I wonder whether it’s just the nature of the beast. Most people search the Web for answers and solutions, and when it comes to bipolar, they may be frustrated and angry, often understandably so. Those who have found their answers and solutions tend to go back to living their lives. Why dwell on it when life is good, right?

Unfortunately, people who achieve stability in their lives rarely return to tell their success stories. Hence, I think, the negative coverage of bipolar tends to considerably outweigh the positive.

This week, I’d like to commend those who are spreading a positive word about bipolar, including Web sites like bphope.com and bp Hope magazine, and encourage anyone out there who has a bipolar success story to share it with others. Please share your story or let us know of sources you have discovered online or off that present a more positive, hopeful view.

I am trying to get back to work and find a better job. But what is “better?” I was doing what I thought I loved to do. I have spent $30,000 on my education, and have been working toward this particular career goal for 12 years. I have tried to get out of it as it seems that my major bi-polar episodes have coincided with work. But the more I get away from it the sadder and more detached from myself I feel.

I am currently applying to a job back in my old field – am I doing the right thing? My husband is worried, he got to see things from the outside (and was terrified for me) and was relieved when I began searching for a job that would put me on a more even keel; for instance, I wouldn’t be bringing my work home. The current position I am interested in seems like it may be a compromise because it is more limited hours and it would be more of a collaborative effort with my co-workers. Advice anyone?

Dr. Fink Answers…

Hi, Sara–

Returning to work can be very challenging, but what you say in your second to last sentence about the new job being a compromise, offering more limited hours, and giving you an environment of collaboration sounds like you’re taking the right approach. Your husband has every right to be worried, but if your meds are effective, you keep taking them, and you carefully monitor the situation with your doctor and others, I don’t see why you can’t return to the work you invested so much of your life preparing for.

We have several posts in the Career category that you may find useful in planning and managing your return to work. We wish you the best.

If you’ve returned to the same job after being diagnosed with bipolar disorder or changed jobs or careers, please share your experiences and insights.

My husband is bipolar and has been exhibiting extreme mania for 4 months. In and out of jail, finally 3 weeks in the psych unit. He came out on 900mg Seroquel at night. Isn’t that an extremely high dose for him to still be manic? Of course, he could not be taking it.

Here is my question. How long can this mania go on? His symptoms of depression usually occur in the fall, as he is seasonally affective. Help! I have filed for a divorce after 20 years. Of course, I have been banned from his appointments with no information on his condition, even though I am highly versed in his disease process and am an R.N.

Numerous family members have expressed the same futility and frustration in dealing with bipolar disorder. They want to develop a greater understanding of bipolar and support their loved ones who have the disorder, but they often feel shut out due to privacy policies and doctor-patient confidentiality.

We would like to know what you think about this issue. Do you think privacy laws are counterproductive in helping a loved one who is experiencing a major mood episode or do you feel that people with bipolar should have the same privacy rights as everyone else?

Before we crack open the medicine cabinet, I’d like to say a few words about bipolar disorder and sleep. Sleep is a biggie. Too much could trigger or be symptomatic of depression. Too little could trigger or be symptomatic of a manic episode. At least one study shows that changes in sleep patterns can be an early predictor of a manic episode. Sleep plays a major role in mood disorders and recovery, so if you’re having trouble sleeping, you and your doctor need to do something about it.

That something could consist of many strategies, ranging from very simple (such as going to bed the same time every night) to more involved – medication, avoiding caffeine and other stimulants, maintaining a strict sleep schedule, and convincing other family members to stop banging around in the kitchen till two in the morning. In stubborn cases, you may benefit from a sleep study to identify factors that may be contributing to the sleep disturbances.

Assuming your doctor and you decide that sleep medication is necessary, your doctor may prescribe one or both of the following:

• A mood stabilizer, atypical antipsychotic, anxiolytic (anti-anxiety agent), or other medication that’s not primarily used for sleep but will hopefully help your sleep if it treats underlying mood or anxiety symptoms. Occasionally these medications are used just for the sedating side effects for sleep, but this is not so common.
• A bona-fide sleeping pill (sedative), which brings us to the main point of this post.

A little-known fact is that the active ingredient in many over-the-counter sleeping pills is diphenhydramine – the generic form of Benadryl!

