Holistic Treatment of Bipolar Disorder
My (MG) first bipolar disorder patient appeared at the doors of a busy emergency room, covered by a dirty white sheet with a crown on his head, surrounded by five police officers. He talked rapidly and incomprehensibly, claiming to be Jesus Christ. I ordered haloperidol, clonazepam, and lithium, then admitted him to our male psychiatric unit. I saw him again five days later during weekly medical rounds. He was drooling, stiff, and confused. Although he was out of four point restraints and his grandiosity had resolved, depression was setting in, owing to the effects of haloperidol and clonazepam. As my psychiatric career continued I saw too many cases like this one. I thought “there has got to be a better way to treat BD than just using medications to treat symptoms because the drugs are not curative and the side effects are often disabling.” This led me on a search for new modalities to treat BD. As I added acupuncture, naturopathic therapies, dietary interventions, and other alternative techniques, I began to notice that many patients improved, regained their lives, and became less dependent on psychiatric medications.
We are currently confronted with a veritable epidemic of Bipolar Disorder (BD). Over the past decade, new diagnoses have increased fortyfold. Patients are often treated with multiple medications in an effort to avoid hospitalizations, but many experience sedation, alterations in personality, and confusion. Furthermore, patients are told that medications must be continued indefinitely. Although several factors have been identified which place patients at risk for bipolar disorder including family history, use of illicit drugs, inflammation, and altered neurotransmitter biochemistry, the specific etiology of BD has not been elucidated. Therefore, current therapies only address symptoms and are not curative. So patients with BD are seen as having an incurable, life-long condition, with only symptomatic treatment available. In this manuscript, we review alternative approaches designed to address potential underlying etiologies, with the goal to make patients well. In our initial two publications19, 50 we describe 11 patients with severe BD with multiple recurrent hospitalizations who were able to reduce their reliance on psychiatric medications, maintain good psychological functioning with return to school or work, and avoid re-hospitalization utilizing a comprehensive holistic approach which will be outlined in this review.
Why Do We Have So Many BD Patients?
The list of reasons for the apparent increase in incidence and prevalence of bipolar disorder and its treatment is quite long. The following text will discuss several possible explanations:
1. Changes in BD definition, and what is normal vs. abnormal:6,7 Under the auspices of the American Psychiatric Association (APA), the Diagnostic and Statistical Manual of Mental Disorders, or DSM-III was created to better characterize psychiatric illness. Over the years the criteria for BD have been expanded thus contributing to the increase in BD diagnosis.
2. Over-reliance on pharmacologic treatment in psychiatry. Over the past 30 years “biologic psychiatry” has become mainstream psychiatry. In this model physicians primarily prescribe medications and monitor symptoms. This trend has been reinforced by payers with economic incentives and has resulted in a myopic overreliance on medication therapy at the expense of psychotherapy and integrative psychiatry. Bipolar disorder became perceived as a lifelong condition with very poor outcomes, erroneously believed to require medications for life. Symptoms upon discontinuation of medication were interpreted as “relapses,” rather than the more likely effects of drug withdrawal.8,9 Furthermore, when treated and untreated patients were followed for over one year, there was no difference in relapse rate.6,7,8
3. Unrecognized iatrogenic complications of long-term antidepressant and stimulant use. Antidepressant medications may cause mood instability and the well-known “manic switch,”11, the sudden change from depression to mania in patients treated with antidepressants. A manic switch due to antidepressant use occurs in 4% of treated patients per year. This rate is compounded, in that someone on antidepressants for 20+ years has an 80% chance of developing mania.12,13 In addition, stimulant medications since childhood impede the ability to naturally regulate mood, causing ongoing symptoms of irritability, explosiveness, poor concentration, and insomnia. Stimulants have become a stepping stone in the progression to BD.
4. Illicit drug abuse. This alters brain chemistry and neurotransmitter balance to cause mood swings which may be temporary, and go away once the individual stops using, particularly if their brain chemistry balance has been assisted by the use of targeted nutritional supplements.
