In their episode on bipolar disorder, Helen and Valerie welcome Dr. Stephen Strakowski, a national leader in the bipolar field. Drawn from his vast experience with research and clinical practice, Dr. Strakowski eloquently discusses the basics of bipolar disorder—symptoms, diagnosis, treatment methods, relationships, and recovery. He then describes his cutting edge research, and the bright prospects that his findings provide for future treatment opportunities for the complexities and challenges of bipolar disorder.
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Bipolar Disorder: The Highs, The Lows, and the In-Between, with guest Dr. Stephen Strakowski
Episode 24
Helen Sneed: Welcome to Mental Health Hope and Recovery. I'm Helen Sneed.
Valerie Milburn: And I'm Valerie Milburn.
Helen Sneed: We both have fought and overcome severe chronic mental illnesses. Our podcast offers a unique approach to mental health conditions. We use practical skills and inspirational true stories of recovery. Our knowledge is up close and personal.
Valerie Milburn: Helen and I are your peers. We're not doctors, therapists or social workers. We're not professionals, but we are experts. We are experts in our own lived experience with multiple mental health diagnoses and symptoms. Please join us on our journey.
Helen Sneed: We live in recovery, so can you. This podcast does not provide medical advice. The information presented is not intended to be a substitute for or relied upon as medical advice, diagnosis or treatment. The podcast is for informational purposes only. Always seek the advice of your physician or other qualified health providers with any health related questions you may have.
Valerie Milburn: Welcome to episode 24, bipolar disorder. The highs, the Lows and somewhere in Between. Helen, you and I are really excited today about bringing the episode we have to share.
Helen Sneed: We really are.
Valerie Milburn: We recorded this wonderful conversation with our guest, Dr. Steven Strakowski. Dr. Strakowski is a national expert in the field of Bipolar disorder and man, we are so fortunate and honored that he joined us for this eye opening discussion.
Helen Sneed: Yes, there's so much that we're all going to learn. First of all, he will talk about the specifics of the disorder, diagnosis, symptoms, treatment strategies for family and caregivers. He shares this vast knowledge as both a clinician and a researcher.
Valerie Milburn: Yeah, and that's what really brought such interesting topics to the discussion, that he is both a clinician and a researcher. And you're also going to learn that he is just involved in the latest cutting edge research and he talks about that and the research potential impact on future treatment, and about his hope for ongoing new discoveries in the field of bipolar disorder.
Helen Sneed: Before we roll the episode, we'd like to give a little information and some statistics on bipolar disorder. Let's begin with the basic definition from the National Institute of Mental Health. Bipolar disorder, sometimes referred to as manic depressive disorder, is a mood disorder. It is characterized by dramatic shifts in mood, energy and activity levels that affect a person's ability to carry out day to day tasks. These shifts in mood and energy levels are more severe than the normal ups and downs that are experienced by most people.
Valerie Milburn: Yeah, and don't we know it Helen, don't we know yes, there are several types of bipolar disorder, but These are the two dominant types, bipolar 1 and bipolar 2. Bipolar 1, the definition is that at least one manic episode has occurred and it may be preceded or followed by a hypomanic or major depressive episode. Manic episodes may trigger psychosis, a break from reality, and in bipolar one there is a high risk of suicide. Bipolar two, you've had
Valerie Milburn: at least one major depressive episode and at least one hypomanic episode, but you've never had a manic episode. Bipolar 2 is not a milder form of bipolar 1. The manic episodes of bipolar 1 can be severe and dangerous, but with bipolar 2, the depression can last for longer periods and cause severe impairment. And with bipolar 2, there is still a risk of suicide.
Helen Sneed: So who is affected by bipolar disorder? Where does it strike? Bipolar disorder affects approximately 5.7 million adult Americans, or about 2.6% of the U.S. population age 18 and older every year. So it affects millions of people each year. The median age of onset for bipolar disorder is 25 years. Although the illness can start in early childhood or as late as the 40s and 50s, an equal number of men and women develop bipolar illness, and it is found in all ages, races, ethnic groups and social classes. And here's a really important more than 2/3 of people with bipolar disorder have at least one close relative with the illness or with unipolar major depression, indicating that the disease has a heritable component.
Valerie Milburn: What about the causes of bipolar disorder? Well, the causes are genetics, environment, and altered brain structure. Chemistry also can play a role. There is no cure for bipolar disorder, and if it goes untreated it can get worse with time. However, with proper treatment and support, individuals can lead full and productive lives. And Helen and I are both absolute role models for the fact that with proper treatment and support, people who live with bipolar disorder can indeed live full and productive lives.
Helen Sneed: Yeah, we really are living proof.
Valerie Milburn: We are. We absolutely are living proof. Before we share the episode, let me tell you a little bit about Dr. Strakowski and his remarkable career. Stephen Strakowski, MD, is the Vice Dean of Research and the Associate Vice President for Regional Mental Health for the University of Texas Dell Medical School in Austin. He is also a professor for the Dell Medical School in the Department of Psychiatry and Behavioral Sciences and is on the staff at the University of Texas Malva Clinic for for the Neurosciences. There at the MOBA Clinic, he specializes in the treatment of young people with mood disorders. Dr. Stakowski received his undergraduate degree from the University of Notre Dame and his MD from the Vanderbilt University School of Medicine. He completed his residency training at McLean Hospital, Harvard Medical School. He then spent 24 years at the University of Cincinnati before accepting his current position in in 2016, in his first role at the University of Texas dell Medical School, Dr. Stakowski received served as Inaugural Chair of the Department of Psychiatry and there he led the development of improved mental health care delivery and research to improve access and quality of treatment for people living with mental illness. In his faculty role he continues to perform research. He co directs the center for Youth Mental Health. He continues to use neuroimaging to understand the brain processes that underlie bipolar disorder as well as the potential causes underlying race and ethnicity bias in psychiatric diagnosis. And lastly, Dr. Strykowski is also a Senior Fellow for Psychiatric Innovation at the Meadows Mental Health Policy Institute where he focuses on providing strategic guidance regarding psychiatric clinical and policy best practices. Additionally, he assists in the development of strategic partnerships with national leaders in psychiatry. Now you know him. Enjoy the conversation. Welcome Steve, to Mental Health Hope and Recovery. We are so delighted to have you with us today. And you know this conversation on bipolar disorder is going to be so beneficial to our listeners because of your expertise and the experience that you bring to this episode. And let's just jump right in.
