Lithium

I'd like to develop this post gradually, as there is a lot of evidence to summarize and refer to.

But here is a start:

"Mood stabilizers" are drugs which are thought to help treat the symptoms of bipolar disorder. It is hoped that these drugs might reduce manic symptoms, prevent recurrence of manic symptoms, while also reducing or preventing symptoms of depression.

The first treatments for manic episodes were sedatives, including barbiturates and antipsychotics.

The first "mood stabilizer" though, was lithium carbonate.

Lithium itself is the third-simplest element in the universe, after hydrogen and helium. It tends to form salts. It is structurally very similar to sodium, which is a salt-forming element essential to most every life function (that is why we find sodium ions abundantly in all body fluids, and in a similar concentration in the ocean; table salt consists of sodium and chlorine atoms which join together as crystals). Yet, lithium is not normally present in the human body, and is much less common in the universe as well, compared to hydrogen, oxygen, carbon, sodium, etc.

The mechanism of lithium's action in the body, when used as a drug, is still poorly understood. Its similarity to sodium is probably essential to its mechanism. I'll add to this commentary later, but for now I will say that the mechanism of lithium salts probably involves multiple actions inside of nerve cells; these actions may modulate cellular activity.

Here are some of the clinical actions of lithium carbonate, when used as a medication in those with bipolar disorder (I will list the actions in order of how clearly proven and substantial the effect is):

1) It reduces symptoms of mania
2) It may reduce the length of a manic episode (note that just because a treatment reduces symptom severity, it may not reduce the duration of the symptoms).
3) It may prevent the recurrence of manic symptoms
4) It may prevent the recurrence of depressive symptoms
5) It may reduce depressive symptoms when they occur

There are other uses for lithium carbonate as well:
1) It can be combined with an antidepressant to improve symptom control in unipolar depression
2) It may help treat specific symptoms such as irritability and rage
3) It helps prevent cluster headaches (a type of severe, recurrent headache)

Lithium is probably most useful in "classic bipolar disorder", in which individuals experience manic episodes with elevated mood (as opposed to irritable or "dysphoric" mood), and in which the mood episodes are not recurring frequently during an average year (i.e. there is no "rapid cycling").

Here are some of the side-effects of lithium:
1) thirst, increased urine production
2) tremor (shaky hands)
3) nausea
4) sedation -- usually it is a much less pronounced type of sedation compared to antipsychotics, benzodiazepines, or other "sleeping pills". But there can be feelings of reduced energy, reduced clarity of thinking, or lethargy
5) toxicity to the kidneys -- this is not common, but needs to be checked for regularly
6) inhibition of thyroid function -- this is not permanent, nor is it harmful to the thyroid gland (in fact, it may "rest" the thyroid gland); but diminished thyroid levels, if present, requires treatment with a thyroid supplement)
7) acne or other skin rashes
8) toxicity in overdose

There have been a few studies questioning the effectiveness of lithium, particularly in terms of its value in preventing recurrent mood episodes. But for many people it does appear to be very effective, both as an acute treatment and as a preventative agent. It probably works much better as an "anti-manic" agent than an "anti-depressant".

There are various forms of lithium, and various dosing regimes. In most cases, it can be dosed simply: once at bedtime. The concentration of lithium in the blood needs to be measured periodically. Levels which are too high can increase the likelihood of toxicity (mind you, excessive levels could usually be assessed on the basis of side-effect complaints); levels which are too low may not be effective.

In my experience, some people may benefit from staying on lithium, but adjusting the dose to a point that is more tolerable for them. It may not necessarily be true that everyone needs to have a full therapeutic concentration of lithium in order for it to work. For some people, the side effects may outweigh the benefit at full doses.

However, it is a frequent situation in an emergency room, or on a mood disorders hospital ward, that people with clear histories of bipolar disorder, stable on medication, end up having a recurrence of severe mania a few weeks or months after tapering or stopping their medication (often lithium). In some of these cases, the manic symptoms may have already been building up, leading the person to discontinue their medication (rather than the other way around). But in many of these cases, it seems to me that the lithium had been protecting them, and that the recurrence of mania happened because of medication discontinuation.

There is also some evidence that sudden lithium discontinuation can provoke increased mood instability. So, while there are no overt withdrawal symptoms from stopping lithium, it should be tapered slowly if possible (I would say over 1-2 months at least).

