Bipolar Wellness Plan - A Roadmap to Emotional Stability

Well, I planned on getting this post out earlier but ran into production problems. Specifically, I picked a topic that was over my head. I was writing about developing a wellness strategy for long-term, successful management of bipolar disorder.

My plan was to write a three part series of posts around (1) creating a well thought out bipolar strategy, (2) writing a plan that addresses elements of the strategy, and (3) implementation assistance. It makes sense to me. In my prior life as an engineer this is how we tackled all sorts of large projects and programs. The steps I would take to execute a large project/program were like this:

Step One - Strategy. A strategy is a set of related activities and actions designed to achieve a specific goal or achieve multiple objectives. The strategy document defines the issues, wellness elements, and directs you toward action required to successfully implement the strategy. It represents the "big picture" about how one intends to address a significant problem or run a new program. The strategy usually articulates goal(s) and purpose.

Step Two - Planning. Planning transforms the strategy into a series of steps that are taken to live a more balanced, healthy life. It is your map to achieving your strategic goals and objectives. It transforms goals into specific objectives. For example, using the goal of reducing depression symptoms, an objective could be to get the right amount of sleep and maintain the same sleep schedule every day.

Step Three - Implementation. Implementations assistance is key to realizing the goals and objectives previously defined in the planning and strategic documents. Implementation guidance is necessary for executing your plan from Step 2. For this step we used things like schedules, status reports, logs, and other tools to stay on course with what has already been planned.

After a few hours of researching and writing I didn't find much about developing a strategy for managing bipolar disorder. Hmmmmm. Instead I found that elements of a wellness strategy were being incorporated into health and wellness plans. In fact, there are books, programs, and training to help us make these plans.  So, I regrouped and decided to write this post about developing a Bipolar Wellness Plan (The Plan).

Bipolar Wellness Plan

A Bipolar Wellness Plan can put you in control of managing the disorder by providing a clear picture of how to take action that moves you away from disorder and towards order. It will help you create an environment that supports and prepares you and those supporting you for challenges along the way.

I used a helpful template from the Black Dog Institute to create my own Bipolar Wellness Plan. The Institute calls the template "MY WELLBEING PLAN to manage my BIPOLAR DISORDER."  I recommend it for starting your own plan. 

There are other cool things online.  The Black Dog Institute also has this introduction slide show called Staying Well with a Stay Well Plan.  

The Plan addresses several key areas including activities to maintain wellness, identification of things that could trigger a relapse of bipolar symptoms; and specific action items to take in the event of a relapse. It also identifies your medical team by name and number, 24 hour emergency numbers, current medications, and a medication contingency procedure.

Ideally, the Bipolar Wellness Plan should be discussed collaboratively with one's health professionals and friends and family that support you. I ran mine by my mother and good friend. They gave it a thumbs up, I think.

A Look Inside

I want to look at three of the components addressed in the Black Dog template: maintaining wellness, triggers, and relapses. 

The maintaining wellness section of the plan points the person towards seven areas: physical activity, sleeping, eating, alcohol and drugs, pleasurable activities, issues related to treatment, and other activities.  

I think "other activities" should be expanded. There are a lot of other areas that can influence wellness like relationships, spiritual, physical health, hobbies, stress and so on. I wrote down friends, family, my faith, hiking, and reading.  I think I will expand on this area.  

Triggers are important to be aware of. Triggers are external factors (e.g., environmental, psychological) that can set off an episode of depression or mania in someone. Stress, alcohol use, and ruminating about negative things are big triggers for me.

The section on relapses was straightforward. Simply put down what things you do that would be considered evidence of relapse and early warning signs of problems. I wrote excessive sleep, anhedonia, slow thinking, and withdrawn behavior are evidence that depression has returned.

Now What?

So, now I have an "approved" Bipolar Wellness Plan that should keep me stable when I get out of this 19 month (so far!) depression. The template recommends carrying a copy of the plan with you and giving it to all your health professionals and support people. I haven't done this yet. I'll put it on my list of things to do.

I was going to put my mostly completed Plan in this post but it is too big.  So if you would like a copy of my completed Plan shoot me an email at bipolarblogguy@gmail.com.

Bipolar Depression Nags and Ninnies

I am going to present here commentary about my thinking on the subject of depression. It is based on my understanding of our culture's view of bipolar disorder and psychiatric disorders in general. I also make the distinction between bipolar depression and other forms of depression.