Dr. Steven Strakowski: Great. I'm thrilled to be here. Valerie and Helen and I appreciate you asking me.
Helen Sneed: Well, we are delighted and
Helen Sneed: what we thought we'd do is for an overview of bipolar disorder, I want to begin with the words of Kay Redfield Jamison. I know that she is is a colleague and friend of yours and she's a hero of mine. And as a writer and doctor who has suffered from bipolar disorder. No one I can think of has done more for enlightening those of us with bipolar and those who are involved with someone who has it. So here's what she said. I compare myself with my former self, not others. Not only that, I tend to compare my current self with the best I have been, which is when I have been mildly manic. When I am my present normal self, I am far removed from when I have been my liveliest, most productive, most intense, most outgoing and effervescent. In short, I am a hard act to follow. Well, to me, what she's done here is eloquently describe the central contradiction of trying to recover from the highs of the disorder and to give up the sometimes extraordinary results. I still miss that dazzling person. And at times I am still in competition with my old self. Here we go. And this is Steve. This is our first question. Bipolar disorder symptoms can be baffling and confounding, and their onset can present differently and at different ages. Once when I was manic in my 20s, I was hosting a party and was racing around uncontrollably. A friend pulled me into the kitchen and she said, helen, what is wrong with you? I can't come down. I said, I can't stop. It was like driving a car with no steering and no brakes going 100 miles an hour towards a huge cliff. So, Steve, what have your experience and research shown about the symptoms and the onset of the illness? I think that our listeners are really very curious about this.
Dr. Steven Strakowski: Those are great. First of all, Kay is also a friend and also a hero to me, too. She's done some extraordinary work and is very, very insightful. As you mentioned, the hard thing for bipolar disorder, and I think for psychiatric conditions in general, is that we like to believe that we are in control of our brains and our bodies. And it's a very. I think it's a very Western philosophy and it's a particularly American philosophy. Right. That I am completely in charge of myself all the time. And the. The challenge these conditions cause. And mania is a great example, but I think it's true for depression and anxiety and for many other things, is that it's a stark reminder that sometimes your brain runs off on its own and it is out of your control. In fact, it's always true. I don't know if you've ever seen the Matt Geo show Brain Games, I think it's called, where you watch the TV show and you miss the gorilla guy in the gorilla suit because they've distracted you in the front of the screen of something else. It's always true to some extent, but I think it's particularly true when the missing becomes maladaptive. And that's unfortunately what ultimately happens when these things get severe. To Kay's point, when they're mild, sometimes they can be adaptive. And. And bipolar disorder is so common that it has to have been selected for evolutionarily. And it must be an advantage to us as a species, but it's certainly not an advantage to us when we're very ill. And so somewhere in there is. I've said for years that we would probably not have moved out of caves if not for people with bipolar disorders and their relatives. But. But back to your question then. I think it's because it interfaces so much with who we are, personalities, our environment, that the onset can be quite different for different people. And Kay's experience isn't everyone's. Many people find mania uncomfortable the entire time. It's dysphoric, it's labile, it's frustrating. And so I think everyone's different. The illness is defined by the onset of mania. And it starts typically as, you know, in teens and young adults. And it can be very different in different people. Sometimes I'll see kids that not sleeping becomes the first one or lots of energy. Probably the best brain description is reward. Hypersensitivity escalates and people become distracted by reward pursuit, ignoring all the negatives and consequences. Some people just notice the mood switch. They become irritable or label. And so I think it becomes very different. I recently saw a kid who developed catatonia within three days of
Dr. Steven Strakowski: the onset of first episode. I mean, you just never know. And so I think that's part of what makes it so complicated. It's dynamic. It's got lots of different symptoms. Ultimately, though, it's defined by that first manic episode.
Valerie Milburn: Right. They definitely are very different. My. My mania was destructive. You know, it was definitely, as you described, unpleasant. And never fun.
Dr. Steven Strakowski: Right?
Valerie Milburn: Never fun. Well, in the beginning it was productive. Yeah, it was a little fun in the beginning, but definitely progressed to destructive episodes. And I. I have never thought about. Society would never have progressed, never have gotten out of the caves if not for bipolar people. That's a different thought for me. I actually like that one of our other things we were really interested in is the common misdiagnosis of bipolar disorder, or what seems to be common to me and Helen because we were both repeatedly misdiagnosed with bipolar disorder. And in my case, I'm Sure. The disorder was masked by my massive use of methamphetamines, marijuana, alcohol. I would do it because when I got sober, the mania and the depression became very clear. So can you talk about some of the reasons that bipolar disorder is often misdiagnosed?
Dr. Steven Strakowski: Yeah, Well, I think you all have already hinted. The first part is that it's mystifying and the onset's variable. Right. And so with people who are inexperienced with it, or if your family doesn't talk about it, so you're not aware of the genetics, it's easy to assume other things. And at some level, when you're working with a 16 year old or 18 year old kid, you're hoping it's not a lifelong condition. That's reasonable goal and hope. And so I think all those things contribute. And then one of the problems we have in psychiatry that I know you're both familiar with is we have yet to have a blood test, brain scan, and a definitive diagnostic tool. And so we rely on clinical assessments and when you have good clinicians, that will work. But you often have to collect information over time. And there's so much pressure to make decisions instantly for billing and coding reasons that I think at times we don't allow the illnesses to emerge as they're going to to make better decisions. And so it gets misdiagnosed with adhd, drug and alcohol abuse, agitated depression, borderline personality disorder, I mean, you can name it, and if you're African American, you end up getting called schizophrenic at much, much higher rates than white people. And so, so all of those are common. And people with bipolar, again, I know, you know, may go often go 7 to 10 years after presentation before they finally get correctly diagnosed. And then the great news about that is when we do that, we can finally treat it and people get better, but we've lost a lot of time getting to that point.
