Bipolar Disorder – Balancing Moods by Balancing Nutrients
While most practitioners, conventional and alternative, focus on fighting heart disease, arthritis and cancer, there is growing concern over the silent epidemic of mental disorders that is becoming one of the most common causes of premature death.
Depression is poorly understood and tolerated in a society that is focused on positivism and a ‘can-do’ spirit. But it is depression’s extreme cousin – bipolar disorder, or manic-depression – that is perhaps the most perplexing of all the mental disorders.
From 1 to 4.5 per cent of people worldwide will develop bipolar disease during their lifetime. It typically emerges in late adolescence or early adulthood. During manic periods, the sufferer may be overly impulsive and energetic, with an exaggerated sense of self. The depressed phase brings overwhelming feelings of anxiety, low self-worth and suicidal thoughts.
The cyclical nature of the illness means an episode may resolve on its own. Nevertheless, treatment to achieve and maintain a balanced state is important – without it, bipolar disorder can lead to suicide in nearly 20 per cent of cases.
For years, lithium has been the standard solution for this problem. Taken regularly, it can effectively control mania and depression, and reduce the likelihood of a recurrence. The problem is, it’s still not known how or why lithium works – or fails – in some cases.
Those who don’t respond to lithium or can’t tolerate its side-effects, which include weight gain, tremor and excessive urination, are generally prescribed mood stabilisers such as valproate – the only anticonvulsant approved by the US Food and Drug Administration (FDA) for use in bipolar disorder – and carbamazepine.
Balancing neurotransmitters
The brain is a chemical factory that produces neurotransmitters, chemical messengers that help to maintain the body’s biochemical balance. To do this job, the brain needs raw materials in the form of amino acids, vitamins, minerals and other nutrients.
Most of us obtain these materials from a well-balanced diet plus daily supplements. But some people have absorption or metabolic disorders severe enough to significantly alter brain function. When this happens, a range of conditions such as bipolar disorder, depression, schizophrenia and attention-deficit disorders can occur.
New treatment approaches
Each of us processes foods in our own way. This is why it is possible for some to thrive on a vegetarian/vegan diet while others need an omnivorous diet to be healthy. Similarly, some individuals seem to get all they need from food alone while others require supplements, sometimes at many times the recommended daily allowance (RDA), to remain healthy.
The complexity of the issue has given rise to what is called ‘orthomolecular medicine’, a term coined by nutritional pioneer Linus Pauling in 1968 (Science, 1968; 160: 265-71). Since that time, advances in molecular biology and brain chemistry have identified many inherited nutritional imbalances and mechanisms that can lead to mental disorders.
A large percentage of depressed people (Br J Psychiatry, 1970; 117: 287-9) and schizophrenics (Psychiatr Clin Neurosci, 1999; 53: 531-3) is low in folic acid and may be deficient in omega-3 fatty acids (Psychiatr Res, 1999; 85: 275-91; Prostagl Leukotr Essent Fatty Acids, 1996; 55: 3-7). Similarly, individuals with bipolar disorder may have metabolic disturbances that can affect levels of important, mood-regulating neurotransmitters such as serotonin, dopamine, acetylcholine and norepinephrine (noradrenaline).
Among the leaders in this field of study are the practitioners and researchers at the Pfeiffer Treatment Center in Naperville, Illinois, USA. Based on the work of the late Carl Pfeiffer, a professor at Princeton University, the centre is involved in both research and the nutritional treatment of a wide range of mental disorders.
Researchers at the Pfeiffer Center have found that most victims of mental disorders fall into one of three main biochemical classes: low histamine; high histamine; and pyroluric. The Center’s scientists have also discovered that excess copper and toxic overload can contribute to certain types of depression (see box above).
Low-histamine, or histapenic, individuals are ‘over-methylated’. Around 25 per cent of those with bipolar disorder, and 20 per cent of depressives, 45 per cent of schizophrenics and 15 per cent of those with autism are thought to be histapenic.
