“Depression and bipolar disorder are often family diseases,” according to Psych Central associate editor and author Therese Borchard. So when your loved one is going through a manic episode, you may naturally feel helpless and hopeless.
What can you do? Fortunately, there are many ways you can successfully support your loved one and help yourself. Renowned expert David Miklowitz, Ph.D, professor of psychiatry at the UCLA Semel Institute and author of the best-seller The Bipolar Disorder Survival Guide and Bipolar Disorder: A Family-Focused Treatment Approach, offers his insight below.
1. Recognize the warning signs.
According to Miklowitz, episodes of mania “vary considerably from person to person.” For some people, it takes several months to reach a full manic episode, while others’ symptoms peak in a day or two.
Still, there are similar symptoms loved ones can watch out for. Essentially, these early warning signs are a “muted form” of mania, he said. For instance, your loved one may begin sleeping less (staying up later and later and waking up earlier) and not feel tired the next day.
Also, “look for a sudden improvement in mood,” which often follows a depressed episode. Miklowitz clarified that this doesn’t mean your loved one has simply gotten over the depression. Rather, they’re “upbeat and optimistic in a way that doesn’t seem realistic.” He described it as a giddy feeling.
Your family member might seem impatient and easily irritated. He may talk rapidly and express expansive and unrealistic ideas. For example, he may start pursuing financial schemes or go from being interested in websites to wanting to revise the World Wide Web, Miklowitz said.
Functional impairment is telling, too. Is your loved one’s behavior interfering with her life, including their work, relationships and other activities? Fights with others are often signs of trouble. In fact, Miklowitz worked with one family where the wife could anticipate a manic episode just by her husband’s behavior at their son’s soccer games. When he was well, he’d cheer with the rest of the parents. When he was ill, he’d scream and argue with the coaches, one time even running onto the field.
In Miklowitz’s experience, families usually can spot the signs pretty well after witnessing several episodes. However, it’s easy to get it wrong. There’s a fine line between potentially risky elation and ordinary excitement. And a wrong interpretation can upset your loved one, who might feel slighted and resent your worry, Miklowitz said. While this is upsetting, “it’s best to err on the side of getting treatment,” he said. Even if the doctor concludes that changes in treatment aren’t necessary, your loved one still receives a professional evaluation.
Also, if your loved one is taking any new medication, especially an antidepressant, watch their symptoms. Antidepressants, including Prozac, Lexapro and Wellbutrin, may trigger a manic episode, especially if your loved one is not taking a mood stabilizer like lithium or Depakote.
2. Create a proactive plan.
When your loved one is well, establish a plan with his or her treatment team (which might include a psychiatrist and psychologist) that lists specific warning symptoms and how best to proceed with each. For instance, if your son has bipolar disorder, the plan might include: calling the doctor as soon as you notice signs of elated mood and working late on the computer; Dad talking to his son about observed changes in the son’s emotions and symptoms; and Mom contacting the psychiatrist and psychologist to set up an earlier appointment.
When creating the plan, also ask your loved one how they’d like to be talked to and treated when their symptoms are worsening. Ask them what type of support they would like.
The key is to be proactive, instead of reactive, Miklowitz said. It’s helpful to anticipate potential problems. For example, it’s not uncommon for families to call the doctor and get the on-call physician, who suggests observing the symptoms for a few days. But this leaves you in limbo. A better approach is to ask the doctor ahead of time what to do if symptoms worsen. They might suggest increasing the medication’s dose and write up a prescription in advance, so that you’re not stuck wondering what to do during an emergency.
3. Set limits around self-destruction.
Mania is often characterized by a lack of impulse control, and that’s where individuals with bipolar disorder can get into trouble. That’s why it’s critical to establish limits around the person’s impulsive behaviors when they’re well.
For instance, say your loved one is impulsive around money and has emptied your account before. Reduce her access to credit cards (and credit limit) and monitor the account online. Younger people might do best with an allowance from their parents, Miklowitz said. Basically, the goal is to set structure “around the kind of damage the person can do.”
Unfortunately, you won’t always be able to help. During a manic episode, many people become hypersexual, go out at night and have impulsive sexual encounters. Parents or loved ones can educate the person about the dangers of such behaviors and make sure they’re taking the appropriate medication. But monitoring these behaviors is tough. Miklowitz said that sometimes friends might be able to step in and do some monitoring, or even better, accompany the person out at night.