Helen Sneed: Well, I think in addition to this misdiagnosis, which, and again, with the various symptoms that you described, I think that justifies the ignorance of some people because it must be so confusing. But there also are frequent misconceptions about bipolar disorder. And when I was first diagnosed, the doctor told me not to have children. This was way back when, but that was, you know, a misconception that scarred me for years. And another thing that I found to be really detrimental is that I was kind of given the impression that it was really a kind of an elitist illness, that if you had to be mentally ill, you wanted to, to have manic depression. Which is what it was called because, you know, you were. You were all creative and geniuses and it was, you know, me and Mozart, that kind of thing, when in truth, you know, it is. That was a grotesque misconception. I mean, it's. It made me grandiose when I should have been fighting it, you know. So what are some of the common misconceptions about bipolar that you have encountered in the past and that you also. The ones you continue to encounter.
Dr. Steven Strakowski: I think part of it, one of them we hinted at already, is that mania is always euphoric. And so if people aren't just having a wonderful time with it, it's not mania. That in fact is not true. And that's not the most common presentation. Labile, irritable, dysphoric mania is far more common. I think a second is that if you have drugs and alcohol, then you can't make the diagnosis. That's not. Not true either. It can be complicated, but it's still possible to do that. The one you raised, I think part of the.
Dr. Steven Strakowski: One of the good things about all the celebrities coming out and acknowledging their bipolar illnesses, it's finally allowed ordinary people to talk about it more because celebrities are powerful enough, they could get away with it before the rest of society could. But to your point, the downside of that is that looked like only rich, wealthy, successful people were the ones getting it. And I think that that fooled people. Bipolar illness is fairly unconcerned with your background, your income, your race, your gender. I mean, it just doesn't care. And so it's really all concerned about your ancestry. And so I think all of those contribute. The other part is that I think the name is frankly misleading. I prefer the old manic depressive illness name because people with bipolar disorder don't really live on polls. The depressive and manic symptoms often coincide and mix. I think found like 40% of people with mania felt depressed during the manic episode at some point. And so again, looking for these pure clean mood episodes that don't mix across kind of affective extremes tricks people into making alternative diagnoses. And so I think them. And just a lot of combined things, they lead people astray. The other one is a brain imager. There's a perceptions. You can't do brain imaging if someone's manic because they can't do sit and scanner. That is absolutely not true. And one of the most youth. We've scanned hundreds of people. One of the most. The youth. Interesting recent findings. Kathleen Marikangas did some of this work and wrote a nice review, showed that in fact, the activity level during mania isn't wildly different than that of non manic healthy people. It is an increase from bipolar people when they're not manic. But the type of activity is this hyper reward seeking focus. And that's the experiences. Right? You get fixated on some thing or thing because you're distractible and that becomes a driving behavior. Doesn't mean you're tearing the sink out of the wall. Right. And so I think that's another part that gets missed. And if you're not wildly out of control, people then assume it's not mania, and that's just not how it actually presents. So I think there's just a lot that we've learned over the last 20 years and fortunately, society's allowed us to talk about a little more.
Valerie Milburn: Yeah, people are definitely talking about mental health, mental illness, so much more than even five years ago or even before the pandemic. I mean, it's one good thing that came out of the pandemic. People are talking about their mental health and mental health struggles.
Dr. Steven Strakowski: They are. And we may finally be able to use that to leverage some policy changes and to improve care and access care. I'm a clinical neuroscientist, as you know, I do brain imaging research. But that's not what's improving care for bipolar disorder. The treatments we have, they're not perfect, but they are actually as effective as any in medicine for a chronic recurrent illness. People just simply don't get them right. If you go 10 years with the wrong diagnosis and it takes you three years to get into a psychiatrist, it's not a wonder that people aren't getting adequate treatment support. So my hope is the pandemic finally highlights what we all knew before. There's been a mental health epidemic going on for decades.
Valerie Milburn: Right.
Dr. Steven Strakowski: It just got revealed now finally in the pandemic. Yes, I think it's worse, but it was there before.
Valerie Milburn: Right. And we've addressed that a lot on this podcast in many episodes, and it's nice to hear it reinforced again and again. So, yes, I am with you about the need for policy changes and hope that there is that on the horizon. And you segued us right into the next topic of treatment methods. And we really want to hear which ones you find effective and what you've used. And the first one we want to talk about is therapy. And there's this great quote. And the quote, I don't know who said it, but the quote is, it may seem Like, I didn't do much of anything today, but what I have going on mentally has me physically exhausted.
Dr. Steven Strakowski: Yeah, that's very true.
Valerie Milburn: And that really sums up why therapy is so important to me, because processing what goes on in my brain, in my head, with my psychiatrist and developing new insights, new skills, new patterns is essential to my healing. And, you know, therapy is just. Has been, you know, really central to my healing in addition to the many other things I do. But can you talk a bit about the role
Valerie Milburn: of therapy in treatment of bipolar disorder?
