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For A Copy of Dr. Federman's article "Treatment of Bipolar Disorder in the University Student Population" currently in press - Journal of College Student Psychotherapy, click here. Anticipated publication - spring, 2011

The following are copies of some bipolar-related e-mails sent by Dr. Federman to the national listserv of the Association of University and College Counseling Center Directors:

Colleagues —

The lifelong brain disease model is problematic, especially with those initially diagnosed in the mild to moderate range of Bipolar II.

One of the more comprehensive bipolar texts to date is the 2007 two-volume work titled "Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression" by Goodwin and Jamison. In their review of multiple longitudinal studies pertaining to long-term outcome of the disorder, they concluded - "long-term data suggest that up to one third of bipolar patients achieve complete remission (p.150)."

Now how do one third of people with a lifelong brain disease recover?? I think the answer lies in the fact that bipolar isn't a specific disease that you have or don't have as is the case with pathology that can be verified through lab work, biopsies, CAT scans etc.

Instead, we see the interaction of genetic vulnerability, personality and environmental influences yielding intermittent/recurrent mood instability and accompanying cognitive changes, particularly in the absence of comorbid Axis I or II disorders that would generate similar symptoms. The neurobiological basis also appears to be more strongly confirmed when these shifts in mood and cognition occur in the absence of other clearly identifiable influences. In other words, for the bipolar individual mood, sleep, energy and speed of thought can all shift upwards or downwards for no apparent reason.

But what we also see is that when the bipolar individual becomes more successful in establishing healthy sleep hygiene, effective stress management, recurrent and predictable daily patterns (structure), accurate self-monitoring and accompanying successful impulse control ... then mood and cognitive instability does indeed begin to smooth out.

If we take this out of the context of psychopathology and look at it in terms of development, aren't we talking about the psychological and neurobiological maturation of the early 20s? The pre-frontal cortex does continue its development into the mid-20s and with that we see improvements in planning, judgment, impulse control, etc., all of which are vitally important factors for the individual with bipolar disorder.

Typically, when the bipolar student experiences a more acute shift away from baseline, he or she isn't able to "self-correct" simply through willful intent. But when you take mild mood instability and combine that with maturation and effective lifestyle management, then I do think we see some people maturing out of their bipolar diagnosis. That's where the more hopeful message comes into play with our University students. Of course there are also those who grow out of their bipolar disorder because they weren't accurately diagnosed in the first place, but that's a whole different ball of wax.

Colleagues —

Many of you know that over the past couple years I've been immersed in bipolar-related treatment. No, I'm not bipolar; but I've recently co-authored a book on the subject and have found myself increasingly seeing most of the bipolar students who come through our service. I'm not drawn to the behavioral aspects of work, though they are central; but more to the process of assisting students to come to terms with an illness that requires enormous acceptance, relinquishing of adolescent grandiosity and shifts in identity. I know the territory well due to my own experience with physical disability. If you can affect those shifts, you've done 80% of what needs doing. My past few years work has been fascinating and I'd like to share some conclusions I've come to which have made a large difference in our work with bipolar students at UVA-CAPS.

First and foremost I want to challenge a notion that most of us operate under which is that bipolar students should be referred out because most require longer-term treatment. Before you get stirred up, I should qualify this and state that if you don't have reasonable psychiatric resources, then yes, an external referral makes sense. Psychiatric medication (mood stabilizers and low dose antipsychotics for assistance with sleep) really are the backbone of treatment for the bipolar student. That said, our recent AUCCCD survey shows us that 64% of campuses provide psychiatric services at an average of 25 hours/wk. I know that most of us don't have enough but some universities have put a fair amount of economic resources into the provision of psychiatric services.

Over the past several years I've regularly offered a bipolar student support group through CAPS. I've found it to be an important resource, but this past year some magic has really happened. We were fortunate to start the year with a group of six students, two of whom had been together in the group the previous year. The initial six also had two Bipolar I students who had been struggling with their disorder for many years - one was 26 and the other 29. Through their own experience they both have thoroughly bought into the importance of medication compliance and sobriety. They provide a degree of maturity and life experience that the other students respect. The group gelled rapidly and despite losing two members at semester break, we are now up to a membership of 10 when all are able to attend! I'm also co-leading the group with a fourth-year psychiatric resident. She's really fine and her presence allows us to make on-the-spot medication adjustments when a student is on the cusp of destabilization.

The psychiatrist I've co-authored with, Dr Andy Thomson, also happens to work with me at CAPS. In addition to the many hours spent collaborating together, we've formed a cohesive team when managing bipolar students. We know each other's practice patterns quite well. We've also found one key to the bipolar psychiatric piece is the capacity to respond rapidly to a bipolar student when he or she is needing a medication adjustment. Seeing someone four to six days after they've expressed the need for help is usually too long to wait for the bipolar student. Andy is comfortable having bipolar patient's call him on his cell and he is excellent about getting back to them quickly, even if it's 9 PM! Furthermore, once you get to know a student, then medication adjustments can be made over the phone without necessarily requiring an individual medication appointment.

The standard I've set in managing the group is that it, in conjunction with students' medication, becomes the primary treatment modality. If students are struggling with complex personality issues, or other co-morbid Axis I disorders, then some are referred out for longer-term individual therapy. Yet of the 10 group members, only two are currently in treatment in the private sector. The remainder find the group to be effective enough that it's sufficient. I am willing to see any of the group members on an individual basis if they're in crisis. Fortunately, being able to limit my clinical work to about 6 - 9 hrs/wk usually provides me enough schedule flexibility to be able to fit a student in within 24 hours when necessary.

So what's this magic I'm referring to? First, it's the robust size of the group. Most of the students find they are easily understood by the other group members - an experience they don't find in their day-to-day interactions with peers, roommates, etc. My guesstimate is that at the University level we have a prevalence of around .8 to 1% bipolar students within the broader student population, compared to national prevalence rates of about 2% to 2.5%. Thus a sense of "being different" and misunderstood is quite prevalent for these students. Their connection to the other group members promotes considerable self-disclosure which further increases the group's cohesion. It also serves to lessen their sense of aloneness and isolation. But beyond the cohesion and belonging which is a byproduct of many successful groups, I find the group's commitment to stability and positive self-esteem is really the magical ingredient.

At any point we may have several students either depressed or hypomanic, but rarely is a whole group destabilized (frightening thought!). And those who happen to be experiencing a period of sustained stability are effective in reminding the others that their instability is transient. Additionally, the group's own recognition of the importance of healthy sleep, medication compliance and refraining from psychoactive substance use becomes a far more potent message than anything I can conjure up. When heard from the group it comes across as truth; not just some line a mental health professional has been trained to say! In other words the successes of some of the group members become important evidence that stability is possible. Furthermore, over time students gradually begin to establish acceptance of the fact that their mood is and will continue to be variable, even with good treatment, which allows them to go through their ups or downs (or both) knowing that the picture will continue to evolve.

I come back now to my earlier assertion about keeping the students in-house. The potent combination of an effective support group, effective therapist-psychiatrist collaboration and rapid response to students makes for a set of positive outcomes that I've not quite seen before. In other words, I find we can do better in promoting stability in these students then we could if they were all seeing separate providers somewhere in the community. And when my clinicians are not repeatedly involved in managing the aftermath of a manic psychosis requiring hospitalization, then the benefit of the resources we do provide easily outweighs the alternatives.

Take care -