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Ask The Expert

Each month, an expert will answer your questions about bipolar disorder. 

Dr. Lisa Eyler


Question: Is it true that bipolar disorder may cause individuals to age earlier and, if so, is there anything we can do about it?"

Answer: Yes, people with bipolar are more likely to suffer from many age-related conditions and have an earlier age at death due not only to unnatural, but also natural, causes. This suggests that bipolar should be considered not just as a brain disorder but as a condition that affects many systems in the body. To prevent or minimize premature or accelerated aging, treatments should focus both on dampening mood swings and increasing overall health and wellness. Providers, family members, and patients can work together to incorporate positive lifestyle changes like healthy diet, exercise, sleep hygiene, and stress reduction, all of which may lead to a better outcomes for those living with bipolar disorder.


Stephen Hinshaw, M.D.


Question: What is stigma, and what effect does it have on people with bipolar disorder and their families?

Answer: Stigma is the psychological shunning and even shaming of members of "outgroups" not favored by mainstream society.   Despite great progress in understanding and treating many forms of mental illness, stigma remains strong in this area, at the levels of policy (e.g., lack of parity for mental health coverage), media coverage (which still features images of violence and incompetence), and low levels of social contact (driven by fear and stereotypes).  The potential unpredictability of manic and depressive cycles may fuel stigma against bipolar disorder per se.  Of particular concern is the tendency for members of stigmatized groups to internalize society's messages and biases, fueling self-stigma--a key predictor, in mental health, of failing to engage in needed treatments.  Even more, family members must often battle associated stigma (formerly called "courtesy stigma") in their efforts to support their affected relatives.   

Signs of progress are apparent: Think of self-help and advocacy groups, more accurate and humanized media coverage, and spreading knowledge of the real benefits of evidence-based treatments for improving the lives of countless individuals experiencing bipolar disorder.  In the end, it will take far better access to proven treatments, along with greater empathy and support on the part of the general public, to turn the tide. 

Aaron Krasner, M.D.

Question: How do I know if my child's thoughts, feelings or behavior are "normal" or signs of concern?

Answer: If your child experiences any signs of concern, ask yourself the following questions:

  • Intensity: How intense are your child's behaviors, thoughts or emotions?
  • Frequency: How often does your child feel or behave this way?
  • Duration: How long do these individual episodes or periods last?
  • Functionality: Above all else, consider how your child is functioning and whether or not your child is impaired in any way at home, at school or with friends.

If your child's emotions or behaviors are more intense, frequent or longer in duration than most other children his or her age and those emotions or behaviors are causing impairment, it may be a sign of concern and you should contact a  mental health professional for a consultation. 

 David J. Miklowitz, Ph.D.

Question: What is Family-Focused Therapy and why is it helpful? Who is it most helpful for?

Answer: Family-focused therapy, or FFT, is an outpatient treatment for adults and children/adolescents coping with bipolar disorder (BD).  It is usually given in conjunction with mood stabilizing medications, and is meant for the person with BD and his or her parents, spouse, siblings, or extended relatives. It is psychoeducational in the sense that people with BD and their relatives learn about the disorder and the early warning signs of new episodes, learn to recognize what are the person's symptoms vs. personality traits, and why taking medications and keeping regular routines are important. In children and adolescents, the role of academic and family stressors in eliciting moods is emphasized. In later stages of FFT, families learn to cope with stress through communication and problem-solving skills training, such as role-playing ways to listen actively or ask positively for changes in one another's behavior. FFT can be most helpful when families have high criticism and conflict. FFT can last between 12 and 21 sessions, with weekly sessions at first and then biweekly or monthly.

 How is it effective for treating bipolar disorder in adults, adolescents or children?
In several randomized clinical trials, we have found that people with BD who get FFT and medications have better symptom outcomes over 1-2 years than people who get treatments such as brief psychoeducation or individual supportive therapy and medications. The effects extend to young people with BD and children or adolescents who are at high risk for developing the disorder. People may get better from their symptoms faster, have less severe ongoing symptoms, or have fewer recurrences. Many people also report a better quality of family relationships after FFT.  

Ellen Leibenluft, M.D.

