Dr Alice Lam 9th December 2019
Though bipolar disorder affects the same number of men as women , there are differences in how it manifests. This may be due to the combination of hormonal changes throughout a woman’s life which can affect both the condition itself and its treatment. We will look at the following factors, including onset of puberty, premenstrual mood changes, pregnancy, postpartum and menopause.
Interestingly, it is a hotly debated discussion amongst experts about whether bipolar disorder in children under 12 years can be confidently diagnosed, for several reasons outside the scope of this article .
Premenstrual syndrome (PMS) is seen in up to about one in three women. It usually begins 4-10 days before a period and settles soon after bleeding starts. The symptoms can be physical, such as bloating and breast soreness, or mental such as mood changes – for example low mood, anxiety and irritability.
Around 3-8% of women with PMS have symptoms that include more severe levels of emotional distress .
A study of almost 300 women  suggested that women with bipolar disorder who experienced premenstrual exacerbation of their mental health tended to have:
Fortunately, some research reports that women whose bipolar disorder is treated optimally will have less mood fluctuation through their menstrual cycle .
As with any woman who does not wish to become pregnant, family planning is relevant to those with bipolar disorder. Part of the reason is that an unexpected pregnancy can have its challenges with symptoms such as mood worsening, but also because some medications are risky to an unborn baby.
The other thing to know is that some contraceptives don’t work well with some bipolar medications. For instance, carbamazepine can stop the combined oral contraceptive pill working properly.
For women who do not wish, or are unable to use contraception, there are options for bipolar maintenance treatment that would be relatively safe in the case of a planned or unplanned pregnancy.
If you have some questions about these issues, it’s an invaluable conversation to have with your doctor.
Here are some factors which may be associated with relapse during pregnancy :
Because of the ethical implications in research, including the testing of drugs for their efficacy and safety in pregnancy and breastfeeding, we have a more limited range of medication options during these times. Some medications that are considered safe in pregnancy are not recommended in breastfeeding, and vice versa. Certain medications such as sodium valproate and carbamazepine, for example, are not recommended in pregnancy.
A woman’s psychiatrist, obstetrician and GP might collaborate to ensure the best way to manage things for mother and baby. Medication advice depends on balancing factors such as whether the woman is stable, her past history of episodes, whether she is already on medications and whether she is/plans to be breastfeeding.
There is a risk of stopping medications in a woman whose bipolar is stable but is planning, or is already, pregnant. The change in drug regime along with the hormonal changes and new stressors around in preparing for a new baby can also sometimes cause negative changes in mental health .
On the other hand, some women will experience fewer recurrences during pregnancy .
A small study followed 89 women who stopped their bipolar medications for six months before, and 12 weeks after conception. The researchers found that:
Between one-quarter and one-half of women may experience a mood episode in the six weeks after delivery. This might be due to hormone changes, disturbed sleep and/or increased stress .
Hormonal changes can cause mood and behavioural fluctuations that may be hard to distinguish from “baby blues” or just the joy of welcoming a new baby into the family. A mood diary and regular check-ins with her partner might help a new mother with monitoring for significant changes more objectively.
It may be beneficial for the woman to have a plan drawn up before pregnancy, listing support persons such as her partner, friends and family, doctors etc. so that any early warning signs can trigger a set of practical actions including urgent medical review.
Ideally the woman would be able to be with her baby should she experience a relapse, and if hospital admission is needed then a mother and baby unit is ideal. Prolonged separation from her infant should be avoided so as not to affect the forming maternal-baby bond. We must also not forget to offer support to the woman’s partner too .
There is some interest in whether menopause increases risk of depression in women with bipolar disorder. Several sources suggest that menopause does exacerbate bipolar disorder [3, 9]
Although nearly one in five women report severe emotional disturbances during the transition into menopause , more research is needed to confirm these findings and to further guide clinicians on medical management during perimenopause.
Disclaimer: this content is not a substitute for individual medical advice.
Dr Alice Lam / 6th November 2019
Do you already use supplements, or are you thinking of trying some for your bipolar disorder?
A study in the USA found that one in five people with bipolar used a supplement long term. The most commonly taken supplements were fish oil, B vitamins, melatonin and multivitamins1.
Even with such popular usage and marketing messages like “safe” and “natural”, one should bear in mind that many supplements:
Because the amount of information can be quite confusing, in this article we’ll try to summarise current knowledge. You can read all the way through or just skip to the section that most interests you. Abbreviations are expanded in the footnotes.
As an aside, diet and supplements are not recommended as replacements for medication. However, there is hope that in the future, individual dosing could be used to minimise or possibly eliminate medication, according to Dr William Walsh, scientist and expert in nutritional medicine of the Walsh Research Institute3.
