“It was really scary,” she says. “It was totally new to my family. There’s no history [of bipolar disorder] in the family, so we were just fully listening to the professionals because we really did not know what we were doing.”

Cassie was later transferred to Sunnybrook. In addition to medication, doctors recommended she participate in regular therapy sessions, but the thought made her feel uncomfortable.

“At the time, I think it was just the stigma around therapy,” she says. “I didn’t want to feel like I was different from the rest of the girls in my house [at university]. I felt like I didn’t need therapy.”

One year later, though, and she says she can’t imagine not continuing with it.

“It’s become something I look forward to doing,” she says. “It’s totally non-judgemental, [the therapist] is listening to what you have to say. Even if sometimes it’s not giving you the solution to everything, it’s nice to be able to share what I’m going through and let it out to someone.”

Dr. Rachel Mitchell, a child and adolescent psychiatrist at Sunnybrook, says evidence shows that a strong relationship between therapist and patient, the “therapeutic alliance,” is key to making talk therapy successful.

“Regardless of the type of therapy, or the focus of the session, the relationship with the therapist is one of the most therapeutic aspects of the treatment,” she says. “It’s the support from that relationship. The stronger the alliance, the better it is.”

Cassie says one of the ways she’s seen a difference in her life since starting therapy is in how she handles tough emotions. She gives the example of selecting her courses for the beginning of her second year and not being able to get the ones she wanted. It was a frustrating experience for her, but she was able to handle it using some tools she’d learned in therapy.

“After emailing the person I needed to talk to, I went for a walk rather than getting very frustrated in front of my computer and freaking out,” she says. “Taking some deep breaths, realizing some things aren’t in my control, and that it will work out helped me manage how I was feeling.”

She says it’s a recognizable change from how she would have handled it before entering therapy, and she’s seeing changes in many aspects of her life.

“I’ve gained the confidence of just being me,” Cassie says.

Dr. Mitchell says while the thought of therapy might be uncomfortable, almost everyone can benefit from it.

“Therapy is an opportunity to learn about yourself,” she says. “So much of the time people feel alone and don’t feel like they have the support they need. Speaking with a mental health care professional can help individuals feel supported, and learn how to manage their emotions and cope during difficult times.”

Cassie says for someone who is new to therapy, or considering it for the first time, it’s important not to expect everything to feel better immediately, but to try and stay positive.

“Trust the process,” she says. “It’s okay to sit with those hard emotions because they will pass. Keep working at it. Things can get better, even when it totally feels like it will not.”

Dr. Mitchell says it’s important to expect therapy to be challenging.

“Therapy is hard work. You’re not going to want to go some days. But if you stick with it and stay committed, therapy can be helpful,” she says. “Sort of like exercise, you’ll feel better after you do it.”

For Cassie, her continued work in therapy, and following her doctor’s guidance for medication, is paying off.

“It’s the best I’ve been in a long time. I feel like things have just been coming into place,” she says. “I feel happy and settled and ready to just get back into the swing of things.”

If you need help in an emergency, please call 911 or visit your local emergency department.
If you’re feeling like you’re in crisis or need somebody to talk to, please know that help is also available through community resources:

• Find a local crisis resource at ca/gethelp
• Crisis Services Canada
  • Phone: 24-hour, toll-free 1-833-456-4566
  • Text: 45645 (4:00 p.m. – midnight Eastern Time)

The post Finding the confidence to be me: how talk therapy helped Cassie King manage bipolar disorder appeared first on Your Health Matters.

One way to deal with these emotions, especially when an individual is in a crisis, is to have a plan.

When Mansoor Nathani experiences feelings of distress, he uses a tool called a coping card.

“It is a quick and easy way to remind yourself of the ways you can distract yourself from negative emotions and lower your distress,” explains Mansoor, a member of Sunnybrook’s department of psychiatry’s Patient and Family Advisory Committee (PFAC). “The coping card can also remind you of the people and resources you can reach out to for support. It is also a reminder of the things you can do to give your life meaning. These are all helpful in times of distress.”

Twenty years ago, Mansoor was diagnosed with bipolar I disorder. Individuals with this illness can experience a cyclical pattern of mental states that include periods of mania, which are abnormally heightened levels of energy and euphoria that can disrupt judgement, and periods of depression.

“I would spiral out of control and lose track of reality,” says Mansoor. “I was making decisions that were not the best decisions. If I had had a coping card back in the early days of my illness, maybe it would have helped me handle things differently.”

What is a coping card?

Simply put, a coping card is an action plan that patients can develop with their mental-health team.