Question: What does psychosis look like in children? How can you tell the difference between psychosis and an active imagination?

Answer: Given how children’s view of the world changes as they get older, it can be difficult to differentiate psychosis from an active imagination, especially in young children. In answering this question, it is important to consider the child’s age and developmental level. Hearing voices or seeing things that aren’t there are very common in children.  These normal experiences usually last for only a short time, and they often occur at bedtime.  Psychosis, unlike active imagination, typically is accompanied by other relatively serious problems, such as major changes in behavior or marked, persistent mood or anxiety symptoms.  If you are concerned, and if your child is not seeing a mental health professional that you can ask, then consult your child’s pediatrician.  

Holly A. Swartz, M.D. 

Question: What is Interpersonal and Social Rhythm Therapy (IPSRT) and how does it differ from other psychotherapies for bipolar disorder?

Answer: Interpersonal and Social Rhythm Therapy or “IPSRT” is a psychotherapy for bipolar disorder that helps people regulate their moods by keeping more regular social rhythms (routines) and doing better jobs of managing their relationships with others. It is based on a scientific understanding of the link between worsening mood symptoms (such as sadness, sleep disturbances, low energy, and concentration problems) and changes or disturbances in regular schedules as well as an understanding of the impact of life events on mood. 

IPSRT has been shown to be effective in preventing relapse of mania and depression in bipolar disorder and in treating acute episodes of bipolar depression. Although there is a lot of overlap among the psychotherapies for bipolar disorder, IPSRT is unique in its focus on the interrelationship among routines, rhythms, mood, and relationships.

Robert M. Post, M.D.

Question: What is repetitive transcranial magnetic stimulation and how can it help those with bipolar disorder? 

Answer: Repetitive transcranial magnetic stimulation (rTMS) is used over the left prefrontal cortex for the treatment of depression. It produces rapidly fluctuating magnetic fields can transit across the scalp and skull to generate electrical impulses in brain that fire neurons. Depression is often associated with deficient neural activity in the prefrontal cortex and rTMS can enhance this and improve depression.Sessions usually last about 20 minutes and are done 3 times a week for 3 to 4 weeks. rTMS is FDA approved for treatment of unipolar depression, but it clearly also works in those with bipolar depression.

It is unlike ECT in that it does not require anesthesia or the induction of a seizure; the patient remains awake and there are no cognitive difficulties. Clinicians who actively and positively talk to the patient during the time of the stimulation may get better results than those who do not interact with the patient, but this has not been systematically proven.

Michael Bauer, M.D., Ph.D.

Question: What is the relationship between the thyroid system and mood?

Answer: Circulating thyroid hormones, produced by the thyroid gland, play a critical role in the metabolic activity of the adult brain, and neuropsychiatric manifestations, e.g. depression, of thyroid disease have long been recognized. Without optimal thyroid function, mood disturbance, cognitive impairment and other psychiatric symptoms can emerge.

Several lines of evidence suggest that there may be abnormalities in thyroid hormone metabolism in patients with mood disorders. Supporting this hypothesis, are observations that suboptimal availability of circulating thyroid hormones may contribute to the high rate of treatment failures in bipolar disorder. Because of this relationship, adjunctive treatment with thyroid hormone is one approach for people with bipolar disorders. Such use of levothyroxine (L-T4) at supraphysiologic doses has offered promise in research studies, including rapid cycling bipolar disorder and refractory depression. The hypothesis driving these studies was that increasing the availability of thyroid hormones to the brain does change the phenotypic expression of the disorder and is associated with improvement of mood and cognition.

Eduard Vieta, M.D., Ph.D.

Eduard Vieta

Question: How is bipolar disorder diagnosed?

Answer: Bipolar disorder is diagnosed using clinical criteria, based on a number of symptoms and their severity and duration. This means that there is no unequivocal objective way to confirm the diagnosis yet. However, if someone fulfills the criteria that are described in either the DSM-5 or the ICD-10 (the two systems that are used for that), the diagnosis is undoubtful and the potential benefit of treatment is very high. 

