Integrative approach to managing bipolar disorder

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By Carolina Brooks, BA, IFMCP

In my clinic, I have seen several patients who have been diagnosed with unipolar depression and prescribed a selective serotonin reuptake inhibitor (SSRI), which usually makes them feel worse or sparks an extreme mood episode. In their intake forms and initial consultation, they clearly describe mood episodes which are more akin to bipolar disorder (BD).

In general, appointments with a primary care physician are ten minutes long, so a lot of these patients are initially misdiagnosed. My first role as an integrative clinician is to write to their doctor, outline my observations and what they have described, and refer them back for a proper mental health evaluation.

A 2018 review in Therapeutic Advances in Psychopharmacology discussed various genetic risk factors which have been identified in BD, including polymorphisms in brain derived neurotrophic factor (BDNF), catechol-O-methyl transferase (COMT), monoamine transporters, gamma-aminobutyric acid (GABA) receptors, and genes for calcium channel subunits (CACNA1C). Many prophylactic medications for BD act on calcium channels or GABA receptors. Environmental factors include childhood emotional abuse, early parental loss, and psychological stressors such as suicide of a first-degree relative, recent marriage, divorce, unemployment, or childbirth. BD is also commonly associated with substance abuse, so it’s important to screen for these behaviors with BD patients.

A 2017 review in Brain Sciences discussed BD and immune dysfunction, with cytokine studies demonstrating BD is associated with chronic low-grade inflammation, with an increase in pro-inflammatory cytokine activity during mood episodes.   The article also talks about BD’s common inflammatory comorbidities include inflammatory bowel disease, autoimmune thyroiditis, psoriasis, rheumatoid arthritis, and systemic lupus erythematosus. Commonly associated chronic infections include herpes viruses, cytomegalovirus, and Toxoplasma gondii.

In addition, a 2019 article in International Journal of Environmental Research and Public Health discussed the increased prevalence and risk of cardiovascular disease, type two diabetes, and obesity in bipolar patients. This is not just a consequence of medication side-effects as these risks seem to also be present in drug-naïve patients. In fact, poor blood sugar regulation in BD is linked not only with a negative, chronic course of disease, but also with rapid cycling and poor response to mood stabilizers.

It is crucial with this patient cohort not just to support mood stability, nutrient assimilation, and address nutrient depletions and medication side-effects, but to address potential immune dysfunction, and clear underlying pathogens, as well as supporting hypothalamic-pituitary-adrenal axis balance, blood sugar regulation and proper sleep. The biggest challenge I see in clinic is treatment compliance, and what I find helpful is explaining brain chemistry to patients, and how nutrition and lifestyle factors can influence how they are feeling. With these patients, I usually start by optimizing the diet to regulate blood sugar and increase phytonutrient intake and fiber, remove inflammatory triggers such as saturated fats, gluten, dairy and increase oily fish, seeds, and nuts. I also work on underlying factors, such as correcting mitochondrial dysfunction, and support patients with nutraceuticals and herbs, frequency specific microcurrent and ear acupuncture.

Case Study

About nine months ago, I started working with a thirty-year old female patient, diagnosed with BD and taking benzodiazepines during episodes of rage, and olanzapine for maintenance therapy, having tried numerous medications, including lithium which made her feel worse. She suffered frequent depressive mood episodes. During manic episodes she primarily experienced rage, to the point where she was breaking furniture and punching holes through doors. In addition, she was suffering with digestive symptoms such as persistent bloating and diarrhea, and severe dysmenorrhea.

She was struggling to put on weight, frequently hypoglycemic, and was experiencing regular periods of insomnia. She was unable to work, and had a fractured relationship with her family, although they supported her by paying for her treatment and therapy. She had recently parted ways with her psychotherapist, and I insisted that before we started working together, she find someone new to work with, and spoke to her primary care physician to ensure that our approach would be collaborative.

Her diet was poor, high in refined carbohydrate and fried foods, while being extremely lacking in phytonutrients. She regularly ordered Chinese takeout as her partner did not cook, did not enjoy healthy food, and she was not motivated. I asked her to stop ordering takeout food, particularly as the Chinese food she was ordering contained monosodium glutamate, which is neuroexcitotoxic. I also asked her to eliminate gluten, dairy, caffeine, processed sugars, fruit juices and dried fruits.