It should be emphasized that lithium is not a perfect drug, either in terms of side effects or in terms of effectiveness. Many people on full doses of lithium still experience relapses of mania. But it is quite clear, from decades of experience, that lithium can be helpful for many people with bipolar disorder.

References:

http://www.ncbi.nlm.nih.gov/pubmed/17547586
(a 2007 Cochrane review of mood stabilizers, showing good evidence for lithium, but also encouraging use of other mood stabilizers--which for some people could be superior to lithium-- such as valproate and atypical antipsychotics)

http://www.ncbi.nlm.nih.gov/pubmed/8120960
(a 1994 JAMA article showing the effectiveness of lithium and valproate, compared to placebo, in acute mania)

http://www.ncbi.nlm.nih.gov/pubmed/10807488
(a negative study, comparing lithium, valproate, and placebo; published in the major journal Archives of General Psychiatry in 2000--it shows very little difference between lithium, valproate, and placebo treatments with respect to relapses in bipolar patients over a 1-year period; however this study was probably biased in favour of high placebo effects and lower medication treatment effects, for a variety of reasons)

http://www.ncbi.nlm.nih.gov/pubmed/10891035
(a randomized, placebo-controlled study from Archives of General Psychiatry in 2000, showing a pronounced effect of lithium in reducing aggression in hospitalized children with conduct disorder)

http://www.ncbi.nlm.nih.gov/pubmed/16924942

http://www.ncbi.nlm.nih.gov/pubmed/3314489

(a Dutch review article from 2006, and an older article from a U.S. nephrology journal, summarizing the risk of kidney disease associated with lithium; about 15-20% of people taking lithium long-term may experience a decline in kidney function. While this decline is usually mild, I think that an alternative mood stabilizer should be strongly considered if someone is developing signs of reduced kidney function while on lithium).

Noise Pollution

Peace and quiet are important for mental and physical health.

Here are a few links to references:

http://www.ncbi.nlm.nih.gov/pubmed/14757721

http://www.ncbi.nlm.nih.gov/pubmed/15936421
(A 2005 study published in Lancet which showed that noise causes increased irritability, and a negative impact on cognitive development in school-aged children)

On a related note, the use of music players such as iPods can cause permanent hearing loss, particularly if people have the volume turned up very high. People are more likely to use higher iPod volumes if the background noise level is also high. Here are some links to information and evidence:

http://www.hearinglossweb.com/Medical/Causes/nihl/mus/ipod/ipod.htm#fast

http://www.ncbi.nlm.nih.gov/pubmed/19124629

http://www.ncbi.nlm.nih.gov/pubmed/17430434

http://www.ncbi.nlm.nih.gov/pubmed/17711774

Also, the sound volume at a rock concert or a nightclub is sufficient to cause hearing damage, especially if this is an activity done regularly without hearing protection. I recommend using earplugs at rock concerts (yes, I'm serious!) Here is some evidence:

http://www.ncbi.nlm.nih.gov/pubmed/8499785

http://www.ncbi.nlm.nih.gov/pubmed/16825883

http://www.ncbi.nlm.nih.gov/pubmed/12176760

Imaginary Numbers - a metaphor

One of my favourite mathematical metaphors comes from an area called "complex analysis".

I can't resist the metaphor, because of the nature of the mathematical language involved.

I've always loved mathematics. It is enchanting, beautiful, yet infinitely challenging. There is no area within mathematics that cannot be developed into an almost impossibly esoteric branch of its own. Its theoretical abstraction must surely exceed the complexity of the physical universe (unless we consider abstract mathematical ideas to actually be part of the physical universe).

The appreciation of mathematics as an art form or as a form of esthetics has, unfortunately, been hampered by an educational approach which often leads people to experience mathematics with dread, anxiety, or despair.

Anyway, here is the mathematics:

1) A "square root" of a number is another, smaller number, which, when multiplied by itself, gives the first number. So, for example, the square root of 25 is 5--since 5 times 5 equals 25. I suppose we could add that 25 in fact has 2 square roots, since (-5) times (-5) also equals 25. This idea of a "second" square root already involves a higher degree of abstraction.

2) There are some numbers which do not seem to have any possible square root. For example, what would be the square root of (-25)? There does not seem to be any number which, when multiplied by itself, yields a negative number.

3) So, how about if we create such a number, imaginatively? Such a number has been invented, and it is called the "imaginary number", signified as "i". The imaginary number i is an abstraction, with the property that i times i equals -1.

