A Functional Medicine Approach To Bipolar Disorder

Bipolar disorder is a group of three distinct types of mood disorders characterized by abnormal, uncontrolled changes in mood, activity, concentration, and energy levels that impact a person’s ability to live, work, care for themselves, and more. The symptoms of bipolar disorder can be mild, moderate, or severe. Bipolar disorder will affect up to 4.4% of adults in their lifetimes. There is an abundance of research about what works to help manage symptoms and slow the progression of bipolar disorder, from pharmaceuticals to the foods we eat, exercises we choose, and the ways we sleep. This article will review a Functional Medicine Approach to Bipolar Disorder, including nutrition, lifestyle interventions, pharmaceuticals, physical medicine, and more.

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Signs & Symptoms of Bipolar Disorder

There are 3 types of bipolar disorder. Each is categorized by some combination of mania/hypomania and depressive episodes.

Symptoms of Manic Episodes in Bipolar Disorder

• Significantly increased energy, movements, and speed of communication.
• Feelings of elevated sped up mood including feeling "up," irritable, wired, anxious, touchy, and like things are moving fast.
• Decreased need for sleep (people in a manic episode often stay up for multiple days and nights in a row.)
• Delusions of grandeur (feelings of being unusually powerful, important, brilliant, unstoppable, etc.)
• Loss of appetite.
• Risk behaviors (drug use, gambling, sex, spending an excessive amount of money).
• Psychosis and loss of touch with reality can occur as part of the spectrum of manic symptoms.

Symptoms of Depressive Episodes in Bipolar Disorder

• Decreased energy, feeling tired and sad.
• Slowed movements and difficulty thinking quickly, concentrating, and making decisions.
• Changes in sleep include oversleeping and experiencing difficulty waking up in the mornings.
• Loss of interest or pleasure in activities that used to be pleasurable, including relationships, work, hobbies, sex, and more.
• Depressive symptoms like low mood, wishing life would be over, feeling hopeless or empty.
• Changes in appetite, including overeating

It is possible for people with bipolar to experience episodes where they have both manic and depressive symptoms at the same time. These are called "mixed episodes."

Sometimes, people experiencing these mood changes are aware of their shift in affect and want help. Other times, the person with bipolar may be completely unaware that their mood and activity level has changed, and friends or family members are more likely to notice and report their symptoms.

83% of people with bipolar report that it causes them severe impairment in their activities of daily living. Bipolar disorder symptoms can be frightening for both the patient and loved ones. Regular, intensive treatment is required to help people with severe symptoms of bipolar to manage their symptoms.

Possible Root Causes of Bipolar Disorder

It should be noted that science is still evolving when defining and classifying bipolar disorder and that there are many things we still don't know. The development of bipolar disorder is still not completely understood and involves many factors, including genetics, brain chemistry, anatomy, neuroinflammation, stress, and more.

As our understanding of neurophysiology, development, and biochemistry advances, so does our understanding of bipolar and other mood disorders that were initially defined in the medical literature before our current neuroimaging, lab analysis, and other technologies.

Brain Changes

Changes in the prefrontal cortex, cerebellum, limbic system, and ventricles of the brain are common in bipolar disorder. These areas of the brain help control attention, planning, motor and thought coordination and more.

People with bipolar disorder and depression also tend to have smaller numbers of glial cells in the central nervous system than people without these disorders. Glial cells provide nutrients, support, insulation, and protection for neurons. They also help clear the brain of waste products, produce cerebrospinal fluid, and control levels of neurotransmitters.

Additionally, abnormalities in serotonin and norepinephrine production and transmission are common in the brains of people with bipolar disorder, as are changes in hypothalamic-pituitary-adrenal (HPA) and hypothalamic-pituitary-thyroid (HPT) axis function. People with bipolar tend to produce more cortisol in response to stress and maybe helped by higher doses of levothyroxine (a thyroid medication) than people without bipolar.

Genetics

Many genetic factors are thought to be associated with an increased chance of developing bipolar disorder. For example, first-degree relatives of a person with bipolar disorder are about ten times more likely than those without a family history of bipolar to develop the condition.

Some researchers estimate that the likelihood of developing bipolar disorder is influenced 85% by genetics and 15% by environmental factors like stress, drug use, etc. Genes that control processes like voltage-gated calcium channel function, BNDF, glutamate metabolism, catecholamine production, blood sugar management, and more are thought to be involved in bipolar disorder.

Hormones and Puberty

It is rare for children or older adults to be diagnosed with new-onset bipolar disorder. The median age at which people with bipolar disorder are first diagnosed is 17.5 years old, with a peak incidence between the ages of 15-29.

