Mood Monitoring in Bipolar Disorder – Have we done it correctly?

“To be evenminded is the greatest virtue” – Heraclitus

This quote hit particularly strong as it came from Heraclitus, a.k.a “the weeping philosopher”, as later scholars speculate the great mind could be long troubled by depression. To be evenminded, calm, undisturbed is the virtue Heraclitus sought after all his lifetime. People now refer to Heraclitus’ school of thoughts as “early-stoicism”, which some regarded as the philosophical basis for modern cognitive (behavioural) therapy (CBT). CBT is built around the idea of dissecting and challenging the thoughts, belief and behaviours that maintained one’s mental illness. To develop insight (read my MSc Dissertation on the topic), or the awareness of the mental illness, is said to be the first step that is necessary for CBT. Lack of insight – at least the illness recognition components of insight – could not blissful within this framework.

Mood Monitoring is widely used in treatment and self management of mood disorders.
Mood Monitoring is widely used in treatment and self management of mood disorders.

For mood disorders such as bipolar disorders, this idea of mood monitoring is widely used in treatment and self-management. This follows the stream of thought that better awareness of one’s mood changes would prepare one better to account for potential relapses. Jasper Palmier-Claus and colleagues (2021) has recently published an article evaluating whether mood monitoring is Always helpful in people with a diagnosis of bipolar disorder.

The authors cited qualitative evidence that mood monitoring could induce counter-effective pre-occupying thoughts, such that people could not tell whether their day-to-day moods are an early sign of an extreme mood state, or are merely a “normal” fluctuation in mood. Authors also cited the MONARCA single-blind Randomised-control trial that mood-monitoring alone does not on itself reduce depressive or manic symptoms. It seems that mood monitoring alone might not deliver the proposed clinical benefits, and are certainly not without risks. As I quote from Jasper’s twitter thread,

We suggest that an individualised, collaborative and normalising approach to mood monitoring may be optimal and reduce potential limitations.

@JPalmierClaus on Twitter

Authors have identified several knowledge gaps in mood monitoring, I am summarising and adding my 5 cents on the topic.

a) Awareness itself isn’t enough, what we do with the new-found awareness is key.

Authors suggested clinicians to develop pre-agreed coping strategies to increase perceived control over foreseeable problems. This means that mood monitoring shouldn’t be used as a plug-and-play band aid for every one, but a tailored intervention plan that is closely followed-up by trained clinicians.

b) We do not know what is within the normal mood variations We have to understand how mood variation patterns and cycles differ in remission, recurrence and relapse, and how it differs inter and intra-individually.

Both of the trials cited above measured changes in mood once a day. In the same cited qualitative study, a common feedback described the limited flexibility of a daily mood measurement to represent the context and variability of mood within a day. But this could go on further, what really is the meaningful time lapse between each measurement? Or is there a meaningful time lapse for each person? Or, whether it depends on other ancillary factors such as – context?

Studies of bipolar disorder using Ecological Momentary Assessment (EMA) methods have explored a lot of different time lapses, from daily, twice-daily, to three times a day. Time-gap between each assessment varied across individuals within study, and between studies. It wasn’t always clear in the papers what the rationale, and the theory behind such decisions. A rational approach to the question would be first establishing a representative norm. The ERC-supported WARN-D project (led by Eiko Fried) is set to investigate what a “normal” biopsychosocial mood systems might look like. I am excited to hear more from the project in near future!

c) The fault may lie in the tools of the trades

Set aside the theoretical complexities, another factor that might hamper people from benefiting from the mood monitoring experience could be the poorly designed digital apps. From a recent review of bipolar disorder related apps, of the 98 included apps, 12 were rated as capable of causing harm to a user, by offering potentially triggering information that goes against the treatment guidelines. Only 1 app had supporting feasibility and efficacy studies, but no people with bipolar disorder was involved in those studies. These publicly accessible yet unregulated apps might undermine the efficacy of properly managed and delivered mood monitoring interventions. With the vast boom of self-help and mental health apps on the market in the last couple years, I feel there is an imminent need for relevant regulating bodies to rigorously assess the boundaries of these self-help apps.

