How is Bipolar Disorder Treated

How is Bipolar Disorder Treated?

Medications and psychotherapy

Medications and psychotherapy If you have been diagnosed as suffering from bipolar disorder, the following pages will help you learn more about how this condition is treated. If you get into a good treatment program and are able to stick with it you may find that the illness is well controlled and that you can move forward with a stable and productive life.

Bipolar disorder is best treated with a combination of medications and psychotherapy. Medications car provide effective treatment during the acute episode and prevent future episodes from occurring. Psychotherapy can help in ways that medications can't and can be an important adjunct to medication.

Medications

Mood-stabilizing medications, like lithium, can bring an acute episode of mania to a halt and can also prevent future episodes from occurring. After the first episode of bipolar disorder, it is likely that another episode will follow in a year or two or three, but taking a medication like lithium can cut the risk of reoccurrence in half - or better. Taking a mood stabilizing medication also greatly decreases the risk of dying by suicide. You should recognize the benefits of medication for acute and preventative treatment.

Acute and preventative treatment

The medications you may take in the acute phase of treatment may be different from those used during the maintenance or prevention phase.

Acute treatment is designed to bring you down from a manic high or up out of a depressive phase. The acute phase of treatment may last just a few weeks or months. The medicines you take during this phase are likely to be a combination of mood stabilizers and antipsychotic medications.

The maintenance phase may go on for years, and may only require that you take a mood stabilizer. You may be feeling just fine and thinking you can stop using the medication, but remember that the
medication you take in the healthy, maintenance phase may well be protecting you from suffering episodes of mania or depression.

Sometimes, maintenance medications may not completely prevent episodes of illness, but they may reduce the intensity of symptoms to such an extent that you can tolerate the milder symptoms and keep working or going to school. This is lot better than having a full-blown episode and ending up in the hospital and losing your job and your friends and all those other important connections to the world around you.

So ... medications may:

  1. Help you get better faster and get out of hospital sooner when you experience an acute episode
    of illness;

  2. Help you stay well longer and also reduce the severity of symptoms during subsequent acute
    episodes;

  3. Reduce any symptoms you may experience between episodes.

How long do I have to take medication?

After the first severe episode of bipolar disorder, especially a manic episode, it may well be hard to decide whether you should take maintenance medications. The remission between the first and second episode could last for years - or not. No-one can predict. The things to talk with your doctor about are:

  1. How severe was the first episode? How badly did it mess up my life? How important is it to
    prevent that from happening again?

  2. Have I been getting episodes of depression - mild, moderate or severe - before the episode of
    mania, that might be prevented or decreased in intensity if I were to take medication?

  3. How much do I hate taking medication every day?

  4. Do I get any significant side effects from the medications?

When the illness is more advanced - when the frequency and severity of episodes is more apparent- the decision about whether or not to take preventative medication gets a lot clearer. Bipolar disorder does not get milder as it advances. In fact, each episode of illness makes it more likely that you will experience another one sooner rather than later. Taking maintenance medication will make it much likelier that you will put off the next episode and have a milder, more benign course of illness.

Mood stabilizers

Mood stabilizers are medications that are effective in treating mania and depression and prevent the occurrence of new episodes during maintenance treatment. The main mood stabilizers are lithium carbonate and certain anticonvulsants.

Lithium carbonate

Lithium carbonate is a simple salt which was discovered to be effective in treating manic depressive illness in 1949. It became widely used in the 1960s and has been in use in the United States since 1970.  It is rapidly eliminated from the body through the kidneys and so it needs to be taken at least twice a day to maintain an adequate blood level, unless you take it in a slow-release form, like Eskalith CR, when it can be taken once a day. Lithium can upset the digestion unless it is taken with food, so many people take the slow-release preparation once a day with their dinner.

The correct therapeutic blood level is known with some accuracy. Doctors aim to maintain the blood level between 0.6 and 1.2 mill equivalents per liter. Your blood level of the medication may need to be checked a few times and the dose adjusted until it is at the correct level. After that, the blood level does not usually vary much and blood tests do not need to be checked very often.

Lithium works well in treating about 60-70% of people suffering from bipolar disorder. In those cases where it is ineffective, one of the anticonvulsants will often be effective, alone or in combination with lithium. Lithium is most effective in treating and preventing episodes of mania, but it can often be effective in treating depression also.

