Apr 28

Impulsivity – Gina

ImpulsivityImpulsivity is something everyone has experienced. We have all had moments when we have said something impulsively that we regret or have gotten carried away with an idea. Sometimes the consequences of an impulsive action are minimal.  But that is not always the case.

Impulsive decision-making is more common in people with bipolar. And this increase is not just something seen during a mood episode, people with bipolar seem to have a generally increased tendency to quick or impulsive decisions.

Nevertheless, in a hypomanic or manic state, an increase in impulsive decision-making is often a key feature of the change in mood. It can result in compulsive gambling, risky sex, excessive spending, and other risky behavior.

When depressed, especially in a “mixed” state, impulsive decisions in bipolar increase the risk of suicide. I

n addition, to impulsivity being linked to mood states, Robin Flanigan in her blog post “Bipolar and Controlling Impulsivity,” notes that research suggests a link to brain differences in people with bipolar disorder regardless of mood states which makes them more prone to risk and impulsivity.

“Studies suggest that the part of the brain that plans and analyzes tends to have a weaker grip on emotional circuitry in people with bipolar—akin to worn brake pads that can’t stop a speeding car in time.

In addition, the reward system seems to be more sensitive, so that the lure of a prize wields more power.

On the one hand, the greater lure of reward can fuel goal-directed achievement. This led John Gartner to write a book arguing that hypomania is responsible for some of the success of American entrepreneurs, The Hypomanic Edge: The Link Between (A Little) Craziness and (A Lot of) Success in America.

“Why is America so rich and powerful?” asks Gartner. The answer lies in our genes, he says. “My new hypothesis became that American entrepreneurs are largely hypomanic,” writes Gartner. “Hypomanics are brimming with infectious energy, irrational confidence and really big ideas. They think, talk, move and make decisions quickly. Anyone who slows them down with questions ‘just doesn’t get it.’ Hypomanics are not crazy, but ‘normal’ is not the first word that comes to mind when describing them. Hypomanics live on the edge, between normal and abnormal.”

On the other hand, impulsivity increases susceptibility to addiction and intensifies cravings for excitement that can be profoundly self-destructive.

The Brain

What is happening in the brain to someone with bipolar disorder that may differ from someone without the diagnosis that may account for an increase in impulsivity? Robin Flanigan discusses some of the relevant research in her blog post “Impulsivity: What’s Happening in the Brain.”

“When  British researchers had a group of people with bipolar perform a roulette-style task, they showed stronger activation in the nucleus accumbens than a comparison group of people without bipolar.”

That 2014 study also found different patterns of activity within an area called the ventromedial prefrontal cortex (roughly, a “forward and middle” segment) that is active when we are weighing risk versus reward.

Those with bipolar had greater neural activity for risky bets, while those in the comparison group showed more response to “safe” bets.

The ventromedial prefrontal cortex has been implicated in other behaviors that involve deciding between future consequences and immediate pleasure, such as overeating, overspending, and substance overuse.

Meanwhile, a neighboring area called the ventrolateral prefrontal cortex (“forward and left”) may be “increasingly relevant to our understanding of impulsivity, particularly in people with bipolar disorder,” says Mary L. Phillips, MD, director of the Mood and Brain Laboratory at the University of Pittsburgh School of Medicine.

In certain situations where a big reward is possible, such as gambling, ventrolateral activity is heightened significantly more in people with bipolar disorder than in those without bipolar.

Furthermore, Phillips and her colleagues have found that the excitement associated with the possibility of a future reward increases disproportionately during mania, feeding even more juice to emotional urges and compromising the ability to regulate them—much as floodwaters may overwhelm a normally sturdy dam.

“These series of vulnerabilities often lead to risky decisions,” Phillips notes.”


Working with people with bipolar, I have learned several helpful strategies that they use to support themselves around managing risks related to impulsivity and risky decision making.

Pause and Reflect

Taking a moment to pause and observe can be incredibly helpful. A regular mindfulness practice can help people be able to take a moment to reflect before an abrupt act. The more often we practice mindfulness, the more readily able we are to use the skill during more challenging times.

Recruit a Helper

Sometimes having someone you can trust to reality test with around a possible decision you want to make can make a huge difference. This can be a therapist, friend, significant other, parent — someone you can check in with to explore if the decision could have negative consequences you are not prepared to face. They can help you weigh the pros and cons – to act, or not to act!

The 48 Hour Rule

If you are considering making an impulsive decision, try waiting 48 hours before acting. Check in with yourself after that timeline to see if anything has changed? Do you have any new information that may inform whether or not you want to act.

Know Your Triggers and Your Warning Signs

Being able to identify when you mood may be shifting can be essential to increasing your awareness around your risk to act impulsively. This may be you noticing a change in your thoughts, sleep patterns, etc. Also, know which triggers make you most vulnerable regardless of your mood state. Are there certain people or situations you are more likely to act impulsively around? Can you come up a with a plan ahead of time around how you may take time to pause before acting?

– Gina


Flanigan, R. (2017, April, 7). “Impulsivity: What’s Happening in the Brain.” http://www.bphope.com/impulsivity-bipolar-brain/

Flanigan, R. (2017, April, 7). “Bipolar and Controlling Impulsivity.” http://www.bphope.com/bipolar-and-controlling-impulsivity

For More Information

Bipolar and Creativity

Early Warning Signs

Janelle Caponigro and Erica Lee

Apr 25

Mood Trends


Mood TrendsMood trends are useful to track in order to prevent a full blown episode of depression, hypomania or mania.

I think of them as equivalent to the idea of a falling or rising barometer.

Before satellites and modern weather forecasting, whether the barometer was rising or falling was the best predictor of the weather. If the barometer was rising it meant sunnier weather, and if it was falling it could be sign of a future storm.

Similarly, keeping track of certain markers of mood can help predict where your mood is headed and therefore what to watch for and how what kind of self care to focus on.

Let’s say you notice that you are waking up a bit earlier in the morning, and that you are feeling like tackling more projects, or are talking to friends more, or chatting more online, this could be a sign that your mood barometer is trending up. It doesn’t mean that you are hypomanic, but it does mean that you are more likely to head in that direction than to suddenly dip into depression.

Or maybe you find yourself having a harder time getting out of bed, feeling like putting decisions off to the future, feeling like you want more quiet time and more rest, it doesn’t mean you are depressed, just that you might be heading in that direction.

Trending Up or Trending Down

Take Advantage of the Trend

Certain things are easier to do when you are trending up or trending down.

When you are trending down –

  • It may be easier to have deeper conversations with good friends than to do a lot of socializing with many people.
  • Quiet and contemplative activities may make more sense. Reading may be easier or listening to more complex music.

When you’re trending up –

  • It may be a good time for generating new ideas and new approaches to problems.
  • Tackle decisions that don’t require too much contemplation or analysis.
  • Clean the house or organize things.

But Make Sure to Balance That with Opposite Action

To avoid going from a trend to a full-blown mood episode consciously balance your activities to include some that counter the trend.

When you’re trending down –

  • Focus on not sleeping in. You may want to restrict yourself to a little bit shorter sleep time and make sure to get plenty of bright light in the morning.
  • Make sure you’re getting enough exercise. 30 minutes a day of brisk walking is plenty.
  • Do reach out to those close friends who can help you keep a sense of perspective when your mind tends to focus on the negative too much.
  • Consciously avoid negative news sources.

When you are trending up –

  • Make sure you’re getting enough sleep. Set alarms on your devices so that you stop using them in time to get ready for sleep.
  • Be cautious about beginning lots of projects or committing to big new ideas.
  • Even a small dose of mindfulness meditation (5 minutes twice a day of Calm.com) can help moderate the trend to hypomania.

