Changing My Mind

by Margaret Trudeau

  Emotion focused therapy is often like composting life’s garbage with the goal of creating fertile soil for wisdom and meaning to grow. As for many patients grappling with mental illness, meditation and hypnosis played a valuable role in helping Margaret to navigate her emotions and to find meaning in her pain. In a state of deep relaxation, imagining Michel and honouring her grief allowed her to accept suggestions about reframing that grief.

  Her pain, after all, was a testament to her profound love for Michel and the depth of their connection, and honouring that pain became a way to honour Michel and the relationship they had. In time, this work yielded room for feelings of gratitude for their precious time together and opened space to honour his life by raising awareness and funds for avalanche prevention and relief. Pain transformed for the betterment of others: what higher purpose and meaning can there be?

  Painstakingly over the years, Margaret did similar work to grieve the death of Pierre, the breakup of her second marriage, and the impact of bipolar disorder on her life. She paid particular significance to honouring her shame and guilt over things done and not done, especially involving her children. Shame and guilt taught her not about being shameful or guilty but about love, being human and her wish that so many things could have been different. And it was out of these feelings that Margaret began to be different, as was suggested by the words of Mahatma Gandhi. “Be the change you want to see in the world,” he counselled.

  Psychiatry and neuroscience have brought great progress and promise, yet there is still so much to learn about mental illness and so much work to be done. Not everyone fully benefits from the treatments available today, and stigma and inadequate resources remain barriers for many people. The ability to achieve acceptance, stability and meaning cannot be reduced to simple answers or any one thing. No one medication or therapy helps everyone. Medication treatment is no doubt frequently central in the acute phase of illness, but over time other approaches tend to come into play and complement one another. These may include diet, exercise, addiction treatment, stress management, meditation, psychotherapy and family therapy, to name but a few. Spiritual pursuits also help many people.

  Margaret’s openness to all these aspects served her well, as did becoming proactively engaged and informed. Changing her mind changed not only her life for the better but the lives of her family and friends. The hope of this book is that others, too, will be changed. Changing My Mind reminds us all that where there is desperation there is hope, and where there is pain there is an opportunity for wisdom and growth. This book also reminds us that much work remains to be done: to end stigma and to expand mental health services, education and research. The challenge for us all is to change our minds about mental illness, to be the change the world requires. Thank you, Margaret, for your work, which is an inspiration to us all.

  Colin Cameron, MDCM, FRCPC

  Clinical Director

  Integrated Forensic Program–Secure Treatment Unit

  Royal Ottawa Health Care Group

  Brockville, ON

  THE IMPORTANCE OF

  MARGARET’S MESSAGE

  by Dr. Paul Grof

  The suffering that comes with depressions and manias has been afflicting people for millennia, but it is only during the past four decades that our knowledge about the brain and bipolar illness has expanded exponentially. There has been much to learn: the human brain is a very intricate organ with a large number of neurochemical, hormonal, metabolic, genetic, electrical and energetic processes running parallel to one another, both in health and in bipolar illness.

  What’s wrong? During the attacks of mania or depression neuroscientists have thus far studied extensively the neurochemical changes that take place, for example, in neurotransmitters to which Margaret has referred. However, the origin of mood dysregulation can also involve genetic factors, difficult experiences from childhood, psychological traumas such as a severe loss, or abuse of chemicals such as alcohol or street drugs.

  Although much evidence points to the brain as the main culprit, when a person becomes ill with depression or mania the whole body suffers. When someone becomes as markedly depressed as Margaret did on several occasions, not just the mind but the whole being transforms; eating habits change, nutrition suffers, the management of electrolytes in the body and hydration are altered and the person often starts looking older and run down.

  Important ingredients of effective help include correct diagnosis, effective treatment, acceptance of the predicament and a good support system.

  The “bipolar label.” To correctly identify the illness, the physician needs to gets to know the patient well. This knowledge includes, in particular, the individual manifestation of depressions and manias, any other psychiatric or medical symptoms, childhood development, the course of problems over time and family background. The more one understands the patient’s situation the more one can help. No small task in health care dominated by rush and waiting lists, this process is an essential one. Unfortunately, a correct diagnosis is too often established only after an unacceptable delay To be practically useful, a diagnosis has to consider several types of bipolar disorder. Each manifests with a different clinical profile and benefits from a different treatment strategy. The relevant aspects of the profile are the same as the elements of comprehensive diagnosis mentioned above, in particular the symptoms, clinical course and family history. Each type of bipolar illness can be identified by a careful, comprehensive assessment. These types appear to be widespread: I found the same patterns while examining several hundred patients in seven countries outside North America.

  Action. Effective treatment of bipolar disorder should include both the mind and the body, and mood regulation can be effectively influenced from several directions. The choice of a primary mood stabilizer carefully tailored to the patient’s clinical profile is essential; otherwise, the patient ends up on a large cocktail of drugs—polypharmacy. Each type of bipolar illness has its effective primary mood stabilizer and helpful ways of treating low moods. There is, for example, a characteristic clinical profile that responds best to lithium. Thus, for some patients lithium is the best solution, while others such as Margaret fare much better on neuroleptics (e.g., olanzapine, risperidone and quetiapine) or require lamotrigine.

