Q&A with David J. Miklowitz, Ph.D.
Professor of Psychiatry in the Division of Child and Adolescent Psychiatry
University of California, Los Angeles
2011 BBRF Colvin Prize for Outstanding Achievement in Mood Disorder Research
2001 BBRF Distinguished Investigator Grant
1987 BBRF Young Investigator Grant
Dr. Miklowitz is Distinguished Professor of Psychiatry in the Division of Child and Adolescent Psychiatry at the UCLA Semel Institute, and Visiting Professor in the Department of Psychiatry at Oxford University. He is widely respected for his research focusing on family environmental factors and family psychoeducational treatments for adult-onset and childhood-onset bipolar disorder. In addition to his BBRF grants, Dr. Miklowitz has received research grants from the National Institute of Mental Health, the MacArthur Foundation, and the American Foundation for Suicide Prevention, among others. He has published over 300 research articles and 8 books, including The Bipolar Disorder Survival Guide: What You and You Family Need to Know, now in its 3rd edition.
Dr. Miklowitz, you have decades of experience in treating patients of all ages with bipolar disorder. Since the illness manifests in a variety of ways, can you go step by step and explain how bipolar disorder is properly defined, and how you recognize it when it occurs?
In most cases, it is a disorder in which a person cycles between depression and mania. Most people understand what depression is. Depression is characterized by sadness, fatigue, suicidal ideation, sleep disruptions and a loss of interest in things. But some people may not understand precisely what we mean by mania. Mania is a period of a week or longer where someone is feeling “on top of the world”—euphoric, or, extremely irritable. There’s a change in behavior, which can be marked by increased spending and impulsiveness, hypersexuality, risk-taking, things that could get someone in trouble with the police. And there’s a change in thinking patterns, where one’s thoughts go extremely fast and one speaks extremely fast, jumping from topic to topic. There are grandiose ideas (such as “I’m smarter than everyone else”) or even full delusions of grandeur, such as believing one has special powers.
Mania tends to last at least a week and may be preceded by a buildup period that we call the “prodrome.” Some people, however, don’t get all the way out to mania. Instead, they get to a condition we call hypomania, which generally doesn’t last as long (we require a four-day minimum). Hypomania involves the same symptoms as mania, but there’s no apparent deterioration in functioning, whereas in mania, the person really does deteriorate. They lose their job, or they get arrested or break off relationships left and right. With hypomania, people around the person may notice the symptoms, and says things like, “Gee, you’re wired today.” The person with hypomania may or may not recognize it, but it doesn’t necessarily change their day-to-day functioning.
To be clear, you are saying that bipolar disorder involves both depression and mania—a cycling between them, or, in other cases, people who periodically have depression and at one or more times in life have also experienced a manic episode.
Technically, “bipolar 1 disorder” means you’ve had one manic episode. You need not have experienced depression at this point, but most people have. More generally, in bipolar 1, you have major depressions and full manias. In “bipolar 2 disorder” you have major depressions and hypomanias. That’s the key distinction.
On average, people with bipolar 1 spend three times as much time in depression as they do in mania. You can also have a “mixed episode,” with both depression and mania at the same time. I’ve heard it described as the “tired-but-wired” feeling: thoughts going fast, mind full of “great ideas,” and unable to sleep. During mania, people don’t feel like they need sleep, whereas during depression, they can be sleeping all the time. In mixed episodes, they might have insomnia, rapid thinking, rapid speech, and increases in activity while also being suicidal and depressed.
Are there some people who just have mania and never get depressed?
There are, and they tend to have recurrent manic episodes. It’s rare to have one manic episode and never have either a depression or mania after that. Most people who have unipolar mania tend to be men. When they crash, they don’t crash down into full depression; they come down to some level close to normality or maybe just a milder depression. But more often what you see are people who periodically get hypomanias in between episodes of mania.
There are so many ways in which bipolar disorder manifests itself. Between periods of mania and depression, or intervals of depression, isn’t there a sort of a maintenance period where patients go to a “baseline” of feeling as though they’re on an even-keel? Is that the way it goes?
Yes. Now, there’s a fair amount of debate about what being “even-keel” means because some people really do return to normality, and they’re indistinguishable from you or me when they’re feeling fine. But a lot of people with bipolar disorder return to a sort of low-grade depression that may not be noticeable to anybody but themselves. The low-level depression may make it hard to hold a job or maintain relationships.
Let’s talk about what to look for. First, what is the typical age of onset?
The average age of onset is 18. But the range is anywhere from very young— i.e., children—to those who don’t have their first episode until their 50s. One thing that is interesting is the average age of onset is getting younger with successive generations. We used to think the average age of onset was about 25-28. Now, it’s thought to be the late teens.