Prescription Sedatives

Several effective sleeping pills are available, which vary in terms of safety, side effects, and other considerations. The following list provides a quick rundown of some of the more common prescription sleep medications currently in use:

• Ambien (zolpidem): Ambien is available in two forms – Ambien (and its generic), which help you fall asleep, and Ambien CR (no generic), approved to help you fall asleep fast and stay asleep. Ambien may not be safe for those who have a history of depression, liver or kidney disease, or respiratory conditions. Ambien may lose its effectiveness if taken longer than two weeks, while Ambien CR can be taken for a longer period of time. Ambien can trigger unusual side effects such as sleep walking, sleep eating, and even sleep driving. Ambien should not be mixed with alcohol – the combination increases the risk of these types of side effects. For more about Ambien CR, visit http://www.ambiencr.com/.
• Lunesta (eszopiclone): Lunesta is approved to help you get to sleep and stay asleep, so you wake up feeling rested. It has a low-risk for developing a dependency, so you can use it short- or long-term, and rebound insomnia (increasing severity of insomnia after stopping the medication) is rare. Lunesta may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; liver disease; or are pregnant, planning to become pregnant, or breast feeding. Lunesta should not be combined with alcohol. For additional information, visit http://www.lunesta.com/.
• Sonata (zaleplon): Sonata is approved to help you get to sleep. Its particular niche is that it is short acting, so is less likely to produce a hangover effect in the morning. It is so short acting that you can take it a second time if you awaken in the middle of night. Sonata can be habit forming and may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; severe liver impairment; or are pregnant, planning to become pregnant, or breast feeding. Sonata should not be combined with alcohol.
• Rozerem (ramelteon): Rozerem works differently from other sleep medications and is designed to work in conjunction with your body’s internal clock. It’s non-habit-forming, won’t make you feel groggy the next day, and is safe to use with many prescribed medications. (It’s not a controlled substance like most other prescription sleep medications.) Although Rozerem is generally considered safer and gentler than other prescription sleep medications, it may not be safe for those who have a history of kidney or respiratory problems, sleep apnea, or depression, or are pregnant or breast feeding. It may interact with alcohol, and high-fat meals may slow absorption of the drug. For more about Rozerem, visit http://www.rozerem.com.

Some older sleep aids include Restoril (temazepam), Halcion (triazolam), and ProSom or Eurodin (estazolam). These are not used frequently anymore – and have a history of being addicting and causing a number of side effects. Halcion has been withdrawn form the market in several countries. If your doctor recommends one of these medications, question the reasoning for using an older drug.

Atypical Sleep Aids

Some medications that are not bona fide sedatives are often used for this purpose. Following are a few of the more common and effective medications in this group:

• Trazodone: This is an old fashioned antidepressant, rarely used for depression anymore, but, because it is so sedating, has become popular as a non-habit-forming sleep aid. Its use is limited to women for the most part though, because of a risk in priapism for men – an erection that will not go away. This seems like it might be fun but it is actually a medical emergency.
• Remeron: Another antidepressant used for sleep because it is so sedating, Remeron is pretty effective, but causes weight gain.
• Clonidine: This medication was primarily used for high blood pressure, but is quite sedating, is often used in children with ADHD, and is a good sleep aid that’s not habit forming. It can sometimes cause a drop in blood pressure or rebound high blood pressure. In high doses, it can cause liver problems.

What about melatonin?

Melatonin is a natural hormone, released by the brain when it gets dark. It is available over the counter. It is an effective sleep aid and is well studied even in children. The safety profile is quite good. Doses range from 1-5 mg per night, and it comes in pills and spray forms.

Common Possible Side Effects

All medications have side effects. Prior to taking any prescription or over-the-counter sleep aid, consult your doctor let her know all the medications you are currently taking, including over-the-counter medications and “all natural” or herbal remedies. In addition, be aware that any sleep aid can cause drowsiness, so avoid driving or operating machinery while taking these medications, especially when you first start taking them and are unsure of the effect they may have on you. Additional side effects may include the following:

• Dizziness
• Allergic reaction, possibly severe
• Facial swelling
• Headache
• Prolonged drowsiness (especially the sleep aids designed to help you stay asleep)
• Sleep behaviors, such as sleep-driving and sleep-eating or a combination of the two, like if you sleep drive to McDonald’s

Sleep Aids in My Practice

I recommend or provide sleep aids frequently, because sleep problems are so commonly associated with mood disorders and other psychiatric conditions. I encourage people to practice good “sleep hygiene” as a primary intervention:

• Regular bed time and wake up times
• No stimulants after 12 noon
• No vigorous exercise in the evening
• Turn off screens and phones and work one hour before bedtime
• Try to keep the bed for only sleeping and sex – no work or other activities
• No TV in the bedroom… it’s bad for sleep

If we do need to use a sleep aid, I will often start with melatonin before proceeding to prescription interventions. We try hard to use medications for brief periods of time. Getting enough sleep is important in recovery from mood disorders, so treating aggressively is important.