5. Changes in our microbiome. Due to the increasing use of antibiotics, pesticides, and hormones by humans and animals, there have been drastic changes in our microbiome.14 Alterations in the microbiome can lead to an abnormal increase in gut permeability (leaky gut syndrome) which can allow passage of antigens into the bloodstream. This in turn can promulgate a whole cascade of immunologic reactions which can result in low grade autoimmunity. Studies in animal models have demonstrated that leaky gut can cause a breakdown of the blood brain barrier with the potential introduction of antigens into the brain itself. This is of significant importance in BD because markers of inflammation are significantly increased in patients with active mania. In addition these markers further increase with a manic episode, suggesting that immune mediated inflammation plays a role in the etiology of the disorder.
6. Spread of poorly diagnosed infections and parasites. Such as the organisms that cause Lyme disease, and co-infections.
7. Becoming a “fast food society.” We are faced with an epidemic of obesity and a greater sensitivity to genetically modified foods, like gluten, corn, and dairy.15,16 It is possible that these dietary changes in combination with changes in the microbiome and increased gut permeability may eventually be identified as a very important factor leading to the significant increase in the incidence of BD over the past two decades.
8. Acceleration in the pace of life. There is a reduction in social support, and an increased rate of anxiety and depression.
Conventional Management of Bipolar Disorder.
1. BD diagnosis as listed in the DSM-5 is a homogeneous disorder with a common treatment algorithm. The DSM’s scientific nature is hotly debated by even the highest echelon of the APA, with studies suggesting that DSM diagnoses are unreliable.17,18. It is likely that BD is a heterogeneous condition with multiple etiologic contributions and potentially multiple treatment pathways. People have different vulnerabilities, and when subjected to stress, they can respond with complex behavioral patterns, including mood fluctuations, mania, and psychosis. Most of these behaviors are short-lived and self-healing. The use of psychotropic medications and diagnostic labels, however, can create long-lasting vulnerabilities, imprinting behaviorally expected patterns.
2. BD treatment is very specific, based on the gold standard of clinical research: randomized, double blind, placebo-controlled (RDBPC) studies. Unfortunately, the “gold standard” has very limited applicability. Studies are biased, selecting only those patients who are otherwise healthy, are likely to respond to medications, and have taken no prior treatment or street drugs. Studies are of short duration, and an improvement in symptoms from severe to moderately severe is taken as proof of efficacy. Even though many medications are used for years in BD, very few studies lasting longer than 4 to 12 weeks have actually been done. Drug discontinuation due to side effects is high and the psychological effects of very long term psychotropic medication use are unknown.
3. Treatment goal: life-long disease management. Conventional psychiatry maintains that BD is fundamentally untreatable, and medications for palliation of symptoms should be prescribed for life. Many patients become disabled, complain of “feeling like zombies,” and have repeated hospitalizations due to drug toxicity. Despite this our current paradigm is focused almost entirely on pharmacologic therapy. The solution then in conventional psychiatry is adding new drugs or changing drug dosing. There is currently not a pathway to try to approach underlying pathophysiology in order to reduce the use of psychiatric medications.
4. The etiology of BD is irrelevant. Because our current research has not clearly defined the underlying causes of BD the standard psychiatric approach to chronic BD does not address the etiology.
Holistic Approach to Bipolar Disorder: A Road Less Travelled
Holistic approaches to BD are employed by only a small number of psychiatrists and integrative physicians. They have incorporated methods developed by naturopathic, nutritional, and alternative practitioners, but are distinct in the following:
• The steps of seeking and resolving obstacles to healing are performed in a sequential fashion. Therapies focus on addressing potential etiologies in order to restore normal functioning.
• Integrative healing treatments are applied in an individualized manner. Natural products with low potential for side effects are utilized for symptom control.
• Practitioners seek to reduce the use of psychiatric medications, due to their side effects and potential for long term psycho-physiologic effects. In some patients psychiatric medications can be discontinued entirely as symptoms subside with combined holistic therapies.