“Emotional crises are extremely common across the population in general and among patients with mental health concerns,” says Dr. Mark Sinyor, psychiatrist and suicide prevention expert in the Hurvitz Brain Sciences Program at Sunnybrook. “People often don’t have an action plan for how to deal with their mental health. Having a plan is important, especially for individuals who experience suicidal crises.”

The coping card can be personalized and asks questions that include:

• What are my warning signs?
• How can I distract myself?
• Who do I trust to share my distress and ask for help?
• Who can I contact in my expert support system?

Filling out the card when an individual is in a state of wellness can help them to comprehensively identify different coping strategies and resources that can be deployed when a crisis arises.

“When you’re in distress, it can be hard to remember how to cope or what important phone numbers are. When you have a coping card already filled out, all that information is at your fingertips,” says Mansoor.

He also points out that an individual’s coping card can change over time.

“It’s like a living document, that can be changed or modified to suit your needs,” explains Mansoor. “A person may want to remove or add things to keep their coping card up-to-date.”

Sunnybrook’s coping card in multiple languages

Sunnybrook’s coping card is digital and can be downloaded or printed out.

It is available in 10 languages including: English, Brazilian Portuguese, Chinese (simplified), Chinese (traditional), French, Italian, Korean, Russian, Spanish and Tamil.

“We originally began translation based on the most common languages of patients at Sunnybrook and ended up expanding translation to other community groups as a result of our staff’s work with various organizations. The translated coping cards continue to be shared with agencies and their clients throughout the community,” says Dr. Rosalie Steinberg, psychiatrist at Sunnybrook.

“The coping card has also been widely disseminated for use in Sunnybrook’s emergency department and general medicine to help support staff and patients in crisis,” says Dr. Ayal Schaffer, head of the mood and anxiety disorders program at Sunnybrook. “Patients who screened positive for significant emotional distress were encouraged to utilize this approach. It’s a tool that can be used beyond the department of psychiatry.”

Why is it important to share your coping card with your support system?

It can be extremely beneficial for the patient, their health-care teams and caregivers to know about the coping card, and perhaps provide more details.

The patient must provide consent to share their coping card with others.

“Talking about the coping card with your physician and family can help offer extra input. They might provide insight on symptoms that they have observed,” says Mansoor.

“We encourage patients to share their completed coping cards with those in their support system because friends and family are often unsure of how to best help someone they care about who is in crisis,” Dr. Schaffer explains. “When they are aware of the coping card details, it can help them support their loved one work through the various strategies.”

“I am glad I invested the time to create my coping card,” says Mansoor. “You don’t realize how useful it can be until you need it.”

Learn how to create your own coping card

Mental health resources for coping during COVID-19 from Sunnybrook experts

If you need help in an emergency, please call 911 or visit your local emergency department.

If you’re feeling like you’re in crisis or need somebody to talk to, please know that help is also available through community resources:

• Find a local crisis resource at sunnybrook.ca/gethelp
• Crisis Services Canada
  • Phone: 24-hour, toll-free 1-833-456-4566
  • Text: 45645 (4:00 p.m. – midnight Eastern Time)

The post How a coping card can help people manage emotional distress appeared first on Your Health Matters.

Many of the potential pitfalls and protective strategies are the same for teens with bipolar disorder as they are for any other teen. But the likelihood of having difficulties, and the stakes associated with those difficulties, are higher on average for teens with bipolar disorder.

Think of the school year as a juggling exercise. Typically, students have at least some difficulty juggling the competing priorities of academics, friends, family, and self-care. But most students can juggle two-handed–they have a lot to keep track of, and yet they’re able to use all of their resources to keep things going. Teenage students with bipolar disorder have to keep all of the usual balls in the air with one hand, while juggling their symptoms and treatments with the other hand. The transition back to school can be challenging. Students may fall behind and some even need to withdraw from a semester. Fortunately, we also see many teens with bipolar disorder who thrive during their return to the classroom.

Tips to help students

There isn’t one easy way, but rather a number of strategies that can boost the chance of school success. There are also potential pitfalls that can get in the way of success. It’s important to be aware of both and have a plan to support your goals throughout the year:

Protective Strategies:

• Routines: Consistency in eating, sleeping, socializing, and other daily routines provides structure, making it easier to stay organized and maximize efficiency. Routines also have mental health benefits—in fact one of the leading therapies for bipolar disorder focuses on optimizing routines.
• Exercise: Being physically active helps students in a variety of ways. Exercise can be a social outlet, a way to reduce stress and improve mental health, a source of fun and distraction. Cardiovascular (i.e. aerobic) exercise in particular helps bolster attention and other aspects of executive functioning.
• Parent/family support: Establishing healthy boundaries with parents is important, as is knowing when to ask for support. Sometimes teens choose to keep their parents almost completely out of the loop. While this incommunicado approach can reduce short-term tensions (e.g. unwelcomed suggestions or guidance) it can also increase later tensions relating to preventable school problems. Both parental over-involvement and under-involvement have drawbacks. We encourage teens to find a happy medium. Having a conversation about this before heading off to school can provide an opportunity to negotiate a middle ground.