If you have bipolar and accompanying sleep-related issues, please share your experiences and insights and any helpful suggestions. This goes for you doctors and therapists out there, too!

Over the past few days, I’ve given more thought to this question. The fact is that I really don’t know what it’s like to be married to someone with bipolar, because I’ve only ever been married to Cecie. The question should have been, “What is it like to be married to Cecie?” And, of course, to be fair, the interviewer should have asked Cecie, “What is it like being married to Joe?” (I must admit I’m not always the ideal mate… if such a creature even exists.)

Every marriage is as different as the two people whom the marriage has joined. So too is every marriage that includes someone with bipolar disorder. Infinite variations can arise based on whether the bipolar is characterized more by depression or mania or a combination of the two, how effectively symptoms are managed, whether children are involved, whether the couple has a strong support network in place, the partners’ attitudes toward mental illness, differences in personalities, family dynamics, the prevalence of stressors including financial or work-related issues, and a host of other variables. Marriage and bipolar do not exist in a vacuum.

I feel honored to be married to Cecie. I’m not sure whether it’s despite the bipolar or maybe, partially at least, because of it. Cecie loves life. She is very charismatic, engaging, intelligent, and talented. We have been married for 25 years, and when she’s not around, I feel awkward and clumsy. Yes, during the episodes of mania, life can be hell… for both of us as well as others in our circle. Bipolar is abusive and can coerce everyone involved into becoming monsters, me included. That’s during the bad times. Fortunately, for us, those times have been few and far between. I would venture to guess that most of the time our marriage is pretty much like most marriages… maybe better than most.

If bipolar disorder plays a role in your marriage or other intimate relationship, please share your insights. Perhaps we can create a collective collage that sort of represents what it’s like to deal with bipolar disorder in a marriage or other intimate relationship – positive and not so positive.

Five months ago, I was diagnosed as having bipolar disorder. First I was on Depakote and then I told my doctor I was still having major problems with my sleep. I was always up and about knowing it was 3 o’clock in the morning. I told her about the lack of sleep, and she immediately took me off of the Depakote and switched me to Seroquel.

I started off with sample packets of 25mg. I was amazed I could finally go to sleep, but it wasn’t a sleepy sleep… if that makes any sense. It was like someone knocked my lights out. I had no complaints to tell my doctor because I was enjoying my sleep so much, but finally I went into major states of depression – racing thoughts and unusual energy and then crashing.

I am now taking 800mg of Seroquel a night and 150mg of Lamictal right in there with it. I still get really nervous and irritable at the smallest things, which is having a major impact on my everyday life. My doctor tells me what is good for me but the symptoms of my illness are still there, causing more harm than good.

Does anyone know what I can do to just tell my doctor, “Hey!!! This just isn’t working?”

Dr. Fink Answers…

Hi, Garett–

I think you answered your own question – tell your doctor, “Hey!!! This just isn’t working.” Describe your symptoms. The trouble with some of these meds is that they take awhile to kick in, and then it may be awhile before you really feel better. But if you’ve spent six to eight weeks on the meds and still are not feeling right, your doctor should be sensitive to this and make the necessary adjustments.

Writing down concerns as they come up can help. Bring your log with you to your doctor visits. This will allow you focus on your interactions with your doc while keeping track of her recommendations. Sometimes doctors hear things better if they’re written down in a checklist form – that’s just how we’re trained.

If your doctor does not respond to your needs, you’ve discussed this with her, and she’s still unable to problem solve with you, then you may think about finding another doctor. Before you switch, realize that it’ll take some time to develop a relationship with the new doctor and bring him or her up to speed on what’s going on and what you’ve already tried. You may be better off working with your current doctor, so you don’t need to start from scratch. However, if you continue to feel that your concerns are not being heard, then you may want to look for another opinion.

