Ohlone Center Therapeutics Program, June 2010
According to the journal, Hospital Pharmacist, one percent of the population will develop bipolarism in their lifetimes. The World Health Organization lists it as the sixth leading cause of disability in the world and it affects approximately 5.7 million adult Americans. This is not a modern affliction as the connection between states of depression and mania, which vastly defines bipolarism, has been noticed since the second century. It was first coined Manic Depressive Psychosis and defined as a psychiatric disorder in 1875 but it wasn’t until 1913 that it gained a clear distinction from schizophrenia (http://www.caregiver.com). However, bipolarism didn’t become a major mental disorder diagnosis until the era of mental health medicalization and drug therapies was ushered in during the early 1950’s with the development of the Schizophrenic drug, Chlorpromozine (Whitaker). From this point on bipolarism, or Manic Depressive Disorder as it was known, became a much more common diagnosis and psychopharmaceuticals were considered the first line of treatment for diagnosable mental disorders and continues to be the main protocol in modern psychiatry.
In the United States, approximately 38 percent of adults (about 4 in 10) and approximately 12 percent of children (about 1 in 9) are using some form of Complimentary and Alternative Medicine (CAM). With the rising cost of health insurance, the increasingly dissatisfying results from pharmaceutical or surgical therapies, more Americans are looking for better and cost effective ways to take care of themselves. In 2007, Americans spent nearly 15 billion dollars on natural non-vitamin or mineral products like herbs and fish oil (http://nccam.nih.gov). With this rise in the use of complimentary medicines to achieve and maintain health, and the potential increase in diagnoses of bipolarism there is a high likelihood that an herbal practice or clinic will include clients with a bipolar diagnosis. Though the advent of prescription psychopharmaceuticals has inarguably helped and even saved the lives of many people suffering from mental disorders, these “wonder drugs” do not come without cost. Many have exchanged mental stability or functionality for a slew of serious, potentially lethal negative drug affects. For most it is a barter that they will pay and see it as a necessary sacrifice. Yet, holistic herbal medicine has proved to be an excellent way for mental health clients to bring more balance to this pact. Most of these clients will seek out herbal medicine not necessarily to replace their pharmaceuticals but to address the side affects of these drugs and to “just feel better” all around. Under the holistic guidance of a trained herbalist, these clients will be seen as a whole person and not simply a diagnosis. They will examine the effects not only of the drugs they are taking but the food they eat, their emotional and spiritual lives, and the way they relate to their world. This can enable the bipolar sufferer to see their health in a more holistic way as well. In this paper, I will examine the current definitions and theories of causality of bipolar disorder, look at holistic therapies that herbalists can incorporate into their work that will address constitution and work with pharmaceutical therapies in order to reduce the side affects and enhance drug efficacy, and explore strategies to more sustainable community support for bipolar people, all in an effort to help clients achieve a broader sense of wellness.
According to the DSM, bipolar (BP) diagnosis is divided into BP I, BP II, and cyclothymic disorder (also known as “rapid cycling”) with the main differences being which altered mood, mania or depression, is more pronounced in the client and the length of each mood cycle. However, each diagnosis must contain a certain amount of both states and fulfill the criteria for Major Depressive Episode and/or Manic Episode. Bipolarism is diagnosed by a trained psychiatrist who examines the clinical symptoms and then determines if the client fulfills the necessary number of criteria for both manic and depressive states in order to distinguish it from ordinary mood swings or another psychiatric diagnosis. Startlingly, the DSM states that a person only needs one occurrence of these episodes to qualify for bipolarism. Seemingly, the little diagnostic criteria and the money to be made by the pharmaceutical companies off drugs prescriptions may be important reasons why there is such a rise in incidents of the disorder.
As described by Bipolar Magazine, bipolar I disorder is characterized by one or more manic episodes or mixed episodes-symptoms of both mania and depression occurring nearly everyday for at least one week-and one or more major depressive episodes. Bipolar I disorder is the most severe form of the illness, marked by extreme manic episodes (extreme highs) and is also referred to as the classic Manic Depressive Disorder. It usually has longer building cycles culminating in severe manic or depressive episodes. Bipolar II disorder is characterized by one or more depressive episodes (extreme lows) accompanied by at least one hypomanic episode. Hypomanic episodes have symptoms similar to mania but are less severe and must be clearly different from a person’s non-depressed average mood. This disorder is often characterized as more depressive and while the rates of BP I do not differ between men and women, the rates of BP II tend to be more prominent in women. Cyclothymic disorder is characterized by chronic fluctuating moods with periods of hypomania and depression. The periods of both depressive and hypomanic symptoms are shorter, less severe, and do not occur with regularity as experienced with bipolar I or II. However, these mood swings can impair social interactions and work. Many people with cyclothymia develop a more severe form of bipolar illness. Of course none of the cycles of bipolar disorder happen the same way for every person but it is important to understand the essential patterns of the different disorders.
