(I realized that sounds backward; they should check the blood level before treating for toxicity. But in my town, they send the blood sample out of town and wait several hours or even an entire day to get the results. In this case, the blood level came back at 1.0, which is mid-range, but that was after my wife had stopped taking the Mobic for a day and drunk about a gallon of Gatorade.)

The moral of this story is that if you’re taking lithium and one of your doctors prescribes an NSAID, you need to have your lithium levels checked every 4-5 days to determine whether the NSAID is increasing the level of lithium in your system. If your lithium level is too high, your doctor may have you stop taking the NSAID or decrease the amount of lithium you take.

The other moral of this story is to double check with the person prescribing the lithium before taking any new medicine — prescribed or over the counter. Lithium interacts with many medications; your psychiatrist is best able to warn you about potentially troublesome combinations.

My wife and I should have known better. After all, on page 102 of Bipolar Disorder For Dummies, Second Edition, Dr. Fink warns:

“Non-steroidal anti-inflammatory medications (like ibuprofen) can increase lithium levels, too, so check with your doctor before taking any of those meds along with lithium.”

But we seem to always assume that when a doctor prescribes medication, he or she accounts for potential interactions.

That NSAIDs may raise lithium levels in the bloodstream is not news. In a study published in the Journal of Psychopharmacology in 1990, entitled “The clinical significance of lithium-nonsteroidal anti-inflammatory drug interactions,” Carl T. Hayden of the Veterans Administration Medical Center in Phoenix, Arizona concluded:

“There is conclusive evidence that nonsteroidal anti-inflammatory drugs can increase serum lithium levels, diminish renal lithium clearance, and possibly induce lithium toxicity.”

I’m just posting this as a reminder in the hopes that it helps our readers avoid the same mistake.

Over-the-Counter NSAIDs

Keep in mind that several NSAIDs are available over-the-counter (without a prescription) — aspirin, ibuprofen, and naproxen. All three of these are found under a variety of name brands and can also be found in many combination medicines such as cold remedies and sleep aids. Always read labels before taking any over the counter medication, and if you take lithium, be sure to check with your psychiatrist before using any of these.

Prescription pills photo available from Shutterstock

“By now it’s well known that 90 percent of the American people support universal background checks that make it harder for a dangerous person to buy a gun. We’re talking about convicted felons, people convicted of domestic violence, people with a severe mental illness.”

I think president Obama is well intentioned, but he should have at least qualified his statement by saying something like “… people with severe mental illness who prove to be a danger to themselves or others.” Here’s why: Grouping all people with severe mental illness in with convicted felons and perpetrators of domestic violence…

• Further stigmatizes those who have been diagnosed with a severe mental illness.
• Falsely characterizes those who have a severe mental illness as being dangerous. Yes, some people who have a severe mental illness are dangerous and should be prohibited from owning firearms, but a large majority of people with severe mental illness do not pose a danger to themselves or others.
• Fails to recognize that many people with severe mental illness manage their illness effectively and are responsible, contributing members of society.
• Fails to recognize that people with severe mental illness are more likely to be the victims of violent crimes than the perpetrators of such crimes. Shouldn’t they have the same rights to protect themselves?
• Discourages people who are struggling with mental illness from seeking the medical help they need or disclosing information that could help in their treatment. This could contribute to an increase in undiagnosed mental illness.
• Does nothing to keep guns out of the hands of people with undiagnosed severe mental illness who have demonstrated violent tendencies.
• Does nothing to prevent access to guns owned by friends, family members, neighbors, and so. (Adam Lanza used his mom’s guns.)

In addition…

• People with guns can experience temporary lapses in good judgment for any number of reasons, leading to senseless gun violence.
• A lot of idiots who probably shouldn’t own guns have the right to own them, and nobody is demanding screening to prevent stupid or irresponsible people from owning firearms.

I think a more general exclusion would be more appropriate, something more along the lines of Arizona’s wording: Arizona prohibits possession of a firearm by any person who “Has been found to constitute a danger to himself or herself… and whose right to possess a firearm has not been restored.”

Personally, I think universal background checks are a good idea. Extending them to guns purchased at gun shows or over the Internet seems like a no-brainer. But we need to be careful not to treat everyone with a severe mental illness as a dangerous criminal.

What do you think: Should severe mental illness be an exclusion for gun ownership?

President Obama photo by borman 818, available through a Creative Commons attribution license

The research team did post-mortem (after death) examinations on the brains of three groups of people:

• People with bipolar disorder who never took antipsychotics
• People with bipolar disorder who had taken antipsychotics
• People without bipolar disorder (the control group)

They looked specifically at the expression of over 2000 unique genes by measuring the proteins that these genes produce. These proteins are involved with the function of the synapses — the gaps between brain cells where communication between the cells occurs. The results:

• The control brains and the brains exposed to antipsychotics had similar patterns of gene expression (the proteins produced by the genes).
• The brains of people with bipolar that had not been exposed to antipsychotics had different patterns of protein production.