“The only thing constant in life is change.” – Heraclitus

Change is only thing that remains to be always, Heraclitus surely helped us avoid all ceiling effects in psychometric surveys! May He enjoy his fair share of even-mindedness in peace.

Loneliness & Suicide in the Pandemic: reconstruct what it means to be human

“We lived through the pandemic.” For some, this would become a badge of honour, how we individually and collectively guarded each another amidst of adversity. For some, this would signify the loss of precious ones, a time to weep and mourn. Albert Camus <The Plague> has tainted how the absurdness in people’s hearts, the degradation of humanity spread along with deadly illness. Gabriel García Márquez on the other hand sees <Love in the time of Cholera>, that love transcends amongst fear of death, and the comfort of solitude. What does the pandemic mean to you? What would the pandemic mean to you?

The first sign of humanity begins with a healed femur bone. We – humanity as a whole – would have certainly progressed a lot from the past, haven’t we? We long possessed the strongest weapon against the virus, and no, you know I am not talking about the vaccines. I am talking about the shared values that marked the progression of humanity (No, not the small steps on the moon). COVID-19 feels much closer to Camus than to Márquez.

I recently saw an interview of the (in)famous Prof. Slavoj Žižek. The bits and bops about international relationships have proven to be too puzzling for my feeble mind, but something did caught my attention.

“We are more bodily isolated, but socially connected. In a situation of social distancing, we are more socialised, open to society, more than ever. What I miss the most is being authentically alone. We are more connected than ever! The most annoying part of COVID is not being able to be alone.”

Slavoj Žižek

I guess when you are Slavoj Žižek, you’re bounded to be crowded by people seeking advice or wanting to share your wisdom at all times. Complaining to be not alone in a pandemic- this must be an ubiquitous experience for Žižek. As UK has re-entered the lockdown for the second time, one literally can not be much more isolated than it is now. But since it is from Žižek, I had to deliberate, are people really more lonely in the pandemic?

Are people really more lonely in the pandemic?
Are people really more lonely in the pandemic?

Loneliness is a major public health concern, associated with a heightened risk of mental and physical illness, cognitive decline, suicidal behaviour and all-cause mortality (Leigh-Hunt, et al. 2017). Loneliness is also associated with severity of depression (Lee et al., 2020 – Shout out to Lee Siu Long, Early Career Psychologist from Hong Kong, first first-author publication on Lancet Psychiatry!). As social distancing measures were widely implemented to put a halt to the raging COVID-19, this led to many worrying and scaremongering claims in the UK, such as “lockdown will trigger a spike in suicide”, some even from “experts” in the field (see open letter from 42 mental health practitioners). These claims often argue that (1) increased loneliness would be an inevitable result of lockdown, and consequently (2) lead to increase number of suicides. I’d like to dissect these claims, and see whether they are supported by evidence.

It is key to separate the constructs of social isolation from loneliness, but differentiate their impact on mental wellbeing could be challenging. Social isolation can simply mean living alone, while loneliness usually is described as the subjective feeling of feeling alone, regardless of the extent of social contact. Although these 2 constructs are correlated, logically, one could be living a life of solitude and never feel lonely (rang me up if you’ve met someone like this).

Researchers in the UK compared the level of loneliness in the UCL COVID-19 Social Study (N = 60,341, March 2020) and the UK Household longitudinal study (UKHLS) (N = 31,064, 2017-2019). They also investigated whether the risk factors of feeling lonely changed in the pandemic. Loneliness levels were higher in the UCL COVID-19 Social Study than in UKHLS, with 32.5% of people feeling lonely sometimes (28.6% in UKHLS) and 18.3% often (8.5% in UKHLS). Around 40% scored 6 or above in the UCLA-3 Loneliness Scale (Range from 3-9 = most lonely)* in UCL COVID-19 Social Study (around 25% in UKHLS).

