Emotional extremes

The ideas come in a swarm, and they can be good ones: Move to Prague and teach English. Study jazz piano in the early-morning hours. Start a dot-com; hike the Appalachian Trail; write an opera.

“I wanted to save people,” said Agnes Zsigovics, 28, a student in social work living near San Diego, who in her early 20s made plans to teach children living in the mountains of Venezuela -- only to ditch the idea at the last minute and fly to Montreal to teach Spanish. “I just had way, way too many projects in my head.... I can tell you this: People with bipolar disorder have the most interesting lives.”

They can also have dangerous lives. Bipolar disorder is another name for manic depression, an incurable, lifelong mental condition in which people zigzag from these effusive emotional highs to paralyzing periods of despair, often accompanied by thoughts of suicide. Recent studies suggest that as many as 10 million Americans are afflicted with the condition to some degree -- far more than previously thought. The illness goes unnoticed or undiagnosed in many people because their manic episodes are neither dramatic nor especially destructive, psychiatrists report. The findings have prompted a wave of research into new drug and talk therapies and an increased willingness among psychiatrists to seek guidance from patients and their families.

“What we’re learning is that patients do a lot better if they’re collaborating on their own treatment,” Dr. Gary Sachs, lead investigator of a large national study that is following about 2,500 patients with bipolar disorder and comparing treatment approaches.

Preliminary evidence from the trial, sponsored by the National Institute of Mental Health, suggests that patients are the best judge of what triggers their manias and that their family and friends are crucial allies in managing the disorder. “It’s as if you’re co-managing a baseball team, working together to decide which combination of drugs and therapy work best, and when,” says Sachs, director of the bipolar treatment program at Massachusetts General Hospital.

For half a century doctors have treated bipolar disorder with regular doses of lithium carbonate, a naturally occurring mineral that acts in many patients like a steady hand on the emotional tiller. Though neurologists don’t yet know how bipolar disorder develops, the mood swings have been linked to tidal shifts in the levels of chemical messengers in the brain, such as serotonin, glutamate and dopamine, which help people experience emotions. Lithium appears to calm these chemical waves, and in the process has spared uncounted millions from suicidal thoughts. Actress Patty Duke, in her autobiography “Call Me Anna,” which describes her battle with bipolar disorder, calls lithium her savior, a drug that rescued her from probable suicide.

People with untreated bipolar disorder are about 30 times more likely to commit suicide than the overall population, in which 12 of 100,000 take their own lives. Even patients who receive treatment experience frequent relapses, and many will plunge into drug and alcohol abuse, or contemplate suicide, psychiatrists say. Often, the relapse can be due to the treatment itself. Researchers at the New York State Psychiatric Institute reported in June that about one of every three bipolar patients who visited psychiatrists during the 1990s received no mood-stabilizing medication. Many got only antidepressants. The problem is, while antidepressants may lift the mood of someone with bipolar disorder, they also often propel them into a manic episode and depressive rebound, accelerating their cycles and making the problem worse, researchers and patients say.

For all its power to dampen mood swings, lithium also fails to prevent relapse in at least half of people with bipolar disorder, according to Dr. Mark Rapaport, a psychiatric researcher at UC San Diego.

But in the last several years doctors have begun to experiment with a variety of anticonvulsant drugs, which appear to be effective at stabilizing mood swings, decreasing the frequency of both depression and mania, he said.

In the federal study led by Sachs, researchers have found that the suicide rate over two years is about half of what doctors would expect to see in a group of bipolar patients receiving treatment. Researchers attribute some of this improvement to the careful attention patients are getting, which likely has a soothing effect. Another possible factor is that about one in four patients is taking lamotrigine, a drug used primarily to control seizures in people with epilepsy. “This drug appears to be especially useful in preventing people from relapsing into the depressive phase,” Rapaport said.

In other trials, drugs such as valproic acid (Depakote) and olanzapine have also proved useful in some patients as mood stabilizers.

Drug treatments almost always work best when combined with some form of psychotherapy, doctors said. For starters, a good therapist makes sure patients take their medication, without fail, no matter how much they may miss the power and energy of their manic episodes. “When you’re on, you can feel very good,” Zsigovics said. “It can be hard to give that up.”

Therapists also can teach patients some of the same self-control techniques that help longtime smokers and drinkers quit: Identify the situations or stresses that trigger episodes; diffuse or avoid them, if possible; and stick to stable daily work and sleep routines. Several recent studies have shown that disruptive events -- work pressure, arguments with a spouse -- are strongly linked to manic episodes in people with bipolar disorder. “I can tell you that for me being extremely rushed, or being challenged aggressively in an argument, can put me at risk” of a manic episode, said Stephen Propst, 38, of Atlanta, who operates a Web site at www.atlantamoodsupport.com for bipolar sufferers and their families. “And when you’re not up to par, there are things, like social occasions, which only aggravate the illness.”

That’s where close friends and family members come in. Over the last several years, David Miklowitz, a psychologist at the University of Colorado, has studied the effect of family counseling on the behavior of patients with bipolar disorder. In a 21-week course, Miklowitz teaches patients’ parents and siblings how to spot the warning signs of an imminent manic episode -- the increased irritability, the big plans, the fast talking -- and manage them by dialing down tension in the home. One of the techniques is called the “three-volley rule”: If a disagreement with the patient prompts an escalating series of three personal attacks, it’s time to back off.

“Change the subject if you can, or enlist the person in solving whatever the problem is,” Miklowitz said. “In some ways these techniques are similar to marital therapy for high-conflict couples.”

In one recent study involving 101 families, Miklowitz reported that bipolar patients who received mood-stabilizing drugs and family-focused treatment had a 29% risk of relapse over the course of a year, compared with a rate of 53% among patients who got medication and no family counseling. A similar study, due to be published next year, finds that a counseling program that involves the patient’s family is a more powerful check on mood swings than programs that focus solely on individual therapy. Relapse rates in those who got drugs and individual counseling were 60% during the year, five times higher than the rate among those whose families were involved in treatment.

Though many prominent artists and writers, including Leo Tolstoy and Vincent Van Gogh, are thought to have suffered from manic depression, there’s no good evidence that the disorder is any more common in creative people than in the general population, researchers say. With the variety of medications and talk therapies now available, psychiatrists say, creative people can find relief from their mood swings without fear of losing their inventive sharpness.

Most patients say the emotional seesaw never completely stops. But new combinations of treatment are making the ride a lot easier for many. “The difference is that without medication and social support, it’s like you’re standing up in the car, with nothing to hold onto,” said Propst. “Once you’re getting good treatment, it’s like you’re seated, with your seat belt on.”

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Bipolarity in degrees

About 5% of the population is believed to have some form of bipolar disorder.

Bipolar I: Severe manic episodes, characterized by grandiose thoughts, irritability, decreased need for sleep. Severe depression often precedes or follows the episode. Sometimes requires hospitalization.

Bipolar II: Distinct periods of depression and hypomania, a less severe manic episode. Heightened mood and irritability typically lasts no more than several days.

Cyclothymic disorder: Chronic, fluctuating mood disturbances with hypomanic and depressive symptoms that are not as severe or persistent as those associated with bipolar I or II, and may occur within a single day.

Bipolar spectrum disorders: Symptoms include one- or two-day emotional highs and often longer-term depression. Recent research suggests these milder problems are related to bipolar I and II.