Though this disorder has been studied by science for decades, much and little is known about the causes of bipolarism. After hundreds of these medical studies, the scientific community seems to find a new link in the chains of bipolarism every year yet nothing comprehensive to connect them all. The leading horse seems to be genetic theory. From epidemiological and twin studies, the generally accepted theory is that a specific number of genes in combination with environmental factors are responsible for the disorder (Hunter 2004). Even with this tentative agreement on the theory of inheritance, the landscape remains murky and the genetic information elusive. Many of these studies may contribute some new light, but most are quite speculative and end with “inconclusive results,” or requirements for “further study.” As many do, if one surveyed the internet for comprehensive alternative theories on the causes of bipolarism they would find just as many notions with just as many flaws and “inconclusive results.” These statements are not to diminish the efforts or work of those studying this disorder but to caution the practitioner against over simplification or grandiosity when thinking about bipolarism. The answers seem to lie where they usually do – somewhere in the middle and all over.
My mother, Joanne Susan Geldner, was diagnosed with the classic Manic Depressive Disorder in 1975 after a complete mental break and institutionalization at age 30. She had been in and out of institutions, received electric shock and had an over all unstable emotional life
since the age of 14. In most ways she displayed classic symptoms of the disorder: wild visions of religious grandeur, psychotic episodes where she would wail and sing at the top of her voice, and times when she couldn’t be restrained unless straightjacketed. When she started having difficulties at age 14 the field of psychiatry had yet to embrace bipolarism like it has today and it took more than 15 years for her to get a diagnosis and a stabilizing drug regime that she would be on for the rest of her life. In every sense of the word, my mother’s diagnosis and subsequent drug therapy literally saved her life and saved her from permanent institutionalization. Unfortunately, this is often a typical scenario for many folks diagnosed with bipolar disorder. Many may suffer years of mental distress or fluctuating mood cycles before some major episode catapults them into the world of psychiatry, a diagnosis and drug therapy. What I have experienced with those in my community who fall into this path is that their recovery tends to mimic the cyclical nature of their emotional states. After a major episode, the drugs tend to stabilize and bring short-term relief for the bipolar person. Then, since bipolar people are usually under the sole care of a psychiatrist and for many reasons often do not or can not seek out additional therapies to provide a holistic sense of health, the drug therapy tends to negatively affect their lives. This picture can play out in many ways, but a frequent result is that the negative affects of the drugs will lead to such a serious decrease in quality of life that they can see the only way out as quitting the meds “cold turkey.” Unfortunately, they are usually doing this without the guidance of a holistic practitioner or therapeutic counselor to help mitigate the problems that can arise, and after while can end up having another serious episode that lands them back where they started.
This cycling of relapses can be largely helped or altogether eliminated through the adjunct use of the holistic therapies of herbal practitioners. Holistic practitioners take into account the whole person and their entire life when working with bipolar clients. Since herbal clinicians do not diagnosis bipolarism, as it is both illegal and unethical to do so, they are freed to look at the larger picture of health for their clients and help to mitigate the negative affects of any drugs they may be taking. Many areas that a practitioner will address for any of their clients, such as chronic stress, diet and lifestyle will also be important to their bipolar clients.
Examining and understanding the impact of stress on hormone balance is extremely important in helping the bipolar client. Strong evidence links episodes of extreme stress to bipolar depressive onset and relapse, and to a lesser extent manic onset and relapse (Hunter 2004). The Sympathetic Nervous System (flight or fight response) is our involuntary nervous system. We are not consciously in control of our heartbeat or our hormonal cascades; they operate involuntarily in response to our stress lives. The Parasympathetic Nervous System (PNS) is like its subtle sibling, controlling our rest and relaxation/digest responses. The SNS releases adrenaline and cortisol into the bloodstream and the role of the PNS is to counterbalance these effects by calming the systems – slowing heart rate and breathing, calming the emotions and restoring spent energy. Ideally, most of our time would be spent under the calming influence of the PNS with only occasional but essential stimulation of the SNS. However, due to the chronic stress levels of the modern world, many people have over active SNS response and underactive PNS response. Since the parasympathetic nervous system is responsible for alertness, cognitive processes, attention, emotional regulation and stress response it is no wonder that many mood disorders and cognition disorders are associated with a depressed PNS. In fact, psychotropic medications used to treat mood disorders may lessen the sympathetic nervous system response but they have not been shown to strengthen the activity of the PNS and may dull cognition, blunt emotions, and interfere with mental functioning (Brown et al 2009).
Stress is managed by two different systems in the body: the hypothalamic-pituitary-adrenal axis (HPA) and the sympathoadrenal system (SAS). These two systems involve communication between the Sympathetic Nervous System and the endocrine system. After a stressful event, the nervous system reacts and neurons will activate the HPA axis and the SAS. If a stressor stimulates the hypothalamus it activates a cascade of stress-response hormones. Under the influence of these hormones, the SAS interfaces with the sympathetic nervous system to create the flight-or-fight stress response in the body. These reactions enact various changes, which cause the body to adapt and try to reestablish homeostasis. This response usually elevates the heartrate while narrowing certain blood vessels so that more blood is sent to the brain, the lungs, and the muscoskeletal system while restricting blood and therefore functioning to the appendages, reproductive system, and digestive system. (Winston 2007).