While males and females seem to be equally affected by bipolar disorder, females are more likely to be diagnosed with bipolar II and rapid-cycling forms of bipolar.

Possible Causes of Increased Symptom Severity in Bipolar Disorder

Several factors play a role in symptom severity in bipolar disorder.

Endocrine and Sympathetic Nervous System Abnormalities

People with bipolar disorder are more likely to experience high levels of cortisol (a stress hormone) and adrenaline in response to stress. Their cells are less sensitive to stress hormones, and they can even experience abnormalities in the timing of hormones and disturbances in circadian rhythms.

Over time, this can lead to adverse physiological effects from stress, like impaired blood sugar control, immune system function, metabolic changes, sleep disturbances, and more. Additionally, high cortisol levels can lead to oxidative damage and mitochondrial changes that impact the energy production of cells.

Oxidative Stress and Inflammation

Neuroinflammation is now understood to be at the root of many mental health conditions that have depressive and manic symptoms as part of their symptomatology. This is because neuroinflammation can lead to oxidation of the fats in the membranes of cells, resulting in "aberrant neurotransmitter signaling and information processing in synapses and circuits mediating affective, cognitive, motoric, and neurovegetative behaviors."

Low levels of antioxidant capacity, altered cholesterol levels, and a flattened cortisol curve with diminished early morning cortisol are predictive of severe episodes of depression and suicidal behavior in people with mental health issues, including bipolar disorder.

This is thought to be because these compounds (antioxidants, cholesterol, and cortisol) play a role in protecting cells from inflammation.

Micronutrient Abnormalities

• Folate

• Red blood cell folate levels are lower in people with bipolar disorder in both manic and depressive episodes. Deficiencies in folate have been found to lessen the effectiveness of medications in controlling symptoms of bipolar and non-bipolar depression. Administering folate along with medications for bipolar has been found to make them more effective.

• Vitamin D

• People with bipolar disorder are 4.7 times more likely to have a vitamin D deficiency than those without bipolar.

• Copper

• Increased serum copper is associated with increased symptomatology in people with bipolar.

• Magnesium

• Changes in serum magnesium are common in people experiencing an acute episode of bipolar, including both increased and decreased magnesium. This may have to do with the calcium channel abnormalities often seen in these disorders.

• Omega 3

• Omega 3' fatty acids are lower in the red blood cells of people with bipolar than those without it, and supplementing omega 3's has been found to improve outcomes in bipolar disorder.

Thyroid Hormone

People with bipolar disorder are more likely to have abnormal thyroid function than those without bipolar disorder. Research is still evolving as to why the link exists. Many scientists theorize that it may have something to do with dopamine production and thyroid hormone sharing many of the same biochemical precursors and are linked by certain enzymatic and hormonal pathways processes that impact brain metabolism. Thyroid hormone abnormalities are correlated with subtypes of bipolar disorder and can make symptoms worse if they are not controlled. Additionally, medications for bipolar disorder can affect thyroid function.

Psychosocial Stress

Stress and early childhood trauma are risk factors for developing bipolar disorder and experiencing acute episodes. Many psychosocial approaches to bipolar involve cognitive-behavioral techniques to manage stress and build both physiological and psychological resilience to stressors.

Functional Medicine Labs to Find the Root Causes of Bipolar Disorder

The members of your medical team are the most qualified to determine which medical and lifestyle factors could be playing a role in your or a loved one's bipolar symptoms. In pursuit of understanding your root cause(s) and developing a plan to help you optimize your health with bipolar disorder, they may order some of the following tests.

Hormone, HPA, and HPT Axis Testing

Thyroid abnormalities are common in people with bipolar and can make symptoms worse if they are not controlled. A Complete Thyroid Panel should include at least TSH, Free T4, Free T3, and Reverse T3 to get a comprehensive overview of how well the thyroid is functioning. Cortisol abnormalities are also common in people with bipolar. There are several ways to measure cortisol, including salivary and serum tests, one-time vs. multiple collection tests, etc. Specialty tests like the Dutch Plus Test allow a practitioner to measure various sex hormones in the urine and saliva, including progesterone, testosterone, DHEA, cortisol, and estrogen. Your primary care practitioner can also run these tests at your annual physical.

