Realistic Expectations for Bipolar Disorder

Since I first began writing this blog my early fall postings have mostly focused upon bipolar issues pertaining to the start of the university academic year. With each fall comes a whole new set of challenges for our college students with bipolar disorder, particularly those who have been recently diagnosed.

My consistent message has been one of maximizing influences which support stable mood and behavior while also mitigating factors which create vulnerability towards relapse. It's the ideal combination we want to strive for regardless of the age of the individual with the illness.

But is it realistic? As educators, parents and clinicians, if we consistently convey a "can do" attitude, are we holding out an ideal that may be beyond the reach for many newly diagnosed undergraduates?

After many years of university-based clinical work my perspective on relapse prevention has undergone some revision. I'm less wedded to a position which declares bipolar disorder as being manageable for those in their late teens and early twenties. My more current perspective is that most students who are newly diagnosed with bipolar disorder are not successful at maintaining a healthy perspective and avoiding the panoply of vulnerability-inducing choices that abound during ones late teens and early twenties.

To my knowledge there hasn’t been a follow-up study that’s focused specifically upon university students recently diagnosed with bipolar disorder. In order to get a reasonable picture of relapse rates we must extrapolate from findings of broader-population follow-up studies. A 2007 study by Melissa DeBello, MD (lead author), published in the American Journal of Psychiatry showed that 61 percent of bipolar adolescents (N=71) failed to experience significant symptomatic reduction during the year following their first hospitalization for a manic episode. In a more recent 2014 study by C, Simhandl (lead author) published in the Journal of Clinical Psychiatry, results showed that 68 percent of bipolar I patients (N = 300) relapsed within 4 years following hospitalization. But even more relevant to the current discussion is the fact that the mean time for relapse was 208 days, which is less than two thirds of a year post-hospitalization. Rounding out this data, a 2003 literature review article by Mark Hyman Rappaport, MD (lead author) in Psychiatry Online states that bipolar symptoms recur in up to 90 percent of patients diagnosed with the disorder.

The fact is that for many college students in the early phases of adjusting to bipolar disorder, the diagnosis and its implications can be too much for the young adult to readily come to terms with. Accepting the changes that bipolar brings and making the necessary adaptations, psychologically and behaviorally, are processes that require more maturation and experience than we see in most 17 to 22 year olds. When I refer to "experience" I specifically mean experience living with the disorder which is completely different from the reality of recently discovering that one has bipolar disorder. If we could view most bipolar university students ten years into their futures, most will have come a long way in relation to their acceptance of the disorder. But for the newly diagnosed the emotional/psychological implications of their new bipolar identity packs too hard a punch.

The four vignettes below illustrate some of the points I'm making:

1) Kate's first manic episode occurred mid-summer and resulted in a five day hospitalization. The beginning of the semester was just around the corner and despite recommendations that she delay her return to college, she was determined not to stay home for the semester. After a month on a mood stabilizer and a low dose anti-psychotic she felt her mood was stable, if not at the low end of mid-range. She did go back to school but she soon discovered that being on campus felt nothing like her first year. She felt different. She had a secret she felt like she couldn't share with others. To her credit she was able to substantially alter her lifestyle. No more partying. No more weekend drinking. This was different. Even her perception of her future was more uncertain than it had been half a year earlier. As the semester proceeded a potent depression settled in. And it progressively worsened with each week that she tried to do the right things and pass as feeling normal.

2) Michael's ADHD had always been there, but for the most part his Adderall allowed him to manage the challenges of university academics. He even liked it when his meds had the occasional opposite effect than they were intended to. Rather than smoothing out some of the bumpiness of ADHD, he would feel like he had hitched a ride on a shooting star. His energy would soar and he perceived his potential was unlimited. He loved his brief hypomanic spikes because he got to leave behind the low self-esteem that’s so common for many with ADHD most ADHD students.

One day towards the end of first semester in his second year, his Adderall-fueled energy took him too high and he ended up being escorted to the ER by some friends. After a few hours of what seemed like endless interviews and some strong sedative medication, Michael had come back down to earth where he was informed by an attending physician that he likely met criteria for bipolar disorder. Given his rapid response to sedatives he was not hospitalized. Instead, he was discharged with a referral to the University's Counseling and Psychological Services where a psychiatrist confirmed the diagnosis: ADHD and Bipolar II. Michael was started on Lithium along with Wellbutrin, which is an antidepressant that is both helpful for ADHD while less likely than other antidepressants to activate mood elevation. But Michael was also informed that his continued use of Adderall was too risky in relation to his bipolar symptoms. He was warned that he'd have to stay away from the psychostimulants. For Michael the news was even more distressing than learning he had bipolar disorder. His ADHD symptoms really did interfere with his academic success and he doubted his capacity to handle university academics without his usual medication. Michael initially struggled with his coursework which only served to increase his concerns. Partly as a function of his own denial, he concluded that his psychiatrist was being overly cautious. After all, he had gotten by using Adderall for several years without incident until just recently. Maybe his trip to the ER and the subsequent diagnosis were all overreactions. If he had just been allowed to ride out the night instead of going to the ER, he wouldn't be faced with his current dilemma.

Michael knew that if his shrink wouldn't prescribe the Adderall, he could score some from a guy in his dormitory. Having bipolar was one thing, but trying to do school with unmedicated ADHD was just too much to ask.