Potential Pitfalls:

• Sleep: The importance of consistent and adequate sleep for teens with bipolar disorder can’t be overstated. Insufficient sleep can lead to a host of problems, such as reduced energy, poor focus, and a tendency to excessively crave sweet/rich foods. So, in addition to  feeling tired, not getting enough sleep can impact other protective factors such as healthy nutrition and physical activity.
• Substances: It’s very common for teens to experiment with binge-drinking and with substances such as cannabis. Although this experimentation isn’t necessarily ideal for anyone, the risk-benefit ratio is more concerning for teens with bipolar disorder. Even relatively modest amounts of alcohol and substance use can potentially precipitate symptoms or interfere with treatment. Ultimately, teens will make their own decisions, and fear-mongering isn’t effective. We focus on arming our patients with the facts they need to make an informed decision, and encourage them to take a minimalist approach when it comes to substances.
• Overly ambitious or inflexible goals: Most teens want to take a full course load and excel. But depending on how stable their mood and other symptoms (e.g. anxiety, inattention) have been in the months leading up to school, it can be helpful to set goals (e.g. number of courses, grades) that are more forgiving. The first year of high school, college or university, involves the most change and is often the most challenging. Deciding on a reduced course load and/or lower grade expectations can be tough, but often teens are grateful they did made this decision. Overall, we encourage realistic initial goals that can be modified over time.

Heading back to school can be both exciting and overwhelming. Being aware of strategies and pitfalls, and being flexible with goals, can help teens and parents plan and prepare for the new school year ahead.

Read more: Tips for teens, from teens who have bipolar disorder 

Written by Dr. Ben Goldstein, Dr. Rachel Mitchell, Danielle Omrin, MSW, RSW, Jessica Roane, MSW, RSW, Vanessa Timmins, MSW, RSW

The post Back-to-school tips for students with bipolar disorder appeared first on Your Health Matters.

The team at Sunnybrook’s Centre for Youth Bipolar Disorder asked some teens in the clinic for their suggestions on how they manage back to school season and prepare for the return to the classroom.  Here’s what they had to say:

What has the return to school been like for you from an emotional perspective?

It can be a bit scary sometimes to go back to a place filled with not-so-good memories. But it becomes easier when I focus on what’s ahead as opposed to what’s behind. There’s always something to look forward to, whether it’s seeing old friends, meeting new ones or just learning something new.”

After working full time this summer, I am excited about returning to school because I look forward to reuniting with my university friends, resuming club activities, and overall grow as a person as I transition into adulthood.”

How do you prepare for the return to school?

“I make sure to build a daily routine before the school year even begins! This includes fixing my sleep schedule before classes start and exercising at regular times throughout the week so I can keep the momentum going into the new school year.”

“I just remind myself of everything that has helped me in the past. It’s reassuring to know that I’ve dealt with this before and I have a plan.”

“A week before the fall semester starts, I typically will set alarm for 8 am to get my body used to getting up at an early time and begin a structured routine that I will experience for the school year. I find this to be extremely beneficial in terms of health and academic achievement. Aside from reading past lecture materials, I use the last week to mentally prepare for the year to come and engage in relaxing activities. “

What advice do you have for other students who are starting the school year, or for students’ in their first year at university, college or away from home?

“Find out if your school or university/college has any support services or accommodations!”

““Take advantage of your school’s accessibility services! As a student with a permanent disability, you may be eligible for a reduced tuition fee if you wish to take fewer than a full course load (e.g. less than five courses per semester), extra time and a private room when writing tests, a note-taking service if you are unable to attend classes, and assignment extensions.”

“Starting post-secondary is a difficult milestone for anyone. It’s important to remember that everyone around you is experiencing the same challenges. However, maintaining a healthy diet, getting enough sleep, and time management skills are imperative for a good school year. Although spending time with friends is important, prioritize school work first and try to maintain a healthy balance between social life and academics. Do not be afraid to take a reduced course load or take your time. Go at your own pace whether it may be faster or slower. It is important to listen to yourself and your body during this time as only you know what is best for yourself. There will be points in the year where you will be stressed and frustrated, just know those feelings are normal and keep imagining the future you are working towards to remind yourself what all of your hard work is for.”