• The treatment goals are to eliminate all symptoms and restore the patient’s quality of life, vitality, functioning, and resilience to premorbid levels.
Making Sense of Treatment Options
A holistic approach incorporates multiple healing modalities, uses them synchronously, and allows potentiation of their healing effects. Specific sequencing, dosing, frequencies, and timing of treatments are guided by clinical intuition and steered by energetic testing. This work is best accomplished by a collaborative group of practitioners working under one roof. There are too many methods to be utilized by one independent practitioner, and methods may require a high skill level for administration. The following section outlines several common treatment options:
1. Lifestyle changes include behavioral approaches, dietary modifications, exercise, regulation of sleep, and the elimination of substance abuse.19,20 ,21
2. Physical treatments following the rules of orthomolecular approaches,19, 22 ,23 ,24,25,26 functional medicine, and homotoxicology.27,28 They include the use of herbs,29,30 vitamins, minerals, amino acids, and other supplements.
3. Energetic modalities include acupuncture,19,31 meditation,19,32,33,34 energetic tapping,35,36 eye movement desensitization and reprocessing (EMDR),37,38 homeopathy,39 modified Emotional Freedom Technique (EFT), – and others.
4. Psycho-emotional modalities include applied psycho-neurobiology,40 energy psychology,41 positive psychology,42 guided imagery,19 writing and drawing assignments, Systemic Family Constellation, and Tennant Biomodulation.43 Psycho-emotional techniques also include the “Analysis of the Compatibility of Matter on the Organism and its Synergy“ (ACMOS), a bioenergetics therapy approach that combines the wisdom of ancient traditional medicine with the scientific discoveries of modern molecular biology.44
Less well-known in psychiatry are German Biological Medicine and Neural Therapy45,46
Four Steps of Holistic Healing
Step 1: Initiation into the holistic model. The first step is the most difficult, but symptomatic improvement should be evident within one to four weeks.
1. Introduction to the concept: We start the process of understanding that medications are not the only, nor the best, long-term option. We discuss that lifestyle changes and other therapies, which could address potential causes, might be helpful. Certainly the patient must play an important role in carrying out this therapeutic regimen.
2. Introduction to a normal lifestyle: Patients are instructed to follow a normal circadian sleeping time, exercise, and eliminate drugs and alcohol. Individually selected diets are recommended, usually to exclude grains, dairy, junk food and preservatives
3. Supplementation: Supplementation regimens are given to reduce body toxicity and deficiencies in vitamins, minerals, and amino acids.
4. Reduction of main symptoms: Supplementation of vitamins, minerals, and amino acids are given to improve anxiety, depression, and mood instability.
5. Energetic balancing and psychotherapy: Energetic balancing and symptom reduction is obtained with ACMOS, acupuncture, and neural therapy,
Step 2: “Peeling an onion” of etiological issues, medication tapering, and organ and functional restoration. The second step is completed over 3 to 36 months.
1. Continuation of previous processes: The processes from Step 1 are maintained, with continued adjustment, modification, and balancing.
2. Taper of medication begins (see below).
3. Examination of etiological issues responsible for emotional instability are addressed and resolved, including:
a. Infections and parasites
b. Physical traumas due to surgeries, dental work, and other causes
c. Emotional and spiritual traumas
4. Restoration of function: Organ and system functions are restored, including digestive, endocrine, and immunological systems.
5. Self-healing: The patient is then introduced to positive psychology and self-healing approaches like meditation and grounding exercises.
Step 3: Strengthened resilience, with reduction of supplements and holistic care. This step is typically accomplished within 3 to 12 months.
1. Continuation of the work in Steps 1 and 2: The patient will continue to eliminate unresolved issues and obstacles to recovery.
2. Strengthening of resilience and beliefs: It should be emphasized that there is a life without medications and the label of bipolar disorder.
3. Reduction or discontinuation of supplements by slow titration.
4. Utilization of tools for self-healing.
Step 4: Back to normal. This stage is continued as long as needed.