The problem is that quite many people have some of the symptoms but not all, and therefore do not qualify for the diagnosis despite having many of its features and consequences. The use of clinical criteria is still the best system until the ongoing research can provide ways of confirming the diagnosis which are not exclusively based on symptoms, as in other areas of medicine. If anyone has reasonable doubts on his/her diagnosis, it may be good to get a second opinion from another specialist.

July: Tadafumi Kato, M.D., Ph.D.

Question: What is epigenetics and how does it help us find new treatments for bipolar disorder?

Answer: DNA delivers the information of the structure of proteins, i.e., amino acid sequences. This is usually thought as "genetic information". In addition to this information, how DNA is read is determined by DNA-protein interactions. DNA undergoes chemical modifications such as methylation, and this affects DNA-protein interaction and gene expression. This phenomenon is called "epigenetics". Whereas DNA sequences are transmitted from parents, DNA modification can be affected by environmental factors including early environment. Effect of early environment is known to be a risk factor of bipolar disorder, but its mechanism is not known. Epignetics might shed light on the mechanism of how early environment confer a risk of bipolar disorder, and if it is clarified, it might be a clue to develop new treatments to counteract early adversity.

June: Michael Berk, Ph.D.

Question: What new treatments are available or being developed for bipolar disorder?

Answer: New treatments can be divided into lifestyle, psychological and biological. The first studies aiming to modify lifestyle variables such as diet and smoking cessation are being done and they hopefully will contribute to wellness.

In terms of psychological therapies, much attention is being directed to adaptation of psychological modalities to the Internet. These include mobile apps, electronic self-monitoring and psychosocial interventions for individuals such as and for caregivers such as Many studies are being done adapting the third-wave CBT modalities such as Mindfulness and Acceptance and Commitment Therapy to people with bipolar disorder.

On the medication front, newer versions of existing therapies, such as anti-convulsants and new anti-psychotics are being developed. Studies are being done to clarify the role of antidepressants in the disorder. Interestingly, a number of recent studies have been published suggesting Lithium remains the most effective agent for the disorder.

A number of more experimental novel strategies are being studied, which vary from aspirin, ketamine, N-Acetylcysteine, minocycline and mitochrondrial augmentation therapies. While these are promising, it is too early for these to be first-line options.

May: Martin Alda, M.D., FRCPC

Question: Can genetics help us find which medication will work best?

Answer: To choose among the multiple treatment options for bipolar disorder, physicians often rely on a trial-and-error approach: different medications are used one after another until an effective one is found. Any such individual trial can take several months or even longer. As a result many patients stabilize after a considerable delay. Ongoing research promises to find effective treatments based on combinations of molecular genetic markers. While “we are not there yet”, we already know that the presence of specific psychiatric disorders in families and how affected family members responded to their treatments can guide us in selecting among treatments such as lithium, lamotrigine or atypical antipsychotics. Thus carefully documented family history alone can be useful for individualizing the treatment of bipolar disorder. 

April: Andrew A. Nierenberg, M.D.

Question: When it comes to nutrition, what is the best diet for people with bipolar disorder? Are there any foods that should be avoided?

Answer: Increasing evidence suggests that people with bipolar disorder may benefit from healthy diets consistent with a Mediterranean diet - that is with plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts along with olive oil. Minimizing salt and red meat and avoiding processed foods including juices can also help. The main idea is to eat foods that decrease inflammation and avoid foods that increase inflammation. Also, foods with high fiber content can help good bacteria grow in our gut (the microbiome). Some also recommend natural probiotics (such as fermented foods, kefir, and yogurt). 

March: Trevor Young M.D., Ph.D., FRCPC, FCAHS

Trevor Young

Question: How can mood stabilizing drugs alter the changes in brain structure and function in patients with bipolar disorder? 

Answer: There are many different treatments for bipolar disorder but no one has figured out what is common between them to account for their mood stabilizing effects. A number of labs including ours have focused on targets inside the cell to explain how the drug works. Among these targets, factors involved in cell growth and protection and the brain’s antioxidant system stand out as the most important. These experiments point to the ability of treatment to prevent potential cell loss and damage that occurs particularly after multiple mood episodes. This suggests that early intervention and prevention against more mood symptoms is a good choice for most people with bipolar disorder.


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