Written By Blanche Adonis [1]

Edited By Ashrene Rathilal and Genevieve Burrow

As part of a critical pathway for raising awareness, driving de-stigmatisation and cultivating an increasingly edifying community of transformation, the 30th of March marks World Bipolar Awareness Day – a day of global commemoration.

Formerly known as manic-depressive illness, the American Psychiatric Association (2013) describes Bipolar Disorder (BD) as a group of mood disorders in which perpetuating symptomatic features of mania and depression are present (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5], 2013). This band of disorders is grouped into the BD diagnostic category that primarily consists of three key subtypes, namely:

1. Bipolar I – fluctuating episodes of mania1 or hypomania2 and major depressive disorder3; or a ‘mix’ of the three 
2. Bipolar II – fluctuating episodes of major depression and hypomania
3. Cyclothymic disorder – is marked by observable symptoms of hypomania and depression for the duration of at least two years (American Psychological Association, 2007).

Mental health and advocacy communities have been witnessing a gratifying global increase in support from celebrities who campaign against the stigmatisation and discrimination of mental ill health, by sharing their personal journeys, challenges and successes, in an effort combat prejudices through education.

The key barriers for recognising symptoms and seeking adequate treatment for BD are largely attributable to factors such as stigma, discrimination, and misinformation (Maseko, 2019). In South Africa, BD affects more than four million of the recorded population (The South African Depression and Anxiety Group [SADAG], n.d.), and a total of 45 million of the global population (World Health Organisation [WHO], 2019). In a 2017 survey, SADAG reported 65% of the surveyed respondents experienced manic episodes (highs), 82% feeling severely depressed (lows), 50% have considered and 34% have attempted suicide (SADAG, 2017).

Various biological, environmental and recreational factors can contribute to the onset, precipitation, episodic triggers, perpetuation and the management of BD:

• Genetic predisposition, biochemical profile and comorbidity: According to Dr. Antoinette Miric, if an immediate family has been diagnosed with BD, one’s chances of developing the condition increases by about 10% (Singh and Miric, 2019). Medical conditions that commonly co-occur in people with BD, are metabolic syndrome, hypertension, diabetes, cardiovascular disease as well as brain and cognitive challenges (Miric, 2020). BD interferes with the chemical transmitters in the brain (SADAG, 2005), and interventions including chemical rebalancing is a crucial part of the treatment plan.

• Lifestyle and diet: Distressing life events may trigger episodes of mania and depression (SADAG, 2005). Miric (2020) recommends a good exercise and diet plan to limit mental health challenges and to maintain a healthy lifestyle by expunging drug and alcohol use.

• Substance abuse: Several studies have repeatedly found a perpetuating relationship between BD and substance abuse, with evidence indicating a cross-connection between early-onset BD and a more severe form of the condition, in comparison with those patients who do not abuse drugs and alcohol (Brady and Sonne, 1995).

• Typical age of onset: Bipolar episodes become initially observable, during the teen or early twenties developmental phases, while major depressive disorder (MDD) may only manifest in late adulthood (Mhlane, 2019).

• Research has shown the dangers of sleep deprivation. According to Bentley (2014), “sleep is not only an effect, but a symptom of the condition too”.  Chiba (2016) emphasises the importance of adequate sleep for optimal cognitive functioning, concentration span, the acquisition of new skills, memory and executive functioning. Sleep deprivation can mimic several diagnostic features of mood disorder and become identifiable, over time, through the presence of impulsivity, hallucinations and manic triggers in those with bipolar disorder, which may cause depressive mood, suicidal ideation and paranoia (Chiba, 2016).

   

Timely intervention is important. When left untreated, BD can have permeating adverse and disruptive consequences spanning across major aspects of one’s private, professional, and social lives (SADAG, 2005). The management of BD has seen increasing rates of success when combining the correct medication (mood stabilisers, antidepressants, anti-anxiety and antipsychotics), a practical therapeutic approach (cognitive-behavioural therapy, psychotherapy, family-focused therapy or electroconvulsive therapy) and a well formulated, integrative and tailored treatment plan with attainable objectives (American Psychiatric Association, 2010; SADAG, n.d.; SADAG, 2005). Essentially, to achieve the best treatment outcome, it is always advisable to follow a combined and holistic treatment journey closely with your healthcare practitioner.