Dr. Steven Strakowski: Yeah, I think it's critical and sorry for people. I see you're going to get CBT, whether you want it or not, as part of the treatment. But again, these are complex, dynamic illnesses. And it's always interesting me how, again, we don't get. We don't. The payment problems that we can't. It's hard to get people therapy. There's some rules, right, where you can't see a psychiatrist and therapist on the same day. What a stupid rule, right? You use a chance to see them both on one visit, go one off the other, and then it exists in policy. You wouldn't do that with diabetes. You can't see the dietitian and your doctor in the same day and. Or your. Your diabetes counselor. Right. Which is also. And so like every the way I think about it, you know, it's a like complicated medical conditions that impact who you are and how you live. Of course you need a program of treatment. It's not a prescription treatment. Do I think you need medicine to treat bipolar? Of course, absolutely. Do I think you need therapy to treat bipolar? Of course, absolutely. They both serve different functions. Mania, for example, doesn't respond particularly well to cbt, but depression does and anxiety does. And all the other pieces of bipolar disorder where in fact, our meds aren't as good. Right. And so I think a good. First, you need to find a psychiatrist that understands how to treat bipolar disorder and treats it proactively, not reactively. You can't chase the symptoms. You start chasing symptoms and changing treatment all the time. You'll never get it under control. It needs to be. The person needs to be working, either providing therapy or working with someone who can do that as a part of a team. And then all the other pieces as they're needed, family support, drug and alcohol support, medical support. We were talking about this in my family the other night with Kirstie alley dying at 71. She had bipolar disorder. Very public about it. And people with bipolar disorder die 10 years younger than their Peers, that's from everything. So there is a need and I'm hoping you all are taking good care of yourselves. There's a need to have good medical care built into that too. And the psychiatrist is often the person that needs to do that. So again, my feeling is when done well, it's a program of treatment. It's not a prescription. Again, you'll get a prescription as part of the program, but that's not the end of the program. At Dell Med, we, myself and Dr. Almeida have initiated a bipolar program where we're trying to create truly fully baked, comprehensive, ongoing program. It's got a basic six week core and then the pieces that are needed after you're stabilized to continue after. And we're working with payers to find ways to get it reimbursed as a program, not individual components. And he's done the bulk of the work, has done a wonderful job. But I think that's the future of good, certainly care for bipolar disorder, but also for mental health issues.
Valerie Milburn: That's definitely the way Helen and I approach our recovery and we call it our daily wellness plans. And part of that is medication for both of us. And you mentioned that and we could discuss medication for an entire episode. But my experience with medication was in the beginning, trial and error patients and really importantly was having the commitment to stick out a new medication long enough for the initial side effects to subside in order to find out if the medication was going to work. Can you give us an overview quickly about medication in the treatment of bipolar disorder? You touched on it already.
Dr. Steven Strakowski: Yeah, that's exactly the right thing to do. There are guidelines that are evidence based and they work great in big groups of people. But then for an individual, we don't have personalized care yet. We're all working toward that, but we don't have it. And so it becomes very, it becomes educated trial and error. If your psychiatrist looks like they're doing random trial and error, you need to find a difference.
Valerie Milburn: Right.
Dr. Steven Strakowski: And so there's educated trial and error based on what tends to work in large groups of people most. And then you're absolutely right. The hardest part about it is having first you need a psychiatrist who's not anxious so that he or she can hang with you as symptoms ebb and flow because they're going to, while you get the dose up, stabilize and see if you tolerate it. And then you make changes gradually with a plan, not
Dr. Steven Strakowski: every time you have a bad day. And with the, with my patients, I again, I can't make anyone do Anything, of course. But I strongly encourage daily mood charting so that we're not reacting to breaking up with my boyfriend this morning. We're looking at what happened during the last month and making treatment decisions based over longer periods of time. I think those kinds of pieces are critical to managing the illness. And why I think it fails often is requires diligence both on the provider side and on the receiver side. And neither are always patient about it. You are fortunate you figured that out. And again it strikes 16, 17, 18 year olds. By definition, that's not what any of us did then. And so it really takes the provider to kind of become the stable predictive. Obviously what makes I'm a good psychiatrist because I'm boring. And that's what you need at that point in your life, right? You don't need a wild goofy scientist. Need someone who's listening and steady and predictable so you can become that.
Helen Sneed: Well, I'm still waiting for you to become boring, but I haven't seen it yet.
Valerie Milburn: You mentioned you can't make anybody do anything. And Helen and I wanted to ask you this. What do you do? How do you guide, advise, encourage someone who, whom you think should stay on medication? Who says I'm going to get off my medication? I know my doctor had a really funny response. I have a psychiatrist I've seen for a very, very long time and has been with me from the beginning and I was about 10 years into medication, had been really stable for a long time and for some reason for the first time felt I should get off my medication and told him that. I said, you know, I'm doing great, you know, I think I should get off my meds. And he looked at me and said, what are you smoking crack? What's your response?
Dr. Steven Strakowski: I don't know that I've said that one, but I. That tone is not far off. I will typically have just a friendly but frank discussion. The data are overwhelming right there. The old lithium clinic data are a perfect example where people 10 years stable in medicine went off their lithium and within six months virtually a hundred percent had relapsed after no relapses for a decade.
Valerie Milburn: Wow.
Dr. Steven Strakowski: It's an old paper by a friend of mine, Johnny Fader and colleagues way back when to Trisha Supis maybe was the first. I can't remember, but we know that. And so that's the conversation. And I say this particularly, I treat a lot of 15 to 25 year old people. I fully understand. Again, back up a little. If you develop a manic episode, it predicts a bipolar course of illness somewhere between 80 to 90% of the time. Right. But it suggests there's this 10% where it's something else and truly is just a fluke and it's not going to recur. And if I'm 17, I'm going to believe I'm one of the 10%. That is a healthy 17 year old response. Right. And so we have first that conversation that I understand where you're coming from, and I hope you are, I truly do. But then the goal is. But you know, the odds are not run. Running against us. And so even if you stop your treatment, you're gonna. I really want to keep seeing you and keep an eye on things and so that if it comes back, you don't end up in jail or running naked down the street or flunking out of college or all the terrible things that happened last time. And then we pick it up early and intercept it. That's tended, you know, does that work 100% of the time? No, but it's tended to be. It's tended to be. My patients tend to stick and. And then the other side, you know, I've been doing. I'm doing great for 10 years. Like, okay, but here's the risk. And so if, you know, I can't make you do it, I can't. I can't make you do anything. But I'm gonna really hope you'll at least keep coming in regularly if that's what you're going to do. Against my advice for us to keep an eye on it together. Because in the end, as I tell everyone, it's not my life, it's yours. And my goal for you is that you're as successful as possible. That's really. It is the way you rate it, not the way I read it. And I can honestly say that stopping treatment rarely helps people do that.
Helen Sneed: Right.
Dr. Steven Strakowski: Single instance. Sorry, I don't think I know a single instance where that's been true. But that's fine.
Helen Sneed: Well, let's just hope no one's testing it as we speak.
Dr. Steven Strakowski: Oh, they are.
Helen Sneed: They are. They are. They are.
Dr. Steven Strakowski: Yeah, they are.