Is there anything else you would like to add?

“As a student, it can be easy to think that school is the number one priority. It’s not uncommon for a student to sacrifice sleep in order to study. That’s not an option for me anymore, and in a way, it forces me to prioritize my health. The problem-solving tools and self-care practices that I use to cope with stress can be used by any student.”

“Please have a balanced lifestyle! When you’re in school, it’s easy to get preoccupied with your studies only and neglect exercise, extra-curricular activities, and socializing with friends. In reality, it might be the activities outside of classes that will allow you to de-stress and actually become productive in the long run without burnout.”

Written by teen patients from the Centre for Youth Bipolar Disorder

Learn more: Back to School Tips for Students with Bipolar Disorder from the Centre for Youth Bipolar Disorder

The post Student-to-student: Tips for managing school stress for teens with bipolar disorder appeared first on Your Health Matters.

It’s estimated one in five Canadians suffer from MetS, a group of conditions that increase the risk of chronic illnesses such as heart disease, stroke and diabetes.  Conditions include: high blood pressure, high blood sugar, obesity, as well as high cholesterol or triglyceride levels.

BD is a severe mood disorder that causes extreme mood swings between “highs” and “lows.”  The highs are called manic or hypomanic episodes and the lows are called depressive episodes. BD affects between one and five percent of teenagers.

MetS and youth with bipolar disorder

The study included young people, on average 21 years old. Researchers determined that the prevalence of MetS among young people with BD is at least double that of the general population. The study also found that MetS is associated with increased depression symptoms, but not with increased manic symptoms.

“The link between cardiovascular risk and depression in this study is likely due to a combination of behavioural and biological factors,“ says Dr. Benjamin Goldstein, a study author and director of the Centre for Youth Bipolar Disorder at Sunnybrook.  “Behaviourally, people who are depressed often eat more and exercise less than when they are well. Biologically, depression is associated with increased markers of inflammation. Each of these factors is also relevant to cardiovascular health.”

While past studies have looked at MetS in adults with bipolar disorder (BD), this study is considered to be the first study focusing on MetS among adolescents and young adults with BD.

“Cardiovascular risk factors among young people with bipolar disorder are associated with worse mental health in the here-and-now and confer longer-term risks of early cardiovascular disease and stroke,” says Dr. Goldstein. “While awareness is important, we have reached a point where it is abundantly clear that action is needed.”

Treatment for bipolar disorder: brain and body

“From the clinical and policy perspectives, physical health should be, but is not yet, integrated into the usual care of people with bipolar disorder and other severe mental illnesses,” says Dr. Goldstein. “That’s unfortunate, because improvements in cardiovascular health or depression may have reciprocal benefits for patients.”

At Sunnybrook’s Centre for Youth Bipolar Disorder researchers are investigating the underlying links between bipolar and cardiovascular disease. An area of interest involves the study of the role exercise can play in the treatment for bipolar disorder.

Experts say physical activity is an important part of a healthy lifestyle and that aerobic exercise can help provide physical and psychological health benefits for adolescents with bipolar disorder.

Research has shown that exercise can help improve symptoms of depression and anxiety. Being active can improve the ability to concentrate, make decisions and problem solve. Physical activity can also help lower the risk of heart disease that is linked with bipolar disorder.

Dr. Goldstein says finding treatment approaches addressing the body and the brain together is integral to the future treatment of adolescents with bipolar disorder.

“From a research perspective, there is a largely untapped opportunity to learn about the causes of bipolar disorder through its link with cardiovascular health.”

Read the study, High Prevalence of Metabolic Syndrome Among Adolescents and Young Adults with Bipolar Disorder, in the Journal of Clinical Psychiatry.

The post Elevated cardiovascular risk in youth with bipolar disorder is related to depression symptoms appeared first on Your Health Matters.

My symptoms began with racing thoughts. I couldn’t sleep. For a fairly controlled person, I was out of control.

After numerous visits to the Queen’s walk-in clinic, I was finally referred for a psychiatric assessment. That’s when I received my diagnosis.

“You have bipolar disorder. Type I.”

I was 18 years old, alone in a new city, and on my own for the first time. I was meant to be preoccupied with parties and midterms. I needed to learn how to do laundry.

I suppose no one is ever ready to hear they have a mood disorder. I certainly was not.

It took about 30 seconds for the doctor to deliver the news. It also took about 30 seconds for me to choose to ignore it.