Finding the right “medication cocktail” that works for you can be a long process and require several adjustments. Shifting your expectations is an important tool for managing frustrations about these challenging medication trials.

Mikal thought that was interesting. He said he only hears about celebrities or famous historical figures with bipolar, like Robin Williams, Vincent Van Gogh, and Theodore Roosevelt – people, who when you hear they have bipolar, you tend to say, “Oh yeah, that explains a lot.” He found it odd that we tend to hold these individuals up as representative of the bipolar community. He suggested it might be better to have some representatives more like the businessman I had described – regular, ordinary people.

On the same day Mikal and I had this discussion, I noticed a post on our Bipolar Blog by Harold Knight, a teacher in a private university.

This may not be exactly germane here, but I think it is. I have discovered a resource for support that I never would have dreamed of. I teach in a major private university, and I accidentally mentioned my blog (about my bipolar disorder and my temporal lobe epilepsy) to a couple of my students. They went looking for it. At first they were shocked. And then they began to be interested. Nearly all of my students know about it, and it has sparked some very interesting conversations.

My sense is that there is a group of young people who have been introduced to the fact that bipolar disorder is not some horrible crazy-making thing, but a disease that even one of their respected teachers can have, and it doesn’t make him either a monster or a bad teacher. I think we need more of this kind of education – even before people get into marriages.

Unfortunately, with bipolar disorder, the depressive side doesn’t make the headlines. Nor does the normal side. Bipolar memoirs, Web sites, and blogs tend to call more attention to the manias, especially when they spiral into psychotic episodes. And celebrities, often eccentric, are the spokespeople – the face of bipolar.

Don’t get me wrong. I appreciate celebrities coming out and speaking out about bipolar and mental illness and raising awareness. I’d just like to see some more attention paid to people in other fields who have the illness, manage it, and live productive and fulfilling lives. I’d like to see more awareness of the fact that Harold brings to light: “That bipolar disorder is not some horrible crazy-making thing, but a disease that even one of their respected teachers can have, and it doesn’t make him either a monster or a bad teacher.”

We would like to know what you think. Please post a comment to share your observations and insights on this topic with other visitors of Bipolar Beat.

Please watch the video and share your insights.

Mrs. Tovornik, Cecie Kraynak, Tatjana Novak, Maja Valic, Darja Budja, Joe Kraynak, Sanja Svajger (Journalist) at Book Presentation in Ljubljana, Slovenia, October 12, 2009

Cecie and I participated in another book presentation for the Slovene edition of Bipolar Disorder for Dummies. Unlike the presentation on Saturday in Koper, this one was dedicated solely to the book and was much more effective in promoting it.

During the last couple days of our journey in Slovenia, I learned a few interesting tidbits about the book and about bipolar:

• Darja, the translator, pointed out that she not only needed to translate the book but also adapt it for Slovenia. A couple interesting adaptations included having to change the information on legal issues and disability in Chapter 13 and replacing Chapter 20, “Ten Ways to Fight the High Cost of Treatment” with a chapter on ten things not to do. (In Slovenia, everyone has health insurance that covers the cost of treatment… nice, huh?)
• Many people here mention Bipolar III and Bipolar IV. I’ve heard almost nothing about these classifications in the U.S. Darja showed me a relatively old publication (September, 1999) entitled “The evolving bipolar spectrum. Prototypes I, II, III, and IV,” by Akiskal, HS and Pinto O., where these types seem to have been first mentioned. As I understand it, Bipolar III is basically what we refer to as antidepressant- or stimulant-induced bipolar, while Bipolar IV describes cases in which the patient may demonstrate symptoms of hypomania for many years followed by at least one episode of severe depression.
• Several people with bipolar who attended the book presentation complained of seeing their doctors for depression, receiving an anti-depressant, and then experiencing mania. A couple people were understandably bitter about it, but one attendee pointed out that he found it best to put that behind him and deal with the current reality – now you have bipolar (with mania), so what are you going to do to manage it?
• One attendee who is currently hospitalized for mania was able to receive permission from the hospital to attend the event. Her family accompanied her, and her father expressed his frustration with the illness – the frustration and anger reminded me a great deal of how I felt when I first encountered bipolar and how I still sometimes feel. I hope he is able to work through this to some degree.

Media were in attendance, so we expect to see something in the Slovenian newspapers this morning and perhaps even on TV. We hope this will bring greater awareness and understanding of bipolar disorder among the wonderful people of Slovenia.

