Bipolar disorder is a readily treatable condition using a combination of medication and psychotherapy. Learn the details of these and other available treatment options here.
Individuals who present with bipolar disorder will be in one phase of the disorder, either a major depressive episode or a degree of a manic episode. This episode of either acute major depression or mania should be the focus of initial treatment. Since the treatment of this disorder nearly always involves medication (usually a mood stabilizer such as lithium or depakote), evaluation of the patient and proper prescription of an appropriate psychopharmacological agent is necessary. Usually the episodes will not be severe enough to warrant hospitalization, although partial hospitalization may be considered to stabilize the individual on the medication. Suicidality should always be assessed, especially for those suffering from a major depressive episode.
One of the central reasons a patient presents with this disorder, after having been previously treated, is because he or she has stopped taking the prescribed medication. Medication compliance should always be an aspect of any treatment in bipolar disorder and compared with other life-long maladies, such as diabetes, where the removal of medication can result in death. Maintenance of the client on medication over a long period of time is common, resulting in a good prognosis. Most people can lead active, healthy lives with this disorder, if they comply with proper treatment regimens.
When an individual presents to a clinician who is suffering from an acute episode of mania or depression, the therapist should seek to stabilize the client quickly. This means treating the episode with the appropriate pharmacologic agent and scheduling follow-up sessions with a psychotherapist or case manager. Closely monitoring medication levels (if appropriate) can prevent future relapses into mania or depression. The physician should be acutely aware of the roller-coaster-like emotional states experienced by someone with bipolar disorder and follow the patient carefully while in treatment.
While there appears to be a genetic component to this disorder (as with most mental disorders), the research is still clear that there is no known single cause for the disorder. Many theories are proposed, ranging from the psychological to the biomedical. As is the case with all mental disorders, it is likely an important combination of factors, which leads to someone having this disorder and treatment should reflect that combination appropriately. Emphasis on one form of treatment over another will likely lead to future relapses for the patient.
Although it is generally acknowledged that psychotherapy alone is inadequate for proper treatment of Bipolar Disorders, psychotherapy is a valuable component of a comprehensive treatment. Some psychological theories exist which implicate various environmental or psychological factors that significantly contribute to this disorder. These are often overlooked in treatment of bipolar disorder, but should be carefully considered.
Either individual or group therapy are appropriate and recommended for someone with this disorder. Therapy is usually supportive in nature, helping the client with increased coping skills and education about the disorder. Cognitive-behavioral interventions can be an effective means of helping the client to better manage his/her stress, improve problem-solving abilities, and work towards acceptance of having to take medication. Helping the client learn to better predict his or her own fluctuations in mood (which may be related to situational or seasonal changes) can also decrease the likelihood of relapse in the future. Prevention of future relapses should be a focus of therapy, with medication compliance as an important topic. This is especially true with individuals who may be experiencing a manic episode (or may be more predisposed to being on the manic side), but it can also be an issue for those who are experiencing no specific episodes of mania or depression.
Therapy should be flexible in its approach since the needs of people who suffer from bipolar disorder are diverse. Often bringing in a family member or close friend (or spouse) who keeps track of the patient can be beneficial to touch base with and ensure that everyone is clear about appropriate behavior and treatment. People with bipolar disorder can sometimes wreak havoc in their own personal lives when in a manic stage. This sometimes spills over to the person's family or friends and should be an aspect of treatment in psychotherapy. Education of family members or significant others can help them better manage the patient at home and ensure medication compliance.
Follow-up care for someone with bipolar disorder is imperative. Whether this takes the form of regular group therapy sessions, case management, medication appointments, or the like, touching base with a professional will help ensure the patient remains compliant with medication and retains mood stability. Discharge planning should take these factors into account; failure of the patient to appear for the next scheduled appointment can be an ominous sign. Unfortunately, many such individuals easily fall between the cracks in the mental health system because follow-up is either not conducted or not conducted in a timely manner. This is especially true when the client is moving from an inpatient or day-treatment program to an outpatient program.
Hospitalization may be needed if the person is suffering from a severe episode of major depression or suicidal intent, or from a manic episode. Partial hospitalization should be considered as a viable alternative as well. As soon as the patient has been stabilized on the appropriate medication, though, the individual should be discharged. Day treatment programs, which allow for greater flexibility in the patient's life while maintaining close support and contact with mental health professionals, are often an appropriate treatment choice.
People with Bipolar Disorders almost always require treatment with medications in order to stabilize their condition. While there are several medications that can treat Bipolar disorder, the treatment of choice allowing for a person's highest functioning is lithium carbonate, taken orally. While it is most effective in those individuals who tend to be more manic in their bipolar presentation, it works quite well with other bipolar presentations. Effects of lithium may take up to 2 weeks to kick in, but up to 80% of those individuals who are prescribed lithium receive beneficial effects from it. Lithium tends to prevent the recurrence of additional depressive or manic episodes, if medication compliance is maintained by the patient. However, lithium generally has little effect on a major depressive episode; these episodes should first be treated by an appropriate antidepressant medication.
Phillip W. Long, M.D. (Internet Mental Health (http://mentalhealth.com))suggests that,
"Complications are relatively infrequent, but a transient rebound depression following resolution of a manic state is not uncommon. Before lithium treatment is started, it is prudent to obtain baseline indices of thyroid and kidney function, electrolyte levels, and, in individuals over age 40, an electrocardiogram. For patients in the acute manic state, a lithium blood level of 1-1.5 meq/L is desirable. After an optimal response has been achieved, the dosage can be decreased. Maintenance lithium levels for prevention of manic or depressive episodes must be individualized but range from 1.5 to 1 meq/L."