  The desired response to psychotropic drugs depends also on the general medical health and metabolic situation of the patient. Otherwise the drugs may not work properly. Medication can be augmented with supplements such as hormones, vitamins, amino acids and omega-3 fatty acids. These additions are particularly crucial in situations such as Margaret’s, when the depression is severe and the metabolism in the body is compromised.

  Explanation. However helpful the chosen treatment could be, it will work only if the patient follows advice and adheres to it for the long run. Margaret gets this point across very well. Thus, individuals who suffer from bipolar illness should be offered a sufficient explanation of the roots of the illness and of the way the treatment may help. Understanding supports acceptance of the illness.

  The brain, like most complex systems, maintains its stability by markedly oscillating its levels of activity. One can see that in bipolar disorder these oscillations are not fine tuned and at times jump out of the person’s normal range. At that level of abnormal biological arousal, the mind cannot function normally and the patient starts experiencing abnormal moods and distorted thinking. Effective interventions help bring arousal back to normal range and keep it there. In a complex system, the desired change can be achieved from different directions and by several mechanisms.

  Having treated and researched bipolar disorders for several decades through observations and systematic studies, my colleagues and I have come to understand that, as with most complex systems, the human brain fortunately has an amazing ability to self-regulate, as long as the conditions are favourable. Under the right circumstances, patients in fact heal their own depression or mania. From this angle, my task is helping to protect the patient
against self-harm and to create conditions for the patient’s self-healing. Treatment must be tailored to the individual’s situation. Thus, in addition to the options already mentioned, self-healing can be achieved through physical exercise, alternative approaches and psychological support focused on reducing excessive stress, removing strangulated emotions and ensuring the patient’s understanding.

  The central legacy I have taken from Margaret’s book is that for healing bipolar illness it is very important that the patient recognize and accept the illness, seek help and follow the correct advice. Such a message is very timely and has prophetic value. The research of Dr. Anne Duffy and others (see, for example, The Canadian Journal of Psychiatry, August 2010 issue) suggests strongly that, for reasons that are still unclear, emerging generations suffer from the manifestations of bipolar illness earlier and more than their parents and grandparents did. Yet they struggle to accept their predicament and available treatments and urgently need to heed Margaret’s words.

  Paul Grof, MD, PhD, FRCP

  Mood Disorders Centre of Ottawa and

  Department of Psychiatry, University of Toronto

  PERINATAL PSYCHIATRIC

  MOOD DISORDERS

  by Dr. Shaila Misri

  In 1858, French physician Louis-Victor Marcé published Traité de la Folie des Femmes Enceintes, a treatise on psychiatric disorders during pregnancy and after delivery. More than 150 years later, doctors are still puzzled by the phenomenon of mental illness related to the perinatal period—which is a time of joy and happiness for most women. The unexpected onset of these conditions has a devastating effect on the mother, her newborn and the family.

  Postpartum psychiatric disorders can present as postpartum blues (up to 70 per cent), postpartum depression (about 12 per cent) or postpartum psychosis (1 to 2 in 1,000). The blues are transient, peak on day three or five and usually disappear without treatment. Postpartum depression is characterized by lack of interest in the baby, insomnia, appetite disturbance, low motivation, difficulty making decisions, crying spells, a feeling of being overwhelmed and, finally, lack of joy. Frequently, these symptoms are associated with moderate to severe anxiety, manifested as panic attacks, constant preoccupation with worry or obsessive compulsive behaviours. Unless these conditions are identified and treated, a mother can become paralyzed/dysfunctional and experience chronic relapsing symptoms that affect maternal–infant bonding. The possibility of suicide can never be ruled out in untreated depression.

  Postpartum psychosis has maximum morbidity and mortality associated with it and is now believed to be closely linked to, if not a variant of, bipolar disorder type I. Some 40 to 80 per cent of women who experience their first psychotic episode in the postpartum period will have subsequent episodes that are not linked to childbirth and will eventually meet the criteria for bipolar disorder. Approximately 50 per cent of women with a history of bipolar disease experience an exacerbation of the illness during pregnancy. Generally, pregnancy does not protect women from the occurrence of mental illness. Therefore, close monitoring of the course of the illness is necessary in each trimester of pregnancy. Postpartum psychosis has a sudden, dramatic onset with rapid escalation of symptoms that shock and disrupt the family. Hypomanic episodes are characterized by elevated mood, rapid speech, hyperactivity, hypersexuality, excessive spending, insomnia, impaired judgment, heightened irritability and labile mood. Hallucinations and/or delusions of harming the baby need immediate management as infanticide (2 to 4 per cent) is not an uncommon consequence. This is a medical emergency for which intervention is warranted, with hospitalization.

  Ideally, treatment of perinatal mental illness requires a comprehensive biopsychosocial approach. Biological management includes medications and electroconvulsive therapy (ECT); psychological treatment involves psychotherapies; social interventions consist of family support, self-care and healthy lifestyle choices such as proper diet and regular exercise.

