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Bipolar Disorder

UNDERSTAND AND PREVENT BIPOLAR DISORDER

 

This course is about a mood disorder that is so commonly discussed in the media of late-bipolar disorder. Although this disorder is not as common as depression, the number of bipolar disorder diagnoses appears to be rising, mainly because of new research and consideration of symptoms that do not meet the full criteria for bipolar but do have many similar symptoms that cause significant impairment. Such symptomatology may comprise other bipolar categories that are considered part of the “bipolar disorder spectrum.” 

(31) Bipolar Disorder

 Child Bipolar Behavior

BPD31

A family member has bipolar disorder. Is there anything I can do to help?

Helping your family member seek treatment is one of the more important ways to assist, particularly when a patient is manic. Because mania is so often perceived by the affected individual as a positive experience, the likelihood of him or her pursuing treatment for it is close to zero. Even when depressed, many individuals have difficulty taking the first step of making an appointment with a mental health practitioner.

Family support is critical to treatment success for these and other reasons. If the person is already in treatment, helping him or her remember the appointments and providing encouragement to stay in the treatment will be of tremendous help. Accompanying your family member to any appointments to provide feedback to the clinician can be of help, as some persons have difficulty identifying either symptoms of mania or depression in their condition.

If the patient is on medication, assistance and reminders to take medication are useful, as a lack in compliance with medication is a common reason for relapse. If you believe that someone is suicidal, seek assistance as soon as possible. If a family member is manic, out of control, and in immediate danger to themselves or others and refuses to get assistance, call the local authorities, such as emergency medical services. EMS will generally bring your family member to be evaluated in the emergency room setting.

Although this option is not always well received by the person involved, it is the best and may be the only choice if someone is at risk for hurting others or, even more worrisome, killing himself or herself.

Leslie’s comments:

I’d like to speak to this question from the perspective of what would be (and is) helpful to me. The key is understanding. However, understanding is not the same as being willing to go along for “the ride” as I move through my mood swings. Understanding means being able to identify behaviors in me that fall outside of my norm and making me aware of them so that I can evaluate my mood and decide if what I am feeling comes from “normal” life stressors or if I am having mood fluctuations that are induced by my brain chemistry.

Being kind and understanding about the reality of bipolar disorder without letting it be used as an excuse is the most helpful to me.

Term:

Compliance - extent that behavior follows medical advice, such as by taking prescribed treatments. Compliance can refer to medications as well as to appointments and psychotherapy sessions.

My mother appears to be hippomanic, but she refuses to see anyone. What can I do?

This situation can be very complicated for the family members of a person who appears to be suffering from hypomania. Hypomania can be difficult to recognize because although it is characterized by a change in functioning, by definition it does not cause marked distress or disability. It can make the person more difficult to work with because he or she is often less willing to listen to and follow directions from others as a result of inflated self-esteem, a situation that often leads to frequent arguments and irritability in the affected individual.

But such symptoms can also be character traits that are always present, though perhaps to varying degrees rather than any dramatic change in personality. Also, because of the stigma of mental illness, many persons with mood disorders never seek treatment. Treatment avoidance may be more likely based on age (older), gender (male), or ethnic and cultural identity (mental illness has a greater stigma in many cultures). Perhaps your mother will not see a psychiatrist but will agree to meet with her primary care physician.

You could accompany her to her appointment, where she might be willing to have you communicate concerns to the doctor. Making an initial appointment with a mental health practitioner on her behalf may be enough to motivate her to seek help, especially if you agree to attend the appointment as well. If, however, your mother absolutely refuses to meet with anyone, a decision needs to be made as to potential for dangerousness to self or others.

For example, if suicidal ideation is suspected, local emergency personnel can be called to take the person to the emergency room. She may be angry about this, but if suicide is a possibility, the risk is worth taking. Some communities have mobile crisis units available in which a team of mental health practitioners can come to the home to evaluate your mother if you feel she is in crisis and agrees to the meeting. You can usually obtain information about home-based mental health services for persons in crisis from the community or city hospitals that sponsor such programs.