Some people get side effects from taking lithium. Some of the more common ones are:

a fine hand tremor
stomach upset or nausea
making acne worse
fluid retention with swollen ankles
a metallic taste in the mouth.

Lithium can also, at times, lead to suppression of the thyroid gland and, over the course of decades, a very gradual decrease in kidney function. For this reason, every 6 -12 months, your doctor will want to check some simple blood tests to assess your thyroid gland and kidney function. Thirst and increased frequency of urination can also be a problem which you should report to your doctor.

Lithium toxicity

If the blood level of lithium gets too high you can develop lithium toxicity. The signs and symptoms of lithium toxicity are severe sedation, unsteadiness, poor coordination, diarrhea and stomach upset, slurred speech, hand tremor, confusion and disorientation. Lithium toxicity is dangerous, so your doctor will want to order a lithium blood level test every few months to check that the lithium level is remaining in the proper therapeutic range.

A few things can push up your lithium level and put you at risk of lithium toxicity:

dehydration
taking ibuprofen (in Advil and other over-the-counter medications)
being prescribed certain diuretics and blood pressure lowering medication.

So let your family doctor know that you are taking lithium and let your psychiatrist know when another doctor starts you on a new medication. Avoid over-the-counter ibuprofen-containing drugs like Advil and try not to get dehydrated if you are taking lithium.

Anticonvulsants

Several anticonvulsant medications are effective in treating and preventing the different phases of bipolar disorder, though they are usually more effective in mania than in the depressed phase. They were first introduced into the treatment of bipolar disorder in the 1970s as an answer to rapid cyclinga form of bipolar disorder in which the person with the illness is experiencing several cycles a year from mania into depression and back. The anticonvulsants are still the treatment of choice for rapid cycling, but they can also be very effective when the course of illness is not disturbed in this way. The most common and effective anticonvulsants are valproate or valproic acid (brand name Depakote), carbamazepine (brand name Tegretol) and oxcarbazepine (brand name Trileptal).

Another anticonvulsant is sometimes used, but should be reserved for a special purpose; the anticonvulsant is lamotrigine (brand name Lamictal) and its special value is in helping to lift people with bipolar disorder out of a treatment-resistant episode of depression. Given in too high a dose, however, it can provoke the appearance of manic symptoms. It can also, rarely, cause a serious, potentially fatal, skin condition known as Stevens-Johnson syndrome, so it must be prescribed with great care by doctors who are familiar with its use. If you are taking Lamictal and you develop a painful rash you should let
your doctor or treatment team know about it immediately.

Side effects of any of the anticonvulsants include sedation, stomach upset, tremor, headache, dizziness and unsteadiness. Weight gain is more common with Depakote. Tegretol carries a remote chance of a catastrophic drop in a person's white blood cell count, which is dangerous. Both Tegretol and Trileptal can lead to a drop in the amount of sodium in your blood, which can have negative consequences, and may mean that the medication has to be discontinued.

We know with some accuracy the blood level of the different anticonvulsants that is likely to be effective in treating bipolar disorder. A complication in the use of these medications, however, is that they are excreted through the liver, and your liver will get better and better in eliminating the drug from your body. This means that, as you are getting started on the medication, though you may have an adequate blood level this week, next week it may be too low. Your doctor will have to keep ordering blood tests for a few weeks and adjusting your dose of the medication, until the level finally reaches a
plateau and remains steady.

Other medications

Antipsychotics such as risperidone (Risperdal), olanzapine (Zyprexa) and haloperidol (Haldol), may be necessary, especially during the acute phase of illness, if you are experiencing such psychotic symptom: as hallucinations or delusions. Often, when the acute phase of illness is over, these antipsychotic medications may no longer be necessary and can be reduced and discontinued. Indeed, sometimes, when the mood stabilizer has done its job and has dramatically reduced the symptoms of mania, the antipsychotic medications, which were previously necessary to control agitation and other symptoms,
may lead to overwhelming sedation and slowing, and may need to be reduced at a fairly rapid rate.

Antidepressants such as fluoxetine (Prozac), paroxetine (Paxil) and citalopram (Celexa) should generally be avoided in the treatment of bipolar disorder. They may cause the person with the illness to switch into a manic state and they may also precipitate a period of rapid-cycling (several cycles of mania and depression a year). Occasionally, when a person is in a severe episode of depression and the previous episodes of mania have not been severe, it may be reasonable to use an antidepressant for a while, in combination with a mood stabilizer, to see if it can lift the person out of his or her depression. If it is successful, the antidepressant may then have to be discontinued before it leads to the patient into becoming more manic and psychotic.