1. Maintenance visits: Infrequent maintenance visits may be helpful to provide continued support.
2. Coaching: At this stage, the holistic practitioner functions as a life-coach or mentor.
Process of Tapering and Eliminating Psychotropic Medications
All psychotropic medications can cause withdrawal symptoms. Withdrawal symptoms are varied and may range from mild discomforts to severe GI issues,. . Emotional reactions may include insomnia, mood swings, irritability, crying spells, and the recurrence of previous symptoms of anxiety, mania, or depression– and even violence, including suicidal and homicidal ideation and behavior. Endocrine issues can be manifested as menstrual irregularities, as well as changes in sexual interest and performance.
Medications are tapered gradually, following some simple rules:
1. Adjust one medication at a time. If there is a reaction, you then know what medication caused it.
2. Go slowly. Reactions may manifest within a day or within 2-3 weeks, depending upon patient resilience.
3. Go small. Decrease by the smallest dose possible. If in capsule form, open the capsules and remove an additional one to three pellets every few days. If in liquid form, reduce the dose by 0.1 cc at a time. Medications can also be compounded in small doses.
4. Substitute with other medications. Short-acting medications may be substituted for long-acting formulations. Medications affecting multiple neurotransmitters can also be replaced by ones with fewer receptors affected.
5. Substitute with supplements. Lithium carbonate 300 mg, for example, can be substituted by lithium orotate 130 mg or homeopathic liquid lithium.
6. Add supplements to control symptoms. Symptoms of hypomania and mania can be controlled by the “Fire Station” supplements: “Branched Chain Amino Acid Formula” (BCAA) containing L-isoleucine, L-leucine, and L-valine (JoMar), choline bitartrate (Douglas Labs), and lithium orotate (Complementary Prescriptions). We strongly recommend keeping these compounds close by, in case of an emergent need. Symptoms of depression can be ameliorated by L-tyrosine, and anxiety can be managed by free amino acids in the proprietary blend of “Total Amino Solution” (Genesa). Use whatever techniques you are good at applying. Possible options depend upon personal experience.
A holistic approach to medication emphasizes improving patient resilience. Any reduction of medication creates an imbalance in the adaption reaction. A lack of ability to adapt to an emerging situation can create many symptoms, which naturally cause the patient distress.
Marrying Etiology with a Holistic Approach: Life Lessons Learned from Patients
Every patient is radically different and unique.
Does one manic episode necessitate medication for life? MM was a 46-year-old radiologist, who had been taking psychotropic medications for over 20 years, including quetiapine 250 mg per day when she came to see me. At 25 years old, she had been stressed by her mother’s death and a boyfriend who had left her, and she found medical school to be impossible. She lost sleep and, within ten days, became grandiose and psychotic. After a week of hospitalization, she was told never to discontinue medications, as she was now deemed bipolar. She had dutifully complied. Now 20 years later she consulted me. Although mistrustful of my non-conventional views, she very slowly and conscientiously tapered her medications over 18 months, substituting them with vitamins and minerals. Guided imagery and systemic constellation work was done to resolve her grief about her controlling mother and help her to learn ways of managing anxiety. Now, several years later, she is medication free and emotionally stable, apparently no longer bipolar. Her visits are infrequent, just to “check in.”
Observations: Most psychotic episodes are short-lived. The key is to resolve the stressful memories about them.
Can food sensitivity and mercury overload cause BD? G was a 25-year-old obese man who first walked into my office sheepishly following his father. He was stiff, drooled, and hardly spoke. He was sedated by the five medications used to control his manic symptoms. For the last four years, he had been on a rollercoaster of drinking, gambling, and acting recklessly with money and marriage. As a result, his father tightly controlled him, forcing the patient to accompany him on his sales business calls around the country. Bioresonance Analysis of Health44 BAH(bio-energetic testing based on Lecher’s antenna)evaluation revealed significant sensitivities to gluten and mercury overload. After six weeks of bargaining, he went on a gluten-free diet and began religiously following a supplement regimen. He replaced his amalgam fillings and underwent chelation using supplements and neural therapy with dimercapto-propane sulfonate (DMPS).47 The injections were aimed at the regions with the highest mercury concentrations, guided by ART. He took himself off of medications much faster than recommended. His behavior dramatically changed; he was again a fast-talking New Yorker and an energetic, assertive businessman. Every time he “cheated” on his diet, however, he felt strong effects. To get rid of my “control,” he changed psychiatrists, but followed original recommendations, remaining off medications and in remission. This case suggests that food sensitivities and mercury toxicity can play an important role.