Bipolar Depression

It is good to remember that bipolar depression is different from other types of depression. From my understanding bipolar depression is more severe, longer lasting (chronic), and treatment resistant than major depression. Mild, moderate, or most situational depressions pales in contrast to the intensity and duration of a bipolar depression episode.

Bipolar depression is a severe form of depression that has a biological component to it. This means that there are actual, physiological changes that occur in the brain when experiencing severe depression. Changes include things like loss of neuron connectivity, low activity in regions of the brain associated with emotion, problems with specific neurotransmitters (e.g., Serotonin) and loss of brain mass in certain areas.

Severe depression goes way beyond how one feels. It also includes adverse impacts to a person's energy levels, motivation, thinking ability (especially concentration and memory), sleep, and sense of self worth.

Because I have Bipolar Disorder I experience severe depression essentially by definition.  And let me tell you it can be unbearably severe.  At one point last year I went into an extreme depression that required partial hospitalization in a two-week outpatient treatment program.  That was a first.

Nags

We all have nags in our lives.  People whom existence thrives on pointing out our problems and reminding you of how you could do this or that to improve.  

Whether it's your mother or a brother from another mother, nags kill mood, start rumination, and piss you off.  Sometimes you will have to tell them to talk to the hand.

Exercise nags.  Everyone is harping about how beneficial exercise is for fighting depression.  Are they excited for good reason?  Well, yes and no.  The problem is exercise is truly effective, but only for certain depressions.

Exercise is known to help people with mild or moderate depression.  It can make a significant impact towards a successful depression recovery in these cases.  Exercise keeps them happier than a flea in a doghouse.  However, this is not the case for recalcitrant bipolar depression.

I find myself doing more exercise as I my depression lifts.  This is the opposite of what is believed.  I exercise when I feel better, versus exercising to feel better as with milder forms of depression.

Exercise as a means to reduce the severity of bipolar depression is mostly poppycock.  This website says otherwise.  However, based on my experiences with this monster, I have consistently found that exercise just doesn't provide much therapeutic value to the severe forms of my bipolar depression.

Diet nags.  After exercise, diet is the most well intended recommendation I hear. In addition to restricting bad foods from your meals, diet in this context includes natural and synthetic supplements that are part of a person's daily intake.

As with exercise it is my conviction that diet has only a limited effect toward bipolar depression symptom relief.  While losing weight and avoiding bad foods is certainly a huge health benefit, the ability for diet to significantly alter mood does not seem to occur with me.

As I write this I am on a pretty crappy diet.  I eat only once or twice a day and usually late at night.  It's been like this for the last couple of years.  Interestingly, as my depression began to lift over the last couple of months I have had the same poor diet.  I try healthier eating from time-to-time, but really don't notice improvements when in the pit of a bipolar depression.  I have similar experiences with dietary supplements such as St. John's Wort, 5-HTP, peppermint, green tea, and others.  I even wonder how much help I'm getting from my current supplements: NAC, multivitamin, fish oil, aspirin, Benadryl, and Provigil.

I've had this diet for many moons now, including the time I've spent in this bipolar depression (21 months).  It may be different for others, but altering my diet on my diet does not noticeably improve my depression symptoms.

Snap Out Nags.  A common myth persists that people should be able to "snap out" of depression.  They think that depression is merely a result of someone wallowing in their grief or sadness.  They believe it can be cured simply with just positive thinking and adjusting one's attitude.

This is nonsense.  Depression is a serious medical condition arising from biological and environmental factors.  It is not a sign of weakness, laziness, or self-pity. 

Depression is a psychiatric disorder of the mind arising from changes in brain chemistry, neural networks, and function.  It is marked by prolonged periods of unexplained hopelessness, profound sadness, lethargy, guilt, and suicidal tendencies.

Ninnies

Ninnies are those people who are completely clueless when it comes to an understanding of mental wellness and psychiatric disorders.  This unawareness often leads them to stigmatize, discriminate, and reject the notion that mental disorders even exist - despite all of today's evidence showing otherwise.  

Further, misunderstanding is perpetuated by exaggeration, inaccuracies, and misrepresentations of mental disorders.  The two main sources for a lot of people's information is the main stream media and the entertainment industry.  News media, social media, and popular websites often present severe disorders in a simplistic, violent-ridden, and deranged manner. 

Since they have no experience with severe depression, Ninnies love to impart their wisdom for relief from what they consider is simply the case of the blues.  Although they have the best of intentions, their simplistic understanding of psychiatric disorders leads to giving suggestions and advice that sound more like accusations, condescension, and hogwash. 

