Dr. Josephine Loftus: A Journey from Paris to Lisbon to Raise Awareness of Bipolar Disorder

Interview with Dr. Josephine Loftus by Houda Bakkali

Published July 2026

Bipolar disorder continues to present major challenges, not only in terms of diagnosis, but also in therapeutic management and public awareness. In this interview, Dr. Josephine Loftus, former Clinical Deputy Director of the Department of Psychiatry at Princess Grace Hospital in Monaco and currently an Honorary Fellow of the Royal College of Psychiatrists (UK), discusses some of the key challenges that still lie ahead, including advances in treatment, the new opportunities offered by technologies such as Artificial Intelligence and Virtual Reality in the management of this disorder, and the use of art as a therapeutic tool.

The interview also highlights her latest charitable initiative in support of the French association Nice Le Phare des 2 Pôles, which led her on an extraordinary adventure hitchhiking from Paris to Lisbon.

What is bipolar disorder?

Bipolar disorder is a mood disorder characterized by extreme highs and lows. Severe depressive symptoms are present during the lows and include insomnia or hypersomnia, diminished appetite with weight loss or increased appetite with weight gain, poor concentration, depressed mood, loss of interest and the ability to feel pleasure, in very severe cases loss of the ability to feel at all, only the ability to feel intense psychological pain and guilt, a general feeling of slowing down physically and mentally, social withdrawal, suicidal thoughts and suicidal behaviour. In the severe depressive phase, there may also be paranoid delusions and auditory hallucinations of a derogatory nature, amplifying the feeling of worthlessness and of being  a burden. This phase of the illness can last several months if left untreated and is the most difficult phase of the illness for patients.

What are the main characteristics of this condition?

The ‘highs’ known as mania and hypomania are characterized by excessive hyperactivity, elated mood, excessive, unjustified confidence, an unshakeable conviction in one’s own capacity to move mountains (sometimes patients will say “I felt like ironman”), accelerated thinking reflected in rapid speech with flight of ideas to the point of becoming incoherent. 

Lack of sleep and decreased appetite with weight loss  due to the hyperactivity as the number of tasks and projects to be accomplished increase are also an important feature of the disorder as well as increased impulsivity with overspending, often to the point of financial ruin, impulsive, unprotected sexual behaviour and a sense of omnipotence and grandiosity which can lead to clashes with others and the law. In severe cases of mania, grandiose delusions can occur which may be life threatening to the patient (jumping off a building because one is convinced one has the ability to fly) as well as paranoid delusions and mystic delusions. Auditory hallucination as in hearing voices may also be a feature of the illness. Hypomania is a less pronounced form of mania but not a less severe form. 

Patients with mania end up very quickly in hospital as their presentation is often dramatic whereas hypomania can go under the radar for months, even years, with longterm negative consequences for the patient.

Can bipolar disorder affect anyone? Which group is currently most affected?

Bipolar disorder affects 1-2.4% of the population. Bipolar 1 which is characterized by episodes of mania and depression is equally distributed between the sexes. Bipolar II, characterised by depressive episodes and hypomania, is more frequent in women.

How do social or environmental factors relate to this condition?

Several factors contribute to the illness. Genetic factors are important. The lifetime risk in first degree relatives is 5-10%. Risk of other psychiatric disorders is also higher in relatives.

Environmental risk factors have also been implicated such as maternal viral infection during pregnancy, extreme prematurity, low birth weight and advanced paternal age. However, the findings in this area tend to be inconsistent. Evidence is also emerging for an association between urban environments and increased rates of bipolar disorder although the evidence is stronger for schizophrenia. Interestingly, one study found a strong association between urban residence and bipolar disorder with psychotic symptoms.

Childhood maltreatment has also been identified as a risk factor. The largest association was found between bipolar disorder and emotional abuse although there were also significant associations with sexual and physical abuse. Early parental loss in 3 out of 10 studies has been associated with bipolar disorder. Substance abuse is also a factor in the development of the illness.

Although it is difficult to tell which occurs first, cannabis abuse or bipolar disorder, there is increasing evidence that cannabis abuse increases  the risk of first episode bipolar disorder.

What challenges do people with bipolar disorder face?

Social isolation, stigmatization and loneliness are some of the greatest challenges facing patients with bipolar disorder. The unpredictable nature of their mood changes and resultant behaviour can lead to estrangement from puzzled family and friends. Divorce and separation are frequent as well as loss of employment and social status. Even if surrounded by family and friends, the person who suffers from bipolar disorder can still feel very lonely as they deal with the symptoms of their illness and the social fallout from the disorder. There is also the guilt and shame following erratic behaviour during manic episodes to process.