There are many hormones involved in the stress response: cortisol, adrenaline, noradrenaline, DHEA, adrenocorticotropic hormone (ACTH) and aldosterone to name a few. Three that have a large long-term impact on adaptive response are cortisol, adrenaline and nor adrenaline. Cortisol, which is essential to metabolism, is released from the adrenal cortex (“outside”) in times of stress and is the most potent of the glucocorticoids. When cortisol is released it causes a breakdown of muscle protein to be synthesized by the liver into glucose for brain function. Under stress, this system increases glucose availability for the brain in the bloodstream by flooding it with this synthesized glucose and by reducing the uptake of glucose in other tissues for energy. Cortisol also leads to an increase in blood triglycerides for muscle use. It also regulates blood pressure and cardiovascular activity and as a steroid it aids in the inflammatory response. However, too much chronic cortisol can adversely affect the immune system by suppressing its response. Symptoms of elevated cortisol include anxiety, hypertension, sex hormone imbalance, insulin resistance (Type II diabetes), obesity, osteoporosis, insomnia, and polycystic ovarian syndrome. Too little cortisol can cause symptoms of depression, chronic fatigue, hypotension, insomnia, PMS, infertility, impotence, and fibromyalgia (Winston 2007).
Adrenaline and noradrenaline are produced by the adrenal medulla (“middle”) and affect the sympathoadrenal system. These are the “fight or flight” hormones and though normally present in the bloodstream in small amounts are secreted in larger amounts during stress response. They stimulate the heart, blood flow to muscles and the brain, constrict blood flow to small blood vessels (i.e. in the appendages), raise blood pressure, increase blood glucose and impact nerve responses in the autonomic nervous system. This impact on the nervous system can lead to a low functioning or damaged nervous system and symptoms of mood disorder.
According to Mark Hyman author of, the UltraMind Solution the following is a researched list of the effects of chronic stress (heightened SNS response/dampened PNS response/increased cortisol and adrenaline):
One of the most important things to address with a bipolar client is their own stress response and how it affects their hormone balance. Fortunately, herbal medicine is quite adept at helping the body balance these systems. Adaptogens and tonics will be of utmost importance in any bipolar formula. Adaptagens work by stimulating the body’s non-specific stress response through the HPA axis and SAS. They help regulate the function of the central nervous system, endocrine secretions, and cardiovascular system, promote immune function and have an affect on stress response. Since adaptogens tend to regulate the use of cortisol in the body they are great at reducing the negative affects of excess cortisol in bipolar people and helping to return the hormone levels to a more balanced place (Winston 2007). Eleuthero Siberian Ginseng is an excellent choice for the bipolar client. It is an adaptogen and a tonic that directly affects the hypothalamus and adrenals, addressing the hormonal imbalances at the very top of the cascade. This works to help the body put itself back in line. It can help on a cardiovascular level by lowering LDL cholesterol and blood triglycerides while relaxing the arteries. As spirit medicine, Eleuthero can melt one out of one’s mind or psyche and back into their body. For a bipolar person who may feel trapped by their thoughts this can be especially helpful. Holy Basil is another great adaptogen for this formula. It reduces the stress hormone levels in the body, reduces blood sugar levels and helps to regulate blood pressure which all can be problems for chronically stressed bipolar people. In Ayurvedic medicine it is used to help clear mental fog (often a negative affect of bipolar drugs). It is generally an uplifting herb, sweetly lifting the spirits without stimulating. There are many useful adaptogens to help regulate the stress response but one that has been used for thousands of years is licorice. This is an important herb in Traditional Chinese Medicine and is considered a balancer of the Five Organ Systems and has a synergistic affect on the other herbs in formula. Licorice has a regulating affect on the HPA axis and specifically on cortisol levels. It helps support and rebuild deficient adrenals and has hepatoprotective properties. In large doses for long periods of time it can raise blood pressure and leach potassium so it is important to use in small amounts in formula and with caution for anyone who has hypertension. Make sure that their diet is also including adequate amounts of potassium. As a pre-cursor to steroids, it is also contraindicated with steroid use, like, Prednisone. Other adaptogens may be appropriate in treatment, but with bipolar clients always be cautious about any herb that may have stimulating or antidepressant affects. Rhodiola and St. John’s Wort, while excellent herbs for other forms of anxiety and depression, are both generally contraindicated for bipolarism because they run the risk of stimulation that can trigger a manic episode. Bipolar people are often very sensitive in general and do not need high doses of herbs as it can be harmful. With any herbal formula for bipolar clients you want to use low doses, tonifying or nourishing herbs, and go slowly and monitoring well. This way you can formulate with confidence and clarity for the best results for your client.