The Science Behind This

The STEP-BD research project, the largest longitudinal study of people with bipolar ever found that so-called sub-syndromal or residual mood symptoms were a major predictor of new episodes.

In particular, residual mood symptoms early in recovery appear to be a powerful predictor of recurrence, particularly for depression. Risk of depressive recurrence increases by 14% for every DSM-IV depressive symptom present at recovery… This is consistent with the work of Keller et al. that found that subsyndromal symptoms were associated with risk of recurrence…

Perlis RH, Ostacher MJ, Patel JK, Marangell LB, Zhang H, Wisniewski SR, Ketter TA, Miklowitz DJ, Otto MW, Gyulai L, Reilly-Harrington NA, Nierenberg AA, Sachs GS, Thase ME. Predictors of recurrence in bipolar disorder: primary outcomes from the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). Am J Psychiatry. 2006 Feb;163(2):217-24. PubMed PMID: 16449474.

Apr 23

Bipolar Type 4

bipolarWe’ve recently been re-reading some of the works of Hagop Akiskal, one of the most important writers about Bipolar of the last 50 years.  He is particularly focused on identifying sub-types of bipolar as well as exploring the relationship between bipolar and creativity.  We were particularly struck with his description of type 4 bipolar.  This is someone (he says usually a man) who has what he calls a hyperthymic temperament.  By this he means someone who has always been very successful at work and in business relationships.  Someone who is high energy and often quite creative.  The example that my colleague came up with was Bill Clinton, not sure if that’s accurate or not.  But it gives you some idea of who Hagop is describing.

Such a person does not generally come in for treatment until he or she develops a depression, usually later in life.

As Hagop points out, someone who has always been filled with energy, enthusiasm, and creativity often is hard pressed to tolerate even a small amount of depression.  He or she comes in for treatment with a great sense of urgency about getting well.  Hagop proposes that this type of bipolar, when depressed, maybe at particularly high risk of suicide because of that difficulty adapting to or tolerating the change.

The good news is that treatment is often very effective, although as with all treatment of bipolar depression, it may take many weeks to see the good results that can eventually be achieved.

We’ll be describing some of the other types over the course of the next week or so as we review some of the material that we presented recently to the residents in psychiatry at the University of California, San Francisco as part of their course on Bipolar Disorder.

Apr 23

Childhood Insomnia

In an eYoung girl frustrated by wakeup of alarm clockra of ever-present video and constant texting and snapchatting, many parents are trying to figure out how to deal with childhood insomnia.

Here is a quick guide for busy parents of things to think about and things to do if your child is having trouble getting to sleep or getting enough sleep.

Consider possible causes –

  • Stress. Kids, just like adults can suffer from stress. Show interest in your child’s life and build trust so they feel comfortable sharing their worries with you. How are things going at school. Online bullying (cyberbullying) is an increasingly common problem for pre-teens and teenagers.  Is everything under your own roof running smoothly (ie, is there arguing, fighting between siblings, marital or financial problems; has there been a death in the family, a recent job change; has the family recently moved)? Children worry more than you might think and excess worry and stress can lead to insomnia.
  • Use of caffeine or other stimulants. Even some clear sodas (Mountain Dew) and most energy drinks have caffeine.
  • Medical, psychiatric and other sleep disorders. Uncontrolled nighttime asthma, a stuffy nose from allergies or itchy skin from eczema can get in the way of good sleep. Also, depression and anxiety, which may show up without clear signs and symptoms, can be a cause of disturbed sleep.

What else to do?

  • Sleep hygiene habits. Restrict time spent in bed to just sleeping (no reading, doing homework or watching TV in bed); maintaining a regular sleep schedule (going to bed and waking up at the same time each day including weekends and holidays); avoiding caffeinated products 4-6 hours before bedtime (caffeinated products include coffee, tea, colas, some non-cola pops, energy drinks, and chocolates); and establishing a bedtime routine that does not include stimulating activities within an hour of bedtime (such as TV watching, electronic gaming, heavy homework, or computer gaming).
  • Comfortable sleep environment. Make sure your child’s bedroom is quiet, calm, comfortable (< 75 degrees F), and dark (a nightlight is acceptable for children afraid of a dark bedroom).
  • Teach children how to relax. We love Calm.com and there are several guides for mindfulness and relaxation specifically for children on the Calm apps.
  • Set bedtime so that enough sleep is possible. Set bedtime so that your child gets his or her usual amount of sleep (Children between the ages of 6 and 12 need about 10 to 11 hours of sleep each night; teens need about 9 hours of sleep each night.)
  • Get up out of bed if your child can’t get to sleep. If your child can’t get to sleep in a half an hour, it is better to get up and do something calming in relatively low light for 15-20 minutes (for example reading or listening to calming music), rather than lying in bed and tossing and turning. After staying out of bed for 20-30 minutes or so, they may return and attempt to sleep. If after a 15-20 minute attempt there is no success, they should get up again and try the relaxing activity again. Repeat the cycle as necessary.
  • Consider cognitive behavioral therapy. Specialists in behavioral and cognitive therapy can work with the child and family to establish regular sleep rhythms. CBT for insomnia is very helpful and can have long term benefits.
  • For kids who have trouble getting to sleep and tend to wake up late. Circadian rhythm disorders can occur in children as in adults. If you have a childhood “owl” trying to function in a world of early rising “larks” a recent article suggests that a combination of nighttime melatonin and early morning bright light may help to reset circadian rhythms. Light therapy consisting of daily bright blue light exposure during 30 minutes between 6:00 and 8:00 am and 3 mg of immediate release melatonin at 7:00 pm. The melatonin treatment was more effective than the light therapy alone and only those receiving melatonin treatment had more total sleep time.


Astill RG, Van der Heijden KB, Van Ijzendoorn MH, Van Someren EJ. Sleep, cognition, and behavioral problems in school-age children: a century of research meta-analyzed. Psychol Bull. 2012 Nov;138(6):1109-38. doi: 10.1037/a0028204. Epub 2012 Apr 30. PubMed PMID: 22545685.

Dewald JF, Meijer AM, Oort FJ, Kerkhof GA, Bögels SM. The influence of sleep
quality, sleep duration and sleepiness on school performance in children and
adolescents: A meta-analytic review. Sleep Med Rev. 2010 Jun;14(3):179-89. doi:
10.1016/j.smrv.2009.10.004. Epub 2010 Jan 21. PubMed PMID: 20093054.

van Maanen A, Meijer AM, Smits MG, van der Heijden KB, Oort FJ. Effects of Melatonin and Bright Light Treatment in Childhood Chronic Sleep Onset Insomnia With Late Melatonin Onset: A Randomized Controlled Study. Sleep. 2017 Feb 1;40(2). doi: 10.1093/sleep/zsw038. PubMed PMID: 28364493.

For More Information

Cleveland Clinic’s Insomnia for Children was the source of much of the information in this article. 

Apr 23

Avoid Intimidation

Avoid IntimidationRick Hanson has written an elegant and timely newsletter article about how to avoid intimidation and fear from paper tigers and media demagogues.

I love his weekly email newsletters and it is again time to encourage readers of this blog to sign up.

Here is the link.

One of Rick’s themes, elegantly outlined in this most recent article, is how we evolved to be much more responsive to threats than to positive news. It was a survival technique that worked well for hundreds of thousands of years. But may no longer be serving us well in an era when threats are not immediate and clear (like a hungry tiger) but distant and complex (like Kim Jong-un’s isolated regime in North Korea).

