Gluten, Celiac Disease and Bipolar Disorder

Here’s the latest from Practicing Mental Illness:

People with celiac disease are 17 times more likely to have bipolar disorder than those without.

I had gut problems for decades.  I thought it was normal to feel like crap after I ate.  Then I was diagnosed with celiac disease and my life completely changed. I feel great since eliminating gluten from my diet.  I have more energy, I’m not sick all the time and I’m less moody.  The moody part really intrigued me, so I looked into how celiac and bipolar relate.

It turns out there is a strong association between the two diseases.  Also, comorbidity with a mood disorder is a key indicator in measuring quality of life in individuals with celiac disease. 1 -2% of the population has celiac disease.  In this group 4.3% are diagnosed with bipolar disorder.  In the research cited, in the non-celiac control group only .4% had bipolar.

There’s growing evidence that autoimmune disorders and bipolar disorder are closely associated.  Celiac disease increases immune activation, which is hypothesized to act as an important factor in the onset of bipolar disorder. The metabolic explanation is that malabsorption of tryptophan leads to a decreased central serotonin synthesis.  Also, cytokines common in celiac may exert an effect on the brain circuits related to mood regulation.

The researchers won’t go as far as to say that celiac disease causes bipolar disorder, but they do surmise that in people with a vulnerability to bipolar, there is a risk that celiac triggers the mood disorder.

The study also noted the profound impact the two disease’s co-occurrence can have on quality of life (QOL).

“The results show, surprisingly, that in the absence of psychiatric illness people with celiac disease do not have an impaired QOL compared to the people who do not suffer from celiac disease. But when measuring the burden suffered by people with celiac disease comorbid with mood disorders, the "dual diagnosis"… lowers the quality of life in the same manner as serious chronic diseases.” In fact, the study suggests that the negative impact on QOL in people with celiac disease and bipolar disorder is second only to that of people with bipolar and MS.

I know my life has vastly improved since my diagnosis of celiac disease.  Small inconveniences such as difficulties in restaurants pale in comparison to the violent mood swings and intestinal distress I suffered before and have since largely disappeared now that I’ve changed my diet.

Please understand, though, that my bipolar disorder is still medically treated as it was before I knew I had celiac disease.  Removing gluten from my diet has not led to the removal of my psych meds.

My bipolar disorder is not cured.  I just feel a lot better.

In concluding their study, the researchers suggest it is advisable to perform an adequate screening for celiac disease on all the people with bipolar disorder that show some key symptoms or have a family history of celiac disease.

Gluten in Generic Medications

What’s in the medicine you take?  There’s a lot more in that pill than the active ingredient.

Pills, tablets and capsules, contain excipients that include the active ingredient and several other ingredients that help bind the drug together and aid with metabolism and absorption so that the active ingredient is properly delivered to the body.

One of the most common excipients is starch, and sometimes that starch is derived from wheat.  While not common, the appearance of wheat, gluten, in a drug poses a real problem for people with celiac disease or gluten intolerance.

Celiac and bipolar disorder may be co-morbid, and gluten may play a role in manic episodes, so people with bipolar disorder should be vigilant about what excipients appear in their medicine.

It’s very rare for a brand name medicine to contain gluten.  However, generic drugs often don’t contain the same excipients as the brand name drugs they copy.  Only the active ingredient is required to be the same.

And while labels for supplements must disclose any allergens, labels for OTC and prescription medicines are not required to do so.  Legislation to correct this has been submitted in Congress, but it is not yet law.

Twice I’ve received a generic that did lead to the headaches, troubled sleep, depression and GI symptoms I encounter when I get gluten.  My pharmacy and psychiatrist both know I have celiac disease, but the manufacturer of the medicine I had long taken changed and I ran into trouble.

In both cases the pharmacy was able to replace the med with one from a manufacturer I had tolerated well, but it’s troubling that two pills with the same name could lead to such very different reactions.

It’s not always gluten that is the culprit.  Some sugars used as excipients can lead to the same symptoms as gluten ingestion does.  It just shouldn’t be hard to determine what’s in the medicine you take, and whether allergens are included in the ingredient list.

But it is hard.

There is a database from the National Library of Medicine and the National Institute of Health called DailyMed that does include the ingredients of all drugs, including generics, from all manufacturers marketed in the United State, and the database is searchable.

