- [Jeff] Welcome to "Healthy Minds."

I'm Dr.

Jeff Borenstein.

Everyone is touched by psychiatric conditions, either themselves or a loved one.

Do not suffer in silence.

With help, there is hope.

(gentle music) Today on "Healthy Minds."

- Some people with bipolar disorder do truly get back to their baseline in between episodes, but that's a minority.

I would say about 15 to 20% may experience, you know, true euthymia, and then have episodes, you know, occasionally.

The majority experience a lot of symptoms in between those episodes.

- [Jeff] That's today on "Healthy Minds."

This program is brought to you in part by the American Psychiatric Association Foundation.

the John & Polly Sparks Foundation, and the WoodNext Foundation.

(gentle music continues) Welcome to "Healthy Minds."

I'm Dr.

Jeff Borenstein.

Bipolar disorder.

Almost 3% of Americans are living with bipolar disorder.

Today, I speak with leading expert Dr.

Sarah Sperry about bipolar disorder.

(gentle music continues) Sarah, thank you for joining us today.

- Thank you for having me.

- I wanna jump right in and ask you to first start with an overview about bipolar.

Tell us exactly what that is.

- The first thing I'll say is that bipolar disorder is not just one thing.

Bipolar disorder really is a spectrum that encompasses several different versions of bipolar disorder.

So I'll talk a little bit about each of them, but altogether the main defining feature of bipolar disorder is that people experience mood episodes, and when I say mood episodes, I mean periods of time when they have a real change in their mood, behavior, thinking, either on the depressive side, so they are feeling depressed, you know, lack of appetite, lack of motivation, sleep changes, difficulty thinking, or the other side, which is mania, and mania is characterized by feeling really elevated, euphoric, sometimes irritable, increased energy, not needing to sleep.

So kind of the opposite of depression, really revved up, and people with bipolar disorder can experience both these types of episodes or just mania.

There are several different types of bipolar disorder.

So bipolar I disorder is characterized by people having mania, that experience I just described, and about 80% of people with bipolar I disorder also experience depression, but there is a subset that just experience mania, and then bipolar II disorder is characterized by hypomania, which are the same symptoms of mania, but it doesn't last as long and it might not be as severe.

So you might recognize a real change in your loved one or somebody you know, but it isn't causing them to have problems at work or with other people or in their home life, but they experience really debilitating depression.

So, a lot of times, people think bipolar II is the lesser of the two, but in fact, people with bipolar II disorder can have a lot of challenges.

It just tends to be on the depressive side.

So the defining feature, again, is having those mood changes.

These are not daily changes.

They last a week to two weeks to months, where it's a real change for a person.

- In addition to the mood changes, I know you've described the issue of the level of energy people have, and I'd like you to speak about that.

- This is an interesting piece because there's almost a change in the field where we think about bipolar disorder as a disorder of energy, not just mood.

In depression, people experience a real lack of energy, so people feel really fatigued.

It can be really hard to get out of bed.

It can be hard to move.

It can be hard to talk.

So we see this decrease in energy, and sometimes people will even describe that as feeling like they're drowning, like they're underwater and they can't get oxygen to their body or their brain, and on the opposite side, in mania, people feel an abundance of energy, and they describe this in two different ways.

One is that they feel like there's energy coursing through their body.

It might feel like electricity or there's a motor running, and, physically, they feel an immense amount of energy.

It can also look like the output of that energy.

So people can be very active, doing a lot more than is typical for them.

You know, constantly starting a new activity, moving around, pacing a lot, having a lot of physical restlessness, and so, in this day and age, in order to get diagnosed with mania, you can't just have that change in mood where you feel elevated.

You also have to experience that change in energy because it really is so such a core part of what we think about in terms of bipolar disorder.

- I want to speak with you a little bit about, you've been speaking about a depressive episode, a manic episode, or a hypomanic episode, the in-between, and a lot of your work has been looking at that in-between period, and I'd like you to speak about that.

- So, traditionally, when you read about bipolar disorder on the internet or in a textbook or you learn about it in a class, it's really taught that bipolar disorder is these episodes and then periods of remission that we refer to as euthymia, which means the absence of mood.