To keep our ancestors alive, Mother Nature evolved a brain that routinely tricked them into making three mistakes: overestimating threats, underestimating opportunities, and underestimating resources (for dealing with threats and fulfilling opportunities). This is a great way to pass on gene copies, but a lousy way to promote quality of life.

So for starters, be mindful of the degree to which your brain is wired to make you afraid, wired so that you walk around with an ongoing trickle of anxiety (a flood for some) to keep you on alert. And wired to zero in on any apparent bad news in a larger stream of information (e.g., fixing on a casual aside from a family member or co-worker), to tune out or de-emphasize reassuring good news, and to keep thinking about the one thing that was negative in a day in which a hundred small things happened, ninety-nine of which were neutral or positive. (And, to be sure, also be mindful of any tendency you might have toward rose-colored glasses or putting that ostrich head in the sand.)

Additionally, be mindful of the forces around you that beat the drum of alarm – whether it’s a family member who threatens emotional punishment or political figures talking about inner or outer enemies. Consider for yourself whether their fears are valid – or whether they are exaggerated or empty, while downplaying or missing the larger context of opportunities and resources. Ask yourself what these forces could be getting out of beating that scary drum.

This bias towards threat is even more strongly present in people who have been exposed to trauma. Posttraumatic stress disorder is a brain mechanism that was designed to “turn up the gain” on our already hyperactive threat detection system. A crude but effective system for making us even more watchful after we have been exposed to serious threat.

For More Information

Stand Up to Intimidation

Foundations of Wellbeing

Rick Hanson – Trust in Love

Apr 22

Move It

You have the potential to change your life. There is an almost magical system for activating hundreds of genes associated with better health and better brain function that you have access to. And it won’t cost you.

I have written a lot about this amazing system, but this video does a better job than any of my posts.

For those who want the science explained in more detail this video of John Ratey, author of Go Wild, Spark, and Driven to Distraction—discusses the research showing the big benefits of physical activity and connecting with nature—mainly for your mind, not just your body.

I hope you are inspired by these two videos. They came to me courtesy of my subscription to the Foundations of Wellbeing which remains one of my favorite websites on the internet.

The Foundations of Well-Being Program

For More Information

Exercise for Health

Exercise Dose – Update

Apr 21

Exercise for Health

Exercise is essential to healthy life. It offers multiple rewards. It improves mood, lowers blood pressure, and improves blood cholesterol levels. It reduces the risk of cardiovascular disease, diabetes, and some cancers. Regular physical activity helps develop and maintain healthy bones, muscles, and joints. It relieves arthritis pain and keeps you younger than your years. If that weren’t enough, it helps control your weight. And many people learn to love exercise, once they have done it for a while.

In order to stay healthy, people who don’t need to lose weight should get a minimum of 30 minutes of moderately intense physical activity every day, or nearly every day. It should preferably be aerobic activity (good for the cardiovascular system), such as brisk walking, running, cycling, or swimming. Vigorous work like raking and bagging leaves or washing the floor can also serve the purpose.

If you need to lose weight, extend your routine to at least an hour a day, six or seven days a week. Do something that raises your heart rate and makes you breathe faster and sweat.

A study (JAMA v. 290: 1323-1330. 2003) found a direct correlation between weight loss at twelve months and duration of exercise in women who were given instruction in how to diet.

Women in this study who exercised less than 150 minutes a week (and who received instructions to follow a low fat, low calorie diet) lost about 5% of their total body weight, women who exercised 150 – 200 minutes a week lost 7% of their total body weight, and women who exercised more than 200 minutes a week lost almost 10% of their total body weight.

In addition, those women who had the highest levels of exercise were still losing weight at the end of the study, whereas those women who exercised the least were quickly regaining lost weight.

Almost all studies of weight loss find that there is a net regain in weight after the first six months, so that the usual goal is to minimize that weight regain in order to maintain the weight loss benefits of the intervention. This study finds that exercise for more than 200 minutes a week may be one of the few interventions that keeps on delivering weight loss for a full year.

You don’t need to pack all your exercise into one session. Short bouts of exercise during the course of the day have an additive benefit, 3 10-minute or 20-minute sessions will do you as much good as one longer session.

Walking is the most practical, accessible exercise as well as the safest. But casual strolling is not enough. Aim for a brisk pace, about 3.5 to 4 miles per hour (so you walk a mile in 15 to 17 minutes). If you are just starting a walking program, check your pace by walking on a treadmill or timing yourself as you walk a measured mile — typically four times around a school track, for example. If you haven’t been exercising it may take you a few weeks to get used to walking briskly.

Make exercise a habit. Walk whenever possible, in preference to driving or taking a bus. Skip the escalator or elevator and take the stairs.

If you are very overweight, have always been sedentary, or are over 70, you may find it hard to get going. A walking pace of 3.5 to 4 miles an hour may seem impossible to achieve. But keep trying. Do what you can do. It is never too late to start exercising and reaping the rewards.

As you get accustomed to a routine, add some strength training with free weights or weight machines. This is especially important for bone health as you grow older. If you have never done any weight training a few lessons can be an excellent investment to get you started.

Elsewhere on this website we have more information on the psychological benefits of exercise.

Apr 19

Sleep Apps and Wearable Devices

Sleep Apps and WearablesMany of the people I see complain of poor quality sleep, and a number of them have tired using various sleep apps and wearable devices to try to get figure out why they are sleeping poorly and what they can do about it.

One of my techie colleagues says she thinks that this is a good thing and praises one app, which is the most popular sleep app in the iPhone App Store, in particular…

“About a third of my clients are using Sleep Cycle. I like it because it marks the 4 sleep stages and doesn’t smooth the splines on the waves, so you can see roughness if sleep is fragmented. The “sleep quality” measure is bogus because it includes time in bed in its nebulous calculation, but the rest of the app I like a lot. A friend turned me onto it a couple years ago. I’d had a sleep problem for several years and when I saw it on the little monitor and guessed at the etiology I was able to correct the issue in 2 days. I’ve tweaked regimens, ordered sleep studies, and caught a lot of late night drinking with this thing.”

This sounded very positive. However many of my patients report different experiences with sleep apps. Sometimes when I look at the graphs on their smart phones it’s hard to know what the data shows and how reliable it is.

In this brief review I will try to summarize the existing data about smart phone sleep apps as well as wearable devices for monitoring sleep and activity.

Sleep Apps

The boom in smart phone apps designed to improve and monitor sleep is phenomenal and it’s impossible to keep track of all of them.

Some apps detect movement on a bed. These apps use the movements registered by the phone, tucked under a pillow, to estimate whether the user is in a state of wakefulness or of light or deep sleep. They offer varying degrees of analysis of sleep patterns, and some propose to wake the user at a moment that is most opportune according to the app’s algorithms. Other apps claim to track sleep parameters by measuring the extent to which the user is snoring (Stippig et al., 2014), or the levels of sleep talking, or (as with my friends app, Sleep Cycle) claim to use a “patented, proprietary technology” which can distinguish the sounds of movement during sleep from other sounds, and can even tell whether it is you moving in the bed or your partner… Fascinating and exciting stuff…

It is a lot easier to keep track of the studies that have been published in the research literature comparing sleep apps with the “gold standard” for measuring sleep duration and quality: polysomnography, than the various apps being brought to market, because there is hardly any published data on these apps.