Leslie’s comments:

It must be difficult when you see your loved one escalate to a hippomanic state. In my case, the only thing that gets through to me is being told (constantly) that my behavior isn’t normal; that perhaps I should call my clinical nurse specialist to discuss my medication; that maybe I should see my psychotherapist for another opinion.Anyway, it’s hard to hear this especially when I have spent so much time in a depression. It feels great to be completely energized; not needing much sleep, completely motivated to do anything and everything. It’s really hard to acknowledge that I am over the top and need some help getting back on an even keel.

What are the different types of treatment for bipolar disorder?

Types of treatment for bipolar disorder fall into two broad categories: psychosocial treatment and pharmacological treatment. Within each category are many choices. Psychosocial treatments include individual therapies, group therapies, vocational services, family/couples therapies, as well as others. Further, there are different types of individual therapies, such as supportive, insight-oriented, or cognitive-behavioral.

There are also various levels of treatment settings, ranging from private practice settings, outpatient clinic settings, day treatment or partial hospital programs, and inpatient treatment. Pharmacological treatment involves the use of medications from various groups, such as anticonvulsants, antipsychotics, antidepressants, mood stabilizers, or anxiolytics.

Psychotropic medicines are primarily used in psychiatric care for the treatment of mental disorders, including bipolar disorder. Many medications are utilized in other medical areas as well, such as the use by neurologists of antiseizure medications (anticonvulsants), which have been found to be efficacious in the treatment of bipolar disorder.

As part of an evaluation, your clinician will consider the most appropriate treatment plan for your bipolar illness. In part, the intervention will be based upon the phase of the illness, such as depressed, manic, or mixed. The first determination will be whether the illness can be managed acutely in the outpatient setting or best as an inpatient.

Manic phases often require hospitalization unless caught relatively early. For severe bipolar depression, hospitalization may also be required if there is risk for suicide. Patients in an acute mixed state are at particular risk for suicide due to the depression along with the impulsivity of mania. If deemed appropriate for outpatient stabilization, medication will likely be recommended along with psychotherapy.

If a clinician other than a psychiatrist makes your diagnosis, he or she will likely refer you to a psychiatrist for medication consultation. The type of therapy chosen for treatment can depend upon many factors such as cost, duration, or patient fit. Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psycho education, family therapy, interpersonal, and interpersonal social rhythm therapy.

Cognitive-behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Psycho education serves to teach people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before relapse occurs.

Family therapy uses strategies to reduce the level of distress within the family that may either contribute to or result from the ill person’s symptoms and can provide psycho education for the family members.

Interpersonal social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Frequency of psychotherapy typically starts at once per week but may be more or less often depending on your individual needs or therapy type. Frequency may be increased around acute episodes.

Family involvement is important as part of the therapy in bipolar disorder, as family members need to be aware of and able to inform the clinician of any signs of relapse.

Again, as part of the treatment plan, the treatment setting also needs to be determined. Most individuals can be treated in private office settings or outpatient clinic settings. Sometimes, a higher level of structure is needed in which more services can be provided, on a daily basis, such as in a day treatment program. If impairments are severe, or safety is in question, hospitalization may be warranted.

Term:

Insight-oriented also known as dynamic - A form of psychotherapy that focuses on one’s developmental history, interpersonal relationships with one’s family of origin, and current relationships with friends, spouses, and others.

 

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(32) Bipolar Disorder

What is Bipolar Disorder?

BD32

Does the type of bipolar disorder I have determine the type of treatment I need?

The type of treatment intervention needed is going to be dependent more on the phase of illness you are in. When speaking of pharmacological treatments of bipolar disorder, usually it is bipolar I disorder that is specifically being addressed, although the same medications are utilized in bipolar II disorder. A manic individual is more likely to require hospitalization, while a hypomanic person can be managed in an outpatient setting. If psychotic symptoms are present, your clinician will more likely prescribe an antipsychotic agent. The pattern of episodes is also useful in determining what mood stabilizer is likely to be helpful. Lithium is typically most beneficial for cases considered “classic”- that is, with alternating episodes of depression and mania with euthymic mood in between. For persons with history of mania only without depressive episodes, an anticonvulsant such as Depakote (valproate) is typically prescribed.

Mixed episodes or patterns of rapid cycling usually require the use of Depakote (valproate) or Equetro (carbamazepine). Atypical antipsychotics are often added to a mood stabilizer but can be prescribed alone, although often one medication is not enough, and a second agent is needed for stabilization.

Psychotherapy is a necessary part of treatment for all types of bipolar disorder, but during the manic phase it is likely to be supportive and educational only.