Rethinking Stigma – Towards a De-stigmatisation of the Self:

Stigma is defined as a broad and dualistic social construct (Corrigan and Watson, 2002) ‘that results in social exclusion, disempowerment, and discrimination’ (Bathje and Marston, 2014). Public stigma refers to society’s reaction to those who are affected by mental illnesses, while self-stigma, an integrant of the broader construct (Bathje and Marston, 2014), ‘is the prejudice which people with mental illness turn against themselves’ (Corrigan and Watson, 2002). 

Samantha Smirin, a life coach, author of the book “Life Interrupted: A Bipolar Disorder Memoir”, and living with BD herself, makes compelling arguments on de-stigmatising oneself. In her book she draws attention to the ways in which those affected by BD can reach beyond the expectation of social and self-discrimination, to a position of personal re-orientation for acceptance, self-forgiveness and self-love. She emphasises her journey of forgiving herself for living a vicariously risky life, in search of filling the voids left by BD and the years of confusion caused by the condition (Smirin, 2020).

BD Vulnerabilities in the Current Climate of the Covid-19 Pandemic:

People in self-isolation or quarantine have reportedly become stressed, anxious and depressed with social distancing leaving many feeling disconnected and alone. Even in the absence of pre-existing mental health challenges the limitations and restrictions imposed on people have become particularly distressing which, naturally, becomes all the more amplified for those with pre-existing conditions (Chaskalson, 2020). Despite a demonstrated interlinked nature between psychosocial well-being and physical health, and the concurrent fostering of psychological and physiological therapeutic outcomes through rich clinical intervention, mass media makes little progress in anchoring the value in this approach, as a way forward for those struggling with existing mental illness (Chaskalson, 2020). 

Sifiso Mkhasibe, who is affected by BD, is a mental health activist and a stakeholder engagement leader at the South African Federation of Mental Health, addresses a personal challenge in the wake of the “out-of-stock” crisis. He attests to having fallen victim to the current medication paucity in the country, fearing that failure to remain ‘treatment-compliant’ may essentially hamper his ability to effectively manage symptoms. This could potentially result in a clinical relapse that would reverse years of commitment to maintaining a healthy and well-balanced lifestyle. Government and pharmaceutical companies are being held accountable and are yet to respond (Nkosi, 2020).

The World Health Organisation has practical guidelines for mitigating the symptoms of loneliness, depression and anxiety. These include prioritisng your needs and feelings and staying connected to friends and loved ones. Their full list may be found here:  https://www.who.int/publications/i/item/WHO-2019-nCoV-MentalHealth-2020.1

Remember:

Meaningful treatment encompasses a reciprocal journey between yourself, your mental health practitioner and your loved ones. The objective of a diagnostic formulation (the process of receiving a diagnosis) is to examine and explain the history, development, maintenance and manifestation of the condition, for diagnostic classification and to develop an effective treatment plan (APA Dictionary of Psychology, 2020).

In the words of the late Carrie Fisher4: “At times, being bipolar can be an all-consuming challenge, requiring a lot of stamina and even more courage, so if you’re living with this illness and functioning at all, it’s something to be proud of, not ashamed of. They should issue medals along with the steady stream of medication.”

Reach out:

SADAG does extensive work in the mental health environment and provides comprehensive information, accessible at . 

You can also find telephonic support by calling the following numbers:

• Suicide crisis line: 0800 567 567 
• Cipla WhatsApp chat line: 076 882 2775
• Cipla 24 hr mental health line: 0800 456 789
• Department of Social Development Substance Abuse Line: 0800 12 13 14 or SMS 32312
• PsySSA directory of psychological practitioners: https://www.psyssa.com/psychologist/ or call (011) 486-3322

Endnotes

1 Mania: a state of excitement, hyperactivity, and physical restlessness, along with boldness, poor judgement and an inflated sense of superiority and self-importance (APA Dictionary of Psychology, 2020).