“In the only study comparing a smartphone app to PSG in adults, Bhat et al. evaluated the Sleep Time™ app that provides users with a graph detailing wakefulness and light and deep sleep and, in addition, claims to help users wake up only during light sleep.Sleeptime

In this study, the authors compared the PSG sleep data from 20 healthy adult subjects with no previously diagnosed sleep disorders with data obtained from the app. There was poor correlation between the app and PSG in terms of sleep efficiency, light sleep, and deep sleep. In addition, there was no correlation between app and PSG sleep latency. The app was poor in terms of detecting wakefulness. Finally, there was no evidence that the app consistently awakened subjects only during light sleep (p = 0.159).”

That’s it. Only one published study on the accuracy of the data in smart phone apps and that study found that the data was very inaccurate.

Wearable DevicesWearable Devices

The Technology

Wearable devices rely on actigraphy (movement monitoring) to try to determine a person’s pattern of wakefulness, activity and sleep. The fundamental idea is a sound one which is actually used in clinical settings.

“Actigraphy, a portable wrist-worn sleep monitoring device, is used in clinical sleep medicine for assessing certain sleep disorders, such as circadian rhythm sleep–wake disorders, and for characterizing day-to-day patterns or sleep disturbances in insomnia [Ando K, Kripke DF, Ancoli-Israel S. Delayed and advanced sleep phase symptoms. Isr J Psychiatry Relat Sci. 2002;39(1):1118.Kripke DF, Youngstedt SD, Elliott JA, et al. Circadian phase in adults of contrasting ages. Chronobiol Int. 2005;22(4):695709.]. It is also used to assess response to treatment in insomniacs and as an adjunct source of information in patients who are unable to provide a clear history Wilson SJ, Rich AS, Rich NC, et al. Evaluation of actigraphy and automated telephoned questionnaires to assess hypnotic effects in insomnia. Int Clin Psychopharmacol. 2004;19(2):7784.Morgenthaler T, Alessi C, Friedman L, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007;30(4):519529].

Wrist actigraphy is based on the principle that physical movements are increased during wakefulness and reduced during sleep [Tilmanne J, Urbain J, Kothare MV, et al. Algorithms for sleep-wake identification using actigraphy: a comparative study and new results. J Sleep Res. 2009;18(1):8598.Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15(4):259267]. It has been found to have a reasonable degree of agreement with PSG, with reported agreement rates of 78.8–99.7% for sleep and 48.5–79.8% for wake [Tryon WW. Nocturnal activity and sleep assessment. Clin Psychol Rev. 1996;16(3):197213.]. Actigraphy has been shown to be sensitive to changes in sleep patterns in response to pharmacologic and nonpharmacologic interventions [Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15(4):259267]. However, its validity in special populations such as the elderly, in subjects with poor sleep quality, or in those with major health problems is not well established [Sadeh A. The role and validity of actigraphy in sleep medicine: an update. Sleep Med Rev. 2011;15(4):259267].”

The Studies

There are more studies looking at the accuracy of wearable devices and the findings from the studies are more reassuring.

The table below lists details of these summaries. First, though, a word of caution, these studies used somewhat different methodologies and so it may not be possible to directly compare the outcomes.

Studies looking at sleep apps

The studies looked at a few devices – two Fitbit devices and the Jawbone UP.

One study of the current  Fitbit model, when compared with the gold standard of polysomnography (PSG), found that the device had a sensitivity of 0.87 and specificity of 0.52 in the ‘normal’ mode and 0.70 and 0.79, respectively, in the ‘sensitive’ mode.

This means that in the normal mode, 90% of the time when someone was asleep it categorized that time period as sleep, but only about half of the time that the device said someone was asleep were they actually asleep. The device overestimated sleep time significantly in the normal mode. In the sensitive mode the device overestimated sleep time less.

The Fitbit Ultra device was also compared to a stand alone actigraphy device in that study and was found to similarly overestimate sleep time when compared with a professional actigraphy device.

In summary, Fitbit was fairly good at detecting sleep but poor at detecting wakefulness. Furthermore, results varied according to age group and sleep apnea status. The older the patient and the more difficulty they had with insomnia, the poorer the correlation with either PSG or actigraphy.

Jawbone UPJawbone™ UP is an activity tracker that also claims to track sleep utilizing bioimpedance sensors.

Three studies looked at the accuracy of the Jawbone.

  • De Zambotti et al. compared the accuracy of Jawbone in measuring nighttime sleep to PSG in a sample of 65 healthy adolescents and young adults (ages 12–22 years) with no prior sleep problems.
  • De Zambotti et al. also studied the same device, Jawbone, in a sample of 28 adult women (mean age 50.1 ± 3.9 years).
  • Toon et al. compared the Jawbone UP device and MotionX 24/7, a smartphone-based app against PSG and actigraphy in a pediatric sample with suspected sleep-disordered breathing (N = 78; mean age 8.4 ± 4.0 years, range 3–18 years).

Across all of these studies, the Jawbone was relatively poor at determining wakefulness, but did a better job at identifying sleep (sensitivity for sleep was high but specificity was not great). Light and deep sleep measured by Jawbone did not correspond with light (stages N1 and N2) and deep sleep (stages N3 and REM) measured by PSG.

However, overall the studies suggested that the Jawbone may be slightly more accurate than Fitbit and Fitbit Ultra in determining sleep parameters and both devices were much more accurate than smartphone apps.

Apps for Sleep Apnea Detection

A final role for smartphone apps is as an inexpensive way of identifying possible sleep apnea. There seems to be better data suggesting that sleep apnea detecting smartphone apps are reasonably accurate than the data looking at general sleep apps.

Nandakumar et al. evaluated a smartphone-based application, ApneaApp™, designed to detect sleep-related respiratory events.

The app uses the smartphone’s microphone to emit an inaudible wave, which functions similar to a sonar system to detect amplitude changes during breathing. It uses a sophisticated algorithm to detect and calculate hypopneas (partial sleep apnea episodes) and obstructive and central apneas. The app measures sleep time by identifying non-breathing body movements and subtracting them from the total recording time. In this study, where the smartphones were used alongside PSG in a sleep laboratory setting, the events as measured by the app showed good correlation with the total number of events recorded on PSG. The ApneaApp correctly classified 32 of 37 subjects with regard to their sleep apnea severity status, and correctly identified those requiring treatment.

The ApneaApp is designed for Android phones with at least two microphones. This includes Samsung Galaxy and HTC One.

Unfortunately, the app is not currently available. The website says that it has been submitted to the FDA for approval –

We can not currently release the app prior to getting the FDA approvals. Please email us at apnea@cs.washington.edu to be on our waiting list so that we can notify you once we get the approval.

There are a number of apps currently available that claim to measure and track snoring. A proof of concept study showed that a smartphone strapped to the anterior chest wall during PSG can detect snoring with reasonable accuracy.

One study of seven commercially available snoring apps suggested that they were not accurate enough to replace current diagnostic standards and worked only in soundproof environments. In real-life environments with background noise, their ability to detect snoring deteriorated considerably.

Quit SnoringAnother study was more positive. Camacho, et al searched Apple iTunes app store for snoring apps that allow recording and playback. Snoring apps were downloaded, evaluated and rated independently by four authors. Two patients underwent polysomnography, and the data were compared with simultaneous snoring app recordings, and one patient used the snoring app at home.

In this study, the Quit Snoring app received the highest overall rating. When this app’s recordings were compared with in-laboratory polysomnography data, app snoring sensitivities ranged from 64 to 96 per cent, and snoring positive predictive values ranged from 93 to 96 per cent.


Camacho M, Robertson M, Abdullatif J, Certal V, Kram YA, Ruoff CM, Brietzke SE, Capasso R. Smartphone apps for snoring. J Laryngol Otol. 2015 Oct;129(10):974-9. doi: 10.1017/S0022215115001978. Epub 2015 Sep 3. PubMed PMID: 26333720.