3) One of Austin’s more prominent bipolar symptoms was recurrent insomnia, for which he was prescribed a nightly dose of Seroquel. He hated having to take sleep meds by 10:00 PM so he could be assured of getting to sleep by 11:00. After all, most of the guys in his dormitory were typically hanging out together until 1:00 or 2:00 AM and Austin was uncomfortable excusing himself an hour or two before everyone else. By the end of his first month at school he perceived some guys were treating him differently. He began to think that his unusual bedtime routine, at least for a freshman, was noticeable to others which felt like a confirmation of one of his strongest fears. Austin wanted so much to fit in that he decided to stop taking his nightly meds. He wanted the same lifestyle that everyone else got to have. He wanted to hang out, have a late night pizza with his friends and go to sleep when he wanted to. After he stopped taking his nightly Seroquel he got to have what he wanted. But he also got more than he wanted as his choices returned him to an erratic sleep cycle with increasingly unstable mood.

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4) Laura had always been concerned about possibly developing bipolar disorder. With both her mother and her maternal grandmother carrying the diagnosis she knew she was genetically loaded for the illness. She was a straight-A student in high school, determined to achieve and demonstrate her strengths as a means of distancing from the emotional instability she was repeatedly exposed to throughout her childhood years. But despite her resolve, the impact of poor sleep hygiene in her senior year began to create a roller coaster of mood fluctuation that she wasn't able to master. She knew her fears were becoming reality and this was confirmed when she sought psychiatric consultation. She was informed that while she did likely have bipolar disorder, hers was different from her mother's in that her mood elevations didn't manifest through acute mania, at least not yet. And with this important distinction Laura was able to continue her resolve to achieve as much mastery over her moods as was possible.

Laura was successful at getting into her first choice school and she did well with her early adaptation to college life. In high school she pretty much stayed out of the drug scene with the exception that she occasionally had a few hits of pot when it was offered. It seemed pretty benign and it helped to smooth out the rough edges of her roller coaster mood. She was aware that her psychiatrist had strongly cautioned against the drug. She had even read that marijuana and the other hallucinogens were dangerous substances for those with bipolar disorders. But Laura was convinced her response to the drug was unique. It was so effective in smoothing her out that she concluded it could be an effective replacement for her Lamictal which she took on a daily basis. Besides, at college pot was so much more available to her. She knew if she could just keep it all under wraps by telling her psychiatrist that the Lamictal was working, she could continue to prove that her genetic destiny was quite different from the bipolar maternal figures of her family.

Fitting in, academic pressure, denial of the illness, substance use, poor sleep hygiene…they’re all part of challenges that the bipolar student faces. And while the vignettes represent only a narrow slice of university life, they also portray the universal reality that most college-aged students do struggle with their acceptance of bipolar disorder.

But there is another side to the story that’s not just doom and gloom: For many young adults, the early experiences of relapse and adaptation will represent some of the most important learning they will have. They may not be able to circumvent their early struggles, but their struggle is an important part of their progression. I can assure you that after a couple of hospitalizations or another whopping depression or a ruined semester due to recurrent hypomanic spikes, most young adults begin to readily see what doesn’t work for them.

I’m reminded of a 22-year-old patient I saw just a week before this blog. In January she was hospitalized for her second time due to bipolar mania. Her hospitalization was preceded by a several month extended period of hypomania where she felt good, had lessened need for sleep, was taking on many commitments and was essentially packing as much life as she could into her waking hours. However, since her hospital discharge she’s been mostly depressed. About a week prior to our session she had noticed that over the course of a few days, her depression had lifted. Her energy was back up and she recognized she was feeling quite similar to how she had felt last November and December. She was both relieved and scared at the same time. She called her psychiatrist who advised that she add some daytime Klonopin to her ongoing lithium dose. She was also advised to take some Zyprexa at night which she had previously taken when she was first discharged from the hospital. Nine or ten months ago she had resisted a similar plan. By contrast, she was now responsibly compliant with the medication strategy. She was also cautious about taking on any new commitments. By her own description she “was trying to stay in at night, remain mellow and get to sleep at a reasonable hour.” When I asked what had brought about the shift from last year she said: “Simple…I finally got it that feeling good isn’t always a good thing for me.” She was quite determined she didn’t want to end up back in the hospital. I was sitting across from a young woman who had matured significantly over the past year.

Now how does this translate into the perspective shift that I refer to at the outset of this blog posting? We need to give our young adults a realistic picture of the challenges they’re facing while at the same time not come across as being overly pessimistic. We need to provide them excellent psycho-educational material in order that they know what will be helpful during the early course of their illness. We also need to remain realistic and empathically attuned to their struggles. Our role is not to admonish or to proselytize about healthy lifestyle choices, but more to be able to accurately assess what the young adult can take in and what they’re not ready for.

We’ve got to know that they’re not just climbing a hill. They’re at the basecamp of an intimidating mountain. And most important, our recently diagnosed college students need to know we’re alongside them and ready with our belaying lines if they stumble or even fall.

You might ask: "Shouldn't we professionals be endeavoring to convey a message of supportive encouragement?" After all, the 19 or 20-something who’s received a recent bipolar diagnosis has enough going on that can easily tip his or her emotional balance towards discouragement. My response: "Yes, but not at the expense of those who need to understand the reality of what they're facing over the next several years." Parents, educators and mental health clinicians need to take a look at their own denial and make sure they’re not unconsciously colluding with the defenses of the individuals they’re trying to help.

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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