Omega-3 fatty acids are nutrients that are naturally occurring and found in the form of EPA and DHA in foods like salmon, tuna, sardines, free-range chicken and omega-3 fortified eggs. A third form of omega-3 called ALA is found in dark green leafy vegetables like spinach, walnuts, flaxseeds and soybean.
Only small amount of dietary ALA can be converted into useful EPA and DHA. It is thought most people in the United States get enough ALA from the foods they eat, as well as small amounts of EPA and DHA5.
Some research suggests that there is body inflammation in acute mania, and to a lesser extent, in bipolar depression4. It is possible that omega-3 fatty acids may reduce inflammation in the nervous system8.
However, though there are conflicting studies on whether omega-3 helps treat or prevent episodes of mania or depression6, Dr. Jeffrey Rakofsky (Assistant Professor in the Mood and Anxiety Disorders Program at Emory University School of Medicine in Atlanta, Georgia, USA) and Dr. Boadie Dunlop (Director of the Mood and Anxiety Disorders Program at Emory University) reviewed data from multiple trials and felt there was reasonably strong evidence compared to other supplements for bipolar depression7.
Dr. Candida Fink, an experienced psychiatrist in New York (who co-authored a book for patients along with John Kraynak, who has lived experience of bipolar disorder) writes that most doctors would suggest 1-2 grams daily EPA for antidepressant effect8.
SAMe is found in the body and is made from methionine, an amino acid found in foods. It has been widely studied in people with unipolar depression and bipolar disorder.
It has been advised that SAMe should not be taken for bipolar depressive symptoms as SAMe may induce or worsen symptoms of mania. There is also concern that SAMe may interact with other supplements and medications by increasing levels of serotonin (a chemical produced by nerve cells), such as antidepressants, L-tryptophan, and St. John’s wort9.
Dr William Walsh even states that some people with bipolar disorder could already have excessive SAMe in their bodies3.
This yellow flower has been used as a medicine since ancient times as “the devil’s scourge” to ward off evil spirits. It was popular in the early 2000’s but popularity has waned due to concerns about lack of efficacy and risk of interaction with other medications8 e.g. may reduce benzodiazepine effectiveness.
Although many studies suggest St. John’s Wort can help treat mild-moderate unipolar depression, there doesn’t seem to be any strong evidence for treatment of bipolar depression. It is also risky to take along with other antidepressants due to the possibility of developing serotonin syndrome (this can cause tremor, diarrhoea and confusion) or triggering mania1O.
Melatonin is produced by the brain in reaction to the amount of ambient light, and thus helps us regulate our circadian rhythm. In turn, it is possible that the body rhythm helps regulate mood and vice versa.
In people with mania, some studies suggest there is an early rise of lower melatonin levels, compared to healthy people and those with unipolar depression11.
Early research shows that taking melatonin at bedtime increases sleep duration and reduces manic symptoms in people with bipolar disorder who also have insomnia. But there is also a risk that taking melatonin might make symptoms worse in some people with bipolar disorder12.
For now, there is a lack of clear consensus on whether melatonin is helpful in bipolar disorder11.
Coenzyme Q10 – This vitamin-like substance is found in the body, and in small amounts in meats and seafood. It is commonly used for heart health. Early research shows that taking coenzyme Q10 may improve symptoms of depression in people over 55 years of age with bipolar disorder, but more research is needed13.
5-HTP – This substance is produced by the body and present in the seeds of an African plant called Griffonia simplicifolia. It increases serotonin production which itself affects mood, sleep and other body functions. There is a little evidence it can help with depression, anxiety and sleep, but just as with St. John’s Wort, if taken along with other antidepressants there is a risk of developing serotonin syndrome8,14.
GABA – Made by the brain, GABA is thought to help anxiety and mood by blocking brain signals. However, there is little evidence to confirm its efficacy for mood and anxiety, nor consensus on safe dosage15.
Inositil7,8 – Mood stabilising medication like lithium and valproate are thought to work by stabilising the vitamin-like inositol’s signals within cells. Dr. Jeffrey Rakofsky and Dr. Boadie Dunlop found just one study that showed possibly efficacy. There is also a risk of triggering mania.
Kava – Part of the pepper family, this herb is native to islands in the South Pacific. Many people take this for anxiety. There are mixed conclusions about efficacy, and it has been linked to severe liver injury, especially if combined with alcohol16.
NAC – this substance is used by the body to make antioxidants (such as glutathione) that help the body’s cells recover from stress and damage. A group of researchers reviewed multiple studies and could not advise NAC as a safe, effective treatment for bipolar disorder17.