Methyls are chemicals consisting of one carbon and three hydrogen atoms. Over-methylated individuals possess too many of these methyls, resulting in excessive levels of the neurotransmitters dopamine, norepinephrine and serotonin. These people are usually nervous and anxious, and prone to paranoia and despair. Generally free of seasonal allergies, they often report a multitude of food and chemical sensitivities. They may also have a history of underachievement, hyperactivity and learning disability.
In contrast, high-histamine, or histadelic, depressives overproduce and retain excess levels of histamine, an important neurotransmitter that affects human behaviour. They are said to be ‘under-methylated’, with low levels of serotonin, dopamine and norepinephrine. They represent 35 per cent of all cases of bipolar disorders, half of all depressives, 18 per cent of schizophrenics, 45 per cent of those with autism and nearly all of those with obsessive-compulsive disorder and anorexia/bulimia.
Symptoms in these patients can include seasonal variations in depression, obsessive-compulsive tendencies, inhalant allergies and frequent headaches as well as perfectionism, high libido and sparse body hair. Such individuals may appear outwardly calm, but suffer from extreme internal anxiety.
About 20 per cent of those labelled bipolar have a genetic pyrrole disorder. This is associated with high kryptopyrrole production as well as fatty-acid abnormalities – especially depressed arachidonic acid – very poor immune function and severe metal-oxidative stress. Rapid-cycle patients – those who experience more than four manic-depressive episodes a year – are often affected by pronounced pyrrole disorder. Around 18 per cent of those with bipolar disorder, 20 per cent of depressed individuals, 27 per cent of schizophrenics and 20 per cent of autistic people have this disorder, compared with 10 per cent of the general population.
Pyrolurics are devastated by stress such as physical injury, emotional trauma, illness and sleep deprivation. These individuals often report an inability to eat breakfast, sensitivity to light and noises, reading disorders, hysteria, rage, severe anxiety, absence of dream recall and frequent infections.
These categories, of course, are general and some crossover among them is inevitable. For instance, a person can be histadelic, but suffer from the same types of imbalances seen in pyroluria as well.
Individualised treatment
The Pfeiffer Center programme involves asking a basic question that few other practitioners ask: who is the patient nutritionally? Finding the answer involves extensive chemical analysis of blood, urine and tissues to define the patient’s biochemistry. Treatment requires supplements of specific vitamins, minerals and amino acids (see box above) that need to be supplied with rifle-shot precision – and sometimes in very high doses.
Research into the biochemical treatment of bipolar disorder is not as prolific as it is for disorders such as depression and schizophrenia. Nevertheless, what there is gives cause for optimism.
Depressed people may have an impaired ability to metabolise certain essential fatty acids (Prostagl Leukotr Essent Fatty Acids, 1999; 60: 217-34), leading to lower blood levels of omega-3s (Lipids, 1996; 31 Suppl: S157-61; Psychiatr Res, 1999; 85: 275-91). For these individuals, the typical Western diet, which greatly favours omega-6 fatty acids, may be disastrous. Conventional medication may also worsen the problem (Eur Neuropsychopharmacol, 2003; 13: 99-103).
One double-blind trial discovered that people taking 9.6 g/day of omega-3s from fish oil in addition to their conventional medications had significantly improved bipolar symptoms compared with those taking a placebo (Arch Gen Psychiatry, 1999; 56: 407-12).
Both folic acid and vitamin B12 are used in the body to make serotonin and other neurotransmitters. A deficiency of either nutrient is associated with depression (Nutr Rev, 1996; 54: 382-90; South Med J, 1991; 84: 1475-81). Those diagnosed with mania also tend to have folate deficiencies (J Affect Disord, 1997; 46: 95-9), though some studies dispute this (Acta Psychiatr Scand, 1991; 83: 199- 201; J Affect Disord, 1992; 24: 265-70). There is evidence that increasing levels of folate can improve the response rate to lithium (J Affect Disord, 1986; 10: 9-13) but, again, there are also other data that dispute this claim (Int Clin Psychopharmacol, 1988; 3: 49-52).