Can infections be misdiagnosed as BD? G was a 27-year-old woman who had been experiencing hypomanic episodes several times per day. Her psychiatrist insisted on prescribing medications, but she declined to take them. At 14 years of age, after visiting India, she contracted E.coli and developed hallucinations. She was hospitalized and treated with risperidone, gained 30 lbs., and developed mood swings. Several antipsychotic medications, lithium, and valproic acid were tried, which caused her to feel dull and prevented weight loss. BAH 44, Autonomic Response Testing 40 (bio-energetic muscle testing) exam suggested vitamin and mineral deficiencies, dysbiosis, food sensitivities, and parasite-related issues. She was advised to change her sleeping regimen, eliminate gluten and sugar from her diet, take Soluna # 8, 10, 20 (Soluna), and manage mood instability with choline bitartrate, lithium orotate, BCAA, minerals, vitamins, and oils. Guided by ART, she was placed on therapeutic trials of ivermectin and praziquantel. She initially developed mania which shifted to depression. Adjusting supplements stabilized her mood. She passed several parasites, and the course of ivermectin was repeated. After passing several more parasites, which she saw in her toilet,, she felt sudden psychological stability, as if some foreign consciousness was eliminated. She currently feels stable and happy, and she has been able to lose weight.
Conclusion: Chronic undiagnosed infections, like parasites, Lyme spectrum disorders, and fungal infections, are accompanied by chronic inflammation. They may present with symptoms of mood swings, depression, insomnia, psychosis, and fatigue, frequently misdiagnosed as BD. As parasites are rarely found by conventional testing, they are believed to be uncommon, contrary to my own experience.
The list of possible conditions labeled as BD is quite long. Frequent causes of bipolar symptoms include dysbiosis due to antibiotics, poor diet, endocrine irregularities, circadian cycle disturbance due to poor sleep patterns, chronic stress, intense rhythms of life, intrusion of social media, societal alienation, post-traumatic stress disorder, heavy metal toxicity, vitamin, mineral and other nutrient deficiencies, drug and medication abuse, and many other factors.
Can holistic approach to psychiatry be scientifically validated?
Use of RDBPC studies could not be applied to test the holistic model, as it is individualized and employing multiple treatment modalities at any given time. Alternatively, we could use a simple study design with community-diagnosed BD patients who have failed all previous treatments. Subjects could be randomized to long-term treatment with conventional or non-conventional/holistic approaches. We could assess outcomes by measuring psychiatric and medical symptoms, side effects (physical and emotional), quality of life, and overall functioning with validated scales, as well as determine total treatment costs. That would be a true scientific outcome study from which we could learn a quite a bit.
The BD epidemic has emerged over the last 30 years. BD has been labeled as an incurable disease, amenable only to lifelong medical management.48,49 My clinical observations are that many psychotropic medications have powerful mood-destabilizing effects, which usually resolve when they are eliminated with the use of brain restorative targeted nutrients.
What can be done? We must re-educate the public and practitioners regarding what BD really is and how it can be successfully managed. We need to advocate for changing the rules of what is considered “real” clinical research. The healthcare system must be revised, to pay providers for keeping patients well, rather than finance a corrupt system. A holistic approach to psychiatry should be considered as one of the best treatment options. It advocates for and has tools to allow patients to regain their health.
Acknowledgements: The authors wish to thank Neurology Research Consultants PLLC for their review and edits of the manuscript.
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Michael I. Gurevich, M.D., C. Ac.
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