De Zambotti M, Baker FC, Colrain IM. Validation of sleep-tracking technology compared with polysomnography in adolescents. Sleep. 2015;38(9):14611468

De Zambotti M, Claudatos S, Inkelis S, et al. Evaluation of a consumer fitness-tracking device to assess sleep in adults. Chronobiol Int. 2015;32(7):10241028

Grigsby-Toussaint DS, Shin JC, Reeves DM, Beattie A, Auguste E, Jean-Louis G. Sleep apps and behavioral constructs: A content analysis. Prev Med Rep. 2017 Feb 21;6:126-129. doi: 10.1016/j.pmedr.2017.02.018. eCollection 2017 Jun. PubMed PMID: 28316907; PubMed Central PMCID: PMC5350571.

S. Bhat, A. Ferraris, D. Gupta, et al. Is there a clinical role for smartphone sleep apps? Comparison of sleep cycle detection by a smartphone application to polysomnography. J. Clin. Sleep Med., 11 (7) (2015), pp. 709–715  http://doi.org.ucsf.idm.oclc.org/10.5664/jcsm.4840

Kolla BP, Mansukhani S, Mansukhani MP. Consumer sleep tracking devices: a review of mechanisms, validity and utility. Expert Rev Med Devices. 2016 May;13(5):497-506. doi: 10.1586/17434440.2016.1171708. Epub 2016 Apr 18. Review. PubMed PMID: 27043070.

M.T. Bianchi. Consumer sleep apps: when it comes to the big picture, it’s all about the frame. J. Clin. Sleep Med., 11 (7) (2015), p. 695

Nakano H, Hirayama K, Sadamitsu Y, et al. Monitoring sound to quantify snoring and sleep apnea severity using a smartphone: proof of concept. J Clin Sleep Med. 2014;10(1):7378

Nandakumar R, Gollakota S, Watson N. Contactless sleep apnea detection on smartphones. In: Borriello G, Pau G, Gruteser M, Hong J, editors. Proceedings of the 13th Annual International Conference on Mobile Systems, Applications, and Services. Florence (Italy): ACM; 2015. p. 4557.

P.T. Ko, J.A. Kientz, E.K. Choe, M. Kay, C.A. Landis, N.F. Watson. Consumer sleep technologies: a review of the landscape. J. Clin. Sleep Med., 11 (2015), pp. 1455–1461

Stippig A, Hübers U, Emerich M. Apps in sleep medicine. Sleep Breath. 2015;19(1):411417.

Toon E, Davey MJ, Hollis SL, et al. Comparison of commercial wrist-based and smartphone accelerometers, actigraphy, and PSG in a clinical cohort of children and adolescents. J Clin Sleep Med. 2016;12(3):343–350.

Van den Bulck J. Sleep apps and the quantified self: blessing or curse? J Sleep Res. 2015 Apr;24(2):121-3. doi: 10.1111/jsr.12270. Epub 2015 Jan 5. PubMed PMID: 25558955.

Apr 16

The Science of Slow Breathing

In an April 5, 2017 article in the New York Times, Gretchen Reynolds reviews new research on the science of slow breathing and how this ancient technique may work to promote relaxation, reduce anxiety, and prevent panic attacks.

The technique of controlled breathing or pranayama (प्राणायाम) is referred to in the Bhagavad Gita, and thus dates back at least to the second century BC.

“Take a deep breath” is the opening to many ancient and modern relaxation and meditation techniques.

Breathing lies and an interesting intersection between the conscious mind and the unconscious mind.

Panic disorder, which involves a dysregulation of rapid breathing associated with an overly strong connection between anxiety and anxious thoughts and hyperventilation, illustrates the complexity of this relationship. Obviously, anxious thoughts are conscious, and these are often part of the trigger mechanism for hyperventilation, once triggered however this rapid breathing remains active until the unconscious brain’s natural homeostatic processes kick in and normal breathing resumes. In the extreme case this happens if a person faints or loses consciousness, but most of the time it takes place as the brain and body reassert a normal balance between sympathetic and parasympathetic activity.

Scientists at Stanford University have identified a small set of brain cells in the brainstem (more specifically in the preBötzinger complex (pBc) of the ventro-medial medulla) that appear to control the balance between rapid breath and slow breathing.

These same neurons play a major role in anxiety.

When these neurons were deactivated in mice, the mice appeared much calmer than normal mice. But otherwise there was no effect. That is until the researcher started to take a look at breathing rhythms.

The mice with the deactivated neurons did not show the normal breathing response (increased rapid breathing) in the face of anxiety provoking stimuli.

It turns out that the deactivated neurons not only controlled rapid breathing but they connected with another part of the brain that plays a key role in sympathetic nervous system activation (the locus coeruleus), and thus affects the entire fight or flight system.

Back to the question of why slow breathing has such a calming effect. The researchers Reciprocal relationship in cells in the pBcspeculate that this is because there is a reciprocal relationship between activation of the rapid breathing neurons and activation of the slow breathing neurons, so that if we consciously activate slow breathing, it has the same effect as the scientists genetic deactivation of rapid breathing neurons.

And the deactivation of the rapid breathing cells in turn deactivates the “fight or flight” cells in the locus coeruleus.

It generates calm.


Yackle K, Schwarz LA, Kam K, Sorokin JM, Huguenard JR, Feldman JL, Luo L, Krasnow MA. Breathing control center neurons that promote arousal in mice. Science. 2017 Mar 31;355(6332):1411-1415. doi: 10.1126/science.aai7984. Epub 2017 Mar 30. PubMed PMID: 28360327.

Apr 14

Early Intervention Can Prevent Episodes

Early intervention can prevent episodes of depression or hypomania or mania.

This is not always the case but most of the people that we work with find that it is helpful to go through a process of systematically identifying possible early warning signs of an episode and working with a friend or partner to come up with a plan for dealing with early symptoms.

This process is outlined in a new page that we added to the website on this topic:

Early Warning Signs

For More Information

Mania Warning Signs in the Eyes – Gina

Predicting Depression Recurrence

Support a Loved One with Bipolar – Gina

Recovery from Bipolar

Apr 13

Cognitive Recovery from Mania

Cognitive recovery from mania or depression seems to lack behind the improvement in mood symptoms. In our experience full cognitive recovery may take up to three months after the mood symptoms have remitted. One way of thinking about this is that an episode of mania, or depression, upsets the normal function of the brain and it takes a while for that normal function to recover.

One thing that seems to predict slower recovery is the presence of what are called “subthreshold” symptoms. Someone who no longer qualifies for hypomania or mania but has some persistent symptoms of mania, or who no longer meets criteria for major depression but still has some mild depressive symptoms, is likely to take longer to recover for cognitive function.

An illustration of this is to be seen in these two neurocognitive tests done on a patient who had an episode of mania in August that mostly resolved in September and was followed by a minor dip into depression in October.

In November, he did not have significant depressive or manic symptoms but he complained of “medication side effects” which had him worried about whether he should be tapering his medications. Compounding this, his employer was increasingly insistent about having him return to work now that his “symptoms” were resolved.

As you can see in the picture below his cognitive function was significantly impaired in November, given that he had been a high performing software engineer before he developed the mania in August.

November CNS VS

His brain had significant slowing (reaction time) and trouble handling any complex task. Based on these results we were able to make a strong case that he needed more time to recover.


Two months later, in January, he finally had nearly full cognitive recovery.

January CNS VS

You can still see a slight slowing in reaction time and processing speed but he was now ready to resume work.

