BDNF is a protein encoded by a gene in the human body. Researchers at Yale University have put BDNF directly into the brains of depressed rats, and, within forty-eight hours reversed the depressive symptoms of these animals. So clearly BDNF plays an important role. The issue is that we need to find medication or develop medication that can, first of all, withstand the acid in the stomach, second of all, be absorbed properly, and, third, be crossing the blood-brain barrier, the barrier between the blood vessel and the brain, to get into the brain to do its job.

Unfortunately, BDNF is a small protein and each time chemists try to make these molecules into something that will be soluble in fat (because the brain is a very fatty), they have to twist the molecule and so on, and it becomes toxic to the liver. BDNF is an evolving story.

-Serge Beaulieu, PhD, Mini-Psych School 2009

Marijuana itself can cause anxiety and depression, as can withdrawal from it. Another bad thing about marijuana is that it can work as a trigger for people more at-risk of developing a psychosis. Finally, people often believe that the marijuana they are smoking is clean, but then, have a bad trip, come to the emergency, and their urine test shows that they have PCP (or Angel Dust) in their system. That drug can trigger a lot of hallucinations. Marijuana is also cut with amphetamines, cocaine, all sorts of things.

The answer to that question is complicated. Would marijuana trigger an episode in someone who is predisposed to have a bipolar disorder because of his genetics and so on? Sure, that would be a good trigger factor. There’s an additional factor – the environmental factor – that would accelerate the process. Basically, you have genes interacting with environment, and, if you have some of the genes that predispose you to develop a bipolar disorder but you are very careful that you are controlling your stress level very well, you make sure that you sleep very well at night, do not have irregular life patterns and so on, and are avoiding drugs, you are more likely to never develop the disorder at all.

We derive this kind of knowledge from colon cancer research. If you have one predisposing gene, but a good environment and diet, then you probably won’t develop cancer. If you have two genes that predispose you to colon cancer, but are careful enough, you may have polyps that they can detect and remove if you get your colonoscopy every year. You will be lucky enough to be ok. But, if you don’t have a good diet and don’t eat enough fibre, eventually you will end up developing colon cancer. And if you have all three susceptibility genes to colon cancer, well, unfortunately, whatever you do, you are bound to get it. It’s this kind of interaction between genetics and environment that we are dealing with in medicine in general, not only in psychiatry. That’s the state of our knowledge so far.

-Serge Beaulieu, PhD, Mini-Psych School 2009

That depends on the state of mania. If the person is really turning into a danger to themselves or others, then you should call the police. And when I say police, the ambulance and the police come together. The Civil Code of Québec (Sections 26 to 30) gives them the power to say that this person, in their opinion, is a danger to themselves or others. And they have the power to force someone to go to the hospital to have a psychiatric exam. They don’t need a judge anymore to do that. Do they do it? No, they are scared of lawsuits. If this patient is known to a doctor somewhere, they will do whatever they can to contact that doctor. Sometimes, I have to argue with the policeman in order to get them to bring the patient because the policeman insists that the patient is not that agitated, etc.

Most of the time, in these kind of situations where we are in a grey zone, the family or friends, or someone who has the interests of the patient in mind, will have to go to the court or the community clinic or the department of psychiatric justice, where they have a psychologist and social worker who know about that stuff, are in touch with the police, can intervene, know the procedures, and will ask you to describe the dangerous behaviour. You will get a court order asking for a psychiatric assessment. And then the person has to come.

But, you know what works the best? It’s the patient’s own signature. That’s what we do in psychoeducation. We ask them to sign a contract with someone whose judgement they respect. This person can then remind them they signed that piece of paper, telling them that now is the time to go in for an assessment. Most of the time, if we are able to do that, then we are able to fix things without too much drama. However, if they are really totally agitated or out of control, there is no insight, and they are getting irritable and violent, I think that then there is no other solution then asking the ambulance to intervene unfortunately.