Helen Sneed: I
Helen Sneed: have another treatment method I wanted to ask you about. Dbt. Dialectical behavior therapy has been tremendously helpful to me, both in recovering and in maintaining recovery. And I wonder, have you found it to be an effective treatment method with any of the people that you work with?
Dr. Steven Strakowski: It has been. And I'm not a certified DBT provider, so I've had other people do it. I know not to be dangerous. Right. But I. One of the things that, again, one of the other misconceptions is that if you have bipolar disorder, you're immune from everything else. Right. And so you weren't, you didn't suffer trauma as a kid, you didn't have problems with alcohol, you weren't assaulted as a young woman. And none of that's true. Right. The rates of trauma are higher in people. Bipolar disorder in the general population.
Valerie Milburn: Yeah. You're looking at two of us right now, both have bipolar disorder and post traumatic stress disorder.
Dr. Steven Strakowski: One of the most distressing things for me that's part of my job is I would think, I think that 90% of the women I treat have been raped or at some point in their lives. And it's awful. And, and so trauma based therapies, which DBT really is at times are critically important. And I, I don't think you can recover from them, from the illness in its full extent without it the other way I think about this is idiosyncratic. But, you know, in the course of bipolar illness, depression is often the bugabear that's the hardest to manage. Depression is not a thing it's caused by. It's got many, many ideologies. I think that there is some depression that is a consequence of the changes in the brain that cause mania, that responds to antimanic therapies. And there's lots of studies that show that mood stabilizers are the first line antidepressants for people with bipolar. But having bipolar disorder doesn't mean you're immune from depression of having been assaulted as a child. It doesn't mean you're immune from the depression of living through stressful times like the last two years. Awful. And so I think part of the work with bipolar disorder is to manage it by being comprehensive in how you think about it. And again, the core basis of depression is often the brain changes, it cause mania. But if, you know, in rates of 50% of trauma in people, bipolar, it's not just that. And so that's a long winded answer to your question, Helen. But I think, of course, trauma based therapies are critically important and it's part of providing full care to anybody, not just people.
Valerie Milburn: Well, that's so interesting. And you also mentioned CBT earlier. I just wanted to point out that's cognitive behavioral therapy.
Dr. Steven Strakowski: Yeah, sorry, I shouldn't.
Valerie Milburn: No, that's okay. We were talking about therapy and I definitely was, I definitely benefited greatly from cognitive behavioral therapy. So you met, you've already touched on the importance of a program for. Of treatment for bipolar disorder. And I mentioned our. Both Helen and I have a daily wellness plan. And I know you incorporate lifestyle. You just talked about that. And mindfulness, we close every episode with the mindfulness exercise. So mindfulness is. This is funny. Mindfulness is at the forefront of our mind.
Dr. Steven Strakowski: That has to be true.
Valerie Milburn: Yeah, it should be as part of our treatment. So in what ways do you encourage your patients to incorporate a healthy lifestyle into their treatment?
Dr. Steven Strakowski: Yeah, again, that's part of the program. And you all have seen any of my books or writings. That's always there. And I know you have. You must have. Could you say that? But yeah, again, first of all, most of the things we're talking about, exercise, you know, things that I wish I was doing better now, exercise, eating well, a regular sleep, wake schedule, not drugging and drinking. Right. All that is good for you anyway. So even if you don't have bipolar, there's no reason to debate it. This is going to make your life better. Second, though, there is evidence that, for example, and I know you know this, people bipolar, their circadian system doesn't regulate itself as well as people without bipolar disorder. So you are more vulnerable to time shifts and changing light. And like right now is the worst time of the year when the day gets so short for me, I hate this time of year. And if you have bipolar, maintaining a schedule, light therapy, things like that can be just critically important, even though they seem
Dr. Steven Strakowski: simple, can go a long ways towards minimizing the amount of meds you need to take and helping you be more effective in therapy and just be generally healthier. And so that's part of the program. And again, I use the diabetes analogy a lot because I think it's, it's not so dissimilar. Right. It's taking good health care measures, some of which are specific to this illness, like regulating your sleep, wake cycle.
Valerie Milburn: Right.
Dr. Steven Strakowski: And then taking the medicine you need to manage. You know, it's just like taking the insulin, diabetes, There are benefits, backbone, mood stabilizer we have to find. And then getting all the other life supports you need to be successful, which therapy is a critical part of that. And so the hard part is that our funding agencies just don't do it that way. It's broken into fragments. And so that's the work now, I think is bringing the, as I talk about a lot, solving the funding puzzle, how do you get the United States healthcare system, which is fragmented, to provide integrated care? And that's, that's what we're really talking about now.
Helen Sneed: They're not real big on it, are they?
Dr. Steven Strakowski: No. And so you all do it, I assume, because you've got, you know, a half dozen different people you work with and you somehow integrate them yourself and they're not all sitting in one place to make it easy for you, right?
Valerie Milburn: No, exactly. Yeah.
Helen Sneed: I had, I think, looking at treatment methods, there's one thing that I find so important and that is relationships, you know, with the people in your life, whoever they might be. And when I was depressed, you know, in that spectrum of bipolar, I isolated and I simply couldn't function at all. And I ignored all support systems, etc. But when I was manic, of course, I was out on the town in work, socially, you know, just. Just shot out of a cannon every morning. So how can you help people maintain relationships? You know, if you have bipolar, how do you keep your relationships when the moods can be so erratic and dramatic?