"But you have so much to be happy about.  Look on the bright side"  They have no idea that depression symptoms include a strong and persistent flow of negative, distorted thoughts, where everything occurs dull, meaningless, grey, and blah.  Severe depression generates apathy where expressions of concern, excitement, and motivation are conspicuously absent.  It can also lead to anhedonia, where there is a lack of ability to experience pleasure. Although I am grateful and thankful for the good things in my life, in the state of severe depression they are seen in a distorted light where all things seem meaningless, of little value, and guilt-ridden.

My bipolar depressions lasts years. Those around me know this. So, when someone asks a simple "How are you?", I sometimes can not believe what I am hearing.  Of course I'm feeling bad, I'm not well.  Of course I end up telling a lie that I'm doing fine just to avoid any more discussion about my depressed state.  

When it comes to understanding, the folks that ask this question are  not paying attention or something.  MLK said it best: "Shallow understanding from people of good will is more frustrating than absolute misunderstanding from people of ill will." - Martin Luther King, Jr.

And then there's "I know how you feel." For most people this is b.s. plain and simple. Unless you are one of the 2.6% of Americans with bipolar disorder, you will have no way to relate to the depths and duration of bipolar depression.

I'm going to stop this post/rant. Something spurred me to write this and I'm not sure what it is. Until next time, live long and prosper.

My Cymbalta Withdrawal - Return of the Mind

This is my third post regarding the continuing saga of my withdrawal from the SSRI antidepressant Cymbalta.  It may be helpful to read my earlier posts on this topic: (1) Bipolar Treatment Update - Cymbalta Wars and (2) My Cymbalta Withdrawal - The Syndrome Strikes Back. 

Background

I have been on Cymbalta for six years.  It was added to augment Wellbutrin, my primary antidepressant, and improve treatment of lingering depression symptoms.

Although it worked for several years, I have come to believe that Cymbalta is no longer effective for me as an antidepressant.  It's known that antidepressants can be effective for a period of time (months or years) and then stop working.

Poop Out
  
A loss of effectiveness during antidepressant therapy can occur with most antidepressants.  A sustained, effective response from antidepressant treatment is not always achievable.  

Unfortunately, it's not fully understood what causes this so-called "poop-out" effect, or why it occurs in some people and not in others.  This effect could relate to the disease itself, pharmacological effects, or a combination of the two. 

Tapering - The Slow Withdrawal

I began tapering down from 120 mg/day of Cymbalta (a very high dose) on 3/20.  I dropped to 100 mg/day for the first week without significant problems.  

But when I went down to 80 mg/day at the start of my second week all hell broke loose.  It felt like a depression alien life form came and infiltrated my mind.  Since then I have had many days with mostly severe depression.  Not good.

Status

Well, my withdrawal from Cymbalta took another big turn lately. This time for the better! My depression has began to lift again. The intensity of my symptoms really dropped and since last Tuesday I've had mostly mild depression!! I remain in communication with my psychiatrist throughout this withdrawal process. We almost went back up to 100 mg/day at the beginning of last week because things were so bleak. On Monday we decided to stay at 80 mg/day for a few more days and see what happens.  It turns out that was a good move!
By the Way 

Adverse withdrawal effects and the discontinuation syndrome from Cymbalta are real.  They can be devastating to a certain percentage of users.  If I recall correctly this figure is in the 10 to 20 percent range.  Withdrawal effects are mostly overlooked by Pharma.  Because of this patients get taken by surprise when they try to get off the drug and experience a debilitating withdrawal process instead.

There are numerous papers, articles, and web sites that specifically address Cymbalta's under reported withdrawal effects.  Cymbalta Withdrawal Forums is a site I found helpful.  It used by folks dedicated to rooting out and addressing the adverse effects that can arise while getting off of Cymbalta.  Cymbalta Attorney gives you direct access to lawyers specializing in Cymbalta withdrawal and injury cases.  I'm sure they'd take my money, but I think I'll pass.  Cymbaltawithdrawal.net is another site that addresses Cymbalta withdrawal only.  It's not a good site but thought I'd include it for no specific purpose anyway.  

What's Next?

I will discuss my situation via email with my pdoc tomorrow.  Since things have lifted for several days in a row now she may okay lowering my Cymbalta dose some.  

I'm leaning towards remaining at 80 mg/day for another week to be safe.  This stuff is dangerous!  Also, we need to figure out how what the next tapering dose will be.  

Another 20 mg/day reduction in dosage is an overall drop of 25 percent.  Hmmm.  Maybe a bit much?  

How much would you decrease the next dose?