Valerian has a distinctive odour and is extracted from a plant native to Europe and Asia. Out of 250 species V. officinalis is most commonly used. A review of nine trials was inconclusive for valerian’s sleep benefits. It can interact with benzodiazepines and other supplements such as St. John’s wort, kava, and melatonin18.
Vitamins B1, B6, B12 – there is a lack of good evidence to say these help people with bipolar disorder.
Vitamin D – some studies show a link between depression and low vitamin D. However, but there is insufficient evidence to recommend it for bipolar depression8.
Folic acid – also known as vitamin B9 and found in the form L-methylfolate, it has been shown in some studies to enhance antidepressant response in people with unipolar depression19. However, in a review, Dr. Jeffrey Rakofsky and Dr. Boadie Dunlop did not find good supporting data for folic acid in bipolar depression treatment7.
Although taking folic acid does not appear to improve the antidepressant effects of lithium in people with bipolar disorder, WebMD suggests that taking folate with the medication valproate may improve the effects of valproate20.
Dr Walsh comments that people with bipolar disorder may have folate under- or overload, so individual tailoring of folate supplementation may be beneficial3.
Zinc – In earlier studies, lower blood levels of zinc were linked to depression. However, evidence seems to be pointing towards a use only in unipolar depression by increasing the efficacy of antidepressant therapy.
Magnesium – A 1990 study of rapid cycling bipolar patients suggested that taking magnesium might have had an effect as strong as lithium in about half the people21. Another study in 2000 suggested that taking magnesium with the drug verapamil reduced manic symptoms better than verapamil alone22. More studies are needed.
In short, with this array of frequently inconclusive data, it would be advisable to have a chat with your psychiatrist first before taking supplements for bipolar disorder.
People with bipolar disorder have a higher incidence of obesity, diabetes, high blood pressure, and unhealthy blood fat levels. The reasons for this may include:
There are even less well-understood possibilities, such as deliberately increasing sugar intake to reduce high levels of stress-induced blood cortisol24.
An interesting recent study25 looked at the eating habits of 113 well people with bipolar and 160 people without bipolar. Those with bipolar were generally less adherent to a Mediterranean diet than the non-bipolar group, and 74% of the bipolar group were overweight versus 68% in the non-bipolar group. The levels of blood sugar and triglycerides (a type of blood fat) were also higher in the bipolar group.
A review of studies24 looking at diet in bipolar disorder suggest the following:
As well as goal-setting towards regular healthier meals and snacks and restoring a regular circadian rhythm (there is more on this is in the October 2019 BipolarLife newsletter), the amount and type of food are also important for our mood and energy levels.
Dr Ellen Frank, Professor of Psychiatry and Professor of Psychology at the University of Pittsburgh School of Medicine, Pennsylvania, recommends having three to four smaller meals per day to help keep mood and energy levels stable26.
Depression and Bipolar Support Alliance (DBSA) suggests keeping a food and mood journal to see if a symptom is triggered by something dietary27. An example might be agitation and nervousness after a certain amount of caffeine, or broken sleep, low mood and poorer impulse control after alcohol.
Given the above study findings, it may help to follow a portion-controlled Mediterranean-type diet (definitions vary) to help with mood and energy.
This diet typically looks like this:
If there are additional challenges to meet such as medication-related weight gain, you could also get support from your doctor and/or dietician. Don’t forget to check out online resources including
Disclaimer: this content is not a substitute for individual medical advice.
by Lana Birgess
Bipolar disorder is a manageable, long term condition that affects a person’s mood. The highs and lows characteristic of some forms of bipolar disorder may affect the way a person thinks, feels, and behaves. This includes how they act in romantic relationships.
People with bipolar disorder experience severe high and low moods. These are called manic (or hypomanic) and depressive episodes. However, with the right treatment, many people with bipolar disorder can have healthy relationships. With the right treatment, people with bipolar disorder may have long periods during which their mood is stable. Or, they may only have mild symptoms, which are unlikely to significantly affect their relationship.
Without effective treatment, manic episodes may cause a person with bipolar disorder to become irritable. A person with bipolar disorder may disagree with their partner more easily during a manic episode.
Risk taking behaviors, such as spending sprees or binge drinking, may happen during a manic episode. These behaviors may create tension within a relationship.
If the person with bipolar disorder experiences major depressive symptoms, they may be less communicative during a period of depression. They may become tearful or feel hopeless and pessimistic. Having low self-esteem may reduce a person’s sex drive, or they may feel less affectionate. It can be difficult for a person’s partner to know what to say or do to help. They may feel rejected, mistaking symptoms as a lack of interest in the relationship.