What are the different types of talk therapies and what do they do?

Following your consultation, the clinician will recommend the most appropriate treatment or therapeutic approach for your circumstances. The type of therapy that is useful in part depends on the stage of the illness.

Most therapeutic approaches are going to be useful for bipolar depressive episodes, as it is optimal to be able to minimize or avoid the use of antidepressant medication because of the risk for manic switch. Most individuals are not amenable to therapy in the midst of a manic phase. Patients in this stage usually have quite limited insight, and treatment approaches typically need to be supportive and educationally focused. For bipolar depression or bipolar II disorder, there are many different approaches to consider. Many therapists utilize a combination of therapeutic approaches in their work. Some approaches are: Psychodynamic therapy assumes symptoms, such as in depression, are due to unresolved, unconscious conflicts from childhood. It is based upon the classic psychoanalytic approach developed by Sigmund Freud. The therapist uses the concepts of transference, counter transference, resistance, free association, and dreams in order to help the patient develop insight into patterns in relationships that can then effect change. It is a nondirective therapy. Although classic analytical therapy can last for years, with sessions four to five days per week, psychodynamic therapy may be shorter in duration, with sessions one to three times per week. Controlled research studies examining the efficacy of this type of therapy are minimal, due to the nature of this type of therapy. This treatment approach is often helpful for those with chronic coping difficulties or with personality disorders. This therapy approach does not address bipolar illness specifically. Interpersonal therapy is useful for depression, conceptualizing it in a patient with the three components of symptom formation, social functioning, and personality factors. It focuses on the patient’s social, or interpersonal, functioning, with expected improvement in symptoms. The goal is to improve communication skills and self-esteem. It is a brief and highly structured manual-based psychotherapy. Areas of social functioning that may be addressed are interpersonal disputes, role transitions, grief, and interpersonal deficits. Therapy is focused and brief in duration, typically lasting twelve to sixteen sessions. Research studies have shown it to be an effective treatment for depression.

Interpersonal social rhythm therapy (IPSRT) is a relatively new treatment specifically geared toward the management of bipolar disorder, and it is based on the idea that disruptions in daily routines and problems in interpersonal relationships can cause recurrence of the manic and depressive episodes of bipolar disorder.

During the treatment, therapists help patients understand how changes in daily routines and the quality of their social relationships and their social roles can affect their moods. After identifying situations that can trigger mania or depression, therapists teach the individuals how to better manage stressful events and better maintain positive relationships. In bipolar illness, focusing on improvement of interpersonal relationships can be very important, as these are often adversely impacted by the illness. In addition, the therapy can be used to help regularize daily routines that can help in prevention of manic episodes.

Cognitive-behavioral therapy assumes that symptoms are due to a pattern of negative thinking. It works to help patients identify and change inaccurate perceptions of themselves and situations. It also is brief in duration and manual-based, typically lasting for ten to twenty sessions. It typically involves the use of homework assignments between sessions. Research studies have shown it to be an effective treatment for depression and some anxiety disorders. In bipolar illness, it can be especially helpful for bipolar depression, when use of antidepressant therapy may be deemed risky. See Question 38 for further discussion on cognitive-behavioral therapy.

Scott’s comments:

I discovered after my diagnosis that I had been hiding or shielding my condition (quite well I might add) from my MFCC therapist. I have been in some form of talk therapy since 1988 and my bursts of rage were easily deflected to my wife’s incessant nagging, irrational requests, or lack of sympathy for my ability to hear her due to my state of mind, work distractions, etc. I did a heck of a job keeping this out of the therapists’ office. After my diagnosis, I found that cognitive behavioral therapy did little in my case to assuage the condition. If I take my medication regularly, I’m fine. If I forget, I feel the manic state come on. In my case, it’s very physiological.

Terms:

Transference - the unconscious assignment of feelings and attitudes to a therapist from previous important relationships in one’s life (parents and siblings).

Counter transference - the attitudes, opinions, and behaviors that a therapist attributes to his or her patient, based not on the true nature of the patient but rather on the biased nature of the therapist because the patient reminds the therapist of his or her own past.

Resistance - the tendency to avoid treatment interventions, often unconsciously (e.g., missing appointments, arriving late, forgetting medication).

