Supplementation for Bipolar Disorder

Bipolar disorder is a mental illness that affects around 2.5 million people in the US and Canada. (17)(21) It is characterized by fluctuations of low mood and high mood. Times of low mood often last weeks to months and high moods lasting often several days to weeks. 

As someone who has been diagnosed with bipolar disorder type 1, I know how scary these fluctuations can be. For years, I was in constant fear of having another manic episode. It wasn’t until I found a practitioner who used a functional and natural approach to mental illness that I felt I was able to learn to accept these episodes, learn to love myself and feel that I have the tools to help manage my mental health symptoms. I have spent the last 16 years helping others with mental illness learn to take back their mental health in my role as a naturopathic doctor.

Types of Bipolar Disorder

There are four main types of bipolar disorder. (19)

Bipolar disorder type 1

Bipolar disorder type 1 involves episodes of mania, where mood becomes so elevated that a person can experience psychosis, require hospitalization and impair a person’s ability to function socially and/or occupationally. Mania can last for at least 1 week and hypo-mania can last for several weeks prior to escalating into mania.

Bipolar disorder type 2

In Bipolar disorder type 2, high moods don’t quite reach the mania state and are called hypomanic episodes. A hypomanic state can last from days to months; however, a  minimum of 4 days in a row in an escalated state is the criteria for a hypomanic episode.

Cyclothymia

Cyclothymia is a type of bipolar disorder which moods fluctuate between highs and lows but are the swings in mood are not as severe as in bipolar disorder type 1 or 2. The lows are often considered subthreshold depression and the highs are hypomania episodes. (6)(19)

Bipolar disorder not otherwise specified

The last type is bipolar disorder not otherwise specified, which is a type of bipolar disorder that does not meet the criteria of the other ones.

Symptoms and Signs of Bipolar Disorder

Bipolar disorder has two distinct stages, the low moods and the high moods. Because these stages occur at different times and can be spread apart by weeks or months it can make diagnosis difficult. Symptoms and signs of bipolar disorder depends on what stage a person is in. (19)

The low moods look very similar to major depressive disorder and includes signs and symptoms such as…

• Feelings of sadness
• Fatigue or low energy
• Feelings of worthlessness
• Lack of pleasure or interest in activities that used to bring joy
• Changes in appetite
• Reduced ability to think or concentrate
• Reoccurring thoughts of death, a suicide plan or suicidal ideation

Manic or hypomanic episodes present with signs such as …

• Reduced need for sleep
• Talkativeness
• Racing thoughts
• Distractibility
• Increase in pleasurable activities
• Lack of appetite
• Increased self-esteem
• Disruption to daily functioning, particularly in maniac episodes

What are the Causes of Bipolar Disorder?

The cause of bipolar disorder is unknown. (7)(19) However, most doctors will tell you that the cause of bipolar disorder is largely genetic. (7) While there does seem to be a strong familial link, what I have come to believe as a naturopathic doctor is that while genetics can make a person predisposed to a mental illness, lifestyle and environmental influences can  have an epigenetic effect as well. 

 Lifestyle aspects that can affect bipolar include… 

• Highly stressful situations 
  • Death of a loved one 
  • Abusive situations
  • Physical illness 
• Disrupted sleeping patterns 
• Alcohol and substance abuse 
• Trauma ( abuse, adoption)  

What is the treatment for bipolar disorder?

The treatment of bipolar disorder focuses on stabilizing a person’s mood. The best treatment for bipolar disorder is to approach it from many different angles. Treatment needs to include addressing sleep, stress, diet and exercise.  To really heal from bipolar disorder you must also take a deep look into your thoughts, emotions, behaviours, reactions, the role of the environment, past trauma, spirituality and love and compassion for yourself.

One of the first steps in managing bipolar disorder is understanding that there is a need to use food and nutraceuticals to provide the brain with the ability to make the neurochemicals it needs to heal the cells and prevent damage.  In some cases, bipolar disorder treatment options may also include the use of mood-stabilizing medications.  

Learning how to manage bipolar disorder is hard work – it takes diligence and a commitment to your health. There will be good days and there will be bad days. There are no quick fixes but you would be amazed at what a little step each day can do for you.

Top 5 Supplements for Bipolar Disorder

Omega 3

Omega 3 polyunsaturated fatty acids (PUFAs) are an important part of treatment in many different mental illnesses. Omega 3’s  help repair cells and reduce inflammation in the body and brain which may be beneficial in bipolar disorder. (2)(20)(22)  In bipolar disorder, omega 3’s provide most benefit during depressive episodes. A systematic review looking at omega 3 use in bipolar disorder showed that omega 3’s reduce the severity of depressive episodes. (20) However, omega 3’s did not have an effect on the symptoms during the manic episodes.  (20) There are two types of long chain omega 3’s, EPA (eicosapentaenoic acid) and DHA (docosahexaenoic acid). For mental health, a higher ratio of EPA:DHA is more beneficial than a lower dose. (20)  The best outcomes appear when supplementation occurs for approximately 3 months, is taken with other mood stabilizing medications and when the ratio of EPA: DHA is either 2:1 or 3:1. (2)(20)