It's thought that, during these periods of euthymia, people are really returning to their normal selves or a state that is different from when they experience mood episodes, and so our entire field has been focused on preventing episodes, right?

Episodes are the things that cause problems.

In reality, this is not what life looks like for a lot of people with bipolar disorder.

Some people with bipolar disorder do truly get back to their baseline in between episodes, but that's a minority.

I would say about 15 to 20% may experience, you know, true euthymia, and then have episodes, you know, occasionally.

The majority experience a lot of symptoms in between those episodes.

This has largely been neglected, I would say, in our field, because, again, we think about it as this episodic disorder.

In reality, about 80% of people with bipolar disorder experience some level of mood instability in between their episodes, and when I say mood instability, I mean having more reactive emotions and moods.

So when something good happens, they feel those positive emotions much more intensely than somebody else.

Conversely, if something negative happens, they feel those negative emotions much more strongly.

So, on a day-to-day basis or a week-to-week basis, we see people experience a lot of strong changes in their mood over and above what we would anticipate or what somebody with bipolar disorder would typically experience, and from talking with patients and from my own research, I've heard time and time and again that this day-to-day and this week-to-week mood instability actually is really contributing to a lot of the functional impairment or the things that keep people from living the life that they wanna live.

It can cause problems with their relationships or at work or in their own sense of self because they just don't feel like they have control over their emotions and moods, and historically, we think about this as affective instability, and it was thought that that was not a part of bipolar disorder, but, again, the data and the lived experience anecdotes from people really suggest that this is a core feature of bipolar disorder that is keeping people from feeling well, and so it's something that we really need to pay attention to and understand better.

- I wanna ask you about the treatment both for the manic and depressive episodes, but also for these in-between aspects.

So tell us about the treatment of bipolar.

- The evidence suggests that the best treatment for bipolar disorder is a combination of medication and psychotherapy.

So, for many people, it is very important for them to be on medication consistently.

We have many medications that work for bipolar disorder.

Sometimes, it does take trying several different medications to find the one that works for you.

So it can be a process, but finding that ideal treatment, medication for you is really important, but it's augmented best by also being in therapy, and we have several evidence-based psychotherapies for bipolar disorder that we know help with both preventing episodes, so relapse prevention, but particularly, I think, for this inter-episodic mood instability.

I really do think that that's where therapy comes in a lot, and the different therapies that we typically use are things like cognitive behavioral therapy, interpersonal and social rhythms therapy, dialectical behavior therapy, and then also family-focused therapy for bipolar disorder.

So whenever I am talking about the treatment, I always emphasize, you know, the importance of both medication and therapy.

and I really think the therapy piece is key for this inter-episodic mood instability, because the goal of medications is really episode prevention and that's what all of our clinical trials were built on.

That's what the drugs are designed to do, but they might not be hitting that more day-to-day problems that people might be having.

- And how does the therapy help with those day-to-day problems in between episodes that may or may not be occurring?

- The way I think about it is that, two things.

One is that therapy can help make those shifts, those deviations either in the positive direction or the negative direction, a little bit smaller, and the way we can do that is through teaching people different skills to react differently to the things that they experience in their daily life.

So when I have patients that have a lot of this inter-episodic mood instability, I often bring in DBT skills, things like emotion regulation skills, mindfulness, distress tolerance skills that help essentially reduce the intensity with which their emotions might change, and the goal is not to keep them from experiencing a change at all, right?

As as human beings, we need to feel positive.

We need to feel negative.

That teaches us about life and our experiences, but again, to reduce that intensity.

So giving people skills to use when they experience triggers or things that we know can make them reactive.

And the second way that I think therapy really helps here is when I think about interpersonal and social rhythms therapy, one of the drivers, my research shows that one of the drivers of this inter-episodic mood instability is the sleep and circadian disturbances that we see in bipolar disorder.

So people with bipolar disorder, when they're in episodes, when they're not in episodes, and even maybe before they develop the disorder, show difficulty with sleep, and that can look like having a hard time going to bed, having really variable sleep where, one night, you sleep eight hours, one night you sleep four hours.