Efficacy - the ability to produce a desired effect, such as the performance of a drug or therapy  in relieving symptoms.

Interpersonal – therapy a form of therapy.

Unlike insight-oriented or dynamic therapy that focuses on developmental relationships, interpersonal therapy focuses strictly on current relationships and conflicts within them.

Interpersonal social rhythm therapy - a form of therapy based on the principles of interpersonal therapy. Specifically geared toward the treatment of bipolar disorder with monitoring of daily activities, including sleep.

Cognitive behavioral therapy - combination of cognitive and behavioral approaches in psychotherapy, during which the therapist focuses on automatic thoughts and behavior of a self-defeating quality in order to make one more conscious of them and replace them with more positive thoughts and behaviors.

How do I choose a therapist and a therapy approach?

Choosing a therapist can be an overwhelming task. One look in the Yellow Pages shows lists of names, and not every therapist is listed there. One factor to consider is that there are many possible credentials of therapists. Some people identify themselves as therapists but do not have credentials that require licensure within their state. In general, a licensed practitioner will have been through a screening process that usually involves testing within their field. Level of training is another consideration. There are master’s levels (social workers), doctorate levels (psychologists), as well as medical doctorate levels (psychiatrists) who do psychotherapy. Clinicians of various credentials may then have further training within a specific area of psychotherapy, such as psychoanalysis. In the treatment of bipolar disorder, you will most likely need medication, thus it may be more fruitful to see a psychiatrist who also performs psychotherapy.

Due to cost considerations, however, this option is not always feasible. Many insurance plans will provide reimbursement for master’s level therapists only, whose fees usually are less than those of psychologists or psychiatrists. If there is a specific treatment modality in mind, one method of finding a therapist is to obtain referrals from professional societies for that specific modality. If modality is not the issue of concern, referrals can be obtained from a primary care physician. You may ask the therapist questions over the phone and arrange a consultation. If you are uncomfortable with the therapist following the consultation, it is important to consider the reasons for your discomfort. Sometimes individual psychological issues are projected onto the therapist immediately and thus are avoided by failing to continue to see the therapist. But certainly there needs to be a fit with the therapist’s style in order to develop a working relationship.

Term:

Projected - the attribution of one’s own unconscious thoughts and feelings to others.

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(33) Bipolar Disorder

LIVING WITH BIPOLAR DISORDER

BD322

What is cognitive-behavioral therapy?

Cognitive-behavioral therapy (CBT) is based upon two separate theoretical models, both cognitive and behavioral. Cognitive models are based upon the premise that cognitions, or thoughts, determine emotions and behavior. Automatic thoughts are one type of cognition that may be distorted by errors of thinking such as overgeneralization, catastrophic thinking, jumping to conclusions, or personalization. Errors in thinking tend to be more frequent and intense in depression as well as in other psychiatric disorders. Behavioral models are based upon theories of learning such as by modeling or by reinforcement to certain responses.

Cognitive-behavioral therapy uses techniques based upon the models described above. A greater emphasis on cognitive approaches or on behavioral approaches may be taken depending upon the disorder and the stage of treatment. Cognitive techniques include:

• Psycho education

• Modifying automatic thoughts

• Modifying schemas

Behavioral techniques include:

• Activity scheduling

• Breathing control

• Contingency contracting

• Desensitization/relaxation training

• Exposure and flooding

• Social skills training

• Thought stopping/distraction

Through many of these techniques, patients learn to manage their anxiety and reactions to stress appropriately. Exposure training is a technique that uses graded exposure to a high-anxiety situation by breaking the task into small steps that are focused on one by one.

CBT has been the best-studied form of psychotherapy, and it has been shown to effectively treat depression and thus can be a very effective treatment for acute cases of mild to moderate depression in bipolar disorder, when antidepressant exposure needs to be minimized.

Treatment typically lasts three to six months with ten to twenty weekly sessions. The patient is expected to be an active participant in trying out new strategies and will be expected to do homework.

Terms:

Automatic thoughts - thoughts that occur spontaneously whenever a specific, common event occurs in one’s life and which are often associated with depression.

Overgeneralization - the act of taking a specific event, usually psychologically traumatic, and applying one’s reactions to that event to an ever-increasing array of events that are not really in the same class but are perceived as such.

Catastrophic thinking - a type of automatic thought during which the individual quickly assumes the worst outcome for a given situation.