Electroconvulsive therapy: Yes or no?

Most people who experience a severe episode of depression in bipolar disorder respond to treatment with some combination of the medications described in this section. A few do not. For those few, electroconvulsive therapy (ECT) may bring welcome relief from the symptoms. The improvement can be dramatic. For patients who are seriously suicidal, it may be life-saving. ECT is also effective in treating mania, but it is rarely needed for this purpose as medications are usually rapidly effective in this phase of the illness.

ECT is the electrical induction of seizures in anesthetized patients. An ECT series may comprise twelve or more treatments conducted at a rate of about three a week. Patients with bipolar disorder undergoing this procedure must first be withdrawn from anticonvulsant medications, as these are likely to prevent the occurrence of the required seizure. Some people undergoing the procedure may experience, memory loss or confusion, but these side effects are almost always transient. The memory loss is most evident for events that occurred during the period of treatment.

Sometimes ECT is only effective in producing a remission of symptoms for a few weeks or months. Recurrence of symptoms is much less likely if the patient is taking medications. Medications which were ineffective in getting the person out of a severe depression may prove to be effective, after ECT, in preventing a recurrence. For those few people where medications do not prevent relapse, maintenance ECT - perhaps a treatment every 4 to 6 weeks - is very likely to prevent recurrence.

ECT has gotten a bad name, largely due to the florid images of its use in movies such as The Snoke Pit and One Flew Over the Cuckoo's Nest, showing how it was used, decades ago, without anesthesia and without patient consent. In fact, it is a safe and effective treatment which is only used selectively for people who have not responded to treatment with medications.

Light therapy

Some people with bipolar disorder find t hat their moods are influenced by the season of the year. As the days get shorter in September and October they begin to get depressed and they don't emerge from the depression until March or April. They may experience episodes of mania in the spring or summer. These people may benefit from exposing themselves to a source of bright light - at least 10,000 lux - during the hours of darkness for 30 minutes to two hours a day. Bright lights of this type are available commercially, some of them with timers that turn the light off and on automatically. Light treatment can be effective for people with bipolar seasonal affective disorder, but there is a risk that it can lead you to switch into mania or hypomania or interfere with your sleep. Adjusting the "dose" of light often corrects these problems.

Psychotherapy

"I cannot imagine leading a normal life without both taking lithium and having had the benefits of psychotherapy," writes Kay Redfield Jamison, a psychiatrist who suffers from bipolar disorder, in her book, An Unquiet Mind.

Psychologist, David Miklowitz, points out in his book, The Bipolar Disorder Survival Guide, that
psychotherapy can help people with bipolar disorder:

Understand past episodes of illness
Make plans to cope with future episodes
Accept and adapt to a long-term medication regime
Develop strategies for coping with stress
Improve academic and workplace functioning
Deal with the stigma associated with the illness, and
Improve relationships with family and friends.

A suitable therapist is one who understands and takes into account the biological basis of your illness and your need for psychiatric care. He or she should be able to help you deal with current difficulties and cope better with future problems. One valuable form of individual psychotherapy for people with bipolar disorder is cognitive-behavioral therapy (CBT), which can help you deal with ingrained patterns of negative thinking. Another individual approach is interpersonal therapy which will help you understand the interactions between your illness and important aspects of your life, like close personal relationships and your workplace, and help you alter these to achieve greater mood stability.

Family and couples therapy can also be valuable for people with bipolar disorder. It is always helpful if people close to you understand your disorder and how you have to cope with it. Family members may also benefit from involvement in a family support . Check with the Depression and Bipolar Support Alliance (800 826 3632; www.ndmda.org) or the National Alliance on Mental Illness (800 950 NAMI; www.nami.org) to see if there is a family support in your area.

Self-help groups can also be very beneficial for people with bipolar disorder, providing opportunities to share experiences and strategies for dealing with illness. Check and see if you can locate a bipolar disorder self-help in your area.

Much more information about psychotherapy and other aspects of the treatment of bipolar disorder can be found in the comprehensive guide written by David Miklowitz, a professor of psychology at the University of California, Berkeley, The Bipolar Disorder Survival Guide: What You and Your Family Need to Know (Guilford Press, 2002).