Another arm of treatment is including nervines to strengthen the parasympathetic response, promoting relaxation and reducing sympathetic system dominance. Nervines, especially nourishing ones will help the CNS return to balance. Skullcap is an excellent nervine for calming the SNS and for people who are very sensitive to stress. It brings about a sense of calm and clarity without sedating. For those who have a difficult time shutting off their brains this can be extremely helpful. The myelin sheath is extremely important in the regulation of neural firings in the nervous system. It has been hypothesized that irregular firings may be linked to states of mania and too rapid of firings linked to depressive states. Wild Oats works directly on nourishing and building the myelin sheath and may have a direct affect on regulating these firings. It is a sweet and gentle nervine that is helpful in a constitutional formula or in an acute attack formula or as a simple. Central nervous system stimulation can also affect the circulatory system with stimulation or agitation and the nervine Passion Flower can have a dual affect. It relieves anxiety and restlessness and has a slight sedative property while also calming to circulatory excitation that is CNS influenced. For cardiovascular toning, soothing and to lift heart energy, it is best combined with Hawthorne Berry.
While herbs will be invaluable in supporting a bipolar person, a more comprehensive evaluation of their diet will be essential. Evidence links many brain disorders, like bipolarism, to mitochondrial injury from oxidative stress, which can be triggered by poor diet and nutrient deficiencies, toxins, infections, allergens, hormonal imbalances, altered gut function and stress (Hyman 2009). Often allopathic therapies like mood stabilizers Depakote and lithium increase oxidative potential in bipolar people (Brown et al 2009). In evaluating this picture, blood work results can be an indispensable tool for the clinician. It may be helpful for the client to keep a food diary, and a food and mood chart, writing down everything they eat and drink for at least a week to get a more complete picture of what their diet is really like and how it may trigger certain moods. Taking these results and a thorough health history, we can look at bipolarism and other brain/brain chemical imbalances from the vision of the whole person. Here we can see how important diet changes may be to creating holistic wellness for that person.
Some of the most important vitamins and nutrients for mental health are those involved in the healthy functioning of nerve cells. Depletions of these are most likely due to poor nutrition, or malabsorption from a poorly functioning digestive system (genetic deficiencies like missing enzymes, functional or structural dysfunction, “leaky gut”, Chrones Disease, etc.). The B vitamins, especially folate, are crucially important for nerve health and mood stabilization. Dietary and supplemental folate/folic acid has to be converted into the useful form of L-methyltetrahydrofolate. Either the reduced conversion or lack of folate in the diet can cause an increased level of homocysteine. Increased levels homocysteine have been linked to increased cardiovascular risks that may develop as inflammation and elevated blood pressure. Higher levels of inflammation can be a product of stress response or can trigger low-level chronic stress, which has been associated with chronic disease, circulatory issues, chronic pain and other disease symptoms. Ultimately, the reduction of folate along with increase of homocysteine may contribute to depression and poor response to antidepressant medication. Common causes of reduced folate levels include chronic disorder, diabetes, cancer, smoking, alcohol use, poor diet, and medications such as mood stabilizers, L-dopa, statin drugs, oral antibiotic drugs, and chemo drugs. (Brown et al 2009). Since most bipolar clients are on at least one mood stabilizing drug, which alone is folate depleting, it may be necessary to supplement with a folate. In addition, improving nutritional folate is essential. Vegetables, especially asparagus and dark leafy greens, and fruits like oranges, strawberries, and melons are excellent sources of folate. Meat, beans, liver, eggs, and sunflower seeds are also good sources. Since all B vitamins are very instable and susceptible to heat it may be better to eat raw fruits and lightly cooked or steamed vegetables as often as possible to preserve as many of the vitamins as possible (Pennington 2005).
Fat is a vital nutrient for bipolar health and specifically Omega-3 fatty acids. Omega-3 fatty acids are essential to cell membrane construction and function. They help provide the fluidity and flexibility of our membranes. This impacts membrane proteins (enzymes, receptors, ion channels) that are intrinsically important in healthy neural transmission functioning. We need quality membranes for a healthy brain and a healthy nervous system. Most cellular reactions require a flexible membrane to affect cellular metabolism, function and transmission. If our membranes are not flexible or are damaged, there may be problems with functioning at all system levels but especially on a neural, brain chemistry level. In a number of studies, bipolar participants who were supplemented with Omega-3 have shown significant improvement of membrane flexibility. It has also been linked to lower lifetime prevalence of bipolar disorder, especially bipolar II and relapse rates (most participants are also on mood stabilizers). For bipolar I clients, it has been shown to decrease depression. For treating depression in bipolar clients doses of 1-2 grams/day of mixed Omega-3 fatty acids (EPA and DHA) have reduced symptoms but for clients with mixed symptoms of mania and depression or rapid cycling a higher dose is needed. In Herbs, Nutrients and Yoga in Mental Health Care, Drs Brown recommend 8-20 grams/day of Omega-3 for these clients while acknowledging that most clients can only tolerate limits of 6g/day because of the digestive discomfort. Omega 3 treatment is considered low-risk and can be appropriate for children, pregnant women and during breast feeding.