Schema - representations in the mind of the world that affect perception of and response to the environment.

Contingency – contracting use of reinforces, or rewards to modify behaviors.

Flooding - exposure to the maximal level of anxiety as quickly as possible.

Thought stopping - a technique used to suppress repetitive thoughts.

Graded exposure - a psychotherapeutic technique applied to rid a patient of specific phobias. A gradual exposure to the phobic situation is set about first through imagery techniques, then through limited exposure in time and intensity before full exposure occurs.

Are there any risks from engaging in psychotherapy?

Psychotherapy appears, on the surface, to be one of the most benign forms of medical therapies. There is (usually) no physical contact. No medications are prescribed. Only words are exchanged between people, nothing more. But never underestimate the force of words. There is a parable that may be recalled from childhood: “Sticks and stones may break my bones but names will never hurt me.” Such a parable was created to provide comfort from the emotional wounds received from being called names. Words carry power. Just as psychotherapy has the power to heal, it also has the power to harm. The various harms range from lack of progress to outright abuse. Most harm from psychotherapy comes from what are known as boundary violations between the therapist and the patient. The most obvious boundary violation stems from sexual or physical relationships that can develop between the therapist and patient. In many states this boundary violation is considered a criminal offense because the power differential between the patient and clinician is so great as to put the patient in a particularly vulnerable position.

Other boundary violations are not as obvious. Simple exchanges of personal information between the patient and therapist are often considered to be boundary violations and may or may not lead to more serious offenses on the part of the therapist. The potential dangers are that they may lead to friendly meetings that move beyond the office, and friendly meetings may turn more intimate. Many patients may experience their therapists as a friend; such feelings generated are known in therapy as transference. Transference is an artificial relationship that the patient projects onto the therapist. In insight-oriented or dynamic (Freudian) psychotherapy a transference relationship is intentionally created to allow the therapist to better understand a patient’s outside relationships. This in turn allows the therapist to help a patient develop insight or greater understanding into the unconscious motives behind his or her relationships so that healthy interactions can be learned.

Therapists also develop transference relationships with their patients, known as counter transference. If the therapist is unaware of his or her counter transference, then his or her behavior can reflect the therapist’s own outside relationships rather than the patient’s. If such relationships are problematic this in turn could be projected onto the patient. As a result a patient may be made to feel that he or she is experiencing problems that are really the problems of the therapist. Patients often idolize their therapist, which makes patients particularly vulnerable to the influence of their therapist’s words.

A notable example of the vulnerability patients can have in therapy occurred a few years back when some cases were made public of patients believing through their therapists’ suggestions that their parents sexually abused them. The process by which this occurred came about through the implantation of false memories on the part of their therapists. The therapists did not do this intentionally.

In their zeal to associate certain symptoms their patient’s presented with to a history of sexual abuse, they began to gradually convince their patients they had repressed memories of abuse. Once they had convinced their patients of past abuse, false memories could easily be constructed by asking them to imagine being abused or by implanting false memories through hypnosis. The term false memory syndrome was coined and several high profile legal cases occurred in which patients sued their therapists for psychological damages as a result of the patients taking action on their false memories.

How can you reduce such risks? You must rely primarily on referrals and word of mouth from friends as well as other professionals. Generally your primary care doctor has developed relationships with various therapists over the years and knows their work. Success in therapy isn’t so much dependent upon the academic degree of the therapist as is the therapist’s training and experience in treating patients. Secondarily, you need to maintain an open mind to make changes if uncomfortable with a particular therapist, no matter how skilled he or she may be. Chemistry between patient and therapist is needed, and no amount of training provides that for any particular patient. Success in therapy depends on how one feels about the therapy sessions as well as the motivation from the therapist to “do the work” outside of therapy in order to make the changes needed.

Leslie’s comments:

It is really important to do your homework when choosing an appropriate therapist. It’s easy to feel intimidated when speaking with a therapist for the first time but remember, in the simplest terms, you are a “consumer” of a “service” and therefore you need to find someone who will be a good fit for you as you do your work.

I made the mistake once of not doing enough homework. I saw a therapist for a few appointments and was made to feel like a dangerous “monster” because of my bipolar disorder; she was actually afraid of me. Needless to say, this experience did far more damage than good.