For six years, I refused to accept that I had a mental illness. After three manic episodes, two depressive ones, and six different medications the reality of my diagnosis started to sink in. It took an episode of psychosis so severe that I realized not getting help could have life-threatening consequences

How I learned to accept my mental illness and be more compassionate with myself

I spent so long being ashamed of my mental illness. I resisted the label “Bipolar” with every fibre of my being. A mood disorder requires a tremendous amount of courage and resilience – both of which are hard to summon when you’re ashamed.

My most recent episode also happened to be the most severe. It resulted in a one month hospital stay. It was my time as an inpatient at Sunnybrook that taught me compassion. I made so many friends in the psych-ward. I became friends with people from all different walks of life and all ends of the mental illness spectrum. I never once judged them for being sick.

I realized that for years, the greatest stigma I had ever experienced was from my own self. I’d always been my own toughest critic. That’s what triggered my epiphany. I realized that people can’t be made to feel ashamed over something that they themselves are not ashamed of.

I have bipolar disorder. It’s a disease. It’s just like any other disease. I would never ignore the fact that I had cancer. I would never refuse insulin for diabetes.

Too many people with mental illness suffer in silence because of the perceived shame of what others may think. We resist treatment because of the social barriers we place on ourselves. I realized I needed to do something positive.

What I am doing to raise awareness about mental health

This past spring, I started Mind Over Miles, a Toronto-based running club raising funds and awareness for mental health. We really want to contribute to the construction of the new Murphy Family Centre for Mental Health at Sunnybrook Hospital, which will provide leading-edge care to people with mental illnesses with the help of brain specialists and researchers.

Our run club is about fostering a community dedicated to understanding mental health. It’s about creating a positive space where anyone can share their story and ask for help. On Facebook, we release videos of people sharing their stories. Each video ends with a screen that reads “Join the Conversation.” Our hope is that as more people talk about it, the easier it becomes to continue the conversation about mental health.

If you need help in an emergency please call 911 or visit your local emergency department.

• Phone: toll-free 1-833-456-4566
• Text: 45645
• Chat: crisisservicescanada.ca

The post I have bipolar disorder. Here’s how I’m shattering the stigma of mental illness appeared first on Your Health Matters.

A clinical trial is underway to compare the immediate effects of laughing gas with those of another anesthetic medication, midazolam, on depression symptoms and on the blood flow in the brain of individuals with treatment-resistant bipolar depression. Researchers hope it will not only ease the depressive symptoms but also offer clues to the role of blood-flow problems in bipolar depression.

Participants 20 to 60 years old with treatment-resistant bipolar depression are randomized to undergo a neuroimaging session that includes either 20 minutes of inhaled N2O plus an intravenous saline solution or 20 minutes of inhaled room air plus an intravenous of midazolam.

MRI scans will capture the blood-flow changes and brain activity prior to, during and after the administration of the two treatments.

“We predict that N2O will improve blood flow in the brain, and that this improvement will be associated with temporary improvement of their depressive symptoms,” says Dr. Benjamin Goldstein, principal investigator of the trial and director of the Centre for Youth Bipolar Disorder at Sunnybrook.

“If proven effective, N2O has the potential to become a game-changing treatment for bipolar depression because it’s generally well tolerated, safe, low in cost, accessible and easy to administer.”

The post Could laughing gas provide relief for bipolar depression? appeared first on Your Health Matters.

Our eyes, it has long been said, are windows to the soul. Now, new research is hoping they can also provide some insight into the link between the health of our brains and our bodies.

This is the aim of a groundbreaking study at Sunnybrook focusing on the eyes of Lauren and dozens of other youth, ages 13 to 20.

The hope is that images of the tiny blood vessels of the retina, at the back of the eye, may unlock part of the mystery about why people with bipolar disorder have a higher and earlier risk of heart disease and cognition problems.

Could it be that atypical blood flow also impacts mood and brain function? The multidisciplinary study is unique in several ways.

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“I’m hoping that for future generations – and possibly even any children I may have – this research will really benefit them“

– Lauren, study participant

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It involves using a special camera to photograph the inside of the eyes of Lauren and other participants with bipolar disorder, as well as a control group without major mental illness.

It also marks the first time retinal photography has been used to capture images of the blood vessels in the eyes of young people with bipolar disorder. The researchers are also looking at factors that may predict small-vessel problems, such as inflammation, exercise, diet and use of medications.

The objective is to examine the blood vessels of the retina, which are “a close relative of the blood vessels in the brain,” notes youth psychiatrist Dr. Benjamin Goldstein, who is the director of Sunnybrook’s Centre for Youth Bipolar Disorder, the driving force behind the ongoing research.

Retinal photography has long been used in studying conditions related to aging, such as Alzheimer’s disease, atherosclerosis (hardening of the arteries) and diabetes.