On average I understand there is a lengthy delay between the first “prodromal” symptoms and the actual bipolar diagnosis. Why does that happen?
In many cases, it can be 8 to 10 years. What often happens is that the first episode is a depression. Either the depression doesn’t get treated or it’s attributed to a normal reaction to “life events.” In such people who are eventually discovered to have bipolar disorder, it isn’t until they have their mania that the full diagnosis is recognized. A typical scenario might be: a teenage girl at age 14, right around the time of puberty, has a first major depression. Her pediatrician says, “Well it’s probably a hormonal thing, or it’s because she broke up with her boyfriend.” It passes, and nobody thinks about it until she gets into college and has her first manic episode. In that case there’s a 4-year gap. In other cases, depression is longstanding, and may go on throughout the teen years and early adulthood. Then, when the person first tries taking an antidepressant, they get hypomanic, manic, or develop rapid cycling (frequent alterations between depressive and manic states). Bipolar disorder often goes unnoticed. There are people who have “cyclothymic patterns,” in which their mood swings a lot, and people just think they’re moody.
Another thing to think about is comorbidities. One of the reasons it takes so long to come up with the right diagnosis is often that the young person presents with ADHD, which can mask bipolar disorder or be comorbid with it.
In view of bipolar’s many manifestations, this raises an obvious question, especially for parents. When do they know if their child is “just being a teenager”? How do you know when to be worried?
In bipolar disorder, it comes down to a question of degree and amount of impairment. First: is there only one symptom of mania? Or, are we talking about a cluster of symptoms of mania? A typical teenager will have rage once in a while or do something very impulsive. Or they will sexually experiment or do drugs. All those things are within the realm of typical teenage behavior. But when you combine impulsiveness with irritability, not sleeping, grandiose thoughts, and functional impairment, then you’re into the bipolar realm.
I think impairment is really the big thing to consider. Lots of teenagers will wake up in the morning, and they’ll say, “I’m too depressed to go to school,” but they drag themselves out of bed. They go. By afternoon, they’re okay, compared to the bipolar kid who honestly can’t get out of bed. They feel like there’s this 100-pound weight on them. It feels like they can’t move. Diagnosing depression in a teenager is tricky. We can’t really tell what is a major depression of the unipolar type versus a bipolar depression—they can both be severe and the symptoms can be similar. So, we have to consider the severity of depressive symptoms, whether they ultimately prove to be the result of unipolar or bipolar depression. Is it so severe that they can’t go to school, and they can’t do their sports, or they don’t want to play their music? And does it go on for weeks at a time? That’s very different from the kind of blues that teenagers have when they have a setback or obstacle in the usual course of things. Severe depression with impairment should be a trigger for concerned parents to seek professional advice.
And also, we must consider context. If a kid is giddy and silly when they’re around their friends, that makes sense. But a bipolar kid will be laughing hysterically in church, or at a more serious gathering, or in the middle of class.
When you have a teenager who is clearly depressed in a non-trivial way, it makes perfect sense to treat them as if they have some form of depression, I would imagine. But if I hear you correctly, it could turn out that that’s the depressive phase of bipolar disorder. Would treating them with antidepressants pose any sort of risk?
They can pose a risk, but it’s not inevitable. Parents should get a full evaluation of the child, which includes a family history of mood disorders. If a kid has a family history of bipolar disorder, and she’s depressed, that increases the probability she will go on to have a manic or hypomanic reaction to antidepressants. It doesn’t mean she will, because we also know that depression and bipolar disorder can run in the same families. So, you might have a bipolar parent and only develop unipolar depression yourself, i.e., depression with no mania or hypomania. But it’s one of those things where you have to rule out bipolar as the likely cause of depression.
What some doctors will do if there’s severe depression and a family history of mania is that they will start the patient on a mood stabilizer and an antidepressant together. If the parents and kids don’t like this idea, and just want to try antidepressants, they should be informed of what the signs of mania look like. That way, they’ll be able to catch it earlier if it does occur.
What are the signs to suggest that it’s not “just” depression?
There are a couple of ways to tell. One is that bipolar depression might have a few mixed features with it. A typical scenario would be someone is depressed but their mind is going a mile a minute, and they’re ruminating over things. There’s a sort of frantic quality to it. Or the adolescent might come up with elaborate ways to commit suicide. They’re getting online and making lists and calling numerous people for help.
In kids, one predictor of developing bipolar disorder—especially if they also have a family history of mania— is “mood instability,” the tendency to change moods all of a sudden. Parents describe that the kid has a “hair trigger” for getting angry, or will be laughing one moment and crying the next.