I am now in long term therapy with a licensed clinical social worker. We work very well together and she is extremely helpful as I face the challenges inherent in this disorder.

Term:

Dynamic - referring to a type of therapy that focuses on one’s interpersonal relationships, developmental experiences, and the transference relationship with his or her therapist. Also  known as insight-oriented.

 

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(34) Bipolar Disorder

 

Bipolar Disorder. Sex, Hyper sexuality, High Libido. Mental Health Professionals

BD33

How is psychotherapy helpful if bipolar disorder is due to a chemical imbalance?

Every thought, feeling, and behavior is associated with a chemical change in the brain. If thoughts, feelings, and behaviors occur with a repeated pattern, structural changes can occur in the brain as well. Learning and memory involve complex chemical changes that lead to permanent structural changes in brain anatomy. For example, consider the first time that you learned how to drive a car. It required conscious processing of complex pieces of information and integrating the information into an organized behavioral pattern. The powers of concentration at that time can be exhausting.

However, with practice the skill becomes second nature as the brain adapts the skill so that much of it occurs unconsciously. Behavior ultimately leads to structural and biochemical changes in the brain.

The chemistry and structure of the brain can change via one of three methods:

1. Change in the environment

2. Change in brain chemistry via chemical modification with the use of psychotropic medication

3. Learning how to modify the environment or perception of the environment by developing new skills.

Moving, changing jobs, and getting married or divorced are examples of the first method, while psychopharmacology is the second.

Psychotherapy is the third method.

Brain imaging studies have repeatedly demonstrated, for example, that changes occur in the same brain regions of patients with obsessive-compulsive disorder on Sarafem (fluoxetine) as those receiving cognitive-behavioral therapy.

Each of these methods has their own inherent costs and benefits and therefore none can be considered inherently better or worse than another. The effects of all three methods are generally cumulative; thus in order for one to have the best chance of recovery from mental illness, a combination of two to three methods is generally warranted. In bipolar depression, therapy can be especially useful in an attempt to treat the depression without an antidepressant or with as low a dose of an antidepressant as possible. Therapy can help patients maintain daily structure and rhythm to help prevent the recurrence of mania. During a manic episode, therapy provides support and psycho education that are critical for treatment adherence and recovery.

What are the different types of medication used to treat bipolar disorder?

How does my doctor choose a medicine?

The treatment of bipolar disorder is fraught with controversy. The two most controversial issues include the definition of a “mood stabilizer” and the use of antidepressant medications for the bipolar depressed patient.

A true mood stabilizer should ideally treat acute mania, acute depression, and prevent both relapse and recurrence of either mania or depression. By that definition there is really no true mood stabilizer outside of electroconvulsive therapy (ECT), which is successful in treating all categories of bipolar illness. Typically, therefore, most clinicians equate the term mood stabilizer with a medication that treats acute mania and prevents its recurrence. More appropriately, these should be termed antimanic agents, as they are parallel to antidepressant agents and treat the other end of the mood spectrum. All mood stabilizers fail in the treatment of acute depression.

The jury is out as to whether they prevent depression in the same way they prevent mania. For this reason antidepressants are still commonly used. But because antidepressant medications may switch an individual from depression into mania and actually worsen one’s overall condition, the issue of antidepressant use remains controversial. Complicating this issue is the fact that some clinicians define a mood stabilizer as any agent that treats one arm of the bipolar spectrum without causing switching to the other arm. By this definition, some antidepressants may meet this standard, though the jury is out in this regard as well. It does appear that some classes of antidepressants cause less switching than others.

These classes include the SSRIs and buproprion. Also by this definition the anticonvulsant Lamictal (lamotrigine) has been called a mood stabilizer even though it is clearly more effective in preventing a depressive relapse or recurrence than a manic relapse or recurrence.

Thus, the term mood stabilizer is generally used very loosely to describe any medication that treats “mood swings,” an equally vague term that can mean just about any type of emotional change, even those associated with personality disorders such as borderline personality. One final caveat: most antimanic agents stabilize neuronal cell membranes. As a result, any type of over stimulation of the central nervous system, whether it is seizure activity, mania, a panic attack, or explosive rage, can respond to an antimanic agent. Therefore, the fact that one’s mood is “stabilized” by an antimanic agent does not necessarily mean one is bipolar.