You are currently promoting a campaign for the association Nice Le Phare des 2 Pôles; tell us about this organization. Why is it important to foster visibility, participation, and support this association?

It is difficult for someone who has never suffered from depression to fully grasp the level of suffering endured during the illness. This is why associations like Le Phare de 2 Pôles are so important. Le Phare de 2 Pôles provides a safe place for people with Bipolar Disorder to meet where they know they will be accepted, understood and supported.

The association also provides activities such as meditation workshops, art therapy, relaxation and social activities with a cultural theme. The association also invites professionals to give talks on relevant themes such as nutrition, addictions and social advice around accommodation etc.

How did the “Un voyage Paris-Lisbonne en auto-stop” (Paris-Lisbon hitchhiking trip) initiative come about?

I first came into contact with the association through my work when I was invited to  give a workshop on mindfulness by the association  and through patients who were supported by the organization. I was very happy to have such an association nearby which I could recommend to patients who were feeling very lost and lonely with their illness. It is an invaluable resource and my  admiration goes to the  people who had the initiative to set up this association.

So, when my lifelong friend, Amanda, informed me, she was going to hitch-hike across Europe for charity and invited me to join her, I agreed after a brief moment of hesitation. She was collecting funds for a mental health association in the UK and the obvious choice for me was Le Phare de 2 Pôles. Not only was this a means of collecting funds for the association but also a way of raising the visibility of the association. It is important that more patients and their families become aware of its existence and, now based in Nice, maybe one day there will be branches  throughout France.

The Hitch-hiking adventure is now over. It took us 5 days to get from Paris to Lisbon. On the way, we met wonderful people whose only desire was to help. Some went out of their way to facilitate us, organizing accommodation, or by driving extra kilometres to leave us in a better, safer hiking position. Even the police helped by picking us up and transferring us to the correct motorway.  We encountered generosity, kindness and selflessness, qualities that are rarely highlighted in the media. It was a truly uplifting experience.

Although the adventure is over, it is never too late to donate to the association. All donations count.

What challenges does diagnosing this condition present?

Bipolar disorder is one of the leading causes of disability worldwide. It is also associated with high rates of premature mortality from suicide and medical illnesses such as heart disease.  Diagnosis can take up to 10 years or longer. There are several reasons for this delay.

The most frequent is that a patient is treated for recurrent depressive episodes or unipolar depression. This occurs in up to 40% of cases. This may be due to lack of inquiry into the presence of manic or hypomanic symptoms on the part of the psychiatrist or the patient may not describe the presence of such symptoms because he/she views them as a normal and very pleasant phase in his/her  life or may have forgotten those episodes. This underlines the importance of a collateral history from family members. Diagnosis of a unipolar illness leads to the prescription of antidepressants which can aggravate the course of the illness.

The global peak age of onset is 19.5 years. This means that a patient may not receive a diagnosis and appropriate treatment during the most formative  and important years of his/her life. Self-medication with alcohol and other substances may occur leading eventually to a dual diagnosis.

What challenges do the symptoms of bipolar disorder continue to pose?

The symptoms and trajectory of the illness may also be masked by other factors such as chronic substance abuse, the presence of ADHD which occurs in about 20% of patients with bipolar disorder, severe anxiety symptoms and the presence of a personality disorder such as borderline personality disorder. The latter can sometimes provide a diagnostic conundrum for clinicians. 

Can bipolar disorder alleviate other conditions, or vice versa?

Bipolar disorder is associated with a high prevalence of other conditions, both psychiatric and medical. Substance abuse, anxiety disorders, ADHD and eating disorders occur in 30 -50% or more of patients with bipolar disorder. Each disorder has a deleterious effect on the other if not adequately treated. Each contributes to increased relapse and admission rates and requires a multidisciplinary approach and collaboration across different teams. Substance abuse also increases the risk of suicidal behaviour. 

What is the relationship between bipolar disorder and suicide?

At least 25-50% of patients with bipolar disorder will attempt suicide at least once. 15-20% die by suicide, a figure much higher than the general population. This is a tragedy for the patient, family members and friends. Most suicides occur during  depressive episodes  and mixed episodes where features of both poles of the illness coexist at the same time. The despair and suicidal ideation combined with the impulsivity and increased drive of the manic end of the spectrum makes for an explosive and dangerous combination. People with bipolar disorder also have a shorter life expectancy because of an increased risk of physical illness. Their lifespan is 8-15 years shorter than the general population, not only due to the increased suicide rate but also due to cardiovascular, metabolic, respiratory and cerebrovascular diseases.

What is the best approach to this condition?