4) What is the use of having such an imaginary number? What application could it have? Well, as it turns out, it is enormously useful in understanding and solving problems in physics and engineering. And, I think, it demonstrates a very beautiful link between phenomena that might initially seem completely different.

The exponential functions are phenomena which, if represented graphically, appear to represent rapidly accelerating growth. If something keeps doubling regularly, the growth is "exponential". Many phenomena in nature can be described using exponentials.

The trigonometric functions are phenomena which, if represented graphically, appear to represent waves, which oscillate regularly; in the case of the "sine" function, we have a "sine wave", which fluctuates, forever, between -1 and 1. Many other phenomena in nature can be described using the trigonometric functions.

There appears, at first sight, to be no obvious relationship between the exponentials, which represent unbridled growth (e.g. population growth); and the sine wave, which represents continuous, regular, well-bounded waves (e.g. the swinging of a pendulum).

But if we figure out a formula which can calculate an exponential, and a formula which can calculate a sine wave function, we find that if "imaginary numbers" are allowed, the two types of functions are variations of the same thing. Hence we have the mathematical fact:
exponential (ix) = cos(x) + i sine(x).

So here is the psychological metaphor:

The link between something which rises, escalates, explodes upwards towards infinity, and something which is stable, repetitious, and finite -- is "imagination". They are variants of the same, larger, thing, as long as you can expand your perspective of understanding.

The introduction of imagination may transform a problem of unbridled excess into one which could include stable regularity. Similarly, imagination could transform the monotony of a "sine wave" type of life into something more excitedly or wildly "exponential".

In approaching seemingly impossible life problems, I think it is important to be able to step back, and sometimes to allow an entirely new perspective or way of thinking.

Family Therapy ideas for Individual Therapy

Long ago I found that ideas from the theory and practice of family or group therapy could be well-applied to individual therapy.

In family or group dynamics, individuals can find themselves in particular types of roles (e.g. observer, leader, critic, outsider, social butterfly, scapegoat, etc.). Sometimes these roles can be "typecast", entrenched through repetition. Such entrenchment of roles may not allow a person's full range of emotion & personality to flourish.

Similarly, within one's own individual mind, it is possible to "typecast" oneself, through repetition of assumed roles.

The same tactics that can help in a group or family setting (e.g. encouraging a deliberate exploration of entrenched roles, and experimenting with taking on different role styles) could be beneficial for an individual.

Another dynamic which is explored in family therapy is the type of boundaries that exist between different members, in conjunction with the strength of the bond between each different member.

There may be "detached" relationships (a weak bond and little involvement), or so-called "enmeshed" relationships (in which people are extremely involved in each other's affairs, sometimes not allowing the individual to have an experience of autonomy).

Boundaries may be weak, absent, or atypical (in different cases, leading to different types of abuse, or to young children taking on the role of parent or confidante with their mother or father). Or boundaries may be extremely rigid, lacking flexibility (perhaps leading to an uncomfortable authoritarian atmosphere in the relationship or household).

In family therapy, reflection and work can be done on building healthy relationship bonds, encouraging a relaxation of enmeshments, so as to permit more individual autonomy. And work can be done to encourage healthy boundary formation.

Similarly, in an individual therapy setting, personal boundaries and "inner relationship bonds" can be a source of problems. "Enmeshments" may occur on an inner level, perhaps in the form of ruminative or obsessive preoccupations. "Detached" inner relationships may occur, in which parts of self or behaviour are held separate, and leading to a non-integrated sense of self, or a sense of self consisting of numerous independent facades or personas. Boundaries could be weak (perhaps leading to impulse control problems), or inflexible (perhaps leading to an inability to adapt easily, or to adjust to another person's style in a relationship).

In individual therapy, similar work can be done to build healthy "inner bonds", and healthy "inner boundaries".

I consider this comparison between family/group and individual therapy to be metaphorical. In the theory of so-called "object relations" such metaphorical ideas may be considered quite literally, i.e. that external relationships become literally "internalized" in the formation of a healthy self.

In practice, I think some of the ideas from family therapists can be imaginatively applied in an individual therapy setting.

As a concluding--but practical and concrete-- tangent, an exercise in one form of family therapy is to research your family tree, and to collect information about the life stories of different members of your family tree. This would include immediate relatives, but also more distant ancestors.