When choosing Omega-3 oil, is it important to select bioavailable oil from quality sources. Traditionally, EPA and DHA were nutritionally obtained through sources of fatty fish (salmon, trout, mackerel, herring, sardines, tuna, anchovies, etc.). However, due to poor fish farming practices, environmental poisoning of the ocean, and mercury or PCB contamination, we are left with very few viable, safe, and ecological fish options. There are vegetable sources of Omega-3 oil like flax, walnut, primrose, and borage oil, which contain alphalinoleic acid (ALA). Your body has to convert the ALA to Omega-3’s and this conversion is usually quite inefficient and varies greatly among individuals. There are many high quality, tested Artic Sea fish and cod liver oil supplements that have little to no mercury and PCB contamination, and this may be the most viable option.
Since there is an increase in oxidation in bipolar people, vitamin C is important to include in the diet or supplementation. It is a strong antioxidant, protecting cell membrane function, increasing immune function, detoxing heavy metals, and improving stress response. Vitamin C levels are highest in the brain and adrenals, and psychiatric patients are often so low in vitamin C to approach scurvy levels. There is continued research illustrating that adequate or higher levels of vitamin C has a supportive effect on bipolar healing. Because it is believed to occupy the same dopamine receptor sites as the pharmaceutical antipsychotics, it may be useful as an anti-psychotic/anti-mania agent. There is some evidence that it may be useful as a main or sole treatment for bipolar mania but the doses have to be so high (at least 10grams/day) to be digestively cumbersome and incur absorption issues. But it may be helpful at slightly higher than normal supplement levels in conjunction with traditional treatments (Edelman 2001). Dietary sources of antioxidants include bioflavonoid like the dark berries and also beans and artichokes.
Of course, building mitochondria through supplementation can only take a client so far. If the causes of oxidative stress are not removed, these neuroprotective agents will not be useful as protectors but simply as minimizers. Since clients will have personal stress triggers that bring on bipolar episodes and they must be able to recognize these triggers and begin to minimize their impact. One way is to map out their moods and keep a record of the changes. This provides a routine for the bipolar person and is extremely important to grounding them on a daily basis. Often their shifting mood cycles will follow certain patterns and using tools like a Mood Chart will help them to recognize this pattern, predict stressors and strategize to minimize or diffuse them. For example, they may drink a cup of coffee everyday and notice that around that same time their mood is extremely elevated, agitated and “high”. Many bipolar people feel that they are at the mercy of their emotions and can feel quite powerless in the face of extreme mood swings. Having them keep track of their own moods, the stresses, foods, menstrual cycles and drugs that affect those moods, will help them have a more appropriate relationship to their emotions and give them more awareness and a tool to have more power over for moods.
Finding ways to regulate the parasympathetic nervous system is another important strategy. The PNS main pathways are through the right and left vagus nerves. The vagus nerves innervate the throat, heart, lungs, GI tract, liver, pancreas, genitals and blood vessels. They carry messages from the body up to the brainstem and vice versa. From the brainstem, the pathways ascend to the limbic system, thalamus, and cerebral cortex, impacting how we experience ourselves, our emotions and our state of consciousness (Brown 2009). Increased vagus nerve stimulation leads to increases in PNS response. One could have a pace maker implanted that stimulates the vagus nerve every few seconds but it would be much safer, cheaper, more realistic to be able to learn to do that ourselves. Since the PNS is mostly involuntary we have a limited amount of control over the reflexes under its domain. While breathing is fairly involuntary – we all breathe in our unconscious sleep – you can have some control over your breathing: the depth, the quality, the timing. By doing some simple exercises one could begin to control the vagus nerve and therefore stimulate the PNS and reduce stress response. Deep breathing practices expand the diaphragm, which stimulates the vagus nerve and is part of the relaxation response, which is necessary for the body and brain to heal, repair and renew (Brown 2009). Deep breathing alone may not be able to bring a bipolar person down from a severe manic episode; it is one more strategy in combating the heightened stress response and helping a bipolar person strengthen their overall health.