-Serge Beaulieu, PhD, Mini-Psych School 2009

Yes. Sometimes people are diagnosed with rapid cycling bipolar disorder, which means that their mood is always fluctuating. However, we often confuse emotional volatility with bipolar disorder. Somebody who has mood swings is not necessarily bipolar. Somebody who has mood swings might have them because they see everything in an exaggerated way—because they have histrionic or borderline personlities or are extremely anxious. That is very different from a bipolar disorder where you have mood fluctuations that are less related to circumstances.

It depends on how bipolar II is diagnosed. People with bipolar II usually suffer from less severe depression and mood elevation than we see in classic bipolar disorder. Sometimes mood elevation occurs when people take antidepressants. As they come out of their depression, their mood becomes a little higher than it had been normally. Sometimes, people suffering from depression can have mood swings based on the way they react to their environment. They are very hyperactive and sensitive. Depression can also combine with some of the personality problems referred to earlier (where people are very emotional and sensitive to rejection, fall in love quickly, fall out of love quickly, are very happy one day and not so happy the next). That combination may appear to be bipolar II disorder, but is more likely to be a combination of depression and something else. The best way to tell is to get to know people over time. Usually bipolar II disorder changes take place over a long period of time and the pattern recurs. If your mood swing changes in one day, it's not the same as being depressed for six months, then up for three months, as you would more likely see in bipolar disorder.
-Mimi Israël, MD

10%

There is potential damage that can be done to the brain through repetitive episodes of depression; it will start affecting your brain to the point where the concentration is not as good as it used to be, etc. Sometimes, it could be the dosage of the medication, and so we look at that too. Are there more risks to developing Alzheimer’s disease? Vasavan Nair, MD, at the Douglas, has been working on this for years and years, and he is not convinced that this is the case at all. There is no proof.

-Serge Beaulieu, PhD, Mini-Psych School 2009

The consequences would be exposing that person to a treatment that will not necessarily give great results. There is also the issue of bipolar disorders being a spectrum and not a yes/no diagnosis. I tend to see a lot of patients who have had five, six, seven, even ten depressions in their life. Huge ones, treated with ECT sometimes. Then they are sent to me because they are having another episode of depression. When you have this repetitive pattern, you have to start asking yourself what you are treating: a unipolar depression or a variant of bipolar depression? Maybe it’s just that nobody saw or prove that there were any hypomanic or manic symptoms before.

-Serge Beaulieu, PhD, Mini-Psych School 2009

What I often say to my patients when they are in a state of depression is that it’s very difficult to do psychotherapy because their concentration is not good. They are tired or they miss appointments. We prefer that the person is at least able to cooperate in the process of psychotherapy when we start it.

What do we do in that psychotherapeutic process? That’s specific to the individual and it depends on what the problem of the person is. Bipolar disorder in one person is not the same as bipolar disorder in another person. It depends on their life story and experiences and all sort of things. Sometimes we have to treat another disorder. A bipolar patient has 35 times more risk of having an anxiety disorder or an obsessive compulsive disorder, for at least one year in their life-time, compared to the general population. Sometimes we have people coming in with bipolar disorder and post-traumatic stress disorder. And also they are addicted to cocaine or alcohol or something else, and we have to treat all of this at the same time. We don’t tell them “Go treat your dependence of alcohol first, and come back to see me after.” Those days are over, we don’t do that anymore. We treat the whole thing at the same time. So it’s time-sensitive, but, yes, we prefer to have some kind of stability before starting psychotherapy.

We also do psychoeducation. We have had successful results with it in research trials and are now asking for funding to transfer these techniques to the CLSCs. We can then focus our efforts on more novel approaches such as MBCT. We’ll do more research on new approaches, and other people will do the psycho-education. That’s what we want to do.
-Serge Beaulieu, PhD, Mini-Psych School 2009
 

Bipolar disorder is a very democratic disease. I see patients coming in Mercedes, and I see patients coming in by foot or on bicycle, I see poor people, I see people who are multimillionaires. I see women and men in the same ratio, and I see it in all cultures. But, there are cultural differences in the way behaviours are interpreted and perceived. In this case, we ask the family and the friends who have the same culture, same tradition, same points of reference. Easy.

