A Psychiatrist's Take on Bipolar Disorder

This is the first of a two-part interview.

I had the honor of speaking with Dr. Tracey Marks, who is an expert witness on forensic psychiatry, a practicing psychiatrist, and the informative powerhouse behind her YouTube channel with over one million subscribers. We discussed bipolar, the difference between psychosis and psychopathy, sleep, and warning signs.

Tracey Marks, MD

Source: Image courtesy of Marks Psychiatry, Atlanta

ML: Your YouTube videos are so popular. What prompted you to take advantage of that platform?

TM: My intention was to reach as many people as possible by helping them understand mental health. It started with a desire to create a library of mental health educational information, partly to supplement what I was doing in my own practice.

I do a lot of therapy in addition to medication management, so I would see people and we’d be so busy talking about their lives that there were things I wanted to explain further, but wouldn’t have the time. Or even if I did launch into a small lecture, it was too much for someone to remember. I could tell because they’d come back and ask questions that I’d already explained. I thought it would be nice to refer them to a video so they could learn more about the topic that we’d touched on.

ML: Right, and as a recording, they can pause it, digest it, and keep moving. So you’re really in tune with your patients.

TM: Correct. That was my initial motivation to help my patients, and that expanded to helping more people than I could see in my office. I like video. I am creative, so I started out editing my own videos. That was a process for me, like someone who likes to paint or color. Editing was also an outlet for me, so that’s why I turned to video and enjoyed it better than the podcast I had earlier. Podcasting is a third of the work of video production, but podcasting didn’t click with me as much as video.

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ML: Understood. I like that you’re finding a way to embrace your own creativity with your knowledge base, help your clients and branch out beyond what you can do as one person in an office. That whole synthesis is something I do with the various things I’m good at. One comment on your YouTube video "Bipolar Disorder vs. Depression" ¹ comes from someone wishing the highs of bipolar lasted longer. How can someone with bipolar be convinced that the highs are symptomatic of a serious medical condition and to seek help?

TM: Usually, that comes with them having some negative consequence from the high. It’s hard for someone be hypomanic for an extended period of time and have no negative consequence. In fact, one of the criteria for the disorder is that there is impairment. That’s one of the things distinguishing hypomania from being just energetic or excited from something. All excitement isn’t hypomania. If someone is truly having manic or hypomanic symptoms, usually the person will crash and burn and there will be negative consequences.

One of the problems with bipolar disorder – particularly people who have recurring manic or hypomanic episodes – is when they start to ramp up, they can forget the bad part. If the fall isn’t that bad, like you didn’t lose that much and it feels good in the moment, it may be harder to remind yourself, “Uh-oh, I’m going and going and I need to slow down or do something to come back down from this.”

You’re getting a lot done, you’re thinking faster, you don’t need as much sleep and all of that stuff. With bipolar and mood disorders, there’s something called a kindling effect, where the more episodes you have that go untreated, the harder future episodes become to treat and get under control.

So someone may have a little hypomania in the beginning and nothing bad happened. They got a lot of stuff done, but they slowed down and recovered. That might happen a couple of times, but at some point that little flame will become a roaring fire that burns out of control and they lose something as a consequence. Those signs, impairments, and consequences are things they have to remind themselves of to prevent future episodes from getting out of control.

ML: Where were you when I was going through it? Four hospitalizations later, I finally acknowledged that the diagnosis was permanent.

TM: I’m sorry that happened. That’s where either getting into treatment early or recognizing early signs becomes helpful. When you have that first benign episode, probably you’re not going to do anything about it. You may not even know what that was. Usually, there’ll have to be some crash and burn.

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You wind up in the hospital or lose a job or a relationship suffers or you have affairs. That’s when it usually takes a village of people who love and care about you to intervene. Another benefit of my videos is they’re not just for the person questioning, but they’re also for people who want to help someone in their lives. The more people can understand the dynamics of what’s going on, the more people can help you hold it together. They can notice, “Oh you’ve only slept a couple hours a few nights in a row. Maybe something is happening here.” The person experiencing the sleepless symptom may think, “But I’m still good though. I painted the house.”

ML: That’s a very "bipolar" thing to do. Middle-of-the night landscaping, rearranging furniture, and heavy projects. I guess the first question would be, “Didn’t you think that was just a little bit strange?” Another comment on the same video: “Sometimes I say, ‘If I just couldn’t think, I’d be the happiest person in the world!!!’” So those comments go from the hypomania to the opposite pole, depression. How can a patient learn to recognize when their thinking is distorted and self-defeating and what can they do about it?

TM: This also relates to having support around you to help you with this. Managing bipolar disorder is best not done in isolation, because you’re not always going to be able to recognize your behavior and thinking as abnormal. Even if you do, like the person in the comment, there probably was a time before the thinking got really bad, you were on the way there and didn’t recognize it. It takes some introspection to notice your own thinking process.

Even in this scenario where the issue is possible psychotic depression, hopelessness, and dark thoughts, the idea is to get the ship before it sinks. Before you get all the way down, start working on making changes before it sinks too far. It could be getting back to seeing the doctor.

Bipolar disorder does need professional treatment and usually medication treatment. There are not many people who can manage their bipolar solely through natural means. Social rhythm therapy is probably the best it gets in containing symptoms, but I’m not sure it’s robust enough to keep someone entirely out of an episode. Making adjustments to medication, working hard on sleep hygiene, and integrating exercise are all helpful. If you’re sinking into depression, activity helps. Behavioral activation² is its own therapy when people are frozen from depression.

Other natural mood enhancers don’t work overnight, but bright light therapy³ is a real intervention. Light is fairly powerful in elevating mood. There’s also high intensity exercise. Mediterranean Diet is getting more research backing⁴ that it treats unipolar depression. Bipolar depression could benefit. I think it’s more related to reducing inflammation in the body. It’s a cleaner diet than hot dogs and hamburgers. I think the depressed phase is the harder phase to treat.

This is Part I. For Part II click here