Depression of the bipolar type tends to occur at a younger age (e.g., 11) than the depression of the unipolar type (e.g., 14-15). If a parent has bipolar disorder and also developed it at a young age, that indicates a greater likelihood in the child. Another thing to notice is if there is any psychosis. If the kid has delusions that their body is rotting, or they’re responsible for something that happened in a faraway place, that’s more likely to be a sign of bipolarity.
Would you recommend that a concerned parent have their child take the Mood Disorder Questionnaire, which is posted online?
You can, but the problem is that it has a lot of false positives, meaning it can look from the results like you’re bipolar when you’re not. I wouldn’t rely on it as a diagnostic instrument. I think it might be a way of deciding whether you should get a full psychiatric evaluation. If a kid’s depressed, and they fill out that questionnaire, and it comes up positive, that’s a sign that you need to get an evaluation.
Where should parents take their child for a serious evaluation? If they’re urban or live close to an urban area, where should they go? A university hospital? What about people not near cities?
There is a huge difference between urban and rural settings. If you’re in Los Angeles or New York, you can always find a bipolar specialist. We have a childhood mood disorder program at UCLA. New York has a bipolar family center at Beth Israel Hospital. If not, you have to go with whoever the local psychiatrist is, and that person may or may not know bipolar disorder. The one good thing that’s come out of the pandemic is that we’re all doing telehealth now. Presumably, you could get on the phone with a bipolar specialist at a university depression center anywhere. But these evaluations with specialists can be quite expensive.
The aspect of suicide risk in this diagnosis is considerable, is it not?
It is. I hear estimates of anywhere from 15 to 30 times the population base rate of suicide. When people are so depressed that they can’t move, that actually poses a lower risk than when they’re depressed and agitated and anxious. A mixed episode is a very high-risk factor.
It’s been well demonstrated that the mood-stabilizing medicine lithium reduces suicide risk. But people looking at 20-year trends in outpatient treatment see lithium is less likely to be given as the first line treatment. Today, someone in outpatient treatment would be more likely to be prescribed an atypical antipsychotic medicine and/or an SSRI antidepressant, correct?
That is true. I think it’s because of two reasons. I still think it’s the best medication we have for bipolar disorder, but it has a tougher side-effect profile than other mood stabilizers or antidepressants. For some, it also has a stigma associated with it. Everyone has heard of lithium but not everyone has heard of risperidone or lamotrigine or valproate. Lithium has side effects like acne, weight gain, and jitteriness of the hands. But it’s got an anti-suicidal effect, more pronounced than other medicines.
If somebody is suicidal and has bipolar disorder, I would say lithium is the first choice.
We know that people with a bipolar diagnosis usually get a medication, whether it’s an anticonvulsant, a mood stabilizer, an antidepressant, or a combination of these. But you’ve discovered and demonstrated in your research that you can get much better outcomes and more adherence to medications if you combine medication with family-focused therapy. Can you tell us how you came upon this discovery?
I have a background in schizophrenia research. When I was getting my degree, there was a lot of interest in family treatment. There was this finding that if you combined antipsychotic medications with family education and skill training, patients did better over time. I was interested in trying to extend that model to bipolar disorder. I was running support groups at the time for bipolar patients. And a lot of them said that their episodes were set off by family conflicts and poor boundaries with family members. The first study I did was on “expressed emotion,” which in the family setting takes the form of criticism and hostility, and over-protectiveness in parents. When parents are highly reactive to the kid (or young adult) and get set off easily by their kid’s behavior, that creates an environment where the kid has a tougher time recovering and staying well. What we did basically was to say, “Okay, let’s take family education and skill-building and see if we can modify communication patterns after an illness episode when all these sparks are flying.” And that’s how Family-Focused Therapy came about.
Walk us through how the therapy happens.
Today, this kind of therapy happens in 12 sessions over 4 months and involves three things: psychoeducation for the family on how to cope with bipolar disorder; communication training; and problem-solving training.
In the first couple of sessions, we teach the family about what a mood disorder is, what does it mean for moods to cycle, and what are the early warning signs of a new episode. The kid’s experience of mood cycling takes center stage. Then we talk about what you can do as a family when you spot the early signs— things like calling the doctor and getting a change in medications, encouraging regularity of sleep-wake cycles, keeping family intensity to a minimum, and lowering expectations during those times. The idea is for families to have a plan for when the kid shows a deterioration in mood or an increase in manic symptoms. That’s psychoeducation.
The second aspect, communication training, involves teaching kids and family members how to talk to each other, how to listen, and how to ask people to change their behavior. It’s a little bit like what’s done in marital therapy when you’re training people how to be empathic, how to validate, how to listen, and how to keep the environment cohesive.