Be on the lookout for the following ingredients:

  • Wheat
    Modified starch (if source is not specified)

  • Pregelatinized starch (if source is not specified)

  • Pregelatinized modified starch (if source is not specified)

  • Dextrates (if source is not specified)

  • Dextrin (if source is not specified; the source is usually corn or potato which is acceptable)

  • Dextrimaltose (when barley malt is used)

  • Caramel coloring (when barley malt is used)

Unfortunately, the information on excipients are reported by the manufacturers themselves and are not always complete lists.  Many generics are manufactured in plants overseas, and the National Library of Medicine relies on the honor system in compiling lists of ingredients.  In fact, many foreign generic pharmaceutical plants have never been inspected by the FDA, and even the FDA relies only on the manufacturer to confirm what is actually in each pill.

It’s no surprise that US marketers often will not explicitly guarantee that the generics they sell are completely gluten-free, even when no gluten-containing excipients are listed in the database.

What’s a person with celiac or gluten intolerance to do?  Take your meds.  If symptoms caused by gluten do appear, don’t stop taking what your doctor prescribed.  That could lead to more trouble than gluten reactions.

Check the database for allergens, and talk to your pharmacist.  Most generics, including popular psych meds, are manufactured by more than one company.  If you don’t tolerate one, an equivalent drug from another manufacturer can be obtained.

Our medicine should make us feel better.  It shouldn’t make us sick.  Be vigilant about what you take, get all the information about it that you can, and listen to your body.

Gluten and Mania

Individuals hospitalized for acute mania show increased levels of antibodies to gliadin, derived from the wheat protein gluten.

Other studies investigating an association between bipolar disorder and celiac disease have focused on bipolar depression.  A study from the Stanley Research Program at Sheppard Pratt in Baltimore specifically looked at gluten sensitivity and mania.

The researchers tested 60 patients hospitalized for acute mania and found they had significantly elevated levels of IgG antibodies to gliadin.  IgG antibodies to gliadin are used to reveal gluten sensitivity and are one of the markers of celiac disease.

While those hospitalized for acute mania tested positive for gluten sensitivity, other markers of celiac disease were not found.

When tested six months after hospitalization, most of the subjects’ IgG antibodies to gliadin had returned to normal, and the individuals no longer met the diagnostic criteria for gluten sensitivity.

Those who’s IgG antibodies to gliadin remained elevated were likely to be re-hospitalized for another episode of acute mania.

Now I don’t know what to make of this.  Many will grasp this research and say, ‘Look!  Gluten causes mania!”  But at best this study only shows a correlation between acute mania and gluten sensitivity, and that sensitivity may be temporary and only occur during manic episodes.  No causation is established.

People try to pin all sorts of evil on gluten, and this will only add fuel to their fire.  I have both bipolar disorder and celiac disease, and I’ve been hospitalized for acute mania several times.

I find this study fascinating, but I’m not jumping to conclusions that aren’t warranted by the data.  The vast majority of people with gluten sensitivity never have an acute manic episode that requires hospitalization.  Hell, these days most people diagnosed with bipolar disorder never have an episode of acute mania that requires hospitalization.

This study concludes only that, in the cases investigated, acute mania and gluten sensitivity are associated.  When the subjects weren’t manic, they didn’t have gluten sensitivity (or vice versa).

Since the subjects returned to normal on both measures, we only know that they’re not always manic and they’re not always sensitive to gluten.

I hope this doesn’t contribute to the shrill voices condemning gluten.  I have to live gluten free, but my wife doesn’t and she eats the stuff.  Yes, we had our daughter tested for celiac disease, and since she tested negative she eats it, too.  I’m not about to deny her pizza and cookies (at least not good ones).

True gluten sensitivity is rare.  Celiac disease and bipolar disorder are rarer still.  So go ahead and eat that chocolate croissant.  I sure wish I could.

Meditation

While I think the most important point of focus in meditation should be the body, and the body is most apt to present you with signs an episode of anxiety, depression or mania is imminent, when meditating you just can’t get away from your thoughts. I write in my book Resilience: Handling Anxiety in a Time of Crisis that one of the reasons our thoughts trouble us is that most of the thoughts we have about ourselves are untrue. Yet we hold onto them and believe them! Meditation gives you the ability to encounter each thought and ask, “what is this?” It does not give you the skill to stop thinking and totally clear your head. But in the answer to the question, “what is this?,” we can find the space to reveal the inaccuracies we tell ourselves that aggravate us so much. We can counter thoughts that don’t hold up to our reality. In the words of the Sutta Nipata: One must sever oneself from the root of delusion, the thought that thinking brings wisdom.