Despite being more lonely during COVID-19, the risk factors for feeling more lonely are very similar in the 2 cohorts, some significant ones include: (1) aged 18–30 (vs aged 60+) (2) living alone (social isolation) (3) Having a low household income (4) being unemployed. Risk of feeling more lonely as a student was much higher during the pandemic. Other known risk factors including non-white ethnicity, being a woman, having low educational attainment and living in urban areas – these were relatively small risk factors.

The first part of the argument stands – people appear to be more lonely during the pandemic (we need more Žižek?). From existing literature, relationship between loneliness and suicide is not crystal clear. There was evidence that the relationship between self-harm and loneliness was strongest when the self-harm had no suicidal intent or was not considered a suicide attempt. The pathway in which loneliness lead to suicide is often through depression. Majority of the studies were conducted in cultures where individualism dominates (Europe). It appears that the second part of the argument demonstrate some face validity. At least, I feel Émile Durkheim would agree!

(This paragraph is heavily inspired by Prof Anthony David – Into the Abyss – 10/10 read!) Durkheim published “On Suicide” in 1897, where he shared his observations on social factors on rates of suicide. One of his key observations was that Protestant Christians has a consistently higher suicide rate than Roman Catholics. Durkheim did not think it was the difference in rituals or doctrines that had led to this difference. He argued that “intense collective life” of Catholics inhibited suicide. This sense of collectivism is vital –

“… not because we need to sustain the illusion of some impossible immortality; it is because it is implicit in our moral being and cannot be lost… [If lost] the slightest cause for depression can give rise to desperate acts”

Émile Durkheim – On Suicide

This need of being part of a group, to live a collective life appears to be an anecdote to why immigrants are at elevated risk of feeling lonely and dying by suicide. There are many reasons why immigrants failed to assimilate into local culture: racism, trauma, and becoming more and more relevant, nationalism etc… I’d love to give this another take.

Catholicism vs Protestantism?
Catholicism vs Protestantism?

We all belong to groups – we all share identities with others. We are members of the family, workplace, country. Some groups are mutually exclusive: some countries do not allow their citizens to own dual-nationalities; some could care less as long as you pay taxes. Some of these groups are inherited, some are results of your choice. Regardless, it is not difficult to differentiate group membership from belongingness. You could be a member of the local gym (where you might have yet to visit twice), but belong to the charity you volunteer down the road. Membership solely denotes status, belongingness is tied to your values, emotions and your emotionally modified experiences (or simply, memories). In my opinion, every group must share at least 1 of the 2 key elements: (1) values (2) mission. A study group share a clear mission, to complete the group project. A great study group shares also the values of scholarship and commitment. A marriage share the same mission, to support each another economically, to share a household, legal responsibility and social rapport. A great marriage shares also the values of fidelity and love. One group could achieve its mission rely on their members, but only those who share its values would belong.

Nationality is an interesting example. Benedict Anderson described nations as imaginary communities, and nationality as a means to gather #wethepeople (jks) to defy against hereditary monarchies. Yet we all seem to be happy to play along as members, or strongly relate to this imaginary construct that we “inherited” (Well I guess in some it could also be a choice – holding the ”green card“ is still a highly-valued asset or social status). Anderson’s theory offers a partial explanation of why nations arise – it’s mission. Ask any patriots you’ve met, I’d hardly imagine their love for their country is fuelled by their will against a monarchy (in some countries, the opposite might be more relevant…). It is the values that the patriots truly support (at least claims to support). In the Era of gods, wars between nations are figuratively fights between divine beings. Religions then were much more than moral teachings, but rules of law and order, and the core of the culture. National boundaries were then defined not by sticks and stones, but by their values. Segregation is a bottom-up phenomenon, not a top-down demand. Projecting our thoughts back to the notion of immigrants, these increased rates of suicides, loneliness and dissociation from society might stem from their non-adjustment to a different set of values. Mere physical membership would not translate to belongingness.