“The retina offers the only way of directly visualizing central nervous system blood vessels,” explains Dr. Goldstein, who is also director of research in Sunnybrook’s Department of Psychiatry.

“Blood-vessel problems may be one of the core causes of bipolar disorder, and [retinal photography] is a very inexpensive, non-invasive way of understanding this link.”

According to Dr. Peter Kertes – Sunnybrook’s chief of ophthalmology and a member of the youth bipolar retinal photography research team – the retina, which is “essentially an extension of the brain,” works like the film in a camera. It’s responsible for interpreting what is out there in the world and sending that back to the brain as vision.

The project illustrates a unique collaboration between different specialists within Sunnybrook’s Hurvitz Brain Sciences Program, one that includes Dr. Goldstein, Dr. Kertes, Dr. Sandra Black, a senior scientist and neurologist, and Dr. Victor Yang, a neurosurgeon and medical biophysics expert.

From left: Drs. Victor Yang, Benjamin Goldstein, Sandra Black and Peter Kertes are part of a cross-departmental team involved in work linking retinal-vascular systems and bipolar disorder (Photo by Kevin Van Paassen).

“This study has brought together researchers who otherwise don’t cross paths, which is highly atypical – and inspiring from my perspective,” Dr. Goldstein adds.

“It’s been the fastest-recruited study we’ve ever had in our research program, and I think that speaks to the appeal of taking a picture of the eye to understand mental illness. These are not typically two things you pair with each other.”

Study recruitment is ongoing; the goal is to include a total of 300 subjects.

In Lauren’s family, another member has been diagnosed with bipolar disorder, her 24-year-old brother, James. Their mother, Gen, has always encouraged them to participate in research and not to feel they have to hide their diagnoses.

“I eventually told my friends [about the diagnosis],” recalls Lauren, who was 16 when she was referred to Dr. Goldstein after experiencing symptoms of bipolar disorder.

“I’m comfortable expressing myself because it’s no different than telling people you have  diabetes or some other health issue.”

And she participated in several youth bipolar studies before turning 21 in the fall.

“I’m hoping that for future generations – and possibly even any children I may have – this research will really benefit them,” says Lauren, who has a graduate diploma in early childhood education and recently started her career.

The primary tool being used in the project to photograph retinas is a Topcon TRC-50DX Type IA camera in Sunnybrook’s Department of Ophthalmology.

To start, drops are administered in the eyes of each study subject, so the pupils are dilated widely enough for the camera to see into them properly.

Next, the ophthalmic photographer positions the subject to sit facing the camera lens, with their chin in a chin rest and their forehead against a bar that’s part of the apparatus.

“I’m comfortable expressing myself because it’s no different than telling people you have diabetes or some other health issue,” says Lauren of her bipolar disorder diagnosis. (Photo by Doug Nicholson)

The photographer then adjusts the exposure to the proper intensity to photograph the retinas. Lauren says the whole process took about half an hour (with the photography component taking less than a minute).

Dr. Black says one of the obstacles the researchers were working to overcome was to figure out how to actually measure the blood flow in the retina.

However, that’s where Dr. Yang’s expertise has proved important. He uses optical coherence tomography (OCT), a revolutionary medical imaging technique that captures high-resolution 3D images showing a cross-section of the retina and all of its layers.

“It allows us to see into the body without injecting any dyes,” says Dr. Yang. “Our lab has been developing OCT technology for the past two decades and is opening up a whole new understanding of the effects of blood flow in the brain and retina.”

Notes Dr. Black, Brill Chair of Neurology, “From this melting pot of different specialties working together, new ideas can spring forth.” For his part, Dr. Kertes says, “I have learned a great deal about dementia [from another study with Dr. Black] and bipolar disease in particular, and feel confident that this insight and knowledge have made me a more caring and better doctor.

“The work that [ophthalmologists] do in restoring and preserving vision has been fantastically gratifying, but the potential of contributing to the diagnosis and monitoring of neurological and psychiatric diseases is tremendously exciting.”

Early results of the study have uncovered some interesting findings about teens with bipolar disorder, specifically the following:

• Those with high blood pressure had poorer retinal blood-vessel health.

• Healthy blood vessels in the body are linked to healthier blood vessels in the eyes.

• Teens that did well in a series of specialized online games aimed at measuring their ability to problem-solve had healthier blood vessels in their eyes.

The researchers hope their work will lead to new approaches to diagnosing, monitoring and treating mental-health issues, with a focus on prevention.

For instance, they foresee a future in which blood-vessel health is considered in the diagnosis, monitoring and early treatment of bipolar disorder, and prevention and treatment approaches may include everything from prescribing exercise (to help improve blood flow in the brain and body), to using different counselling methods and medication that may not have been standard practice before.

