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I t p a y s t o b e A B M P C e r t i f i e d : w w w. a b m p . c o m / g o / c e r t i f i e d c e n t r a l 45 dangerous interactions with other common medications, including hormone supplements and oral contraceptives. Consequently, many patients find themselves bouncing back and forth between the mood states that are connected to their own internal chemistry and those that are externally imposed by the medications they take. In addition, medications for bipolar disorder carry a host of unpleasant side effects, including irritability, weight gain, and a general sense of lethargy. Finally, lithium and its analogues can impair thyroid function. This can cause fluctuations between high energy and low energy states, much like bipolar disorder—so in this case the medication's side effects may mimic or exacerbate the symptoms it is intended to subdue. It is not difficult to understand why many bipolar patients are resistant to taking their medication. All that said, it is vital that a bipolar disorder patient does not suddenly change his or her drug regimen. This can lead to dangerous rebound effects, and a sudden and extreme exacerbation of symptoms. Electroshock therapy is sometimes used to treat bipolar disorder, but it is usually reserved for cases when medications don't work, or when a patient wishes to avoid drugs for other reasons, such as pregnancy. Experts agree that, in addition to medication, psychotherapy and education of the patient and the patient's loved ones are important parts of managing this challenging disorder. Knowing how this condition affects function, and having a predetermined plan for emergency situations, can help the patient and his or her supporters cope. WHERE DOES MASSAGE FIT? No studies examining the interactions between massage therapy and bipolar disorder have been published. Consequently, to determine whether massage is appropriate in this situation, we have to look at other considerations. Persons with bipolar disorder are strongly advised to keep a reliable and consistent schedule, to maintain good social connections, to get quality sleep, and to eat well. In short, they are counseled to engage actively in their own self-care. Clearly, massage therapy can play a part in this self-care effort. The accumulated evidence for massage in the context of major depressive disorder and anxiety disorders is fairly strong. Many bipolar patients initially seek medical attention because their depressive symptoms can be alarming. It seems reasonable, therefore, that massage therapy might be a strategy to pursue, at least during the depressive phase. Further, the self-awareness that massage therapy can promote may be helpful to bipolar patients. Many specialists suggest that mindfulness—the practice of increasing awareness of one's mood and physical state—can help bipolar patients determine whether their mood shifts are within a healthy range or not. It is important to point out massage does not have the power to "fix" bipolar disorder. People who have bipolar tendencies will probably find that massage alone is not capable of smoothing out their mood shifts. Massage is not a substitute for the careful combination of psychotherapy, medication, and education that a person with bipolar disorder needs to successfully manage this condition. In this situation, massage may be helpful, but it is not the answer. It is possible that people with bipolar disorder could derive great benefits from massage, but we won't really know this until someone writes it down. Do you have clients with this condition? For the sake of your profession, please consider writing a case report that tracks your client's symptoms and goals. Then share the report with the rest of us—we are eager to learn from your experiences. Ruth Werner is a former massage therapist, a writer, and a continuing education provider approved by the NCTMB. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams & Wilkins, 2013), now in its fifth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com. It is important to point out massage does not have the power to "fix" bipolar disorder.