Dr. Steven Strakowski: Yeah. I think part of it is getting in early on agreement that the friends or family are part of the care program. At least somebody is. Right. And that you get that permission to keep them included early, particularly family, particularly the younger folks we treat so that we don't get boxed out from them because again, legally we can get boxed out from your friends and family very, very easily by you. Right. And that's the way it's set up right now. So I think that's part of it. The other piece is I encourage my patients to. To read a lot and then to give their friends and family the same books. Right. So hoping the spouse has read K's books too. And so to educate everyone as much as possible. It's like psycho educational approaches that I know you're aware of are. That's part of the work is engaging the family. Then of course there's always formal family therapy and couples therapy when people will agree to do that. That's hard to do in our culture because our culture tends not to want to do that, particularly mental health. But men are hard to treat, by the way, as you both probably know. And, and so I used to. This is a side. When I had this brief spell, I was a senior executive in the health system and for reasons related to people quitting marketing, ended up reporting to me, which is crazy because I don't know anything about it, but the people fortunately running it did. And one thing I learned is that in healthcare we did no marketing to men because 85% of the healthcare decisions were made by women anyway. And so that brings it. Yeah, because. So it's someone's wife sister, mom who's forcing guys into care. So that then becomes a challenge with male patients and with women whose significant other is a male. And so we also have to work that and recognize that limitation. I don't know if I answered your question, but it's really kind of a combination of pieces. Again, as part of a program.
Helen Sneed: Who.
Dr. Steven Strakowski: Can we bring in that can let me know you're doing poorly if you're not going to let me know? Who needs to come in to be encouraged with their own therapist about how to live with someone with bipolar disorder? And so I think it's that kind of work when people are willing to participate.
Valerie Milburn: Yeah, I think that's important. Friends and family for sure.
Valerie Milburn: Let's shift into talking about the amazing research you've done and what's out there right now that's, you know, hot in the research field. And one of the research studies I think Helen, you wanted to talk about is the one coming out of the University of Texas Malva Clinic for the Neuroscience.
Helen Sneed: Yes, we are dying to hear about it. The one from the University of Texas Malva Clinic for the Neurosciences. I hope I got that right because the study, it sounds so promising and so fascinating. The study addressed factors for recognizing bipolar disorder sooner by identifying changes in brain development that could predict the onset of bipolar disorder. Now, I know you're going to correct me if I Have this completely wrong. But can you tell us about these research outcomes and what is their potential for intervention and treatment? It sounds so terrific, you know.
Dr. Steven Strakowski: Well, that's nice of you to say because as you know, I'm the PI of this study.
Valerie Milburn: Yes.
Dr. Steven Strakowski: Because so as you all know, bipolar disorder is highly heroin. Right. 85% of the risk is just pure genetics. And so one thing my whole career when we studied at the onset of the illness, and then we've been progressively trying to get to the pre onset of the illness because we know that with any medical condition, the sooner you intervene, typically the better outcomes you get. And if you can prevent it or prevent progression, either one. Right. Maybe we can't stop the first magnetic episode, but we can delay the second one forever. The outcomes inherently improve. The challenge is, of course, that in any sample of individuals who have a risk because of a parent, or that's what we focused on, or a sibling, only one in four of them are ever going to develop psychiatric problems and they're not going to happen, or bipolar rather, and they're not going to happen next year necessarily. And so you have the numbers of subjects you have to follow to, to pick off everyone who's going to develop mania is, exceeds the ability of what most funding agencies will fund. So, so what we've done though is we know that there are kind of predecessor events that happen more commonly that increase the likelihood of mania coming on, which is the defining moment for a bipolar diagnosis. And so we're concentrating also on those. And so we're recruiting young people who are 14 to 21 years old who have at least a parent or a sibling. They have a parent with bipolar I disorder or a sibling with bipolar 1, and a parent with something else like recurrent depression or bipolar disorder. And then we're following the development of their brain, their prefrontal. I can talk about specifically these networks in your brain that are, we know, are involved in the expression of bipolar illness, the reward system and the emotional signaling systems. And so we're going to follow how those develop in teenagers, which is when they develop the most in these groups of people with or without the family risk, to see how they differ. And then look at events that include suicidal ideation and attempts and behaviors, depression or anxiety, onsets of drug and alcohol abuse, and changes in reward sensitivity, which is a marker for bipolar disorders. And so we're looking at the whole gamut of things in addition to mania
Dr. Steven Strakowski: coming on. Right. To try to understand what's changing in the brain to get you to a Point where your brain can express mania, which is hard to fake. Right. I don't know if you ever. Actors can't do mania. They can do depression. It's hard to fake. I mean it's, it's a true change in how the brain's working. If we were. Our hope is if we can find those changes earlier and they, we can create a marker for better predicting risk from just because I have a parent, I have a 25% to I have a parent and I have these changes. So now my risk is elevated to 90%. That can change in what we might do to intervene to try to either prevent onset or like I said, be really prepared for onset so that we can prevent progression of the illness. And so that's what the work is. It's a five year project between the University of Texas Dell Med School and the University of Cincinnati, my old bipolar disorder research program. And we're going to collect 180 folks, with or without the risk, young people to study brain development over time. We think that bipolar is a adolescent brain developmental illness. That you inherit this genetic scaffold and then the parts of the brain that manage reward processing and emotional signaling develop differently when you have that genetic scaffold and that presents the underlying brain structure that allows it to occur. Does that make sense?
Valerie Milburn: Yes. Yes.
Helen Sneed: It's fascinating.
Valerie Milburn: Such valuable research. Yeah. Those events you're talking about, as you were going through them, I was doing a checklist in my head of my adolescence. Check, check, check. Another area of research is your work in the area of co occurrence of bipolar disorder and substance use disorder. And I know firsthand how those two disorders interact with and intensify one another. Just a little background to kick off this discussion. The research shows that in subjects in the research study, the subjects who had bipolar I disorder, there was a 58% lifetime prevalence of co occurring alcohol use disorders. And it's, you know, very high. Obviously the co occurrence between the two and there's much to talk about the course and the severity of the condition. We. I'd love to hear your comments on those. I'm also hoping that you can address the four hypotheses that you've put forth in regards to this co occurrence because I think they're just fascinating.
