding the college student  to learn to live with the disorder.  It’s also important to recognize that whatever the episode acuity  – depressed, highly elevated, intensely irritable, psychotic – the period of time after mood symptoms have lessened is one where the brain is recovering.  I liken it to an ankle sprain. You don’t just get back up and start running or walking normally. Recovery takes time, as does the return to normal functioning following strong mood instability.

Jonathan and Heather’s stories depict two opposing sides of a broad continuum. There’s also much that occurs in the middle where bipolar symptoms may not be acute enough to require hospitalization, but they’re also not mild enough to be easily dismissed. In fact, most of the time, when a medical withdrawal from enrollment is necessitated, the single biggest impediment in the student’s return to school is that he or she doesn’t give adequate consideration to the importance of what just occurred as well as what needs to change when he or she returns to the academic environment.

In the aftermath of a medical withdrawal the student and the student’s family are faced with multiple choices involving the recovery process as well as the student’s return to the academic environment. Some of these are addressed below: 

1) How long should a student remain out of enrollment?

There’s no one-size-fits-all answer to this question. The student’s mood should be stabilized – relatively steady  without significant depression or elevation. The student’s ability to study and do academic work should be close to the  functional capacity when in mid-range mood. Attaining this will usually require that the student is prescribed a combination of psychotropic medications. The length of time that’s required to attain stability will be related to symptom acuity as well as  responsiveness to medication, both of which are very individually specific.

My experience with the university population is that the above objectives can take between a few months up to an entire year to achieve. I do become concerned when I see a student or the student’s family trying to rush the process due to external factors, like when the next semester begins or limitations to the amount of time a student can remain out of enrollment and still be eligible for scholarship. Granted, these are not insignificant things, especially scholarship funding but the negative consequences of prematurely returning to full-time study will almost always outweigh the funding issues. Besides, they become irrelevant if one isn’t able to function adequately in the college environment.

2) Are there circumstances where returning to school before full recovery may be preferable to staying home for a period of time? 

In most situations I think the answer is no. If the student is still unstable, then there should be no realistic consideration for areturn to school. Colleges and universities are not interchangeable with residential treatment andcannot be expected to take on the task of stabilizing and monitoring a student who is still in the early stages of recovery.  Premature return to enrollment is a setup for failure. 

But do we ever see exceptions? Occassionally, yes …

Consider Virginia’s situation: She’s a third-year  student who withdrew from enrollment in late March. She lives with her parents in the midst of farm country where she has no access to providers who are well versed in bipolar treatment. Once monthly since March Virginia has been traveling a few hours each way, to her university’s town in order to meet with her private-practice-based psychiatrist. At present Virginia is only mildly depressed, but all other areas of her functioning are good. Her sleep is stable and she’s been tolerating her prescriptions of Lamictal and low-dose Seroquel without any noticeable side effects. If she does return, the university will allow her to drop below full time credit load and enroll in nine credits (three courses). She will also be able to participate in a weekly bipolar student support group provided by the university Counseling Center. 

Should Virginia stay home on the family farm with little support and engagement beyond her connection with parents, or should she return to a low stress academic load while also receiving good professional support and guidance in relation to her bipolar condition? This is a situation where even though Virginia’s not yet symptom free, she may still be better off continuing forward with enrollment rather than sitting out for an additional semester. The option is at least worthy of consideration.

3) What kinds of activities are good for the student’s recovery while at home?

Similar to question #1, it’s difficult to generalize here as students’ home situations vary widely. That said, the pace of engagement should be guided by the student’s emerging capabilities. If a student has just been discharged from a psychiatric hospital, then basics like healthy sleep, exercise, good diet and relaxation may be ideal within the home environment during the initial period of recovery. Once one begins to gain more strength and particularly as cognitive functioning begins to return to normal, increasing engagement with the world is a good thing. Jonathan’s choice to do some on-lines courses was smart. If Heather had been less impatient, then she might have tried a semester’s worth of courses at her local community college. A part-time job can also be a good choice.

What students need to avoid, especially once they’re beginning to feel better, is sitting around and doing nothing. This does little to help rebuild self-esteem and doesn’t give the student any indication of what to take on next. It’s important to remember that the time away from school does not just entail recuperation. It is also a time of reestablishing strength and resilience.    

4) Should the student return to the same university or possibly consider alternate options?

There are many issues to be taken into consideration here. The strongest is whether returning to an environment the student can be successful in maintaining a healthy lifestyle. This entails the quality of the living environment  such ashaving a single room in a quiet setting that supports the maintenance of healthy sleep hygiene while avoiding drugs and alcohol. Healthy living is a prerequisite for bipolar mood stability and it's crucial that such can be attained at the student’s university of choice.

Additionally, some universities simply have better student support services than others. For the student with bipolar disorder this is an important part of the “goodness of fit” which the student should seek. If the university’s support services, particularly student psychiatric or mental health services are not well resourced and the local community does not hold good alternatives, then it may be preferable for the student to transfer to a school with a stronger profile of student support services.    

Sometimes distance away from home is also something that should be factored into the collegiate decision. If the student is attending a university out of state and travel distance is quite far, it may be wiser for the student to consider options closer to home so family support can be more readily available.

5) What are the lifestyle and treatment components the student should have in place to lessen chances of relapse?

The key components are:

  • An environment that is conducive to establishing a consistent and stable sleep cycle
  • Minimal use of drugs and or alcohol.
  • Regular exercise – at least three to four times weekly.                                       This point goes hand in hand with very intentionally developing effective methods for stress management. Each student needs to find what works. For some, exercise does the trick; for others it’s yoga, meditation, playing an instrument or simply becoming masterful at planning and organizing ones approach to studying. It’s important to recognize that when attending college with bipolar disorder, stress can be a prominent trigger for recurring mood instability.
  • Relatively easy access to psychiatric and psychotherapy services.                 There are some colleges and universities where most students with ongoing psychiatric needs are referred off-campus for treatment. I don’t necessarily agree with this strategy, but it is a reality that some students will encounter.  If one is able to find a good treatment team (psychiatrist and psychotherapist) that is responsive and competent in treating bipolar disorder, then it can be a viable alternative to utilization of university mental health resources.
  • Access to a campus-based student bipolar support group.                                     In addition to good medication choices and adhering to the basics of healthy living, this can be one of the most helpful choices out there for a student with bipolar disorder. And if the university Counseling Center doesn’t have an active bipolar support group, I’d even recommend meeting with the Counseling Center Director and  requesting that one be added.   
  • A university administrative culture that provides good, strong advocacy for students with mental health issues.                                                               The offices usually involved in this would be Student Disability Services, Office of the Dean of Students and the student’s Academic Dean(s).

The last question I want to address is whether there’s any harm in taking a longer period of time – longer than four years – to complete one’s college education?

The answer is unequivocally no!

There is no race to the finish line. For some the process may take longer than for others. Life, with all its possibilities still awaits, whether it takes four-and-a-half or six years to earn a degree. Graduate schools will not reject someone two years older than most college graduates, nor will employers, nor will friends, nor will potential spouses. The important theme through all of this is to treat yourself gently and to recognize that your bipolar disorder will likely create a different life trajectory than if you didn’t have it in the first place. That’s not a fun thought, but it is what’s real. Your task is to make appropriate adaptations that will yield good outcomes.   

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Russ Federman, Ph.D., ABPP is in private practice in Charlottesville, VA (www.RussFederman.com). He is co-author of Facing Bipolar: The Young Adult’s Guide to Dealing with Bipolar Disorder (New Harbinger Publications).                       www.BipolarYoungAdult.com