On their own, both mania and depression are associated with vitamin-B12 deficiency, and injections of B12 can help clear these symptoms (Am J Psychiatry, 1984; 141: 300-1; J Clin Psychiatry, 1991; 52: 182-3). Although B12 deficiency is poorly researched in bipolar disorder, case reports suggest it may be a factor (West Ind Med J, 2000; 49: 347-8).
A double-blind trial found that, compared with a placebo, both manic and depressed bipolar patients significantly improved after a one-time-only administration of 3 g of vitamin C (Psychol Med, 1981; 11: 249-56). Vitamin C helps the body reduce its load of vanadium (Nutr Health, 1984; 3: 79-85), an excess of which may cause bipolar disorder, and 4 g/day combined with the chelator EDTA (which removes elements such as vanadium from the body) helped depressed bipolar patients, but not those with mania (Psychol Med, 1984; 14: 533-9).
The amino-acid L-tryptophan can improve depression (Fortschr Med, 1998; 116: 40-2), and high doses (9.6 g/day) may help bipolar patients with acute mania (Psychopharmacologia, 1974; 34: 11-20). Those taking lithium or an antidepressant markedly improved when L-tryptophan at 12 g/day was added to their treatment (Am J Psychiatry, 1979; 136: 719-20; J Clin Psychopharmacol, 1984; 4: 347-8).
Supplemental 5-HTP (a serotonin precursor) at 200 mg/day had antidepressant effects in bipolar patients, although it was not as effective as lithium (Acta Psychiatr Scand Suppl, 1981; 290: 191-201). 5-HTP may also enhance the effectiveness of antidepressants (J Affect Disord, 1980; 2: 137-46).
Yet another amino acid, S-adenosylmethionine (SAMe), has been proved in clinical trials to have significant antidepressant effects in bipolar patients (Acta Psychiatr Scand, 1990; 81: 432-6; Drugs, 1989; 38: 389-417).
However, in common with conventional antidepressants, some patients have swung from depression to mania with SAMe at 500-1600 mg/day (Br J Psychiatry, 1989; 154: 48-51). This mania can resolve spontaneously with continued supplementation (Acta Psychiatr Scand, 1990; 81: 432-6), but those with bipolar disorder should probably take SAMe only under the guidance of a qualified practitioner.
Inositol may be reduced in depressed and bipolar patients (Am J Psychiatry, 1997; 154: 1148-50), and can have significant antidepressant effects at a high dose of 12 g/day (Am J Psychiatry, 1995; 152: 792-4; Isr J Psychiatry Relat Sci, 1995; 32: 14-21). However, some bipolar patients have reported either little benefit (Br J Psychiatry, 1994; 164: 133-4) or a worsening of their symptoms (Am J Psychiatry, 1996; 153: 839).
Orthomolecular treatment can take weeks before a change in symptoms becomes evident – or it may not work at all. It is said to be most effective in those who have significant biochemical imbalances, but such patients may also have the most severe symptoms and may be resistant to the more aggressive forms of conventional care. For these individuals, using nutrition to balance glitches in their genetic make-up may help, at the very least, to reduce dependence on medication and, as such, can be considered a positive step on the road to good mental health.
Sidebar: Toxic overload
Along with nutrient imbalances, the Pfeiffer Center has found that an overload of copper and toxic substances also contributes to mental problems such as bipolar disorder. Depressives with high copper levels usually have a history of hyperactivity, tinnitus and skin sensitivity to metals. Women with this condition often have significant premenstrual syndrome (PMS) and are prone to heightened depression during other hormonal events such as childbirth and menopause. Symptoms often worsen when given oestrogen or multiple vitamins. Treatment needs to release excess copper from tissues, promote copper excretion and stimulate metallothionein (a metal-binding protein).