Until now, we have focused on how medications affect the neurotransmitters, but this research suggests the possibility that what really makes antipsychotic medications effective in treating bipolar may be related to how they affect gene expression. In other words, we know that antipsychotics increase dopamine levels decrease dopamine effects in the brain, but this may be a secondary or even possibly a coincidental effect of changes to gene expression.

This research opens some Interesting possibilities, and I think this kind of study indicates how much the terrain of understanding, diagnosing, and treating mental illness will continue to shift dramatically as the genetic and neurobiology research explodes into the next decades.

Research like this may help in the development of medications that are more effective — targeting specific genes or proteins that are abnormal in bipolar disorder. This kind of specificity in medication may also reduce the risk of side effects by affecting fewer types of cells in the body.

Gene image available from Shutterstock

“We have no national database of these lunatics… We have a completely cracked mentally ill system that has these monsters walking the streets.”

— Wayne LaPierre, Executive Vice President NRA

Since the tragedy at Sandy Hook Elementary School in Newtown, Connecticut there have been pages and pages written and hours of audio and video created by people from all sides of the gun control/gun safety discussion. The conversation about the need for better mental health awareness and care, especially for children, is welcome. Comments like Mr. LaPierre’s are not. His and many others’ inflammatory rhetoric about those suffering with mental illness stokes unwarranted public fears about mental illness — legitimizing stigma that we work so hard to eliminate.

The vast majority of those with mental illness are not going to commit violent acts with guns. A compassionate approach coupled with access to good mental health care systems will help to reduce the burden of all symptoms of mental illness, including self harm, which is much more likely in those suffering with psychiatric conditions. The narrative of the dangerous mentally ill person as the main operator behind the devastating toll of gun violence in this country is dangerous and deluded. It often discourages those who need help to seek it out.

I heard a gun rights supporter on a radio show emphasizing the well-worn saw that “Guns don’t kill people — people kill people.” He said that if someone puts a gun down on a table it doesn’t hurt anyone until a bad person picks it up. My mind raced over the images of the small child picking up the gun out of curiosity, the teenager picking it up in a moment of despair, the intoxicated man picking it up in a moment of rage. These people would typically not be identified as dangerously mentally ill in a background check.

Much of the destruction from easy access to firearms is not from the bad guys but rather from the person in your home who, in a moment of immature judgment or human frailty, acts impulsively. Gun deaths in the home are far more likely to be caused by people who live there than the by the phantom “villain” who comes in uninvited. Public health data has shown repeatedly that having a gun in the home increases the risk of someone in the home dying by gun violence. Suicides, accidents, and domestic disputes cause many, if not most, of the gun deaths in this county.

The ridiculous polarization of this complex discussion into histrionics characterized by sound bites such as “We don’t need gun safety measures, just lock up the crazy people,” is heartbreaking and absurd. In ignoring stacks of research, gun rights advocates vastly overestimate human beings’ capacity for self-control. It is not just “bad people” who cause harm with guns — it is you and me. People living with bipolar disorder, and all other serious psychiatric illnesses, need more support and care — not to be treated as the scapegoat for this most complex and painful social problem.

“Stop Violence” sign image available from Shutterstock

As I prepared my story for the presentation, I realized that I am never the one who calls 911 when my wife is experiencing a manic episode. My wife has always been the one to call, usually because she is experiencing paranoia and psychosis and feels the need to call the police for protection.

This made me wonder… why? If my wife fell down the stairs or collapsed in the kitchen, I wouldn’t hesitate to call 911 for help, but when she’s in the throes of mania, a serious medical emergency, I don’t call for help. Why? Well, I came up with the following list of possibilities:

• When I ask my wife if she wants to go to the hospital or needs to see her doctor or therapist, she usually tells me, “No.” (Of course, this makes me wonder why I accept this answer when she’s manic. Maybe I’m just a slow learner.)
• I’m too proud, thinking that we can handle the situation ourselves. (Occasionally, we do manage to pull out of a tailspin with medication and lifestyle adjustments.)
• I’m ashamed that my family has mental illness. I’m pretty much past this now, but I think that maybe subconsciously, the whole “What will the neighbors think?” question finds its way into my internal dialogue.
• I re-enter the denial stage that we talk about in our NAMI support group meetings, hoping against hope that the symptoms will magically disappear, and everything will be okay.
• I’m afraid that my wife or I will be arrested and taken to jail, even though this has never happened.
• I’m afraid that my wife will blame me for having her “committed.” Even when I realize that hospitalization is necessary, I have a terrible time making that decision. Fortunately, in our situation, the doctor has, on occasion, stepped in and taken the decision off my plate.
• I’m not sure when to step in or step back… the situation might escalate over several days, and I’m just not sure at what point we’re actually in crisis stage.
• In some cases, family members try to get help for their loved one but the legal system gets in the way. This hasn’t been the case for me; usually, I’m the one getting in my own way.

Is it me? Am I the only one who hesitates to dial 911 when my loved one is experiencing a manic episode? Please share your experiences and insights.