2 Hypomania: elevated or irritable mood accompanied by combinations of inflated self-esteem, sleep disturbances, excessive talking, racing thoughts, inability to concentrate, increased activity or physical restlessness and increased risky behaviour, for example poor financial judgement and sexual indiscretions etc. (APA Dictionary of Psychology, 2020).

3 Major depressive disorder: a mood disorder marked by loss of recreational pleasures, persistent feelings of sadness and negativity, changes in eating habits, weight fluctuations, feelings of worthlessness and guilt, sleep disturbances, concentration problems, fatigue or restlessness, suicidal ideation and/or attempted suicide, but without episodes of mania, hypomania or mixed episodes of depressive and manic or hypomanic symptoms (APA Dictionary of Psychology, 2020).

4 A prolific author, and recognised globally as Princess Leia, the late Carrie Fisher was a heroine working against the stigma of bipolar disorder. Instrumental in the launch of bp Magazine, Carrie featured on three magazine covers since the year 2004. Her work and energy inspired many in the mental health community. Retrieved from   https://www.bphope.com/bipolar-buzz/carrie-fisher-15-honest-quotes-about-bipolar-disorder/ 

[1] Author writes in her capacity as Vice-chairperson of the PsySSA Student Division’s Media and Marketing Subcommittee. The PsySSA Student Division is a division of the Psychological Society of South Africa (PsySSA).

REFERENCES:

World Health Organisation. (2020). Mental health and psychosocial considerations during the COVID-19 outbreak. Retrieved from: https://www.who.int/publications/i/item/WHO-2019-nCoV-MentalHealth-2020.1

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: Author.

Maseko, C. (2019). Bipolar disorder misinformation prevents people from seeking help. Retrieved from https://health-e.org.za/2019/06/20/bipolar-disorder-misinformation-prevents-people-from-seeking-help/

Smirin, S. (2020). De-stigmatise yourself. Mental Health Matters, (7)2, p. 43 – 44

APA Dictionary of Psychology. (2020). American Psychological Association. Retrieved from https://dictionary.apa.org/ 

The South African Depression and Anxiety Group. (2005). Bipolar mood disorder: The illusive disorder. South African Psychiatry Review, (8)2, p. 79 – 80

The South African Depression and Anxiety Group. (n.d.). Bipolar disorder treatment and referral guide. Retrieved from http://www.sadag.org/images/sadag_downloads/bipolar.zip

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Mhlane, T. (2019). Bipolar disorder. Mental Health Matters, (6)4, p. 8 – 10

 Gaveeta Chiba, G. (2016). Dangers of sleep deprivation. Mental Health Matters, 3(2), 38 – 40

Bentley, A. (2014). Sleep easy – the highs and lows of sleep and bipolar. Mental Health Matters, 1(1), p. 20 – 22

Brady, K. T., & Sonne, S. C. (1995). The relationship between substance abuse and bipolar disorder. The Journal of Clinical Psychiatry, (56)3, 19–24.

Miric, A. (2020). Cognitive impairment in Bipolar Disorder. Mental Health Matters. (7)5, p. 13 – 15

Nkosi, B. (2020). Mental health patients hit hard by drug medication woes due to Covid-19. IOL online. Retrieved from https://www.iol.co.za/the-star/news/mental-health-patients-hit-hard-by-drug-medication-woes-due-to-covid-19-3d4b3ac4-7460-47e0-af13-1cbb95c7be3f

Chaskalson, J. (2020). COVID-19: Giving meaning to “social solidarity” through mental health support. Retrieved from https://www.spotlightnsp.co.za/2020/03/25/covid-19-giving-meaning-to-social-solidarity-through-mental-health-support/

Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 1(1), 16–20.

Bathje G.J., Marston H.N. (2014). Self-stigmatization. In: Teo T. (eds) Encyclopedia of      Critical Psychology. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-5583-7_395

World Health Organisation. (2019). Mental Disorders. Retrieved from https://www.who.int/news-room/fact-sheets/detail/mental-disorders#:~:text=activities%20is%20important.-,Bipolar%20disorder,by%20periods%20of%20normal%20mood.

               American Psychiatric Association. (2010). Practice guideline for the treatment of patients with Bipolar Disorder, 2nd Ed. Retrieved from https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf%20