Knowing that bipolar disorder isn’t just a mental illness can be “empowering,” notes Dr. Black, and can “motivate kids to do the right thing, which is to exercise [and] take it seriously, because you can change your outcome, and you can change your life by dealing with that biology.”

Other Sunnybrook-led studies get to the heart of youth bipolar disorder

Sunnybrook’s groundbreaking retinal photography project is just the latest of a wealth of research examining the link between youth bipolar disorder and blood-vessel and heart health.

Dr. Goldstein – director of research for the hospital’s Department of Psychiatry, as well as director of its Centre for Youth Bipolar Disorder – was also the lead author of a 2015 scientific statement published in Circulation, the American Heart Association’s Journal. The paper determined that depression and bipolar disorder increase the risk that young people will develop atherosclerosis (hardening of the arteries) and heart disease.

In late 2016, Dr. Goldstein led another study, the first to examine the link between cardiovascular health and mental flexibility in adolescents, ages 13 to 20, with bipolar disorder. The results of his research found that elevated blood levels of triglycerides (a type of fat that can be measured in the blood), which are known to increase the risk of heart disease, are also associated with decreased “executive function,” determined based on mental flexibility during a computerized task.

Earlier studies had already concluded that adults with bipolar disorder had greater cardiovascular risk factors, such as obesity, high blood pressure and high levels of blood sugar and triglycerides, compared to adults without bipolar disorder.

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“The goal is to prevent these kids from developing heart disease in the first place.”

– Dr. Benjamin Goldstein

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In Dr. Goldstein’s research findings, the adolescent subjects with bipolar disorder also had greater cardiovascular risk factors and didn’t do as well on a computerized test measuring mental flexibility and impulsive risk-taking, compared to the control group.

So what’s happening with the vascular systems of teens with bipolar disorder?

“There are multiple things going on,” Dr. Goldstein points out. “These teens are similar to adults with bipolar disorder – they’re more likely to smoke, less likely to exercise, and their nutrition is not as good [as individuals without bipolar disorder]. “But it’s also stressful to live with bipolar disorder, so [the strain] impacts their risk for heart disease.

And then there’s another piece – some of the medicines used [to treat and manage mental health conditions] increase weight. All these factors are part of the story.”

“We know that the reality for middle-aged adults with bipolar disorder includes excessive heart disease which can shorten their life by 10-15 years. That’s the status quo and we’re not happy with the status quo,” Dr. Goldstein continues. “The goal is to prevent these kids from developing heart disease in the first place.”

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ANSWER: Numerous studies have found that patients who suffer from either depression or bipolar disorder face elevated chances of getting heart disease at an early age.

“It is quite clear there is an increased risk of coronary artery disease, which ultimately causes heart attacks,” says Dr. Benjamin Goldstein, director of the Centre For Youth Bipolar Disorder at Sunnybrook Health Sciences Centre.

Of course, many people who struggle with major depression or bipolar disorder – also known as manic depression – adopt habits that can contribute to the development of heart disease.

For instance, their psychiatric disorders increase the likelihood that they will smoke, not exercise regularly, and fail to stick to a healthy diet. What’s more, some of the medications used to treat these conditions can cause weight gain, as well as alter cholesterol and blood-sugar levels in ways that can be bad for the heart.

But even in studies that control for the effects of lifestyle and medications, these patients are still more prone to get heart disease early compared with the general population.

“Their rate of heart disease goes well beyond what we would expect to see with traditional cardiovascular risk factors,” says Dr. Goldstein. “Smoking, a sedentary lifestyle and poor nutrition just doesn’t explain the whole story. So, there is something else going on.”

People with bipolar disorder develop heart disease an average of 17 years sooner than those without a psychiatric condition.  This means that when they’re in their mid-40s, they already resemble individuals in their late 50s or early 60s in terms of the condition of their blood vessels.

Similar trends, although not as extreme, are seen in people who suffer from major depression. This group show signs of heart disease an average of six years sooner than would ordinarily be the case.

“It’s like premature aging – and people are literally dying early because of this,” says Dr. Goldstein.

So how does depression set the stage for heart problems?  Dr. Goldstein notes that mood disorders are linked to a wide range of biological changes that seem to speed up vascular deterioration.

In particular, people with bipolar disorder and depression tend to have increased levels of inflammation – and inflammation, in turn, is known to boost the risk of cardiovascular disease.

During a manic episode or a bout of depression, inflammatory markers – such as C-reactive protein – proliferate in the blood stream.  Once the mania and depression subside, the inflammatory markers return to normal levels.