Dr. Steven Strakowski: Yeah, that's been work I've been doing for a very long time. It reminds me how old I am. Yeah. I think there's been a historical belief that people with mood disorders, not just bipolar, but they drink to treat themselves. And our work has suggested that there is A cohort of people where that probably true in the sense that the mood symptoms precede increasing alcohol use, but it's actually not most in. There's, there's another group that is kind of the opposite problem, that drinking and drugging lead to the onset of the, the mood relapse. And again we see that too and it makes sense because it's a chemical and psychological stressor to drink drunken to drink and drug. Right. But then there's, we've done, we've done a fair amount of work where we follow the courses of the two conditions over time and they actually don't correlate at all in many people. In other words, you've inherited two risks and they're again, having bipolar doesn't make you immune from inheriting your father's alcohol genes. Right. And alcoholism is a 70% genetic illness. And so the two can also just run completely away from each other and have almost no relationship. And so any of these can, can be in a given individual, can be the underlying cause for the increased rate. Then there's just risks of having a chronic illness. And two chronic illnesses brings you to worse outcomes and more treatment. And so I caution people from taking sort of simple minded one views one approach to the comorbidity because it's got a 75% chance to be the wrong one. And so you know, I've been, I've been asked for years, do you make people get sober before you treat their suspected bipolar illness? No.
Valerie Milburn: That's a great question. Your answer is no.
Dr. Steven Strakowski: It's no. And then what's, why would I do that? I'm sure I'm trying to treat both things at the same time.
Valerie Milburn: Right.
Dr. Steven Strakowski: And
Dr. Steven Strakowski: you know, if I can't get you to take, remember to take your meds because you're drunk and unconscious. Okay. Well then I may focus on the alcohol first to get you to remember to come to therapy and take your meds. But they need to be treated independently and then tracked over time in the individual to notice if there's patterns. Right. So we see that you start drinking is one of your first manic symptoms. There are people like that. That's their, that's one of their early things. Or you, when you get depressed, one of your retreats is to drink to sleep or drink to isolate or drink to. No. And so if depression is coming on, then we pay attention to it. But again, a large chunk of them, they just seem to run, you know, kind of run independently through lives, which means you have to pay attention to both. Does that make sense?
Valerie Milburn: It does. And I. I'm so glad you talked about those things, Helen. I know you wanted to address family members and caregivers.
Helen Sneed: Well, I had one other just. It's not a quick question, but it sort of follows this, all this comorbidity topic, which is I don't have a substance use disorder, but I have five diagnoses.
Dr. Steven Strakowski: Okay.
Helen Sneed: And you know, eating disorders, ptsd, borderline personality disorder, as well as bipolar. Is there a different treatment method for people that have the comorbidity?
Dr. Steven Strakowski: But.
Helen Sneed: But it's not with substance abuse.
Dr. Steven Strakowski: Yeah, it could. Could very well could be. So we can take any one of those and then remind me to just say something about borderline personality at the end if I forget. But an anxiety disorder, anxiety comorbidity is very, very common. And so people with bipolar disorder, well, everything will seem to be under control. And they still have generalized anxiety that can be crippling. It's kind of the same thing. There are times where these symptoms are expressions of the bipolar illness and sort of leader follow episodes and respond to the treatment for bipolar disorder, which is often the first intervention. I have a three drug maximum rule that I really try to adhere to. Right. And so we watch for that. But even. But I guess part of paying attention and tracking symptoms over time, if the bipolar disorder is being well managed and yet these other symptoms persist, then we may have to treat another thing. ADHD is another one like that, where there's distractibility and poor concentration is part of being depressed and manic. Right. But if it persists when you're not depressed and manic, and it started when you were seven, then a stimulant makes sense and we treat it. And so it's really the same approach. Sometimes the symptoms are additional expressions of the underlying bipolar illness. But having bipolar illness doesn't make you immune to the risks of other things. PTSD was a good example. We talked about that. Right. Having bipolar disorder doesn't mean you don't have ptsd. It doesn't mean you didn't experience trauma. In fact, your risk was higher. And so both things are going to need to be attended to. And so that's generally our portion. I forgot to mention our study. One of the things we're tracking is childhood ability abuse and trauma and how it's associated also with brain changes.
Helen Sneed: Because I'm glad to know you're doing that.
Dr. Steven Strakowski: Yeah. And I forgot. I can tell you I haven't made a borderline personality disorder diagnosis since probably 1991. The reason is that My experience I've yet to find and there's debate about this. I'm one extreme. But my experience is it seems to be an expression of chronic PTSD as much as anything it's been.
Helen Sneed: They're sort of finding that they sort of over. They overlap so much you can't really pull them apart. Really.
Dr. Steven Strakowski: In fact, that's my point of. Why then call it a personality disorder when we already have a recognized syndrome, which is ptsd.
Helen Sneed: That makes me feel a lot. I feel a lot better. I feel disembarked.
Dr. Steven Strakowski: Well, the other thing, Borderline personality disorder. The. The name has become pejorative, which is what makes it hard. Yeah, that's a problem. And it's based on a psychoanalytic concept that's just plain silly. The borderline. I don't know if you know what the borderline was.
Helen Sneed: Well, I know what, what they, why they used it, what it mean.
Dr. Steven Strakowski: But with the borderline between schizophrenia and, and non. Non psych. I just lost the word. But non psychotic illness, which is silly. I mean they're not a continuum. And so, and so, so I, I really haven't, I haven't made that diagnosis since I was a senior resident.
Helen Sneed: Well, it's, it's good to hear you sort of speak about that. That you know, if a person has more than one that you, you know, and again you sort of got to have to go after all of them at one time or another. But one of. I'm switching gears here. One of the. Our major
Helen Sneed: goals with this podcast is to empower family members and caregivers with information and skills. And what advice do you have for family members and caregivers as they care for and support their loved ones during this difficult illness? And you know, it can take a long time.
Dr. Steven Strakowski: Yeah. My first thing I kind of alluded to before. Read. Read as much as you can to try to demystify as much as possible and re I again, I guess I'm old, but reading books, books still have a tendency to have been better vetted than the website you're getting.
Valerie Milburn: Right.