The third part of the therapy is providing problem-solving techniques for conflicts the family has not been able to resolve on their own (such as those around medications, schoolwork, or household tasks). And we teach them a structured way of breaking a problem down and solving it.
Families feel like they have a better understanding of the illness at the end of treatment. And patients feel like their family is more of an advocate than they had thought before.
So, part of this is consciousness-raising.
Absolutely. In fact, I had this very conversation with a patient yesterday. The young person won’t take his medication, and he said, “It’s my body, and it only affects me if I take my meds or not. So, I should be able to decide.” And we pointed out, “Well, you live with your mother. So, if you go off your meds, and you’re angry and irritable and anxious, that’s going to affect her. It’s not just you.” Parents sometimes bring out the heavy hammer and say, “You have to take your meds, otherwise, get out of my house.” Or imagine a dad who says, “There’s nothing wrong with you. You’re just being a brat. You’re disrespectful, and you don’t listen to anybody.” These are wrong ways to handle it— you need to be able to understand the kid’s point of view, and they need to understand yours.
The idea of making a list of things that have “triggered” an individual’s bipolar episodes sounds very useful to me.
It is. There’s a distinction, please note, between triggers and prodromal signs. Prodromal signs are the symptoms before an episode, like not needing sleep or feeling suicidal. But a trigger could be a life event. It could be breaking up with your girlfriend or a change in work hours. There’s a whole theory about sleep/wake regularity and daily rhythms. If you go from the night shift to the day shift on a job, or stay up all night studying for an exam, those changes can be triggers for a manic episode. When you anticipate having to make these changes, you’ve got to adjust your sleep cycles accordingly: go to bed at the same time each night and get up at the same time the next day.
Ultimately, if all the stars align—you have a good therapist, the family is conducive to being involved constructively, and the patient is willing to submit to this process—it would seem there’s a way of actually moving toward prevention here.
Yes. And that’s what we try to do in the most straightforward way possible. We give people a chart with four columns: What are triggers, what are prodromal signs, what can you do about it, and what could get in the way. So: the trigger might be, I’m going from summer to fall, and school is going to start. I have to get up earlier. What are the warning signs? Getting depressed and feeling anxious. What can the family do? Talk to me. Help me get my medication changed. What are the obstacles? That I may not want to talk about it.
Is it helpful to chart moods?
It helps to a certain extent. I think it helps in consciousness-raising for the kid, especially for one who doesn’t recognize they have mood swings. So, you tell the kid, “Every day, make a rating of how high or how low you feel, or whether you’re feeling normal.” Sometimes, we ask the parent to do the same thing to see if the mood charts have any discrepancies. We may say to a kid, “Wait a minute, you say you were stable all last week, but mom says you were up and down. Let’s talk about what really happened.” That’s where it can be useful.
Or, if you start a new medication, and you want to know how it leads to highs or lows, or you’re worried about some sort of manic rebound. So, we ask you to keep a mood chart and see if there’s a trend. But it’s not natural for people to want to rate their moods every day. Patients who take it up the most, I think, are young adults who have had a couple of really damaging manic episodes. They will be motivated to keep a mood chart. With a teenager, it’s a tougher sell.
Let’s conclude by discussing the findings of a very important paper about treating bipolar disorder that you and colleagues published in the journal JAMA Psychiatry within the past year. You surveyed the available literature and tried to discover, in a sample of 39 prior studies involving almost 4,000 bipolar patients, whether there are certain ways of delivering therapy that tend to deliver superior results.
Yes. It indicated the effectiveness of combining psychoeducation therapy with medications. The most surprising finding for me was that on average, doing psychoeducation in a family or a group setting was more effective in terms of preventing recurrences than doing it in an individual setting. I think the reason is that bipolar disorder is one of those illnesses in which the patient really needs a support system to recognize their episodes. It doesn’t have to be a family. It could also be a group of other people who have the illness. Many patients cope that way. They go to bipolar support groups and learn about the illness, and develop relapse prevention plans.
Your study also had important things to say about psychoeducation and structured support. What does structured support mean?
Structured in the sense that the therapy follows a script. There’s a session on understanding and monitoring symptoms. There’s a session on developing a relapse prevention plan. There might be a module on how to keep regular sleep-wake cycles. This typically works better for people with bipolar disorder than free-form talking, whether in a group or a family setting. Other specifically helpful things that we found included patients working with their therapists to regularly challenge negative “self-talk,” keep their sleepwake cycles consistent, and learn communication skills in the family setting. These components prove to be important interventions for managing bipolar depression.
Editor’s Note: Dr. Miklowitz’s book, The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (Guilford Press), is now in its 3rd edition and was most recently updated in 2019. It contains a wealth of practical advice that may help patients and family members who are learning to cope with bipolar disorder.