|Treatment - Bipolar Disorder|
Table of Contents
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 lithium), 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 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 in proper treatment.
When an individual presents to a clinician while suffering from an acute episode of either mania or depression, the therapist should seek to stabilize the client quickly. This means treating the episode with the appropriate pharmacologic agent and scheduling followup sessions with a psychotherapist or case management. Closely monitoring lithium 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 lead 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.
Psychotherapy can be a valuable component of treatment for someone suffering from bipolar disorder. 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.
Both 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. With specific episodes of depression or mania, additional therapy can focus on the treatment of those disorders. Helping the client learn to better predict his or her own fluctuations in mood (which may be related to situational or seasonal changes) can 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 is 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 suffering 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.
Followup 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 in 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 followup 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, is often an appropriate treatment choice.
Overall, the treatment of choice for bipolar disorder allowing for a person's highest functioning is lithium carbonate, taken orally. While it's most effective in those individuals who tend to be more manic in their bipolar presentation, it can also show effectiveness in other individuals. 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. 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."
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 few treatment options for mania. Depakote is the most commonly prescribed treatment alternative to lithium, and should be considered. 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.
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.
Phillip W. Long, M.D. also notes,
"A number of factors may affect lithium level in patients in spite of a consistent intake of medication. Any condition which 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)."
For a depressive episode, the usual treatments for major depression are as appropriate for bipolar disorder. Antidepressant medication, such as tricyclics or SSRIs are appropriate for use and should 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.
Electroconvulsive Therapy (ECT) is a highly invasive and traumatic treatment which is usually contraindicated in the treatment of bipolar disorder. It is a treatment of last resort and its side effects (loss of memory and identity confusion) can be severe and cause as many complications as the original problem. According to the latest research literature, ECT is not an appropriate treatment to routinely be recommended or used for people who suffer from bipolar disorder.
Self-help methods for the treatment of this disorder are often overlooked by the medical profession 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 which are devoted to helping individuals with this disorder share their commons 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.
Internet Mental Health