Nationality - an imaginary construct.
Nationality – an imaginary construct.

Back to the topic, what we’ve discussed seem to support the claim that lockdown measures are detrimental to public mental health, and suicide rates should rise in the pandemic. Early studies predicted suicide rates to increase from 1% to 145% in the pandemic, using different assumptions. There is no ways to verify or disprove these claims, as there is no real-time suicide surveillance systems. It is a technical and legal challenge to determine whether a death is classified as a suicide (see this post for more). Finally, a long awaited report by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) (UK) was published earlier this week, and a publication on the British Medical Journal describing suicide trends in several high-income countries. Paper suggested that suicide rates did not rise in Massachusetts, USA; Victoria, Australia; England, and fall in Japan and Norway in the early months of the pandemic. The claim that suicide would spike in lockdown is not supported by evidence.

Suicide rates did not increase in the pandemic. But this does not imply people do not need support on their mental wellbeing. People are feeling more lonely, and experiencing increasing number of mental health difficulties. Non-evidence based claims has achieved nothing but division, elicit our primal emotions of fear, and corrode our decision-making process. Ill-advised approaches, such as “herd immunity”, is killing off our comrades with the broken femur bones. Have we travelled backwards as a civilisation? Or progressively speaking, have we progressed beyond what humans should mean?

What has gone wrong in the argument? We’ve spend a big chunk of this article alluding the rise in suicide rates, but it did not convert. The answer has to be Slavoj Žižek. In the same interview. Žižek encourages his fellow philosophers that during COVID-19 is no better time to study philosophy. There is no better time to reflect and develop what it truly means to be a human in this trouble-found times.

We all belong to groups, we all support different values: Biden vs Trump, Science-first vs COVID-Deniers, no matter which group you are a member of or belong to, we all share a largest common factor – we are humans. We are, indeed. In the pandemic, we experienced collectively the brittleness of human lives. In this sense, along with Žižek, we were not alone. We were forced to accept “the new norm”. We had to resist our nature as social and communal animals. We are more exposed than ever from our concrete buildings, professional certificates and luxury, that we are – humans. Perhaps this sense of collective living/suffering protected us from the suicide spikes. Are we merely a member of the human class – our mission being sustaining the status quo? Or do we belong to this group, by uplifting our values in the ways we treat each another? This question warrants a rethink of the values of being human, and whether we’d share these values.

“We lived through the pandemic.” We can still right our wrongs. We can still win this war. We have to find our values, and uphold these values in every way forward. Because we all are rightful humans.

With the love of God.

 We have to find our values, and uphold these values in every way forward.
We have to find our values, and uphold these values in every way forward.

*UCLA-3 is one of the widely evaluated loneliness measure, consist of the 3 following questions:

(1) how often do you feel a lack of companionship? (Never – 1, Some of the times – 2, Often – 3) (2) how often do you feel isolated from others? (3) how often do you feel left out?

TL:DR; – People have been claiming that lockdown will lead to a “suicide epidemic” due to loneliness, thus refuted against the lockdown decisions. This narrative in my opinion led to regrettable public health policy and decisions. Lives were lost – not to suicide. Recent figures from Australia, British Columbia, US, UK & Norway compares suicide rates prior to and during lockdown. NONE of the figures show that suicide rates increased compared to pre-COVID numbers. This does not imply people do not need support on their mental wellbeing. People are feeling more lonely, and experiencing increasing number of mental health difficulties. These claims of increased suicides were busted. These non-evidence based claims has achieved nothing but division, elicit our primal emotions of fear, and corrode our decision-making in protecting lives. We dropped our comrades with broken femur bones in our “herd immunity” approaches – evident in the US & Sweden. The way forward has to begin from reconstructing what it means to be human – what are the values that group us together, and we should uphold these values every way forward.