Magnesium 

Magnesium comes in various forms and is important in supporting mental health. Serotonin, our happy neurotransmitter, is made from an essential amino acid called tryptophan. In order for our bodies to convert tryptophan to serotonin, there needs to be adequate sources of magnesium.(22) A study found that a lot of people with mental illness were magnesium deficient, and therefore it becomes a very important mineral to supplement (8) . There are several studies of magnesium used in bipolar disorder. Magnesium has been particularly studied in manic episodes. In a study by Chouinard et al., participants took 40 mg of magnesium aspartate hydrochloride per day there was a significant decrease in symptoms of mania. (10)

Magnesium oxide and magnesium sulfate also have a significant impact on manic episodes when used in conjunction with prescription medications. (13)(14) There are many different forms of magnesium with slightly different actions, choosing one that makes most sense for you and your health concerns can be tricky and requires the advice of a licensed practitioner.

Tryptophan

As discussed earlier, serotonin comes from the essential amino acid tryptophan which is found in certain food sources such as turkey, tuna, salmon (wild), cashews, halibut, shrimp, oatmeal flakes, pork, avocado, cottage cheese, wheat germ, eggs, collards, spinach, raisins, yogurt, chicken, and sweet potato. (23). Having a tryptophan rich diet can reduce symptoms of bipolar disorder, particularly mania. Two different studies have shown that supplementing with tryptophan can help reduce symptoms of mania. (1) (11) Products for supplementing tryptophan come in 2 forms: tryptophan or 5-hydroxytryptophan (5-HTP) . There are some interactions and side effects with these products so it is best to talk with a healthcare provider before starting treatment.

Probiotics 

One of the underlying causes of mental illness can be inflammation. There is a strong link between what happens in the gut and what is going on in the brain, this is called the gut-brain axis. One of the best ways to ensure that this axis is healthy and strong is by ensuring the gut has an adequate balance of beneficial bacteria. A study examining the effect of people who had recently been hospitalized with mania found that taking a probiotic containing  Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp. lactis BB-12 everyday reduced the risk of rehospitalization by 74%.(12)  If a person was to be re-hospitalized their stay was 5 days shorter than the average person with bipolar disorder. (12) Probiotic supplementation is one of the natural remedies for bipolar disorder.

N-Acetylcysteine

N-acetylcysteine (NAC) is another amino acid. It has strong anti-oxidant properties and can reduce inflammation. N-acetylcysteine may be effective in treating bipolar disorder. When participants in Berks ‘s study were given 1 gram of NAC twice per day, there was a significant improvement in depression scores. (3)(4) However, there does not seem to be an effect for helping to manage mania symptoms. (3) (16). While there is still a lot of research needed in this area, NAC seems to work best when used for longer periods of times and used in conjunction with other nutraceuticals such as L-acetylcarnitine, coenzyme Q10, alpha lipoic acid and magnesium. (2) (5)

The Bottom Line

Recovering from mental illness, and in particular bipolar disorder, is possible with a committed approach to one’s health. The most effective treatments are ones that address physical, mental, emotional and spiritual aspects. As someone who has been there, I know that you can get better. The key is to start building the foundational physical pillars of health by emphasizing diet, sleep, exercise and stress management to help ensure hormone and neurotransmitter balance. Taking a step, however small, towards better mental health is always better than doing nothing at all. If you need help or support, reach out to a healthcare profession, friend or family.