Sitting: Peter Smole and Roman Peklaj and Maja Valic; Standing: Joe Kraynak, Darja Budja, Cecie Kraynak, Emi Kladnik, Ana Sorc, and Katja Jus

Cecie and I were invited to visit Ljubljana (lyoo-blee-ah-nah), Slovenia for the release of the Slovene edition of Bipolar Disorder for Dummies. We accepted and have been in Slovenia since this past Thursday, 10/8/2009. We flew into Venice on Thursday to meet our gracious hosts, Darja Budja (”j” is pronounced “y”) and her husband Simon Perko. Darja translated the book into Slovene and is a devoted bipolar advocate. She has created her own bipolar blog (bipolarna.si) and is one of the organizers of an active bipolar support group in Ljubljana.

Darja informed me that Bipolar Disorder For Dummies is one of the only books on bipolar to be translated into Slovene – the other two being children’s books – hence all the hoopla surrounding the release of our book.

Thursday evening, Cecie and I met with Darja’s support group to present the book, share our experiences with bipolar, and discuss various bipolar-related topics. A high percentage of the Slovene population speaks English, so we had no huge communication barrier. Many of the group’s members are accomplished professionals and all were very articulate with an excellent sense of humor. During the meeting and afterwards, we shared plenty of laughs.

A couple highlights from our meeting included the following:

• Dr. Mojca (moy-tsah) was in attendance. I had heard much about her (all good). Several of her patients were in attendance and all sung her praises. She stressed the need for sleep and informed us that she provided her patients with medication and instructions on how to use it effectively to enable them to more effectively manage their own sleep issues. We found this surprising. Our experience is that doctors in the U.S. seem reluctant to prescribe sleep medication out of fear of the patient developing a dependency. Dr. Moyza said she preferred using Klonopin (clonazepam), an anxiolytic, to help with sleep, because she found it to carry less of a risk of dependency. Specifically, she said that at high doses, it causes the tongue to swell, which is generally enough to convince patients to back off on the dose.
• When relating our experiences with bipolar, I described the illness as a monster that could create all sorts of chaos and meanness in a family and that it’s the monster that causes all the trouble, not any of the individuals involved. Everyone seemed to relate well to that. One member joked that his monster was now a little kitty, but he was always aware it was still there and could turn into a lion at any time.
• The members also seemed to welcome the message that although chaining up the monster is important, we needed to be careful about locking our dreams away. I pointed out that I found most people with bipolar to be highly intelligent and talented, and with bipolar, we need to be careful about letting it become our lives rather than simply a part of our lives.
• We discussed the stigma of bipolar disorder (and mental illness in general). I pointed out that we still have a problem with this in the U.S. but I thought it was improving due to efforts in the community to educate the public. One member pointed out that he has noticed more movies and television shows coming out of the U.S. about mental illness or with characters having a mental illness, and he saw this as a positive sign. The consensus, however, was that in Slovenia, the stigma was still rampant.
• Dr. Mojca pointed out that because Slovenia is a smaller country, it is easier for them to get things done, especially in terms of passing legislation to help with mental illness. Organizing efforts in Slovenia may be a little easier than in the U.S. and may have more of an impact.

On Saturday, we traveled to Koper, on the coast of Slovenia (Adriatic Sea) to present Bipolar Disorder For Dummies at a conference on the state of psychiatry. The conference began with a roundtable discussion (in which I did not participate) followed by the book presentation, which was relatively brief. Attendees seemed to be a bit worn out by the end of the roundtable discussion, so having a brief book presentation was probably a good thing.

Today, we will hang out. Tomorrow (Monday) we are doing another book presentation in Ljubljana. Later in the week, we may have an opportunity to appear on local or national television to discuss bipolar. We sincerely hope that the book will help our new friends in Slovenia and contribute in some small way to reduce the stigma surrounding this illness.

I would like to thank Darja Budja for organizing this trip and pulling everything together to make it possible, her husband Simon for patiently attending to all our needs, and his parents for giving us a place to stay. Thanks also to the DAM Society, Zalozba Pasadena, and AstraZeneca for their efforts in publishing the book and their financial support of this trip. Thanks also to my mother-in-law, Jo Howard and my parents, John and Adeline Kraynak, for their contributions; PsychCentral’s John Grohol for pledging his support; and all the wonderful people of Slovenia we have met who have been so hospitable and generous.