It is important to have things that a bipolar client can do for themselves to take control of their health like diet, relaxation practices and lifestyle choices but having further support for this journey of emotional wholeness and balance is essential for the bipolar client. A psychiatrist who only prescribes pharmaceuticals once every few months does not a support system make. Recommending that they find a number of qualified professionals to support them like herbalists, nutritionists, a therapist or spiritual guide and any other practitioners they will need is invaluable to help them get a structured support network together outside of family and friends. Having a round table of the practitioners working in communication and each other an efficient and effective form of support. This roundtable will be better equipped to track the client’s progress and hold them accountable to their healing plans. If the bipolar person cannot afford or doesn’t want to see that many different practitioners, a licensed therapist may be the most invaluable help they can get. These professionals can work with them to unravel the core issues and are trained on dealing with and recognizing the mood cycles of bipolar people. Since much of what disrupts a bipolar persons life is about the mind and emotions, they are often not aware of their bodies though their bodies are very impacted by their emotional cycles. It may be helpful to them to seek out a somatic therapist, one who uses body-oriented approaches to counseling and psychotherapy. This therapeutic method uses developmental and psychodynamic approaches and addresses the crucial role of the body in the structure and process of the psyche (http://www.somaticpsychotherapycenter.org/). This form of therapy along with other body oriented modalities, like yoga, Feldenkries, or the Rosen Method may be very helpful to your bipolar client.
Even with these herbal, nutrition and therapeutic supports in place the bipolar client may find pharmaceuticals helpful or essential. Usually after a psychiatric diagnosis, the client will be prescribed psychopharmaceuticals depending on the emotional state or needs of the client. Whatever the presenting issue is, it will be addressed first with either antidepressants or antipsychotics. Most commonly prescribed anti-depressants are SSRI’S (Selective Serotonin Reuptake Inhibitors) which block serotonin from being reabsorbed into the cells and allow for a higher amount of available serotonin in the blood that can alter mood. If depression is the dominant issue and a maintenance antidepressant is needed, it’s usually given in low doses to ensure that it is tolerated. Antidepressants may cause some people with bipolar disorder to shift into a manic episode and because of this risk anti-depressant use, both pharmaceutical and herbal, should be monitored closely. Antipsychotics work on changing the levels of neurotransmitters in the brain. Typical antipsychotics affect dopamine transmission while atypical antipsychotics can affect dopamine and other neurotransmitters. Changes in neurotransmitter levels directly affect the transmission of nerve impulses from the brain. This dopamine blockage alters the pleasure signals and in essence curbs the euphoria and mania that is often present for bipolar people. These types of medications are usually first line defense during serious bipolar episodes and may be used alone or in combination with other mood stabilizers in bipolar mania (http://www.webmd.com).
Mood stabilizers generally enter the picture after a more serious episode has been addressed and are used for mood maintenance and to prevent relapse. Though lithium salts are most often prescribed for mood stabilization, many of the mood stabilizing drugs are also anticonvulsants. These work by calming hyperactivity in the brain in various ways. These are most commonly used in seizure related disorders like epilepsy. Anticonvulsants were first used to treat bipolar disorder when it was noticed that epilepsy patients taking them had improved mood. They are often prescribed for people who have rapid cycling (http://www.webmd.com).
Lithium is one of the most common drugs for bipolar disorder. It is a naturally occurring metallic salt and has been used in medical practice for about 150 years. Lithium salts were first used to treat gout and its mood stabilizing affects were first utilized in the late 1800’s. The way lithium works is not entirely clear, but it is probably due to its effects on other electrolytes such as sodium, potassium, magnesium, and calcium. Because it is a salt, it is important that patients have normal kidneys and thyroid if they are to take Lithium and have regular blood lithium monitoring to avoid toxicity (Raber 2010). One of the most common and serious negative affects of taking lithium long term is kidney issue. Due to the large amounts of lithium salts that clients generally take (600-2,400mg/day) the kidneys can easily become over loaded and have difficulty retaining water and sodium thus altering the sodium potassium balance. Often clients can combine lithium with another mood stabilizer to reduce the amount of lithium needed and reduce the affect to the kidneys. It is extremely important for those on lithium to drink adequate amounts of water - more than eight glasses a day- and have their blood lithium levels monitored. At least 30% of those taking lithium experience excessive thirst and urination. Considering a lower salt (but not no salt) diet may lessen the kidney load as well. This is an area where dandelion leaf is recommended. It is a diuretic, which is a contraindication for lithium use, and one study says that it may enhance other negative affects of lithium (http://www.umm.edu). However, an herbal dosage in formula would be vastly lower than those used in experimental or clinical studies and should be considered generally safe in lower doses. It does not leach potassium further harming the kidneys like most diuretics and when used under the care of an herbal clinician who will monitor for any negative affects, it supports kidney function safely and effectively. While the Nettle leaf, a vitamin and mineral rich green leafy plant, is a stronger diuretic the medicine of Nettle Seeds is a much safer and minimally diuretic specific for kidney healing. It would be a great choice for building kidney strength and preventing nephron damage. Pam Fischer, director of the Ohlone Herbal Center and Clinic in Berkeley, California suggests the use of adaptogenic kidney tonic Guduchi. She says that though it is very mildly diuretic as most kidney tonics are, it actually moistens the kidneys, drawing water to them instead of flushing them. Caffeine, as another mild diuretic, in long-term chronic use is known to exacerbate kidney problems. Avoiding or eliminating caffeine in coffee or soda, would not only help minimize simulating a manic episode but also help to reduce its impact on the kidneys.
