The Vancouver Sun by Gerry Bellett 10 May 2013
Seldom does a person suffering from severe mental illness find relief right away. More likely it involves a protracted journey through medication and psychotherapy, or such treatments as transcranial magnetic stimulation or electroconvulsive therapy.
Now research underway at the Vancouver General and University of B.C. hospitals is investigating new treatments for depression and bipolar disorder — two leading mental illnesses that will affect five per cent of the population this year.
Dr. Erin Michalak, a psychologist and associate professor in the UBC’s department of psychiatry, has been studying bipolar disorder for over a decade and is involved in a one-of-a-kind research program that is hoping to discover how people with this potentially lethal and debilitating condition manage to cope with it.
“When I started research on bipolar disorder the message one got was that it’s a pretty bad-news story. It’s certainly true that suicide rates are high, that there’s lots of disability, which can impair people and destroy relationships and families.
“But something we didn’t hear much about was that there are lots of people with severe forms of mental illness — such as severe bipolar disorder where the person has been hospitalized and experienced psychosis — who have learned over time to function really well with their condition,” Michalak said.
“Bipolar disorder is often treated with medication but for most people to have good health and quality of life, medication in isolation is not enough,” she said.
“We’ve conducted many interviews with people that are living well with bipolar disorder and we’ve learned from them that other aspects of life are also critical, such as family and social support, psychological therapies and learning self-management strategies to keep well on a day-to-day basis,” she said.
“And so our research project is focusing on what, in addition to medication, are the other things that are going to be important in terms of a holistic journey toward wellness and recovery.”
What Michalak has come up with is CREST.BD, the only research network in the world that is using persons with bipolar disorder to carry out research into the condition.
Her Canada-wide network includes a core group of about 30 researchers and over a dozen people who live with bipolar disorder, and hundreds of others with bipolar disorder involved on the periphery. This is a $600,000 three-year research project called Knowledge Translation in Bipolar Disorder.
“We hire people with bipolar disorder as co-researchers, we train them to conduct interviewers and run focus groups, and we analyze data with them. I don’t hold a single (government) grant right now that doesn’t have a bipolar person named on it as well.
“And the majority of papers I produce include a co-author who is a person with bipolar disorder,” she said.
It’s a form of democratic research that’s quite unique in psychiatry, she says.
The goal of CREST.BD is to discover ways to improve the health and quality of life for bipolar disorder sufferers.
One of the studies involved interviewing 33 persons with bipolar disorder who were managing to cope.
“Instead of just focusing on what brings people back to hospital we’re interested in looking at the other end of the spectrum, which is: ‘OK, you are holding down a job successfully, you’re being a good parent, you have a good quality of life and you are satisfied with your life — what have you learned?
“‘How did you figure out a way to navigate through this condition, what tips did you pick up on the way, how did you gain that information?’”
As well as gathering scientific studies on bipolar disorder, the research team has scoured the Internet and social media for clues on how people successfully cope, visiting websites such as Bipolar Crazy in Heels.
“We found the top 20 bipolar bloggers in the world, looked at all the grey literature on the subject, all the top books on bipolar disorder that come up on Amazon, government reports, documentaries and podcasts. We wanted to find information that doesn’t come through normal scientific channels and throw it all together and distil it down to a few key strategies,” she said.
This data is being sifted by a large panel of academic experts and bipolar disorder sufferers with some strategies being approved, others rejected, until it all boils down to a manageable list of tips on how to cope.
“We are in the final stages of the study, which should be ready in the next few months. I hope it will help people who have just been diagnosed.
“Bipolar disorder is often diagnosed when a person is in their teens or 20s, and I hope we will provide these youth with a tool-kit of resources and information that is credible and comes from the experience and expertise of a wide range of people,” said Michalak.
While bipolar disorder can affect up to 1.5 per cent of the population, depression affects many more. For those suffering depression who have found no relief in psycho-therapy or medication, there is an alternative treatment available at VGH that uses transcranial magnetic stimulation (TMS).
“I tell women it’s just like getting their hair done,” said Dr. Peter Chan, a psychiatrist and a clinical associate professor in UBC’s department of psychiatry, who uses TMS to treat depression.
A patient sits in a chair and the stimulator is placed on their head for about 45 minutes. A course of treatment calls for it to be applied five days a week for up to six weeks.
The device emits a high-pitched clack as it intermittently fires and patients are given earplugs.
“It’s a non-invasive treatment and it’s well tolerated by most patients. There are some who complain of facial pain or headaches and we can do certain things to decrease that but most people tolerate it very well and there are no side-effects,” said Chan.
The stimulator directs a concentrated magnetic field of about a centimetre in diameter onto an area of the scalp that lies above the part of the brain that is of interest — usually on the left side of the brain. This magnetic field produces a weak current that flows through the frontal cortex of the brain to a depth of about three centimetres.
“This current depolarizes the nerves, which means it causes the nerves to fire,” Chan said.
This portion of the brain, for persons suffering depression, is often less active, he said, and sustained treatment can cause the nerves to continue firing once treatment has ended.
“Increasing the activity of an under-active part of the brain is the most common way of using TMS to treat depression,” he said.
However, in some patients TMS — using lower frequencies — can be used on the right side of the brain to inhibit over-active nerves, which can also be effective, Chan said.
In general the treatment benefits between 30 to 40 per cent of persons who undergo it, he said.
“To put that in perspective, of those who are given a medication, perhaps 20 to 25 per cent say it benefits. So this is slightly higher.”
Chan and his team have received a grant from Vancouver Coastal Health Research Institute to investigate if TMS can be used to treat people with post traumatic stress disorder (PTSD).
“We know people with symptoms of PTSD have cortical areas of the brain that are dysfunctional and by stimulating or inhibiting those areas one might be able to help treat the symptoms,” he said.
Research will also be done with bi-polar disorder patients.
“There have been some people who have had disabling bipolar depression who have benefited from this treatment without their switching into mania,” he said.
Research will also be conducted on elderly persons with depression as some studies show this class of patient doesn’t respond as well to treatment as younger patients.
“Unfortunately, as we age our brain shrinks and so it’s harder — with the equipment we have now — to get down and reach those areas we need to reach for it to be therapeutic,” said Chan.
For those who have had episodes of depression and want to prevent a reoccurrence, VGH offers an eight-week course in mindfulness-based cognitive therapy (MBCT).
This week Dr. Andrea Grabovac, a psychiatrist and clinical assistant professor in UBC’s department of psychiatry, and psychologist Dr. Mark Lau, a clinical associate professor in the same department, will be presenting their research on MBCT at the first international mindfulness conference in Rome.
“MBCT has been rigorously tested and found to prevent recurrence of depressive symptoms. It’s as effective a way to prevent symptoms from coming back as medication is in most people,” said Grabovac.
In Rome, Grabovac and Lau will be presenting the results of research that involved a group of VGH employees who were offered MBCT in various formats — in a group, individually, over the phone or online — with the aim of discovering how effective each format was.
Mindfulness therapy teaches a form of meditation, Lau said.
He describes mindfulness as just “being aware of your experience as it is and not trying to change it. It’s about changing your relationship with your experience in an non-judgmental way.”
And that’s important, because people prone to depression tend to personalize events and ruminate upon them, he said.
“If you’re walking down the street and you see someone you know and they just walk by, that can produce a whole range of reactions from ‘he didn’t notice me’ to ‘last time I saw him I must have said something wrong.’”
“Where your mind goes can influence how you feel. So if people become more aware of those thought streams and learn to work with them in different ways, they can change symptoms. And that’s helpful in treating acute depression and preventing relapse.