To start, I asked her to use a meal delivery company which provided healthy gluten and dairy-free fridge fills. When she complained about the cost, I pointed out that her takeout meals were costing more. I provided smoothie recipes to ensure she was getting a good amount of greens and other phytonutrients, made up a herbal nutritive and superfood powder for her including wild blueberry, acai, nettle, dandelion, and medicinal mushrooms including reishi, cordyceps and lion’s mane to add to smoothies along with an organic plant protein. She had previously had adverse reactions to herbal medicine and did not want me to use anything else, so this was a rare case where I did not use a lot of herbal medicine.

I highlighted the need to implement regular stress management strategies, and we started with Heartmath and breathing exercises. I also left a few semi-permanent needles in her ears in the Shen men, point zero and her liver point to calm her. I recommended that she come into clinic for her bi-weekly appointments so we could regularly frequency specific microcurrent on her during the sessions.

Her initial bloodwork showed low alkaline phosphatase, ferritin, B12 and folate. Her protein and globulin levels were low which made me suspect protein malabsorption, and inflammatory markers were raised.

Her triglycerides, cholesterol markers and vitamin D were all low, indicating fat malabsorption. Her fatty acid panel indicated a very low omega-three (n-3) fatty acid index high levels of arachidonic acid. I recommended a high dose docosahexaenoic acid (DHA) fish oil supplement for her to take twice a day.

She was also presenting with subclinical hypothyroidism, which is likely why prescription lithium did not work for her. A 2011 paper in Journal of Thyroid Research stated that overt and subclinical hypothyroidism is the most common abnormality present in BD. Rather than immediately recommend a porcine thyroid glandular, I worked on ensuring adequate minerals in the diet and optimizing stomach acid production by supplementing with digestive enzymes which included betaine hydrochloric acid. I recommended that she do a stool test and referred her back to her doctor to be screened for celiac disease. A 2015 review in Clinical Practice and Epidemiology in Mental Health found that the frequency of risk of bipolar disorder in celiac disease was seventeen times higher than in a control sample. Her celiac markers came back positive so we worked on restoring her gut structural integrity and mucosal immune function with pre and probiotics, short-chain fatty acids and short-term high dose vitamin A.

Within the month, she had already started to feel better. Her digestive symptoms had improved dramatically, and her mood felt more stable. She was enjoying her new diet, and was being consistent with the supplements, partly because she was coming into clinic every two weeks and felt accountable. Her rage episodes had reduced in frequency, although she broke a chair in the first week after seeing me, but she had started breathing exercises and was doing Heartmath exercises three times a day. Within three months, her dysmenorrhea had completely disappeared, and she had started to put on weight. Nine months down the line, I continue to monitor her and communicate frequently with her primary care team.

References

Carta, M. G., Conti, A., Lecca, F., Sancassiani, F., Cossu, G., Carruxi, R., Boccone, A., Cadoni, M., Pisanu, A., Francesca Moro, M., & Demelia, L. (2015) The Burden of Depressive and Bipolar Disorders in Celiac Disease. Clinical Practice and Epidemiology in Mental Health : CP & EMH, 11, 180–185. Retrieved from: https://doi.org/10.2174/1745017901511010180

Chakrabarti S. (2011) Thyroid functions and bipolar affective disorder. Journal of Thyroid Research, 2011, 306367. Retrieved from: https://doi.org/10.4061/2011/306367

Łojko, D., Owecki, M., & Suwalska, A. (2019) Impaired Glucose Metabolism in Bipolar Patients: The Role of Psychiatrists in Its Detection and Management. International journal of environmental research and public health, 16(7), 1132. Retrieved from: https://doi.org/10.3390/ijerph16071132

Rosenblat, J. D., & McIntyre, R. S. (2017) Bipolar Disorder and Immune Dysfunction: Epidemiological Findings, Proposed Pathophysiology and Clinical Implications. Brain sciences, 7(11), 144. Retrieved from: https://doi.org/10.3390/brainsci7110144

Rowland, T. A., & Marwaha, S. (2018) Epidemiology and risk factors for bipolar disorder. Therapeutic advances in psychopharmacology, 8(9), 251–269. Retrieved from: https://doi.org/10.1177/2045125318769235