Julie Fast wrote about this recently in Bipolar Hope:

My friend Dr. Jay Carter, author of The Complete Idiot’s Guide to Bipolar Disorder, told me, “Mania seems to cause significant brain dysfunction, which can take six to eight weeks to resynchronize—the same amount of time a bone takes to heal after it has been broken.” And yet, how often are we expected to just get right back to being the partner, parent, friend, and coworker we were before, as though nothing has happened?

Society expects so much from us. I still expect way too much of myself. But if I don’t take the time I need to heal, my bipolar may go away—but it doesn’t go far, and not for long.

True healing is not just about getting rid of mood swings; it’s about letting the brain and body get back on track over time.

Mood swings whittle away at my cognitive functioning, work ability, relationship availability, and even my immune system. YES, I know the feeling of “I have to get back to work or I will lose my job!”—but I’ve also lost work because I tried to go back too soon. I wish we could come out of mood swings quickly and immediately pick up our lives, but we rarely do. No matter what your age, physical health, or even how much support you have, everyone needs time to get well.


Volkert J, Schiele MA, Kazmaier J, Glaser F, Zierhut KC, Kopf J, Kittel-Schneider S, Reif A. Cognitive deficits in bipolar disorder: from acute episode to remission. Eur Arch Psychiatry Clin Neurosci. 2016 Apr;266(3):225-37.  doi: 10.1007/s00406-015-0657-2. Epub 2015 Nov 26. PubMed PMID: 26611783.

The Bipolar Disorder Marathon. BP Hope. Julie Fast. 

Apr 10

Smartphone Apps for Bipolar

Smartphone Apps for BipolarHow good are smartphone apps for bipolar? A 2015 journal article provides details of a careful review of 82 apps providing either information or tracking tools. There were a range of resources available…

  • 32 apps provided information
  • 35 apps offered symptom monitoring
  • 10 apps included screening and assessment tools
  • 4 apps offered community support
  • 1 app provided treatment of some kind

The complete list off apps reviewed can be seen below…

List of Apps Reviewed

Less than a quarter of apps (18/82, 22%) addressed privacy and security by providing a privacy policy.

The apps providing information were not generally high quality. Overall, apps providing information covered a third (4/11, 36%) of the core psychoeducation principles found in Colom and Vieta’s psychoeducation for bipolar disorder manual.  Even fewer (2/13, 15%) referenced best-practice guidelines. Only a third (10/32, 31%) cited their information source.

As in previous reviews of medical apps, there was no correlation between the quality of the information and user ratings.

Symptom monitoring apps generally failed to monitor critical information such as medication (20/35, 57%) and sleep (18/35, 51%), and the majority of self-assessment apps did not use validated screening measures (6/10, 60%).

For More Information

Smartphone Mood Tracking Startup

Technology and Bipolar


Colom F, Vieta E. Psychoeducation manual for bipolar disorder. Melbourne: Cambridge University Press; 2006.

Nicholas J, Larsen ME, Proudfoot J, Christensen H. Mobile Apps for Bipolar Disorder: A Systematic Review of Features and Content Quality. Eysenbach G, ed. Journal of Medical Internet Research. 2015;17(8):e198. doi:10.2196/jmir.4581.

Apr 07

Support a Loved One with Bipolar – Gina

Support Loved One with BipolarMany family members I speak with struggle with the question of how to best support a loved one with bipolar. As a loved one, it can be incredibly stressful to battle with unknowns, one’s own anxiety and feelings of helplessness. People are understandably eager for information that can equip them with tools to help. I have found there are numerous things a loved one can do to be a strong support to their partner, friend or family member.

Listening to your loved one, what they are experiencing, their stressors, and what they personally find helpful and unhelpful is a very important place to start. Your initial goal is to be able to paraphrase what your loved one is telling you about their experience well enough that it makes sense to them. They feel “heard.”

It can be crucial to have someone who can listen and help clarify the confusing world of stress and emotional turmoil that faces many people with bipolar. Additionally, your loved one has the most insight into what they personally find helpful and unhelpful; taking the time to ask them and listen is essential.

In a recent blog post by John Press, he describes what is specifically helpful and not helpful to him as someone living with bipolar disorder:

What is not helpful
“You should…”
“You should get more exercise…get out more…pray more…stop feeling sorry about yourself, etc.” While some of those things might help, realize that clinical depression is a medical illness. It saps all energy and motivation. I’ve literally struggled with getting up to get the TV remote. And just forget about Herculean tasks like getting the mail or washing dishes.
“Is there anything that I can do for you?”
The question is often sincere and heartfelt, but non-specific. Depression makes me muddy-minded, unable to tell you what might help. I tend to feel ashamed and self-conscious of being needy. I believe I’m a burden and a disappointment to my friends and family, even though I’m probably not.

What is helpful
When offering help, be specific
“I’ve heard that depression makes you feel really tired and small tasks seem overwhelming. I’d like to come over to vacuum and dust…do your laundry…or go grocery shopping. Is that ok?” Can I drive you to your next doctor’s appointment?
Just show up
I am tend to be reclusive when I’m depressed. We are likely to decline or cancel social commitments. But if you show up on my doorstep with pizza or my Ben and Jerry’s and a movie, there’s a high probability that I’ll let you in.
Become comfortable with silence.
You don’t need to find the right words to say. If thoughtful sentiments were the cure to depression, Hallmark would put pharmaceutical companies out of business. My daughter told me that when is suffering depressive symptoms, “the words just won’t sink in”. But if someone actually wants to be in our unpolished, unshowered, eyeore-y presence, that speaks volumes.” (http://www.bphope.com/blog/a-note-to-loved-ones/)

Ask your loved one if they are open to creating a list of their own and sharing it with you.

Educate yourself about early warning signs and symptoms. This knowledge will allow you to better support your loved one and communicate with them about their disorder. It will increase your understanding and personal access to tools. This can help you assist them in coping with symptoms as they occur and possibly prevent those symptoms from escalating.

A good resource is the Depression Workbook by Mary Ellen Copeland.

Having a plan in place and agreeing to it ahead of time can be very valuable. Knowing how and when to identify an emergency and having a plan for responding to it can reduce anxiety and increase accessibility of support in urgent times.

For example, when should you contact your loved one’s psychiatrist or therapist? When would you need to go to the emergency room? Planning for changes in symptoms that do not indicate an emergency situation can also be helpful. What kind of support would your loved one like if you noticed them becoming more depressed? Is it taking a walk with them, going to the nearest cafe in the morning, or being available if they need to talk? What actions would they like you to take if you start to noticed their mood is elevating? How would they like you to communicate with them about it? Deciding on a plan together ahead of time during stable periods allows for more receptivity during more challenging times.

Don’t forget to access your own support. I’ve always appreciated the metaphor of being told to put on your own oxygen mask before you assist your loved one when on a plane. In the same sense, when caring for someone with bipolar disorder, if you do not care for yourself first you may not be as effective in caring for your loved one. Family members can access support for themselves by finding their own therapist or support group. NAMI, the National Association of Mental Illness offers great resources and support to friends and family members.


For More Information

It Takes Two to Fight

Support Groups for Bipolar

Friends and Family Don’t Understand – Bipolar Communication Problems


Press, J. (2015, March, 3). A Note to Loved Ones: How You Can & Can’t Help Me With Bipolar Depression. Retrieved from http://www.bphope.com/blog/a-note-to-loved-ones/.
10 Ways To Help Someone Who Has Bipolar Disorder. Retrieved from http://ibpf.org/article/10-ways-help-someone-who-has-bipolar-disorder.