-Serge Beaulieu, PhD, Mini-Psych School 2009

Zindel Segal has written books on mindfulness-meditation therapy, and is one of the three authors who developed this technique. Kabat-Zinn is a biologist and the therapy we use at the Douglas is based on his technique. It is called mindfulness-based cognitive therapy (MBCT).

I was inspired by a study done by Zindel and his colleagues that showed that, in patients who have had three major depressive episodes in their life and are now doing fine, MBCT works to improve their maintenance and prevent a relapse. However, MBCT does not work in patients who have had only one episode of major depression – that is, it won’t delay their relapse into another episode.

I was impressed because it was the first time I saw a therapy that was almost designed for sicker patients. That’s why we are focussing on studying this technique. In order to get the funding we need to continue our work, we need to obtain pilot data on MBCT. This is what we are currently doing. It’s not blinded because it’s a pilot and we want to see how it works, what kind of problems occur, whether people come to the therapies, and whether they stop applying the principles of MBCT. These are the kinds of questions we ask. How many patients persisted in the study? How many patients stopped coming, and how will this affect the power of your study and your result, etc? If we get the funding, we would have a four or five year study to really find the data we are looking for regarding the effectiveness of MBCT.

-Serge Beaulieu, PhD, Mini-Psych School 2009
 

Tryptophan has been studied not so much as a stand-alone treatment for depression or bipolar depression, but certainly as an add-on to antidepressants and other agents to stabilize and improve the mood. Simon Young at McGill University has demonstrated that, by depriving people from tryptophan in their diet for 24 hours, you can trigger depressive symptoms. So, clearly, it has a role.

Now, tryptophan comes from our diet. So, if you eat well, unless you have a problem with the absorption of proteins and amino acids, you should have enough tryptophan in your system in order to synthesize enough serotonin in your brain. So, it would be surprising that tryptophan alone would be sufficient enough a treatment to resolve depression. But as an add-on agent, it could be tried.

-Serge Beaulieu, PhD, Mini-Psych School 2009

Psychoeducation is basically giving the power to the patient. It’s teaching the patients what their disease is all about and how they can help themselves to be better treated. When you are diagnosed with diabetes, for example, you have to go meet a nurse who will teach you how to eat properly, check the sugar in your blood, inject insulin into yourself if you need to, etc. That’s psychoeducation, and that’s the motto of treatment with any chronic disorder.

Bipolar disorder is not something that will go away. Sure we can treat the first episode, the second episode, etc. Except that, if you don’t take the treatment, it will come back. And the treatments are not always perfect either. So the patient needs to be able to tell me “Dr. Beaulieu, you need to see me, because I’m not doing too well” They need to be able to identify that for themselves.

-Serge Beaulieu, PhD, Mini-Psych School 2009
 

No. If a person is bipolar and goes off Lithium, chances are that this person will relapse. It could happen that there will not be a relapse but evidence suggests that most people will relapse. 

- Joseph Rochford, PhD, Mini-Psych School 2009

Research conducted in Montreal and Canada has shown that bipolar disorders are quite rare before the age of 16. This does not mean that bipolar disorders do not exist in children; I treated an 11-year-old child who presented with a profile that was clearly manic. In the United States, there has been a current of thought in the past 10 years that bipolar disorders could appear in children between the ages of 6 and 12, especially if the biological parents also suffered from bipolar affective disorder. We have to be very careful because it is difficult to determine whether a child has bipolar disorder, bipolar depression, or something else. The other problem is that the treatment is lithium, which causes a lot of side effects. We need to carefully consider putting a child of 7 or 8 on this kind medication for life. We try to delay medication and manage the problems in some other way.
- Johanne Renaud, MD, Mini-Psych School 2010