4. Help them delay their impulses.
Early in the manic episode, Miklowitz suggested using logic with your loved one. Say they want to put a lot of money into a particular stock. Instead of shutting them down, you respond with, “Let’s see how the stock does on Thursday.” If it does well, you suggest meeting with an investment counselor. “You also can suggest he check with two trusted friends outside the family to see if they agree that this is a good idea.”
If they suddenly want to make a big move and change professions, you say, “Let’s think about where you’re going to live and where you’ll work.”
Your loved one might still rebel, “but at least you’re engaging with them rather than fighting with them.” Miklowitz likened this to being a “surrogate frontal lobe” for the person.
5. Call the police whenever necessary.
“If there’s a physical threat to anyone in the household, or if your loved one is actively threatening suicide, the police need to be involved,” Miklowitz said. When it comes to suicide, “more often what families deal with is vague suicidal ideation, which doesn’t involve the police,” he said.
Instead, it’s important for loved ones to listen and be supportive and compassionate. What also may help is doing “something that interferes with the negative spiral of thinking,” which includes helping the person re-engage with the world.
Of course, “this is the time when meeting with a trusted therapist may be most helpful, although it may also be the time when your loved one is least likely to want to do it.”
(Learn more about how to help someone who’s suicidal here.)
6. Don’t assume medication is a cure-all.
Families and friends tend to overvalue the effectiveness of medication, seeing it “as the answer to everything,” Miklowitz said. But don’t forget about the importance of therapy and positive life events or interactions with close friends or family members.
“Some people with bipolar disorder benefit from behavioral activation exercises that encourage them, in step-by-step fashion, to gradually increase rewarding activities available in their immediate environment.”
7. Attend support groups.
Support groups often play a pivotal role in helping families and friends cope. Because they experience similar struggles, members are able to share tips and insights and truly empathize with each other.
Your loved one also can benefit greatly from participating in support groups. According to Miklowitz, “some support groups are moving toward an AA model with having a sponsor.” This buddy system may be helpful for spotting changes in your loved one’s symptoms and preventing impulsive behavior.
8. Know your limits.
Supporting a loved one with bipolar disorder can be exhausting, and many people feel like failures when things go wrong. And for some families, especially aging parents, caregiving can become almost impossible, Miklowitz said. Close friends and family members, such as siblings and cousins, might be able to take over in some cases.
Taking care of a person with bipolar disorder takes a major toll on a family’s mental health. Many family members develop depression and anxiety as a result of their loved one’s illness, he said. Spouses may decide that they can’t handle the symptoms anymore and want out of their marriage.
At the same time, it’s also important for loved ones to remember that bipolar disorder is a “biologically-based brain and behavior disorder,” so to an extent, the person doesn’t have full control over their actions. Still, as someone told Miklowitz, “If a bus runs you over, it doesn’t help to know that the person had vision problems.” Your loved one’s actions, such as extramarital affairs, arguments, legal problems and monetary misdeeds, may be too much to take.
Additional Treatment Tips for Bipolar Disorder
It can be hard to find a psychiatrist who specializes in bipolar disorder. This tends to be even trickier in rural areas. Miklowitz suggested seeking a one-time consult with a specialist. That practitioner can evaluate your loved one and create a report with the medications they’ll need, which you can then bring to your general practitioner.
Participating in research studies is another way to gain access to treatments that you wouldn’t otherwise, he said. Even if participants are placed in the placebo or “minimal treatment” condition, they still have the opportunity to attend a specialized clinic and get careful oversight.
Collaborating with your loved one’s treatment team is important. But it’s not always possible if they refuse to sign release forms to facilitate communication. If that’s the case, you can get tips and insight into bipolar disorder by reading books on the topic (such as Miklowitz’s publications above) or from newsletters (he recommended Muffy Walker’s “My Support” newsletter, but you might also try Psych Central’s own bipolar newsletter as well) or websites (he also suggested McMan’s Depression and Bipolar website, but you might also try Psych Central’s Bipolar resources section).
Also, even if you can’t obtain information about your loved one from their doctor, you can provide them with information, especially during emergencies. So if your loved one’s symptoms are worsening, tell their doctor immediately.