Toxic substances capable of producing depression include lead, cadmium, mercury, and a wide variety of organic and inorganic chemicals. Overloads of this type can produce a sudden, prolonged bout of depression without apparent reason even in those without a prior history of depression. Treatments vary according to the toxic substance involved. Heavy-metal overloads can be corrected quickly by in-hospital chelation, though care must be exercised to avoid flooding the kidneys with toxins during the early stages of treatment. A long-term ‘cure’ of a toxic overload often requires high-dose antioxidants as well as lifestyle adjustments to help the individual avoid toxic triggers.
Sidebar: Official Resistace
So compelling is the evidence for a nutritional approach to bipolar disorder that it’s a wonder why more physicians and psychiatrists aren’t flocking to learn more. But there’s strong official resistance to the idea that simple nutrients can help. Health Canada, the Canadian equivalent to the UK Department of Heath, has seized and banned supplies of the nutritional formula Empowerplus, which has a good track-record for treating all kinds of mental disorders, including bipolar disease. Since 1996, Empowerplus’ manufacturer Truehope Nutritional Support Ltd has fought to obtain scientific validation of the product through independent research and clinical studies. This suggests that, unlike many nutritional formulas, Empowerplus does have research to back up the claims made for it.
The results of several studies are encouraging (J Clin Psychiatry, 2003; 64: 338; J Child Adolesc Psychopharmacol, 2002; 12: 205-19). In one, those who completed a six-month trial reduced symptoms by up to 66 per cent, and decreased the need for medications by more than 50 per cent (J Clin Psychiatry, 2001; 62: 936-44).
Truehope says thousands of individuals with bipolar disorder and other mental disorders have been helped by Empowerplus and is actively fighting to lift the ban. However, none of the studies is placebo-controlled, so all fall short of the ‘gold standard’ for medical trials.
Scientists at the Pfeiffer Center, while acknowledging that Empowerplus is useful in some cases of bipolar disorder, also warn that a scattergun approach may be unhelpful because not all biochemical imbalances are caused by deficiencies. Indeed, many involve overloads of certain nutrients, and careless supplementation can make some people worse. Elevated copper, for example, is associated with paranoia (Intern Rev Neurobiol, 1972; Suppl 1: 141-85), excess phenylalanine (in the form of aspartame) can worsen depression (Biol Psychiatry, 1993; 34: 13-7) and excess levels of vanadium may be a factor in the disorder (Nutr Health, 1984; 3: 79-85; Psychol Med, 1981; 11: 249-56). Empowerplus contains all three. Yet, even with this caveat in mind, the Canadian government’s response to the supplement, which has clearly helped some individuals, seems heavy-handed.
Sidebar: Individualised approach to bipolar disorder
Orthomolecular specialists such as the Pfeiffer Treatment Center in the US and the Optimum Nutrition Institute in the UK offer highly individualised treatment programmes based on nutrition and supplements. At these centres, diagnosis is the key to helping people. It is not uncommon for patients at the Pfeiffer to undergo as many as 150 different lab tests to determine nutritional status vis-`a-vis depression. Such comprehensive testing can be difficult and time-consuming but, according to the Center, it can lead to an improvement in as much as 92 per cent of patients. Their own records show that two-thirds of those using this approach for rebalancing body chemistry no longer require medication.
To illustrate the need for careful diagnosis and supplementation, the table below shows the frequency of each biochemical class of depression and the supplements that are likely to help as well as harm.