Dr. Steven Strakowski: So right. You know, find. Find people who have a reputation for credibility and evidence based conversation and rely on those first doesn't mean there aren't others. And it doesn't have to be academic position. Lay people who like you guys who spent the time to understand what you're talking about and aren't just making up. Be careful about just searching the web for solutions because you can find. I think, I don't know if it's true, if it's literally true. You can find everything on the website, but it's pretty darn close. So that's the first thing. Education, education, education. Work with the family member to try to when they're well to reach an agreement that you can be involved when they're not. Like I said, yes, as a treating psychiatrist or a therapist, my patient or client can lock me out of their family with a word. Right? It's like do not talk to my family. I'm done. I can't. And so if we can get stuff like that set up ahead of time, that can be helpful. Particularly one thing I do tell family members. So even if they lock me out and that I can't reach out to you, nothing ever stops you from sending information. You just have to recognize that I can't respond necessarily right. But it doesn't mean I don't look at it. And so I think that's part of the work. And then couples therapy or family therapy is probably undervalued and needs to be incorporated as much as possible. Or your own individual therapy to help you manage a stressful life circumstance. To your point, most people bipolar can do very well with good treatment. And, and in our work with first episode kids, they really are young people is the vast majority. Figure it out about the third episode. I have to take this seriously. They never figured out after the first episode. Very, very. Yeah, because they're teens, right?
Valerie Milburn: They're teens. Well, what did we say? Three is a charm. We are running out of time and we traditionally wrap up our conversation with our guests by asking the question what makes you hopeful? So given your vast experiences in research and as a clinician, what gives you the most hope for the understanding and treatment of bipolar disorder today?
Dr. Steven Strakowski: Somebody. I think we, we talked about this a little before. The fact that we can. This podcast wouldn't have happened 30 years ago. The fact that we can have public conversations. The people with the illness, you know, the again the rich and powerful, the right ones to first come out because they won't get, they can't get fired the minute they do. But, but as we start getting more and more public about it and we start hearing public officials talking about the importance of mental health, that to me is, is what makes me most hopeful. I, I think the, the, the research we do is really cool and has the potential to change the landscape in time. But the low hanging fruit right now of mental health is get more people access to care and then demand clinicians follow evidence based care and stop doing goofy stuff. If we can do those two things. And I believe we can, we could revolutionize how the United States cares for people mental illness. While we can continue to understand the brain basis and find, you know, ultimately cures for these conditions.
Helen Sneed: This brings our episode to a close. Now you can see why we are so thrilled and honored to have had Dr. Strakowski for this critical discussion. Bipolar disorder is a difficult, complicated illness for those who have it and those who love and care for them. Yet recovery is possible and can be achieved through the right treatment and relationships. Valerie and I, as we have told you, we know firsthand how fierce is the battle in the face of the highs and the lows. What we experience now is somewhere in between. How a life in recovery is rich, fulfilling
Helen Sneed: and full of challenging and creative achievements. Carrie Fisher, the late actress and writer, said, bipolar disorder can be a great teacher. It is a challenge, but it can set you up to be able to do almost anything else in your life. And now Valerie will lead us in a mindfulness exercise.
Valerie Milburn: Yes, we will close with our traditional mindfulness exercise. What is mindfulness? I always give a definition. Mindfulness is a mental state achieved by focusing one's awareness on the present moment while calmly acknowledging and accepting one's feelings, thoughts and bodily sensations without judgment. Today's mindfulness exercise focuses on how to maintain a consistent positive identity. I don't know about you, but I can slip into negative self talk or assume someone is thinking negatively about me or negatively interpret a situation. But I can turn these thoughts around by mindfully focusing on positive self talk or acknowledging that I can't read someone else's mind and focusing on the reality of a situation rather than my negative interpretation of it. Let's begin our mindfulness practice, as always, with diaphragmatic breathing. If you can close your eyes, settle in and breathe whether your eyes are open or closed. Let's steady our breathing with two diaphragmatic breaths. When you do this on your own, take as many breaths as you need to become calm and centered. I usually take about 10 diaphragmatic breaths to start my mindfulness and meditation practice. Let's breathe. Inhale through your nose, expanding an imaginary balloon in your stomach as you inhale. Now hold it for a second. Exhale through your mouth, pulling in your stomach as you do, deflating that balloon forcefully, exhaling again. Inhale through your nose, expanding that balloon in your stomach as you inhale. Hold it. Exhale through your mouth, pulling your stomach all the way in, exhaling forcefully. Keep this slow, steady breath going. Now bring to mind negative self talk word or phrase you sometimes tell yourself if you have one, what is the positive opposite of that word or phrase? What are your strengths that this opposite positive word or phrase describe? In what situations does this positive word or phrase fit your actions? Become mindful of the possibility of speaking to yourself gently and sympathetically when you're in a tough spot, as you would most likely speak to a friend no matter what they were going through. Now let's focus on a time you may have assumed someone was thinking negatively about you. What did you assume that person was thinking? Was there anything to back up what they were you thought they were thinking? For example, if you assumed your boss thought you did a bad job on a project, did your boss tell you that you did a bad job on the project? Or maybe there was a time you felt someone was staring at you and judging you? Could it have been you reminded that person of someone? Or could that person have been thinking of something else and it was perhaps just a blank stare? Become mindful of the fact that we cannot read another person's mind. Let's shift our focus once again.
Valerie Milburn: Bring to mind a time you found yourself in a situation you felt negatively about. Maybe a party, an office event, a family gathering, or maybe dinner with friends. Was something negative said or done to you at this event to warrant your negative thoughts or feelings? Were the other people at the event acting negatively? What was your self talk? Take a few deep, slow breaths. Imagine what positive self image means to you. Perhaps when you think of positive self image, you can envision confidence, self acceptance, good self esteem, or other characteristics. Be mindful that we can focus on positive self talk. We can acknowledge that we can't read someone else's mind and we can focus on the reality of a situation rather than our negative interpretation of it. If your eyes are closed, please open them. Thank you for doing this mindfulness exercise with me.
Helen Sneed: Thank you Valerie. Our Deepest gratitude to Dr. Stephen Strakowski for his brilliant discussion and to those of you who listen. Today we hope to have given something of value and want to hear from you about its impact. Please email us@mental healthhopeandrecoverymail.com Our next episode is our holiday gift to you. It will include our favorite mindfulness exercises that Valerie has led us in this year. Don't hesitate to join us in the holiday season if it becomes a bit stressful or exhausting, or if you just want a quiet moment to yourself. Until then, I leave you with our favorite word Onward.