So you just don't have this strong circadian rhythm that's giving you the signals to sleep and wake at the same time, and in interpersonal and social rhythms therapy, we really work with people to try to get their schedules regularized.

So trying to go to bed around the same time every day, trying to wake at the same time every day, even trying to eat at the same day time of day because metabolism is linked to the circadian rhythm, exercising at the same time of day.

So giving some structure and really helping support people to have more regular schedules can also help reduce some of that day-to-day mood instability.

- So we're talking about medicine, therapy, and then lifestyle and how somebody manages their life, and I want you to speak a little bit about social support, especially supportive family and friends.

- We know that people do best when they have social support.

People who have loved ones that are educated about bipolar disorder, that are kind of brought in to understand what their loved one's treatment looks like have better outcomes, and so that's why we have family-focused therapy for bipolar disorder, where it's not just about educating the family, but also teaching the family about how to react to their loved one's reactions.

If you see your loved ones start to sleep less, how do you have an effective conversation with them that isn't just saying, "Oh my gosh, are you becoming manic?"

So how can you effectively have those types of conversations to have support, to recognize early warning signs so that intervention can happen sooner and keep the relationship between the person with bipolar disorder and their loved one.

Whenever I have somebody newly diagnosed with bipolar disorder, I emphasize and have conversations and collaborative conversations with that person about how can we identify people in your life that you would be comfortable sharing your diagnosis with, sharing what bipolar disorder means, and what to look out for to support you?

And that is a really important component of treatment, and it goes beyond just family, right?

Sometimes people don't have a direct family member that can be brought into those conversations.

It can be a friend.

It could be a coworker.

It could be somebody in your spiritual circle.

You know, somebody that you trust and feel like has eyes on you and you feel like you can go to as well.

If you are feeling like things are are not going well, that you have somebody to talk to and get support from that isn't a health professional.

- I wanna ask you about use of technology, whether it be cell phones, other digital technology, again to help the person monitor themselves and work with their treating professionals in terms of that monitoring.

- So I've spoken a lot about how bipolar disorder is a change in mood, activity, energy, sleep, and digital technologies give us a way to monitor those types of things in the real world.

So they have a lot of potential in bipolar disorder.

If you see your psychiatrist once per month, sometimes that's too late.

Sometimes you're already depressed or sometimes you're already manic by the time your provider gets eyes on you and recognizes that something has changed.

Particularly if you don't have those social supports who are educated and keeping an eye on you.

we can use smart phones and different apps to self-monitor mood and different symptoms, and the self-monitoring of mood has been around for a long time.

In therapy for bipolar disorder, this is one of the first things we do.

We set people up with, you know, it used to be pen and paper, rating people's moods day to day, but now we have easier and more sophisticated ways to do it on the smartphone.

In an ideal world, what if your provider or a family member or loved one who's involved in your care gets dinged, saying, "Hey, we've noticed a pattern over the last three days that sleep looks more erratic, activity looks more erratic, and they, you know, rated feeling out of control over their emotions," or something like that, and we weren't waiting until the appointment to understand those symptoms.

That would be really, I think, life-changing.

- I think you're absolutely right.

Tremendous potential to help a person monitor themselves and the team of people, family, friends, professionals, help them as well over time.

Another area of research that you've been involved in, you and your team, has been the use of stem cells and trying to better understand the mechanisms of bipolar disorder and potentially then develop more individualized treatment for people, and I'd like you to speak about that.

- Yeah, so essentially we're growing cells from skin biopsies of people with bipolar disorder so that we can understand how individual neurons fire and how they respond to different medications.

Using these types of methods, we can understand maybe who responds to what treatment, so it tells us something about the disorder and what is is different about the brain, but it also can help us understand who might respond to what treatment or develop new treatments, and there's really amazing work being done in this field as the technology is getting more and more sophisticated to be able to learn from these stem cells.

- We obviously can't take actual brain cells from a person.

