Clara Pirani, Medical reporter
The Australian
August 25, 2007

FOR almost 40 years, Jennifer Howell pretended to be someone else. Since her teens, the now 61-year-old Melbourne woman "acted happy" in front of family and friends, all the while experiencing episodes of extreme despair and sadness.

"I pretended to be a bright, happy person because I knew that it was not acceptable to be depressed. I was always trying to be a nice person to cover up my feelings of irritability. I didn't understand why I felt like that. I was looking for reasons, but never quite grasping the fact that it could be a mental illness."

Unable to work full-time, Howell worked in a variety of part-time jobs as she tried to understand why she never felt the same happiness that seemed to come so easily to others.

Four years ago, she finally had an answer.

"I went to see a new GP because I had a broken bone in my foot. After a few minutes talking to her, I began to cry. After about five minutes, she said I was really depressed and she called a psychiatrist and I was diagnosed with bipolar disorder. That was the beginning of my recovery."

Bipolar disorder, which affects more than 100,000 Australians, is caused by an imbalance of chemicals in the brain and results in extreme mood swings.

The condition was previously known as manic depression, because a person's mood can alternate between the "poles" of mania (highs) and depression (lows).

These mood swings can last for hours, days, weeks or months.

Howell was prescribed various medications, including Zoloft, which she says allowed her to feel happiness for the first time in her life.

"I was on that for about three months and it allowed me to feel happy for the first time in my life. I'd never really known what it felt like. But you can only stay on Zoloft for about six months."

Howell tried several medications before finding one that eased her wild mood swings. "But medication alone is not a long-term answer." In June last year, Howell enrolled in the trial of a therapy-based treatment aimed at teaching people with bipolar how to realise when they were about to experience a manic or depressive episode, and take steps to prevent it.

The program was developed by a team at the Mental Health Research Institute of Victoria, with funding from the MBF Foundation and beyondblue.

"We developed a program which assists people with bipolar to deal with their illness in a more coherent way, and enable them to take control of their life by identifying their own individual pattern and early warning signs of relapse," says professor David Castle who led the research.

"The program taught them skills to reduce stress and to intervene early as soon as they notice signs of relapse. It's important, because bipolar disease is a lot more common than we originally thought. We used to think that about 0.5 per cent of the population had bipolar, but now we think it's about 3 per cent of the population."

In a controlled randomised trial, the team recruited 84 people diagnosed with bipolar disorder. About half received weekly therapy sessions, in addition to their medication, for 12 weeks, while the remainder only took medication. Those on the intervention program had half the number of relapses after 12 months as the control group which received medication but no therapy.

Relapse rates for people taking medication for bipolar disorder are as high as 75 per cent over five years.

The early warnings signs of a relapse vary between individuals, but Castle says some signs include a slight decrease in appetite, needing less sleep and increased irritability.

"Sometimes they don't seem to need as much sleep. It's not that they can't sleep, but that they don't seem to need as much sleep. They have so much abundant energy. They also experience great irritability."

Participants were taught strategies to prevent the onset of an episode including increasing medication, resting, avoiding stress and alerting a support network of family and friends.

"Volunteers kept a diary system which is a hand-held record that allows them to have specific plans to address episode and collaborative partners to help them," Castle says. "We are very excited about the program's success. This is the first time that we are aware of in the world that we've been actually been able to reduce manic episodes and get people to reduce their signs of mania much sooner."

Bipolar is a very difficult disease to live with, for individuals and their families. Some experience depressive episodes that are much more than than just sadness, but lack of self-worth and self-esteem, poor concentration, lack of interest in anything.

"The other side is the manic pole and that's characterised by elated mood, talking fast, they feel they have special abilities or powers, they might think they have lots of money so they'll go on a spending spree.

"They may believe that they are very sexually attractive so it can lead to sexual indiscretion. It can be very destructive."

MBF general manager health product, Michael Carafillis, says the new program provides a much-needed bridge between the mental health services that treat people when they are acutely ill and the GPs and private psychiatrists who would provide ongoing care.

"Bipolar is a complicated disease involving periods of depression and mania, and its sufferers don't alway take their medications when they should," Carafillis says.

"People with the condition straddle the divide between public and private systems resulting in poor continuity of care for many sufferers.

"They tend to gain access to the public system in the most severely disabling phase of their illness, typically mania, and are often too ill and the disorder too complex to be easily managed in primary care."

Howell says the program has changed her life. "I can't believe how helpful the program was. It helped me to understand the role of medication, but also how responsible I am for how I feel. It provided practical advice and incredible support."

"They taught us to monitor our thoughts because your thoughts influence your actions. That was crucial for me to learn to watch what I think.

"Before I was diagnosed, I used to stay up later and later, to two or three in the morning to try and lose myself in movies so I couldn't think. I can't speak highly enough of it. I'm a different person."

Carolynne Holdsworth, an occupational therapist and research clinician at the Mental Health Research Institute, says the treatment will change the way health-care professionals treat bipolar disorder.

"In the 1990s the idea began to emerge that rather than being just a biological illness, other factors, including the social environment, contributed to a person's bipolar. This program put those ideas into practice."

Holdsworth has trained 28 clinicians including occupational therapists, psychologists, psychiatrist and social workers to conduct the treatment, and hopes it will be rolled out nationally.

"At the moment it's only offered in Victoria but we're also training staff in Rockhampton and in South Australia."

People with bipolar disorder typically have to endure almost 13 years of manic-depressive mood swings before being correctly diagnosed.

A report from Melbourne researchers last year also found that during that time, 55 per cent of those with the condition will be misdiagnosed and given the wrong medication or treatment.

The study, which tracked 240 people with bipolar disorder, has found many doctors confuse the condition with other mental illnesses.

"It's usually misdiagnosed as a personality disorder or depression," said lead researcher Jayashri Kulkarni, director of the Alfred Psychiatry Research Centre in Melbourne.

Castle says 80 patients are now on waiting lists in Victoria to undergo the treatment.

"We didn't want this to just be a research project. We know it can prevent nasty relapses and hospitalisations."

A combination of the right medication and the therapy helped Howell to the point where her GP says she will no longer require medication.

"My doctor says that if I keep going the way I am, she won't need to see me for another six months.

"My friends can't believe how I've changed. And my husband and I can now communicate because I'm not always snapping his head off. I'm just so grateful that I'm finally happy."