I think this is an interesting exercise in individual therapy for a variety of reasons:
1) because psychological symptoms, problems, personality styles, etc. are substantially influenced by genetic factors, it can be interesting to examine the life stories of those who are genetically related to you. It may also be true that the SOLUTIONS that work best for various life problems are also influenced by genetic factors (e.g. there is some evidence that a particular medication, if it works extremely well, has a higher chance of working extremely well for another person who is genetically similar). In a broader, "life story" sense, you may find stories in your family of various adversities that are similar to your own, and you may come to understand how these different ancestors coped. Some of these stories may be cautionary (i.e. warnings about how NOT to cope with certain problems), but some of the stories may be inspiring, and may guide or reassure you in your own pathway to solving your life problems.
2) the process of examining stories from family and ancestors can increase your sense of connectedness, identity, and meaning. Many families in our modern culture have become quite disconnected, and perhaps this disconnectedness fosters loneliness, materialism, or a cultural vacuum. As you gather information about these family stories, you may end up re-connecting with distant cousins, etc. and this could expand or enhance your network of friendships.
3) If many of the stories you find are very negative, this type of information could be upsetting, traumatic, or exacerbate more recent post-traumatic symptoms. If this is the case, such an exploration may need to be taken very slowly, if at all. But sometimes, if you feel ready, the process can become part of healing from the trauma. The exploration of a full story--even if the story is very negative--can sometimes be a prelude to healing. This task encourages the exploration of stories from distant relatives, as well as immediate relatives--this increases the likelihood that you will find some positive, inspirational stories, even if many of the stories are traumatic or turbulent.

Vitamin D & other vitamins

I'm re-posting this as a separate entry, because I think it's important.

I recommend multivitamin supplements as standard advice, because I think there is negligible evidence of risk (other than the effect on your wallet), and potential benefit.

The role of vitamin supplements ought not to be overvalued -- I think they are unlikely to cause a pronounced change in any symptom. But a vitamin deficiency could possibly prevent other treatments for depression from working optimally. Many people with psychiatric symptoms have less than optimal nutrition, for various reasons; therefore I feel that vitamin and mineral deficiencies are more likely.

There is some evidence of vitamin supplements being used to augment antidepressant medications, but the level of evidence is quite weak.

Vitamin D in particular is probably important to supplement, particularly for those of us who experience dark, cold northerly winters (vitamin D is normally produced in the body when our skin is exposed to the ultraviolet rays from direct sunlight). Furthermore, most of us wisely use sunscreen when it is sunny and warm, so most of us are getting less vitamin D from the sun. There is some evidence that the RDA for vitamin D (200-400 IU per day) is too low, particularly when we consider that brief whole-body skin exposure to sunlight generates an equivalent of perhaps 10 000 IU.

Here is a reference to a very interesting and promising recent study suggesting beneficial mood effects from higher-dose vitamin D supplementation (people received the equivalent of about 3000-6000 IU per day, for a whole year); the study is from a major, highly respected internal medicine journal:

http://www.ncbi.nlm.nih.gov/pubmed/18793245
Here is an excellent reference examining the issue of vitamin D safety, dosage, and toxicity:

Vieth, Reinhold. "Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety", American Journal of Clinical Nutrition 1999;69:842–56

A recent study by Bischoff-Ferrari et al. (2009) showed that elderly hip fracture patients given 2000 IU per day of vitamin D for 12 months, had a 60% reduction in fall-related injuries and a 90% reduction in infections leading to hospitalization, compared to a group given only 800 IU per day of vitamin D.

Here's a reference to a 2008 study from a clinical biochemistry journal showing toxicity from prolonged very high-dose vitamin D, of over 40 000 IU/day over several years. It concludes that the lowest dose at which hypercalcemia can occur is about 3800 IU per day:
http://www.ncbi.nlm.nih.gov/pubmed/18275686

Based on the evidence I recommend supplementing with an extra 2000 IU of vitamin D daily (possibly up to 3000 IU), in addition to the 400 IU that is present in most vitamin supplements, unless you have a medical condition associated with abnormal calcium metabolism or abnormal sensitivity to vitamin D (e.g. sarcoidosis).

If you are taking high-dose vitamin D you should have serum calcium levels checked periodically, and possibly a serum vitamin D level.

I do not recommend "mega doses" of any other vitamin, since I do not see a good evidence base for this being helpful, and higher doses of many such nutrients can be toxic or dangerous. A few recent studies have shown that people taking certain vitamin supplements, such as vitamin A or E, actually do more poorly than the control group.