  Pharmacotherapy during pregnancy and breastfeeding is a dilemma for the patient and the treating physician alike due to the contradictory nature of ongoing research about its safety. Nonetheless, exposure to the untreated disease itself has been demonstrated to have detrimental effects on the mother, the developing fetus and the newborn, and these can persist into the latter’s adulthood. Therefore, the risk of exposure to medications has to be carefully weighed against the effects of the illness. Not treating these suffering women is not an option!

  For postpartum blues, simple reassurance and support is usually enough to alleviate symptoms. Mild postpartum depression responds well to psychotherapy, specifically cognitive behaviour therapy. However, for moderate to severe depressive/anxiety illness, both pharmacotherapy and psychotherapy are recommended. Other than paroxetine, antidepressants appear to be safe in pregnancy. Mothers can continue to nurse while on antidepressants, as only a very small amount of the medication is secreted through the breast milk. These medications do not affect the intelligence, cognition or development of the children negatively, in either the short or the long term.

  Depending on the presenting symptoms, atypical antipsychotics, mood stabilizers, hypnotics or benzodiazepines are recommended for extreme agitation in those with acute hypomania/psychosis. Conventional antipsychotics such as haloperidol transfer across the placenta at a higher rate than some of the newer, atypical antipsychotics such as quetiapine. Nursing while taking these compounds should be decided on a case-by-case basis. The severity of the illness drives the risk–benefit analysis of medication treatment in pregnant or nursing mothers.

  Depression that follows a hypomanic episode should be treated with an antidepressant medication along with a mood stabilizer. Given that the recurrence rate of this disease after the baby is born is about 90 per cent, administration of prophylactic mood stabilizers may prevent relapse in the majority of the women. However, some mood stabilizers, such as valproic acid and carbamazepine, are teratogens and carry the risk of major anomalies in the newborn—about 10 and 5 per cent, respectively. Therefore it is best to plan a pregnancy to avoid exposure in the first trimester if possible. In case conception occurs while a woman is on these drugs, triple screening and amniocentesis is recommended. The American Academy of Pediatrics states that nursing is safe on valproic acid and carbamazepine. Although lithium is considered to be relatively safe in pregnancy, a cardiac ultrasound is recommended at sixteen to twenty weeks to check for Ebstein’s anomaly (a heart defect that occurs in one in a thousand exposed fetuses). Lamotrigine use in pregnancy does not appear to be associated with cleft lip and cleft palette in the fetus, according to current research. Lamotrigine and lithium are secreted into breast milk at a higher rate than other psychotropic medications, and the decision to nurse while taking them should only be made after an in-depth discussion with a treating physician.

  Despite the mental health issues that plague women in the perinatal period, health care providers are reluctant to diagnose and institute treatment in this population. These biases cause further barriers and stigmatize women, making it challenging for them to seek help; they feel marginalized and isolated. In writing about her haunting struggle with bipolar disorder, Margaret Trudeau has spread a message of bravery, determination and resolve to fight the perils of mental illness.

  Shaila Misri, MD, FRCPC

  Clinical Professor

  Psychiatry and OB/GYN

  University of British Columbia

  Medical Director

  Reproductive Mental Health Program

  St. Paul’s Hospital and BC Women’s Hospital

  PHOTO CREDITS

  All photos are provided courtesy of the author, except for the following:

  5. The Canadian Press

  7. Margaret Trudeau Collection; Photo: Fred Schiffer

  8. (c) Bettmann/CORBIS

  9. (c) Bettmann/CORBIS

  10. Brian Kent/Vancouver Sun

  11. The Canadian Press/Peter Bregg

  12. John Evans, Ottawa

  14
. Peter Bregg

  15. Margaret Trudeau Collection; Photo: Cordon Counsell

  19. The Canadian Press/Peter Bregg

  20. Bregg Archives

  21. Peter Bregg

  22. Rod MacIvor/Ottawa

  28. Glenn Baglo/Vancouver Sun

  29. Glenn Baglo/Vancouver Sun

  30. John Evans, Ottawa

  32. The Canadian Press/Fred Chartrand

  33. The Canadian Press/UPI

  35. The Canadian Press

  36. Rod MacIvor/Ottawa

  37. AP/Wide World Photos

  38. Bregg Archives

  39. Rod MacIvor/Ottawa

  40. Bill Brennan/Ottawa Citizen. Reprinted by permission.

  42. Rod MacIvor/Ottawa

  43. The Canadian Press/Felice Quinto

  44. (c) Bettmann/CORBIS

  46. (c) Bettmann/CORBIS; photo: Jerry Soloway

  51. Courtesy of Sherman Hines

  59. Photo by Boris SPREMO, C.M. (c)

  60. Photo by Boris SPREMO, C.M. (c)

  67. Photo by Boris SPREMO, C.M. (c)

  74. John Curtin and Paul Carvalho

  77. Peter Bregg

  78. Peter Bregg

  83. Randy Cole

  84. Rod MacIvor/Ottawa

  85. Calgary Herald–Dean Bicknell/The Canadian Press

  86. Bryan Adams

  87. The Canadian Press/Adrian Wyld

  88. Peter Bregg