Apr 05

Mania Warning Signs in the Eyes – Gina

Recognizing Mania Warning Signs, Even in the Eyes

Knowing and understanding warning signs of depression, hypomania and mania can be crucial in accessing the resources and supports needed at different times in your life. Warning signs can vary across individuals but there are also many warning signs that are thought to be more universal such as changes in sleep. The International Bipolar Foundation, discusses the importance of examining warning signs that predict and/or indicate changes in mood. These can be changes in symptoms specifically related to bipolar disorder, symptoms of other co-occurring disorders such as anxiety, changes in behaviors, changes in how you are thinking or feeling, and changes in physical symptoms. Here is a list of their 100 warning signs:


Warning signs can even be as specific and visible as someone’s presentation in their eyes. In a recent blog post in bphope.com by Julie Fast, the idea of examining one’s eyes is presented as a way of determining states of mood. Julie reflects on her own changes in eye presentation in a depressed and manic state and discusses how 3 clues can be used to evaluate her mood state.

“Clue #1  Sparkling Eyes in Euphoric Mania: Euphoric mania often creates a shimmering quality to the liquid in the eyes. We sparkle! When I look in the mirror during a euphoric manic episode, I’m entranced with my face. I see NO flaws. My skin is perfect. My eyes are brilliant. My hair shines. Believe it or not, this is often physically true as well. Mania does make those changes. I have seen what look like silver, shimmering flicks in the whites of my eyes when euphoric. People find this very attractive. We all know how easy it is to get a relationship when you’re euphoric. How we look at people is a big part of this. We focus these sparkling eyes on our unsuspecting prey and they are lost!Julie-Fast-bipolar-mania-eyes

Clue #2 Darker Eyes in Dysphoric Mania: Once I started asking clients to notice eye changes in a loved one,  I heard many stories of how dysphoric mania turned the eyes black. I tried to figure this out on my own, and finally asked an eye doctor about it. She said, “Oh, I’m not surprised by that. It’s documented that adrenaline can make the pupil take over the eye. Mania sounds like it’s something to do with adrenaline, so I would think the eye is the same color, but the pupil is huge. This creates the the all black eye.”

Clue #3  The Eyes Change Shape: The eyes can widen with euphoric mania and often get mean and narrow with dysphoric mania. I’m not talking about a few minutes of this- the changes can last for months. I know my own dysphoric mania makes me as mean as a snake and as suspicious as a jealous husband. Suspicion narrows the eyes and purses the lips. In contract, I’m open to the world when euphoric and this widens my eyes. I have seen it in pictures. My entire face brightens in euphoric mania, so it makes sense I would open my eyes wider as well.”

Read more of this post here…


What are some of your warning signs? What warning signs do you identify with on the list of 100? What warning signs are unique to you? Don’t be afraid to ask a trusted loved one what changes they’ve seen in the past. Sometimes getting perspective from others about what they have seen from you during changing mood states can be helpful to learn as well!



Fast, J. (2016, April, 21). 3 Clues For Recognizing Mania In The Eyes, Plus Other Physical Symptoms. Retrieved from http://www.bphope.com/blog/your-eyes-hold-the-clues-how-to-read-the-eyes-to-spot-euphoric-and-dysphoric-bipolar-disorder-mania/

Lin, C.E. Spotting Icebergs From Miles Away: How To Use Early Warning Signs In Bipolar Disorder Relapse Prevention. Retrieved from http://ibpf.org/blog/spotting-icebergs-miles-away-how-use-early-warning-signs-bipolar-disorder-relapse-prevention.


Apr 03

Pace Yourself for More Manageable Moods

Pace YourselfI have been doing a lot of thinking about how to pace yourself so that you can capture some of the energy and creativity associated with being mildly energized while not getting so involved that you burn out or edge into full-fledged mania.

There’s nothing quite so exciting as entering a time of increased energy and ideas after a long stretch of time feeling uninspired. And many good and valuable things come out of such periods.

At the same time it’s quite possible to overdo it. Get too caught up in lots of ideas. Spin off new projects. Lose focus. Have trouble getting to sleep. Get frustrated with loved ones who seem to be a barrier to getting everything done. And then if you become depressed find yourself facing a mountain of tasks that are overwhelming or dealing with the consequences of mania.

The Past Predicts the Future

If you’re entering such a time in might be a very good idea to think carefully about previous periods of increased energy. How did they end? Did you overdo it and what was the consequence of overdoing it?

Wellness Recovery Action Plan is a formal way of thinking this through and developing a plan for dealing with changes in moods. Some of the ideas in the books on this subject by Mary Ellen Copeland may be worth looking over.

There can be a benefit in less detailed thinking about the past as well. In the midst of energy and excitement, remembering that it won’t last for ever, and having some notion of when it might be “too much of a good thing.”

Particularly watch for –

  • Optimism that others suggest might be unrealistic. They are often right.
  • Sleeping less than 6 hours a night for more than one night.
  • More and more projects and ideas. Having a hard time prioritizing.
  • Using substances to sustain the high energy – stimulants, more caffeine, even more alcohol…
  • Taking risks – driving faster, lots of new relationships, particularly sexual ones, spending more money than usual.

Contrarian Thinking

We have written extensively about the notion that it is not just the “ups” that may be useful. Sometimes a “fallow” period may be necessary for good ideas to germinate, and to separate those that might seem like a good idea but are not, from those that are truly noteworthy.

Fear of depression can drive excessive behavior when you are energized, or desperation when that energy seems to fade.

Pacing yourself is also about accepting the idea that there will be slow periods, and preparing for those as well.

For More Information

Running a Marathon

Winter Leads to Spring

Fallow Fields

Appreciating Depression?

Bipolar and Creativity

Apr 01

Support Groups for Bipolar


Support Groups for BipolarSupport groups for bipolar seem like such a good idea. There are so many questions and it is hard to find good sources of information. Family and friends can be a resource, but they may not understand the challenges of living with mood instability. Professionals (a therapist or psychiatrist) can help, but they are not available all the time, and there are some things that you want to talk about with a peer rather than a professional.

Finding a group that is a good “fit” can be a challenge. After all, bipolar affects people of all types, all ages, and all backgrounds. It can be hard to get beyond the differences when joining a group of people who have been in and out of hospitals, or are homeless, or are all much older than you. So finding the right group may be something of a project.

Broadly speaking, support groups can be divided into those that are “in person,” and those that are “virtual.” Each of these can also be categorized as “peer run” or “professionally run.”

In person support groups

Depression and Bipolar Support Alliance. DBSA is the largest national organization focused on helping people with bipolar and depression. There are local affiliates throughout the country. The quality and extent of local programs varies depending on the folks who run them and the people who attend the groups. But DBSA does offer its affiliates a good deal of support and information to try to make sure that all of its programs meet certain standards and follow a similar format. In addition, DBSA offers some “virtual” support groups.

The National Alliance on Mental Illness. Primarily has focused on family support but now offers support groups for “consumers.” Most of the groups tend to focus on people who are more severely ill.

Alcoholics Anonymous. And many other twelve step programs are often good resources for people with bipolar plus other common problems – substance use, alcohol use, overeating, sexual addiction, etcetera, etcetera.

Online or “virtual” support groups

Bipolar Support is a resource with both information and online forums.

Stigma is an online mood tracking and social support app that is available only on the iPhone. In the words of one of its users… “This is a mood tracker, peer support app, and digital journal all in one. You can share your entries with the community, your pen pals, your group, or just yourself.”

Yahoo Groups. Probably the largest set of groups available on the internet. There seems to be a group for everything. Just to give you an idea, there is a Yahoo Group for Bipolar Witches…

MedHelp. They have online tools and moderated and unmoderated forums.