References

1. Applebaum, J., Bersudsky, Y., & Klein, E. (2007). Rapid tryptophan depletion as a treatment for acute mania: A double-blind, pilot-controlled study. Bipolar Disorders, 9(8), 884–887. https://doi.org/10.1111/j.1399-5618.2007.00466.x
2. Ashton, M. M., Kavanagh, B. E., Marx, W., Berk, M., Sarris, J., Ng, C. H., Hopwood, M., Williams, L. J., & Dean, O. M. (2020). A Systematic Review of Nutraceuticals for the Treatment of Bipolar Disorder: Une revue systématique des nutraceutiques pour le traitement du trouble bipolaire. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 706743720961734. https://doi.org/10.1177/0706743720961734
3. Berk, M., Copolov, D. L., Dean, O., Lu, K., Jeavons, S., Schapkaitz, I., Anderson-Hunt, M., & Bush, A. I. (2008). N-acetyl cysteine for depressive symptoms in bipolar disorder—A double-blind randomized placebo-controlled trial. Biological Psychiatry, 64(6), 468–475. https://doi.org/10.1016/j.biopsych.2008.04.022.  
4. Berk, M., Dean, O., Cotton, S. M., Gama, C. S., Kapczinski, F., Fernandes, B. S., Kohlmann, K., Jeavons, S., Hewitt, K., Allwang, C., Cobb, H., Bush, A. I., Schapkaitz, I., Dodd, S., & Malhi, G. S. (2011). The efficacy of N-acetylcysteine as an adjunctive treatment in bipolar depression: An open label trial. Journal of Affective Disorders, 135(1–3), 389–394. https://doi.org/10.1016/j.jad.2011.06.005.
5. Berk, M., Turner, A., Malhi, G. S., Ng, C. H., Cotton, S. M., Dodd, S., Samuni, Y., Tanious, M., McAulay, C., Dowling, N., Sarris, J., Owen, L., Waterdrinker, A., Smith, D., & Dean, O. M. (2019). A randomised controlled trial of a mitochondrial therapeutic target for bipolar depression: Mitochondrial agents, N-acetylcysteine, and placebo. BMC Medicine, 17(1), 18. https://doi.org/10.1186/s12916-019-1257-1
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7. Bipolar disorder—Causes. (2018, October 3). Nhs.Uk. https://www.nhs.uk/conditions/bipolar-disorder/causes/
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9. Botturi, A., Ciappolino, V., Delvecchio, G., Boscutti, A., Viscardi, B., & Brambilla, P. (2020b). The Role and the Effect of Magnesium in Mental Disorders: A Systematic Review. Nutrients, 12(6). https://doi.org/10.3390/nu12061661
10. Chouinard, G., Beauclair, L., Geiser, R., & Etienne, P. (1990). A pilot study of magnesium aspartate hydrochloride (Magnesiocard) as a mood stabilizer for rapid cycling bipolar affective disorder patients. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 14(2), 171–180. https://doi.org/10.1016/0278-5846(90)90099-3
11. Chouinard, G., Young, S. N., & Annable, L. (1985). A controlled clinical trial of l-tryptophan in acute mania. Biological Psychiatry, 20(5), 546–557. https://doi.org/10.1016/0006-3223(85)90026-5
12. Dickerson, F., Adamos, M., Katsafanas, E., Khushalani, S., Origoni, A., Savage, C., Schweinfurth, L., Stallings, C., Sweeney, K., Goga, J., & Yolken, R. H. (2018). Adjunctive probiotic microorganisms to prevent rehospitalization in patients with acute mania: A randomized controlled trial. Bipolar Disorders, 20(7), 614–621. https://doi.org/10.1111/bdi.12652
13. Giannini, A. J., Nakoneczie, A. M., Melemis, S. M., Ventresco, J., & Condon, M. (2000). Magnesium oxide augmentation of verapamil maintenance therapy in mania. Psychiatry Research, 93(1), 83–87. https://doi.org/10.1016/S0165-1781(99)00116-X
14. Heiden, A., Frey, R., Presslich, O., Blasbichler, T., Smetana, R., & Kasper, S. (1999). Treatment of severe mania with intravenous magnesium sulphate as a supplementary therapy. Psychiatry Research, 89(3), 239–246. https://doi.org/10.1016/s0165-1781(99)00107-9
15. Integrative Treatment of Bipolar Disorder: A Review of the Evidence and Recommendations. (n.d.). Psychiatric Times. Retrieved February 1, 2021, from https://www.psychiatrictimes.com/view/integrative-treatment-bipolar-disorder-review-evidence-and-recommendations
16. Magalhães, P. V. da S., Dean, O. M., Bush, A. I., Copolov, D. L., Malhi, G. S., Kohlmann, K., Jeavons, S., Schapkaitz, I., Anderson-Hunt, M., & Berk, M. (2013). A preliminary investigation on the efficacy of N-acetyl cysteine for mania or hypomania. The Australian and New Zealand Journal of Psychiatry, 47(6), 564–568. https://doi.org/10.1177/0004867413481631
17. McDonald, K. C., Bulloch, A. G. M., Duffy, A., Bresee, L., Williams, J. V. A., Lavorato, D. H., & Patten, S. B. (2015). Prevalence of Bipolar I and II Disorder in Canada. Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie, 60(3), 151–156.
18. NIMH » Bipolar Disorder. (n.d.). Retrieved February 1, 2021, from https://www.nimh.nih.gov/health/publications/bipolar-disorder/index.shtml
19. Price, A. L., & School, E. V. M. (2012). Bipolar Disorders: A Review. Bipolar Disorders, 85(5), 11.
20. Sarris, J., Mischoulon, D., & Schweitzer, I. (2011). Adjunctive nutraceuticals with standard pharmacotherapies in bipolar disorder: A systematic review of clinical trials. Bipolar Disorders, 13(5–6), 454–465. https://doi.org/10.1111/j.1399-5618.2011.00945.x
21. Surveys Reveal Gap in Understanding of Bipolar Disorder | NAMI: National Alliance on Mental Illness. (n.d.). Retrieved February 1, 2021, from https://www.nami.org/Press-Media/Press-Releases/2005/Surveys-Reveal-Gap-in-Understanding-of-Bipolar-Dis
22. Sylvia, L. G., Peters, A. T., Deckersbach, T., & Nierenberg, A. A. (2013). Nutrient-based therapies for bipolar disorder: A systematic review. Psychotherapy and Psychosomatics, 82(1), 10–19. https://doi.org/10.1159/000341309
23. Daisy Whitbread. (n.d.). Top 10 Foods Highest in Tryptophan. Retrieved February 1, 2021, from https://www.myfooddata.com/articles/high-tryptophan-foods.php