Police officer photo available from Shutterstock

Maddie’s tale is very inspirational and well-written. Definitely recommended reading for any college students who suffer melt-downs, which unfortunately is all too common. We encourage you to read Maddie’s story, “I Am Who I Am.”

College woman photo available from Shutterstock

In their study, published in the British Journal of Psychiatry and titled “Treatment in a specialised out-patient mood disorder clinic v. standard out-patient treatment in the early course of bipolar disorder: randomised clinical trial,” Lars Vedel Kessing et al. followed 158 patients who were discharged from their first, second, or third hospital admission with a single manic episode or bipolar disorder.

72 patients received treatment in specialized mood disorder clinics, which combined evidence-based psychopharmacology treatment with group psychoeducation once a week for 12 weeks followed by three additional booster sessions. The remaining 86 patients received standard care from a primary care physician, private psychiatrist, or local community mental health center.

The rate of readmission to the hospital was significantly decreased for patients who received treatment in the mood disorder clinic. In the six years following discharge from the clinic, the rate of readmission to a hospital was 36.1% for the group receiving treatment in the mood disorder clinic versus 54.7% of the group receiving standard treatment. The duration of readmission stays in the hospital were also shorter: 12 versus 22 days for the first readmission and 33 versus 49 days for cumulative readmissions over the course of six years.

Researchers also found that those who received treatment in the mood disorders clinic more often used a mood stabilizer or an antipsychotic and their satisfaction with treatment was more prevalent than among patients who received standard treatment.

Not Surprising

These findings are not very surprising. Most psychiatrists would agree that people who receive some sort of intensive outpatient care following a hospitalization will generally have a more positive prognosis. I might add the importance of including family members in some sort of outpatient counseling programs, particularly psychoeducation for families who are dealing with bipolar for the first time.

Other Benefits of Mood Disorder Clinics

I am curious about other potential benefits of this type of clinic. Do these clinics help to prevent hospitalizations overall? Do they act sooner and/or more intensively when symptoms of an episode appear? Are such clinics more effective at keeping people in care between episodes?

Mood Disorder Clinics in the United States

In the U.S., these clinics are most commonly found at University Centers where research is being conducted. Many people don’t live near these types of centers. Is there potential for creation of free-standing types of clinics that could reach more people? What about accessing these mood centers through technology for people who live further away? Can we develop a more integrated system that would provide mechanisms for community-based psychiatrists and mental health centers to receive support and consultation from specialty mood disorder clinics?

Looking Forward to Future Developments

I will be looking forward to seeing more research in this area and in working with colleagues, patients, and families to harness the power of advances in communications, information systems, and technology to assist us in translating these findings into real world help for people with bipolar disorder.

Let us know what you think.

You may also want to check out “Mood Disorder Clinics Help Many Bipolar Patients Avoid Hospital” also on PsychCentral, by Traci Pedersen, Associate News Editor.

Depressed girl photo available from Shutterstock

• Support: An employment network (EN) that contracts with the Social Security Administration offers career counseling, job placement, and ongoing support services.
• Nine-month trial work period (TWP): The TWP allows you to test your ability to work for at least nine months. During your TWP, you will receive full SSDI benefits no matter how much you earn as long as your work activity is reported and you have a disabling impairment.
• Expedited Reinstatement (EXR) of benefits: If your benefits stopped because of your earnings level, you can request to have your benefits reinstated without having to complete a new application. While Social Security determines your benefits reinstatement, you are eligible to receive temporary benefits for up to six months.
• Protection from Medical Continuing Disability Reviews (CDR): You will not have to undergo a medical continuing disability review (CDR) while participating in the Ticket to Work program.

For additional details, including information on how to sign up for a free Webinar on how the program works, visit Ticket to Work.

If you’ve participated in this program, please post a comment to share your experience.

As the article points out,

Lithium is the most effective mood stabilizer for the treatment of bipolar disorder, but it is toxic at only twice the therapeutic dosage and has many undesirable side effects.

The researchers discovered ebselen by searching through the National Institutes of Health Clinical Collection, “a library of bioavailable drugs considered clinically safe but without proven use,” looking for a medication to see if any had effects that overlapped with those of lithium, and they found ebselen.

Ebselen appears to function as a neuroprotective agent. Lithium, the traditional and most effective treatment for many people with bipolar disorder, also has neuroprotective qualities. Ebselen also has far fewer side effects than lithium. Lithium can be toxic in only modestly elevated doses, but ebselen does not have this problem.

The researchers found that ebselen reduced manic symptoms in mice that were made manic by giving them amphetamines — a common mouse “model” for mania. The next step will be for ebselen to be tried in humans.

This is an example of looking at medicines that were made for one thing and seeing if they might work on another condition — a process commonly referred to as “repurposing medication.” Having such extensive databases available about medicines and how they work makes it much easier for scientists to look for and find medicines that can be tried in new ways.

Hand with pill photo available from Shutterstock