A bipolar person should also be aware of their thyroid health. Studies have shown that there is a clear connection between hypothyroidism, especially autoimmune hypothyroidism and incidence of bipolarism, especially cyclothymic bipolarism. There is also evidence that those bipolar people with a lower functioning thyroid even if their levels appear in the “normal range” are less likely to improve than those with higher levels of thyroid (Phelps 2009). Whether due to stress related disruption of the endocrine system taking its toll on the thyroid or the affects of lithium, this tiny organ will need special attention for the bipolar client. Again, working with the endocrine system as a whole (the hypothalamus, pituitary and adrenals) with adaptogens will be the most important strategy. Supporting the thyroid directly will also be necessary. Fucus is a specific for low functioning thyroid and if there is a problem with low iodine, any seaweeds like, kombu or kelp will help increase iodine. Coleus forsckoholii, an Ayurvedic herb, has traditionally been used for cardiovascular health and blood pressure regulation and recently has been shown to stimulate thyroid function. A common dosage is 50-100mg TID of a 10-20% standardized extract. It may have some antidepressant affects and so should be monitored with bipolar clients. Certain other herbs known to help build the thyroid like Red Ginseng, Maca, or Gotu Kola may be too stimulating for bipolar clients and if added to a formula should be used with extreme caution.
Though lithium’s primary negative affects are on the kidneys and thyroid it also affects the liver, especially when used with other drugs. The liver is our main metabolizing and detoxification organ and pharmaceuticals, especially at the bipolar dosages, will tax or damage the liver. They can also cause symptoms of liver deficiency like dry skin, eczema and allergies. Hepatoprotectives like Oregon Grape Root, Yellow Dock and Milk Thistle are important additions for supporting the liver to take on the extra load and prevent liver damage. In fact, Herbalist Matthew Wood testifies to using low dose Dandelion root, another liver herb, to help relieve the symptoms of bipolarism (Wood 2008). Reducing or eliminating other dietary liver toxins like alcohol is another way to reduce liver impact. Many of the liver supportive herbs are also alterative and can help stimulate the body’s natural metabolism to remove toxins in the system. Most alteratives like burdock, nettles, alfalfa, red clover and red raspberry leaf are gentle and safe tonics that are often best combined in a therapeutic tea that is drunk daily. With the highly green nutritive herbs like nettles and alfalfa one should make sure to monitor for any diuretic affects while taking lithium. If a client’s urination amount is regularly excessive for their liquid intake readjust the dosage or frequency or consider using other herbs.
In addition to a circle of professional support and assistance, the bipolar client will need other support in place for whatever therapies they are seeking out. It is important for them to involve family and friends in an organized support network. Often the bipolar person suffers alone or is reliant on one person like a partner for all their support. This is often not sustainable for anyone in this scenario and can lead not only to further difficulties for the bipolar person but to alienating any existing support. Just like any health related matter, the bipolar client is in charge of their healing process. There should be a clearly articulated directive from the bipolar person for their healing plan: strategies for daily mental health balance and support, what the bipolar person is doing on their own, and what they will need from their support system to help achieve this. Developing a written plan for crisis (manic or depressive) is essential and making sure that the group has discussed and is clear about what the bipolar loved one does and does not want done in these situations (i.e. hospitalization is never ok or call my mother if I’m having a manic episode, etc) is crucial. In many friend and family circles of bipolar clients, there is a tendency for the support systems to be disorganized, take on too much, and to place the bipolar persons emotional needs above their own. The support system should seek out education on bipolarism from qualified sources so they can begin to understand what is happening to their loved one. Often for bipolar people, it is a daily struggle to simply remain functional in their emotional lives and many may need a lot of support to achieve this goal. However, adult bipolar clients are the subjects of this paper and they are capable of making their own choices and taking responsibility for their lives. It is not helpful to a bipolar person to not be held accountable for their actions or decisions. When the support system focuses entirely on the supported person and has no plan for making sure that they are also getting their needs met it can lead to stress, anxiety or depression and also burn out, anger, blame and abandonment. They might think their problems are minor in comparison to what the bipolar loved one is coping with, but that doesn’t mean they are any less deserving of help and comfort. It’s important for loved ones to build their own support system of people who will listen and be concerned about their well-being, including friends, relatives, and other professional healers.
Children are affected by a family member’s bipolar disorder or depression, even if they don’t understand exactly what is happening. They learn from observation very quickly when they are young and if they are not included in the discussion and support network for a bipolar family member they will devise their own coping skills that may have negative impacts on their development. It’s important to spend time with children, explain the situation and encourage them to share their feelings and questions. Talk to children at a level they can understand. Younger children might be satisfied with “Mommy (or other relative) doesn’t feel good right now but is getting help to feel better.” Older children may be given educational materials and encouraged to learn about bipolar disorder or depression and how they can help their family member. Reassure children that there will be someone to take care of them and that they are loved and prioritized by their family. Parents should always apologize to children for any hurtful things they may have said or done during an episode of mania or depression and allow their children any reactions. Let children know their parent is working to keep these things from happening again. Appropriate child therapy models like, writing therapy, art therapy, play therapy and movement-based therapies may be helpful but it is important to emphasize that there is nothing wrong with them and that their family members disorder is not their fault.