Total Antioxidant Capacity / Micronutrient Testing

Total antioxidant capacity is determined by the number of nutrients like omega 3's, vitamin C, vitamin E, CoQ10, zinc, lycopene, selenium, polyphenols, glutathione, and more in the blood. A standard CBC and CMP that your doctor runs every year at your check-up can also detect nutrient deficiencies. A trained practitioner can also help you evaluate your diet to see if your typical eating pattern has nutrient gaps that may impact the progression rate of your or your loved one's bipolar disorder symptoms.

Oxidative Stress Biomarkers

Markers of inflammation and oxidative stress like IL-6, TNF-a, hs-CRP, and more can be used to determine the amount of oxidative stress and inflammation that may be affecting bipolar symptom expression.

It should be noted here that functional medicine labs that assess total metabolic health are also important for people with bipolar to consider, as they tend to be more affected by disorders like cardiovascular disease, diabetes, etc. Additionally, lab testing is only one type of testing that is important in identifying all aspects of bipolar disorder. Thorough neuropsychiatric testing and psychological testing are a vital initial step in classifying bipolar and identifying other comorbid mental health or development disorders that may be present.

Functional Medicine Treatment for Bipolar Disorder

The proper treatment protocol for any individual's bipolar disorder will depend on their unique history, genetics, lifestyle, preferences, and symptoms. This is because functional medicine practitioners don't treat symptoms - they treat people! Standard functional medicine approaches to treating bipolar disorder usually contain a combination of the following approaches.

Pharmaceuticals

For acute symptom management, pharmaceuticals are the gold-standard treatment. They include options like lithium, quetiapine, lurasidone, olanzapine and fluoxetine, valproate, lamotrigine, carbamazepine, and cariprazine lorazepam, and more. When medications are not enough, electroconvulsive therapy (ECT) can help manage acute symptoms.

Movement and Exercise

Exercise improves symptoms of depression and improves the quality of life in people with bipolar disorder. The reasons for this are too vast to enumerate here but include the increased production of feel-good neurochemicals, boost in the circulation of oxygen-rich blood to the brain and nervous system tissues, improvement of glycemic control, and insulin sensitivity, and more.

Diet and Supplements

Research suggests that diet, supplements, and lifestyle changes can improve bipolar disorder symptoms.

• A diet high in fruits, vegetables, nuts, seeds, legumes, and fish decreases the risk of mood disorders compared to a western diet.
• Omega 3 supplementation can improve symptoms of bipolar disorder. Top sources of omega 3's in the diet include salmon, chia seeds, flax seeds, and walnuts.
• Amino acid changes to the diet have successfully improved symptoms of mania in people with bipolar disorder, including tyrosine depletion and BCAA supplementation.
• Choline can change brain concentrations of purines in people with bipolar disorder, which may improve symptoms. Eggs are an excellent food source of choline, as is beef liver.
• N-Acetyl-Cysteine (NAC) at doses above 1 gram twice daily has been shown to improve depressive symptoms in people with bipolar disorder as long as they are used continuously.
• Magnesium supplementation, including IV infusion, can rapidly improve symptoms of bipolar including acute mania. They can also improve the efficacy of other pharmaceutical treatments for bipolar. Magnesium's food sources include pumpkin seeds, chia seeds, almonds, spinach, and cashews.
• Inositol improves depressive symptoms in bipolar disorder when used alongside medications.
• Vitamin C at 3 grams per day includes depressive and manic symptoms in bipolar.
• Multivitamin and multimineral supplements can improve symptoms in bipolar and decrease the need for medication by up to 50%

Therapy & Mindfulness

Psychological treatment (cognitive behavioral therapy, etc.) is effective for reducing symptoms and improving psychosocial functioning in people with bipolar disorder. The effect is most significant for therapy sessions that last 90 minutes or more. Mindfulness interventions are successful in helping people with bipolar to reduce symptoms of anxiety and depression when combined with cognitive-behavioral therapy.

Multidisciplinary Approach

The best approaches to bipolar disorder are multidisciplinary and involve a team. Usually, this team combines a primary care doctor, psychiatrist, therapist, functional medicine doctor, supportive friends and family, and more. Caregivers for people with chronic mental health disorders also need support. If you're a caregiver or close family member of someone with bipolar disorder, make sure you're caring for yourself!

Summary

You can thrive with bipolar as part of your health history. A skilled practitioner who knows your history can help you develop an evidence-based treatment plan that includes nutrition, mindfulness, therapy, medications, and more to help you feel stable, happy, healthy, and in love with your life. Consistency of medical care, routine appointments where interventions can be adjusted, and a holistic plan that addresses nutrition, stress management, and more are incredible components of a world-class plan that will keep you on course if bipolar is part of your picture.

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