"A number of factors may affect lithium level in patients in spite of a consistent intake of medication. Any condition that alters electrolyte balance (e.g., dehydration, low salt diet, severe vomiting or diarrhea) alters the serum level and cell membrane transport of the lithium ion. The most common problem is a transient increase in level leading to mild toxicity. Dosage needs may change considerably with age, change in physical condition, pregnancy, or prescription of additional drugs (particularly thiazide diuretics and nonsteroidal anti-inflammatory medications). Serum for lithium level should be obtained at least eight hours after the last dose (12 hours in the case of "slow-release" preparations)."
As mentioned in the previous section, medication compliance is an important issue. People with bipolar disorder can be maintained indefinitely on lithium with relatively few harmful side effects and generally lead a productive, active life. Regular contact with the mental health professional is usually an important aspect to the equation. This allows the patient to "touch base" with them, check lithium serum levels, and ensure proper medical compliance with treatment recommendations (if not with the client, then with a family member or spouse). Decreased lithium levels often lead to a relapse of the individual to a manic or depressive episode. The prescribing physician should be familiar with possible side effects of lithium treatment, as well as the long-term effects of lithium treatment (which can include renal and thyroid problems). Ongoing evaluation should be conducted on these potential physiological side effects as necessary.
Lithium will usually bring most people out of a manic episode. For those people who cannot tolerate lithium carbonate or its side effects, though, there are other medication treatment options for mania. Several of the anti-convulsant medications have been found to be helpful in treating Bipolar disorder. Depakote, an anticonvulsant, is the most commonly prescribed treatment alternative to lithium. Although Depakote can cause side effects such as nausea, headaches, dizziness, blurred vision, and others this medication seems to be better tolerated than Lithium. For someone experiencing more manic episodes, research indicates that Tegretol, another anti-convulsant medication is the medication of choice as compared to Depakote. Another anti-convulsant medication that is also now being used to treat Bipolar disorder with success is Neurontin. It is important for the prescribing physician to clearly evaluate each patient's unique mixture of manic, depressive, or mixed episodes because depending on which mood episodes are more prevalent will help shape the medication strategy used. For milder levels of depression, one of the mood stabilizers is a good treatment choice such as Lithium, Depakote, or Tegretol. For more severe cases of depression, the person should be treated with an antidepressant and a mood stabilizer. The antidepressant should be from the tricyclic family of medications because an antidepressant from the SSRI family of medications can exacerbate symptoms of mania , and should therefore not be prescribed to treat Bipolar disorder.
Anti-psychotic medication is often prescribed in more rare instances, such as haloperidol or chlorpromazine. The outcome for such individuals is markedly less than those who can tolerate the prescription of lithium or depakote; the reason for this differentiation is unclear. Anti-psychotic medications also tend to interfere more with normal cognitive functioning and have notably increased side-effects. They are generally tolerated less well than lithium because of their side effects and medication compliance is usually an equally important issue.
For a depressive episode, the usual treatments for major depression are as appropriate for bipolar disorder. Antidepressant medication, such as tricyclics are appropriate for use and should be prescribed according to typical clinical guidelines. When the client overcomes the depressive episode, the medication should be tapered off slowly and eventually discontinued. The introduction of lithium carbonate at that time (or, if appropriate, concurrently) is recommended. As with the treatment of any depressive episode with antidepressants, dose level should begin at the recommended level by the manufacturer or clinical guidelines, until a therapeutic level is attained.
The medical profession often overlooks self-help methods for the treatment of this disorder because very few professionals are involved in them. Support groups, though, offer an excellent adjunct to continuing medication check-ups once a month, and a way to gain emotional and social support through the community. These groups also allow others to ensure the client is doing well and promotes the client's independence and stability. Many support groups exist within communities throughout the world that are devoted to helping individuals with this disorder share their common experiences and feelings.
Such support groups are recommended to individuals suffering from this disorder, especially if they have found therapy unhelpful or too expensive. Self-help mutual support groups, though, are unlikely to benefit a person with this disorder unless they are also under the care of a psychiatrist for the prescription of one of the medications mentioned above.
Research suggests that other types of self-help, such as exercise, stress management, and getting adequate rest can really help to manage symptoms of Bipolar disorder. Some studies indicate that because of exercise's affect on improving mood that consistent regular exercise can help balance out some of the mood swings experienced from Bipolar disorder. Exercise can also be used to improve medication compliance because it is helpful in counteracting a common side effect of Lithium, which is weight gain. Because Lithium can cause weight gain it is a common reason many people will stop taking the medication. However, by engaging in regular exercise, which helps to reduce the amount of weight someone will gain on Lithium or other mood stabilizers, it is more likely a person will comply with taking medication regularly. Stress management tools can also be quite helpful in managing bipolar symptoms. Often bipolar symptoms, especially manic episodes, are worsened by stressful times. So, by engaging in common stress management techniques such as deep breathing, progressive muscle relaxation, getting enough sleep, and time management skills it can also help reduce the likelihood of facilitating a manic episode.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association.
National Institutes of Health, National Institute of Mental Health, NIH Publication No. 95-3679 (1995) Phillip W. Long, M.D. (Internet Mental Health: http://mentalhealth.com)
Sachs, G., Printz, D., Kahn, D., Carpenter, D., Docherty, J. Medication Treatment of Bipolar Disorder 2000. In The Expert Consensus Guidelines. (2000), A Postgraduate Medicine Special Report.