A well-supported and organized circle of friends and family will enable the bipolar person to feel clearly supported and reduce the amount of stress and confusion for the whole group. To help this process, it may be necessary for clinicians to see bipolar clients together with members of their support system or to see the support people separately. It is also appropriate to refer the loved ones to existing therapeutic support groups for friends and relatives of bipolar people. In helping the loved ones, adaptogens, nervines and adrenal tonics are useful because they will undoubtedly be undergoing heightened stress. Having loved ones keep a Mood Chart too may be helpful for their own tracking of emotional highs and lows and the situations that trigger them. Flower essence therapy may be one of the most important supportive measures that clinicians can utilize. They are safe and have no interactions with any drugs or herbs and can be added to a family’s water, meals or spritzed into the air. Many of the same flower essences that will be helpful for the bipolar client with also be helpful for their loved ones. Using Self-Heal and Lotus Flower can start anyone off on the right foot with removing blocks that we put in the way of our own healing and instilling confidence in our own ability to heal. Lotus also has a special affinity for bipolar people who can tend towards visionary or spiritual excess in that it can assist in learning the spiritual lessons of everyday life. To ground in the path of healing Black Eyed Susan can help to accept that we need help and we need to heal. Rock Rose can help both the supported and the supporters deal with the terror and panic of mental crises while Cherry Plum can be useful for the person who is displaying out of control or destructive behavior. To further protect against negativity on a psychic and psychological level and clear these poisoning affects from the body we look to Pennyroyal. There are many essences for support in building and maintaining healthy boundaries, which can be extremely important for those supporting people with mental health issues. Pink Yarrow enables us to maintain our self in all situations, helping those with a tendency to merge with other people or take on their issues to remember what is ours and what is theirs. Essences of Rue or Ocotillo are the heavier hitters for psychic protection. They are called on when we need to have major protection and act as psychic barbwire for our spirits. The bipolar person may have difficulty trusting other people especially if they have been abused by the psychiatric industrial complex or been forced against their will into hospitalization. Oregon Grape helps them to accept the love and good will of their support network and trust their intentions. Stress and exhaustion will play a huge part in all those involved in this work and many flower essences supply support and relief. For the supportive person who doesn’t know when to stop and pushes herself even when exhausted, Oak and Elm can be helpful. Supportive people can often have an unbalanced need to care-take or serve others in need and Centaury can help bring balance. Often since bipolar people are made reliant on psychiatrists and family members they can develop an over reliance on others advice. Cerato aids them to make their own clear and confident decisions. Simple lavender essence can be calming and rejuvenating when nervous tension leads to depletions and dandelion can help clear stress and anxiety that is held in the body and manifests as physical issues. Of course, happiness, joy and fullness of life are important to any healing process. Borage has been used to supply heart lightness and courage and optimism when facing difficulties. Violet or Johnny Jump Ups provide springy, buyout joy and happiness while Mustard Flower can transform the gloom of depression into a balanced and contented happiness. Lastly, for children helping them cope with a potentially dysfunctional family and the hurt is causes is a key affect of Nettles flower essence. These are but a few of the possibilities that you can call on from the flower essence repertoire and deep consultation with the individuals will reveal what specific needs they will have.
Whether due to over diagnosis or better diagnosis, an extreme rise in modern stress levels, environmental factors, dietary factors, genetic factors or any other reason, there is a consistent rise in the occurrence of bipolarism. As an herbal clinician you will most likely see clients with this diagnosis and many of them will be seeking holistic help adjunct to their pharmaceutical therapies. With the tools of the holistic Western herbalist – in depth health and medical consultations, comprehensive constitutional and acute herbal formulas, diet, lifestyle, and supplementation evaluation and consultation, stress, mood and emotional evaluation, flower essences– combined with therapy and spiritual work, and a healthy and functioning support system, there is much to be offered the bipolar client. These strategies combined can help to bring about a more full and secure sense of wellness for the bipolar person and hopefully lead to long lasting aid and support.
Footnotes:  Criteria for Major Depressive Episode (DSM-IV, p. 327) A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. 1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood. 2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). 3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. 4. Insomnia or hypersomnia nearly every day 5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). 6. Fatigue or loss of energy nearly every day. 7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). 8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) 9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Criteria for Manic Episode (DSM-IV, p. 332) A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1.inflated self-esteem or grandiosity 2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. more talkative than usual or pressure to keep talking 4. flight of ideas or subjective experience that thoughts are racing 5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli) 6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.