Psych Central is a resource with information about all kinds of mental health conditions and problems. They also have a moderated online community. moderated online community as well as a list of other bipolar support groups list of other bipolar support groups.

Patients Like Me. A social networking tool that also tries to gather the “collective wisdom” of people with similar problems. Interesting but we aren’t sure how well it works yet.

Mental Help Net : home of the oldest and largest online mental health guide and community.

Facebook. Facebook has groups but it is a bit hard to find them. This is one… Bipolar Disorder Support Group.

Mar 29

Celebrating World Bipolar Day 2017


Celebrating World Bipolar Day

On March 30, 2017 we will be celebrating World Bipolar Day as a platform to provide global education, open dialogue and improved sensitivity about bipolar disorder. Stigma can play a huge role in access to care, and the way an illness can impact our relationships, work and engagement in the world. World Bipolar Day is about battling stigma and engaging the world in a conversation that enhances support and understanding. Join us on March 30th to connect with others in gaining access to resources and relationships that will be promoting acceptance and community.

For more on World Bipolar Day, visit the International Society for Bipolar Disorder’s website at http://www.isbd.org/world-bipolar-day, and the World Bipolar Day website at http://www.worldbipolarday.org/.

Mar 25

Hope and Self Efficacy – Gina

Man lifting hands to sunsetBelieving you can create change in your life is the foundation for successfully making the change. Self efficacy is the sense that you can make change and thus hope and self-efficacy are intimately connected.

Often people with bipolar or depression are overwhelmed with feelings of hopelessness. They feel stuck and unable to manage their moods.

And yet a great deal of research shows that the act of embracing hope and believing you have the power to create change in your life predicts better mental and physical health outcomes.

Albert Bandura is the psychologist who developed the mental health field’s understanding of self-efficacy. He noted that believing in your capability to follow through on a plan of action predicts both what you do, how you act, and what the outcome is.

Confidence provides the motivation to act effectively. If you believe that your self care behavior – going to the gym, getting sunlight, creating a regular sleep routine – will change your mood, and you believe that you can do these things, you are more likely to succeed.

BP Hope and Harmony describes this as the “confidence game” and the “power of self-trust.”

“Belief that things can change for the better is called hope, and it’s crucial to living well with bipolar disorder. So is belief that you can influence things in your life for the better. In psychological circles, that’s called self-efficacy. You and I might call it self-confidence or self-trust. Researchers have studied the role of self-efficacy in managing mood disorders and medical conditions like diabetes. The bottom line: Good things come from strengthening your sense that you can do what you need to do to.”

How can you work to develop an increased sense of self-trust, self-efficacy, confidence and hope? See the tips below…

Start Small

Having the experience of completing a task helps you build confidence to try a bigger task. Start out small with an easy task . We like the idea of coming up with something that takes only a few minutes a day. If you want to go to the gym and do great workouts, how can you move towards that goal? You might start by adding a short physical activity every day that doesn’t require you to drive fifteen minutes, change clothes, spend an hour working out, change clothes again and drive back… How about adding several flights of stairs to your daily routine… walk rather than taking the elevator.

Log Past Successes

Learn from past experiences of success. What did it take to succeed? What barriers did you overcome, and how did you overcome them?  This increases self-efficacy and creates momentum for future success. Try journaling about past successes or keeping a log on your phone or computer to review on a regular basis. We do a remarkable job reviewing our mistakes but often dismiss our successes.

Find A Role Model

Witnessing someone else accomplish a task can reinforce the belief that that action can lead to success. This may be why people find value in support groups, and also why some support groups are ineffective. A support group of people who talk about how to achieve success in a meaningful way can be life changing… A support group of people who complain about failures can be discouraging.

Surround Yourself with Encouragement and Social Support

Having others around you who provide you with encouragement and verbal reassurance of your ability to perform a task helps reinforce self-efficacy. Constructive feedback can assist you in overcoming self-doubt and maintaining confidence.

And remember, as Mahatma Gandhi once said, “If I have the belief that I can do it, I shall surely acquire the capacity to do it even if I may not have it at the beginning”.


For More Information

Self-Esteem: A Key Aspect of Mental Health

Selective Attention


  1. Bandura, A. (1977). Self-efficacy: Toward a Unifying Theory of Behavioral Change. Psychological Review, 84, 191-215.
  2. Hope & Harmony Headlines: Managing Your Moods—The Power of Self-Trust
    March 16, 2017 • Volume 10, Issue 11.

Mar 23

Support for Depression – How to Get More

Support for DepressionMany of the people I see feel that it’s very hard to get support for their depression. They may find it hard to talk about the subject altogether or they may have had some experiences that suggests that “people just don’t want to know.”

This morning I saw several people with depression and bipolar and what struck me was that my sense of enthusiasm for helping these different people, who are all dealing with more or less similar problems, did not correlate very well with how depressed they were.

One woman who has been wrestling with depression for many years has had a significant worsening in her mood associated with suicidal thoughts this past week. After our session, during which I don’t think I came up with any particularly brilliant idea for how to solve her problem, she turned as she was leaving my office and said “thank you for your help.”

After the session, not only was I smiling, but I found myself thinking that I needed to spend some more time coming up with better answers for her.

Another woman who has also been wrestling with depression for many years and recently has seen a modest improvement in her mood, although it is certainly far from where either of us would like her to be, ended our session by saying how frustrated she was that we still hadn’t found a solution.

I’m not trying to suggest that expressing frustration to your psychiatrist is not entirely appropriate, it is. But what occurred to me this morning was how this difference in working with a psychiatrist might play itself out in other ways in the lives of these two women.

Then I happened across an article on exactly the subject in the Bipolar Magazine. It is called “advice for the support team.”

“Sometimes managing your bipolar disorder can feel so overwhelming, it’s easy to forget that the people who love you are living with bipolar, too. They get stressed. They may feel angry or hurt by your words or actions. They want to help, but don’t know how.”

“Sometimes meaning well isn’t enough: People in your support team need education and simple, concrete guidelines. That’s what columnist Stephen Propst gives inWhat Helps and What Hurts.” So make it a point to sit down together and review his ideas.

For example: “Remember to acknowledge any effort your loved one makes to deal with his or her situation.””

People wrestling with depression deserve compassion and love, but so do those who were trying to support loved ones with depression.

Thank you can be a real gift, and can help you build a strong support system.

Mar 19

Positive Emotions

positiveWe had a wonderful conversation (see the conversations tab on this site) with two smart young UC Berkeley graduate students in psychology (Janelle Capnegro and Erica Lee) who have developed an intervention designed to help people with bipolar regulate and develop positive emotions.

It started us thinking about emotions in terms not only of how positive or negative the emotions are but also in terms of the intensity the emotion (or the level of physiologic arousal associated with those emotions).

According to this scheme, emotions can be high or low arousal and positive or negative.

People with depression and bipolar are often drawn to high arousal emotions (intense emotions).

And all of us tend to be drawn towards topics associated with negative emotion as a way of trying to prevent bad things from happening… Valence-Arousal_Circumplex

The conversation suggested that we should perhaps pay more attention in our lives to LAPF’s (low arousal positive feelings).

States of calm, serenity, tranquility and harmony are easy to lose track of in our lives, and to focus on urgency and intensity.

Taking a LAPF break on a regular basis can help us maintain a sense of balance. And even a small amount can go a long way (why we think that even two minutes of mindfulness practice twice a day can sometimes have such a good effect).

Check out the interview. And watch for more from these two women.

For More Information

Conversation with Janelle and Erica

Mindfulness – The Power of a Minute


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