It's too invasive and dangerous, but using the skin cells to develop stem cells and then turn them into brain cells really allows us, down the road, to individualize treatment for that particular person.

- Individualizing treatment is so important in bipolar disorder.

While we can define what bipolar disorder is, what the symptoms are, the combination of symptoms, when they're experienced, with what intensity they're experienced is so heterogeneous in bipolar disorder, and so I think when it comes to medication, when it comes to therapy, all of that needs to take a very individualized approach.

It needs to take into consideration the symptoms, what that person's goals are, that person's other lifestyle factors, other medical comorbidities, and treatment really needs to be a collaborative process.

- One of the challenges sometimes is that the person who is living with bipolar may minimize or not really see the need for treatment and the family clearly sees the need.

What do you say to both the family and to the person to help engage them and move them into treatment that would be beneficial?

- A lot of times, people living with bipolar disorder, particularly when it comes to medication, don't want to pursue that treatment because there's side effects or things like that, or they don't see the need.

They don't wanna be on medication, and the way I always have those conversations is to find common ground.

So what I like to do is have a conversation with that person to find out, what's going well in your life?

What's not going well in your life?

And whatever they say is not going well, I try to use that.

So let's say somebody says, "Oh, I don't have bipolar disorder," or, "Oh, my bipolar disorder is managed.

I don't need treatment."

But I ask them, if you could wake up tomorrow and your life looked better, what would change?

Let's say they say, "Oh, I would really like to be getting better sleep," Or, "Oh, I really wanna be in a romantic relationship and I'm having issues getting into that romantic relationship."

I use that.

I say, "Well, you know, actually, you know, what do you think is going wrong in that area?

What might be contributing to that?"

And, often, they can then get themselves to the point where they're saying how their symptoms influence those, and then I can use that to say, "Well, you know, we could work on your sleep or we could work on, you know, getting you into a romantic relationship or giving you those skills.

That's something we can work on."

And I don't even talk about bipolar disorder, right?

Even though I'm treating the bipolar disorder, I'm finding that common ground to try to help people live the life that they wanna live, and forgetting about, "Oh, you have a disease and we need to treat this disease."

- I wanna ask you about another challenge, which is the initial diagnosis, and often, it takes many years to get that diagnosis, and what do you say if somebody's watching and they are concerned about themselves or a loved one?

Maybe they have it.

What should they do?

- The first thing to do, because it's often the lowest barrier, is to talk to a primary care provider if you're concerned about these things.

Many primary care providers do have some training in behavioral health, but they also know when to refer you and can help refer you to a mental health provider.

I think, you know, if you're concerned about symptoms or you're hearing about bipolar disorder on this show and you think, "Hey, that sounds like me," or you've read about it and think that, talk to a healthcare provider.

Don't try to diagnose yourself.

Don't use ChatGPT, but get in front of a health provider who can direct you to the right professional.

Bipolar disorder is hard to diagnose.

On average, this statistic is very sad, but it takes, you know, eight years to get a proper diagnosis, and that's something that we're really trying to work on as a field, but getting a proper diagnosis often takes multiple appointments and it often takes that health professional talking to people in your life, getting what we call collateral information.

So talking to your family or loved ones that you're willing to bring into the process to hear, what have you seen?

Because it can be hard for people to talk about past experiences, right?

In a way that fits our diagnostic criteria, so it's helpful to get other people's perspectives on when your mood and behavior and thinking changes, and that takes time.

So it's not always as easy as going to one 60-minute appointment and getting a diagnosis.

- Very good guidance.

Sarah, I want to thank you for joining us today.

For the work that you do both clinically, helping people directly, and the research to help more people over time, thank you so much.

- Thank you for having me.

(gentle music) - If you're living with bipolar disorder, in addition to professional help, make use of the support of family and friends.

Remember.

With help, there is hope.

(gentle music continues) Do not suffer in silence.

With help, there is hope.

This program is brought to you in part by the American Psychiatric Association Foundation, the John & Polly Sparks Foundation, and the WoodNext Foundation.

(gentle music continues) (gentle music continues) (gentle music continues) (gentle music fades)