During a mixed episode, a person with bipolar disorder may have symptoms of mania or hypomania and depression at the same time. This may be confusing or stressful for their partner, who may not know what kind of reaction to expect.
Tips for when your partner has bipolar disorder
All relationships take work, and being in a relationship with a person with bipolar disorder is no different. A healthy partnership requires empathy, communication, and self-awareness.
There are many ways to build a strong relationship with a partner who has bipolar disorder, including by:
Workplace stress and a lack of sleep can trigger the symptoms of bipolar disorder.Triggers are events or circumstances that could disrupt the mood state of a person with bipolar disorder. This could increase their risk of experiencing a manic or depressive episode.
Triggers could include dealing with a stressful work scenario, not getting enough sleep, or missing doses of medication.Not everyone with bipolar disorder will have triggers, but if they do, they may have learned about them through their own experience with the condition. Asking about personal triggers can help someone support their partner when those events or circumstances arise or help them avoid triggers. However, many mood changes can occur without triggers.
Asking what behaviors are typical for a person with bipolar disorder during high or low periods can help someone recognize their partner’s shifts in mood.
Some behaviors may be a warning sign for one person but not for another. For example, for a person with a high sex drive, wanting to have sex often may be normal. For others, however, it could be a sign of a manic episode.
Likewise, for those whose libido is usually low, showing little interest in sex may not coincide with a low mood. However, for someone whose sex drive is usually high, losing interest in sex may indicate a depressive episode.
Learning which behaviors are normal for a loved one and which can indicate a shift in mood can be very helpful. This enables the partner of a person with bipolar disorder to distinguish usual behaviors from symptoms of bipolar disorder.
To support a person’s treatment plan, start by discussing what the plan involves. This may help reduce any anxiety in the relationship.
While some people appreciate being asked about how their treatment is going, others may find it intrusive or paternalistic. It is crucial to talk about how best to support treatment and whether there are aspects of treatment that a person does not want to discuss.
Creating a support plan is a useful way for someone to learn how to help their partner with bipolar disorder. This might include planning activities, making a list of useful contacts — such as a trusted relative or a therapist — and making adjustments to daily routine. Having a support plan in place reassures both partners that they will know how to respond to a very high or low period.
High or low periods may be emotional for both partners. For this reason, open communication is crucial. A partner should explain how the behavior of a person with bipolar disorder makes them feel, without judging them or stigmatizing the condition. Talking openly can be a powerful way to reduce the negative impact that certain behaviors may have.
It is vital for the partner of a person with bipolar disorder to support their own mental health by practicing self-care. Through self-care, a person can strengthen the relationship. It can also improve their ability to care for their partner.
Some ways a person can practice self-care when their partner has bipolar disorder include:
Below are some additional relationships tips for people with bipolar disorder to consider:
Sharing this information may not be first date territory for everyone, but it is important to discuss in the early stages of a relationship. Not everyone will understand how bipolar disorder can affect a person’s life. Telling a partner about bipolar disorder and noticing how they respond is one way to gauge whether they are likely to be supportive.
Being consistent with treatment is the best way to reduce symptoms, but which treatments work best may vary between individuals. A combination of therapy and medication works for many people. Regular exercise, yoga, mindfulness, or journaling may also help support a person’s overall well-being.
Sharing any changes in mood with a partner can help both parties recognize and respond to a high or low period before it escalates.
Telling a partner what to expect during manic or depressive episodes, as well as recognizing and telling them about warning signs, can help ensure that they do not blame themselves. For example, if a person with bipolar disorder is starting to feel a low mood, telling their partner early not only helps the partner be supportive, but it can also prevent them from thinking that the low mood indicates a lack of interest in the relationship.
If a partner tells a person with bipolar disorder that they have noticed signs of a mood change, it is vital to listen to them. Listening to and discussing feedback without being defensive can improve intimacy. Of course, not all mood changes are due to bipolar disorder. It is human to feel happy or sad in response to life’s events.
Having a diagnosis of bipolar disorder does not mean that a person will have relationship problems. However, without effective treatment, bipolar disorder symptoms may cause relationship tension. By sticking to a good treatment regimen, a person with bipolar disorder may have long periods with few or no symptoms. All relationships require empathy, communication, and emotional awareness. These qualities help a person be a supportive partner to someone with bipolar disorder. People with well-managed bipolar disorder can build healthy, long term relationships.
Come along to our newly formed Women’s Support Group held on the fourth Tuesday of every month at The Youth House next to the Monash Church of Christ, 44-48 Montclair Ave, Glen Waverley 3150, 7:30pm – 9:30pm.
Gain support, understanding and friendship in a safe and open environment.
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