“Inflammation is your body’s immediate response to any threat, such as an injury, an infection or even stress,” explains Dr. Goldstein.  “At the right time, and in the right amount, inflammation is super important for maintaining health.”

However, prolonged inflammation can be harmful. The cascade of proteins released by the inflammatory process can damage the inside lining of blood vessels.  This can result in a build-up of plaque and other deposits, narrowing the arteries, and ultimately leading to heart disease.

Those who suffer from bipolar disorder are particularly vulnerable to the effects of inflammation because they can experience repeated bouts of manic behavior and depressive episodes over many years.

“If you have a few weeks of depression in your whole life, the magnitude of increased risk is pretty modest,” says Dr. Goldstein.  “But if you’re 50 years old and have spent half the past decade depressed, then the risk is probably substantially elevated.”

Aside from inflammation, mood disorders can cause other changes in the body that fuel the advance of heart disease. Studies show that depression is linked to an increase in the stickiness of platelets, which cause blood to clot. As well, there is evidence suggesting depression affects the autonomic nervous system that regulates the heartbeat.

“There are many different mechanisms and we don’t fully understand them all,” says Dr. Brian Baker, a psychiatrist and Associate Professor at the University of Toronto.

Some researchers even speculate that certain genetic traits may predispose some individuals to both mood disorders and heart disease.

Dr. Goldstein believes physicians should pay more attention to the onset of heart disease in young people with mood disorders. Unfortunately, it’s often overlooked because health-care providers are primarily focused on treating the depression and the mania. And the relatively young age of the patients make them less obvious candidates for cardiovascular-disease prevention.

“When you look at the data, you realize that we need to start addressing this issue early on,” says Dr. Goldstein. “There is a lot to be gained by increased recognition and knowledge about the higher heart-disease risk faced by this group of patients.”

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Although the cause of Carrie Fisher’s death was reportedly a massive heart attack, one could say that she actually died of bipolar disorder. It is well known that heart disease is society’s leading killer. In contrast, it is largely unrecognized that people with bipolar disorder are at particularly high risk of heart disease. Shining a light on the heart-bipolar connection serves a number of important parallel purposes, including the promotion of assertive approaches to optimizing heart health, reducing the ongoing stigma toward bipolar disorder and other forms of mental illness, and encouraging further research efforts on this topic.

Carrie Fisher was not only a luminary artist, she was also a luminary advocate for mental health, focusing especially on bipolar disorder, a condition from which she suffered. Because of Ms. Fisher’s profession and talents, hers is an epic and singular story that has and will continue to touch the world for many years. But hers is also a typical story, albeit tragically so, of a young woman who experienced the onset of bipolar disorder early in life, who survived decades of the effects of bipolar disorder on her mind and brain, and who, it could be said, was ultimately felled by the impact of bipolar disorder on her heart.

Based on the most recent data from the United States general population, not only are people with bipolar disorder more likely to have heart disease, they also experience heart disease up to 17 years earlier, on average, than people who do not suffer from mood disorders. A sixty year-old woman with bipolar disorder may have the heart of a mentally healthy woman in her late seventies. The extent to which bipolar disorder increases and accelerates the risk of heart disease exceeds what can be explained by smoking, drug and alcohol use, sedentary lifestyle, nutrition, physical side effects of psychiatric medications, and even traditional heart disease risk factors such as high blood pressure and obesity. All of these factors are particularly common among people with bipolar disorder, but they are only part of the story.

Almost certainly, the distress caused by the symptoms of bipolar disorder, alongside the stress caused by the impact of those symptoms on people’s lives, contributes in part to elevated heart disease risk. There are a number of biological processes that could form the heart-bipolar bridge, including elevated levels of inflammatory markers, which have been shown to coincide with the episodes of mania and depression that define bipolar disorder and which increase the risk of heart disease.

Studies have also found evidence of poor blood vessel health among people with bipolar disorder, in the brain as well as the body. The scientific literature on this topic is so compelling, and yet so under-recognized, that a recent scientific statement from the American Heart Association positioned bipolar disorder (as well as major depressive disorder) among youth as a risk factor for early heart disease.

It is worth noting that among teenagers, bipolar disorder is twice as common among girls than boys. It is also worth noting that the extent of increased risk of heart disease attributable to bipolar disorder is even greater for females than it is for males. In losing Carrie Fisher, the world has lost a warrior princess who gifted us with valiant efforts both on and off the screen. As we each consider the ways in which we will honor her memory, let us consider all of the young warrior princesses (and princes) with bipolar disorder for whom the prospects of a long and healthy life rest on early and assertive approaches to heart health.

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