Medication is the cornerstone of treatment. However, learning to manage bipolar disorder is very important for the patient. Becoming aware of the effect of life events on the illness, even minor events, including happy ones and learning to recognize early warning signs of a relapse and take appropriate action in time is a common theme in the psychotherapeutic approaches available. These include psychoeducation, cognitive behavioural therapy, mindfulness approaches and more recently compassionate focused approaches. 

EMDR for patients with a history of trauma can lead to better emotional regulation and potentially less mood episodes. Psychotherapy combined with medication has shown to lead to better outcomes.

How can technology and digital tools support people living with bipolar disorder?

For patients, unable to access therapists or centres, programmes are available online including digital tools such as mood charts. These enable patients to chart their mood, help them discriminate normal mood variation from a pathological one and recognize warning signs such as decreased sleep or increased irritability. Patients can also monitor their sleep with connected watches and use apps on their phones to monitor excessive emotional variation.

Continuing with the topic of digital environments, immersive technologies are already being tested in certain mental health therapies. What impact are they having?

The use of other approaches such as Virtual Reality has been used in other psychiatric disorders and has shown promise as a tool for the assessment and treatment of social functioning impairments. A review published in 2024 showed positive effects on stress levels, anxiety and depressive symptoms as well as improved cognition and emotional awareness. Engagement with the therapy was good and its usefulness in situations where access to therapists is limited was underlined. Although clinical research in this area is still in its infancy for bipolar disorder, there is evidence that VR may be of benefit to patients with Bipolar disorder.

To what extent is artificial intelligence impacting patient diagnosis and monitoring?

This also brings us to the subject of AI in the management of bipolar disorder. Studies have looked at the application of AI in mood tracking, peronalised treatment plans and to improve mood episode prediction. The studies suggested that AI can enable more proactive and personalized treatment plans, improve treatment outcome and decrease the burden on healthcare professionals. More studies are necessary but there is already good evidence that use of AI has the potential to improve patient care. 

To what extent can art therapies aid in addressing this condition?

Art therapy has also been shown to be helpful in patients with bipolar disorder as it provides a nonverbal means of expressing their emotions which in turn makes them more aware of their emotions and mood changes. It may also enable them to monitor mood changes as changes in art form will reflect their mood. The black and grey paintings of Rothko before he committed suicide come to mind.

What is the link between bipolar disorder and creativity?

Increased creativity has long been associated with bipolar disorder. The list of eminent people-writers, composers, artists (Rothko, Hemingway, Keats, Rachmaninoff etc) who were thought to have suffered from bipolar disorder is impressive.

There is the belief that this increased creativity stems from cognitive processes that emerge during mania. This belief can motivate some people to discontinue or defer treatment. Several studies addressing this question suggest that milder symptoms such as happiness and increased energy may be more important for increased creativity than severe symptoms whereas other studies suggest that family members at risk for developing the illness may show greater creativity than family members diagnosed with the illness.

Creative productivity is associated with hypomanic /manic periods. Emily Dickenson composed poems at 10 times her normal rate during hypomanic episodes, similarly Schumann’s compositions increased during his manic periods but the overall quality of his compositions did not differ from those in his well period.

However, Virginia Wolff was only productive when she was well. So, although there does appear to be a link between bipolar disorder and creativity, it is not straightforward but more complex than we might envisage.

Where does bipolar disorder research stand today?

Advances in the use of AI tools to predict and improve treatment outcome is an important area of research in Bipolar Disorder. The development of therapeutic strategies for bipolar depression is also important as this is the most difficult part of the illness to stabilize and the most chronic debilitating aspect of it for patients. 

More recently blood tests have been developed to help differentiate bipolar depression from unipolar depression and increase in sensitivity when combined with a clinical assessment. This is a promising development for the future although it will take time for such tests to become widely available and more studies are required to determine their validity. Research is also ongoing into other biomarkers.

The recent advent of esketamine has provided an important therapeutic strategy when all other strategies have failed and a patient is reluctant or unable for medical reasons to avail of ECT (electro-convulsive therapies). Similarly rTMS is an important addition to the therapeutic options available in addition to mood stabilisers.

Unfortunately, these treatments are not available in all countries and in some countries, only available in certain areas. Perhaps the most important advance of all would be to ensure equal access to adequate clinical care and treatment for all patients regardless of their geographical location.

If I were to ask you for a realistic headline for patients with bipolar disorder, what would you say?

Headline of hope for Bipolar Disorder: Major Breakthrough in the treatment of Bipolar Depression.

If I were to ask you for a hopeful headline for patients with bipolar disorder, what would it be? 

Realistic Headline: Advances in Early Diagnosis of Bipolar Disorder.