Under-methylated (high histamine)
Subtype patients – 35 per cent
Potentially harmful supplements – Folate, choline, DMAE, copper, histidine
Potentially helpful supplements – Methionine, SAMe, calcium, magnesium, omega-3 fatty acids (DHA, EPA), inositol, vitamins A, B6, C, E
Over-methylated (low histamine)
Subtype patients – 25 per cent
Potentially harmful supplements – Methionine, SAMe, tryptophan, phenylalanine, St John’s wort, tyrosine, copper, TMG, DMG
Potentially helpful supplements – Folic acid, niacinamide, DMAE, choline, manganese, zinc, omega-3 fatty acids omega-3 fatty acids (DHA, EPA), vitamins B12, C, E
Pyroluria
Subtype patients – 18 per cent
Potentially harmful supplements – Histidine, copper, omega-3 fatty acids
Potentially helpful supplements – Zinc, vitamin B6, primrose or borage oil
*SAMe = S-adenosylmethionine; DMAE = dimethylaminoethanol; TMG = trimethylglycine (betaine); DMG = dimethylglycine
Sidebar: How to get yourself back into balance
Many things can influence bipolar disorder, such as imbalances in blood sugar and thyroid hormones, or lifestyle. Orthomolecular practitioners believe that lifestyle changes should only be attempted after chemical imbalances have been corrected (or at least lessened). Trying to do everything at once can be overwhelming, resulting in a tendency to give up.
Food allergies. These can devastate both the gastrointestinal tract and brain function, and are thought to be common among bipolar sufferers. Allergies include gluten (the protein in grains like wheat, rye, oats and barley), aspartame, chocolate, caffeine and casein (a protein found in dairy). A number of food-allergy tests are available, but none is 100-per-cent accurate. The best test remains the ‘caveman’ elimination diet, which avoids grains, dairy, eggs, legumes, sugar, citrus, caffeine, certain vegetables such as the nightshade family, and processed meat products. This can be carried out at home under the supervision of a qualified nutritionist.
Candida overgrowth is extremely common among those with psychiatric disorders. Every bipolar sufferer should be investigated for this condition, and learn how to treat it through dietary changes and other yeast-killing and/or controlling methods.
Hypoglycaemia (abnormally low blood sugar) can be due to consuming large amounts of sugar and refined carbohydrates. The body’s response to hypoglycaemia is to release epinephrine (adrenaline), which can cause sweating, nervousness, hunger, faintness, palpitations, hypothermia and headaches. More severe low blood sugar can lead to a reduced glucose supply to the brain, resulting in irritability, confusion, dizziness, fatigue, weakness, visual abnormalities and coma. Dietary adjustment and adequate amounts of chromium, zinc, magnesium and other nutrients are required to maintain blood-sugar balance.
Thyroid problems are a common cause of depression and should always be checked for by your GP. An overactive thyroid gland, or hyperthyroidism, can trigger restlessness, hyperactivity, insomnia and irritability – symptoms that could be mistaken for mania. A sluggish thyroid (hypothyroidism) may result in feelings of coldness, depression and low energy (Acta Psychiatr Scand, 2001; 104: 72-5).
Digestive enzymes help the body absorb nutrients from food. These may be lacking in some bipolar individuals, resulting in a lack of B vitamins, which protect the nervous system. Digestive enzymes such as pepsin, betaine and papain aid in digesting fats and proteins, and are available at healthfood shops, though some may not be potent enough to be adequately therapeutic. If in doubt, consult your practitioner.
Low stomach acid. Adequate stomach-acid production is necessary for an adequate supply of minerals and amino acids to be delivered to the body. A hydrochloric acid (HCI) test is worth considering as it can immediately reveal whether low stomach acid is a problem.
Parasites are far more common in all of us than is often thought, and these ‘nutrient robbers’ and ‘toxic releasers’ often go undiagnosed for decades. They should be cleared out.
Alcohol and recreational drugs. About 60 per cent of people with bipolar disorder have drug and/or alcohol abuse or dependence problems, the highest rate among patients with major psychiatric illnesses (JAMA, 1990; 264: 2511-8). One review revealed several factors that increase the risk for multiple substance use among bipolars, including early age of illness onset and the presence of mixed symptoms (Harvard Rev Psychiatry, 1998; 6: 133-41).
Psychotherapy can help sufferers manage their symptoms better. Emphasis is placed on recognising early signs of relapse so that patients can seek medical care before a full-blown illness develops as well as learn how to modify the detrimental or inappropriate thought patterns and behaviours associated with bipolar disorder.
- This article first appeared in the October 2003 (volume 14 number 7) edition of What Doctors Don’t Tell You