With that introduction let us now proceed with the different classes of medications that are used in the treatment of bipolar disorder. The classes more specifically break down into several of the following categories in order of understanding and importance in treating the condition:

• Lithium carbonate and its different formulations

• Anticonvulsant medications• Atypical antipsychotic medications

• Typical antipsychotic medications

• Benzodiazepines

• Antidepressant medications (specifically the selective serotonin reuptake inhibitors, or SSRIs)

• Calcium channel blockers

• Mood stabilizers

• Others under investigation

Note that the antimanic effects of anticonvulsants do not exhibit a class effect. That is, just because a medication is considered an anticonvulsant one cannot immediately assume it has antimanic properties. This was prominently demonstrated after the medication Neurontin (gabapentin) was touted for its potential antimanic effects prior to any clinical trials, which later demonstrated that it was not superior to placebo and led to a series of lawsuits against the manufacturer for false promotion. Alternatively, both the typical and atypical antipsychotic all demonstrate antimanic effectiveness and therefore clearly exhibit a class effect.

The specific medications, whether or not FDA approved, whether or not clinical trials exist to demonstrate their effectiveness, and whether or not they are routinely used clinically regardless of either FDA approval or the existence of clinical trials supporting their use. Bear in mind that this table does not represent all the medications used to treat bipolar disorder but rather the most common. The majority of medications used in the treatment for bipolar are used off-label as they are not FDA approved. First, the FDA is slow to approve medications. Second, pharmaceutical companies are slow to perform clinical trials. Trials are expensive, and once a drug is approved for acute mania, the need to seek approval for the other aspects of the condition diminishes considerably unless increase in market share can be anticipated with FDA approval. Third, once a drug becomes generic, only the government will spend money on a clinical trial.

Finally, just because there are negative clinical trials does not mean that a medication is no longer used. There is enough individual variability in bipolar disorder to not immediately discount any medication, particularly when one is refractory to those medications that have proven beneficial. This is one reason why Neurontin (gabapentin) continues to be used, although in a very limited, circumscribed manner today than prior to the uproar around it. There are individuals who may idiosyncratically respond to one medication just as there are individuals who have idiosyncratic paradoxical responses to another, neither of which condition can be predicted.

There are published treatment guidelines and algorithms that psychiatrists follow in order to simplify this table and start with the most appropriate medication depending upon the clinical presentation. There also appear to be many differences between bipolar I and bipolar II disorder.

All clinical trials leading to FDA approval are based on bipolar I disorder, and it is not clear if these medications have the same effect on bipolar II disorder. It is also not clear if bipolar II disorder is truly a “spectrum” disorder-that is, lying on a continuum with bipolar I disorder rather than a unique entity itself.

This uncertainty is partly based on genetic studies that suggest that bipolar I disorder shares more genes in common with schizophrenia and schizoaffective disorder than with bipolar II disorder. It is also partly based on at least some clinical reports that bipolar II patients may respond differently to the listed medications than bipolar I patients.

That being said, the general guideline makes the following recommendations. If a patient presents with acute mania, use of one medication is indicated; the choice between lithium and Depakote (valproate) is based partly on each medication’s side-effect profiles as well as the presence or absence of various symptoms.

For example, for patients who have suffered from depression but are currently manic, lithium is recommended. Lithium appears to be the closest to meeting the definition of a mood stabilizer in that it appears to prevent both depression and mania. For those patients who have recurrent manic episodes without depression, anxiety/agitation, or a substance abuse disorder, valproate is recommended. Patients with rapid cycling symptoms (four or more episodes annually) may respond better to either Equetro (carbamazepine) (if the episodes include more depression) or Depakote (valproate) (if the episodes include more mania). For manic patients with psychotic features (delusions, hallucinations, and/or grossly disorganized thinking and behavior) the addition of an atypical antipsychotic medication is recommended, but most atypical antipsychotics have FDA approval for monotherapy treatment of an acute manic episode.

Alternatives to lithium and Depakote (valproate)  include Equetro (carbamazepine) and Trileptal (oxcarbamazepine).

If symptoms are not adequately controlled within 10 to 14 days, addition of a second first-line agent is indicated (e.g., adding an anti-psychotic if not already prescribed). Clozaril (clozapine) may be effective in refractory cases.

For bipolar depression, either Lamictal (lamotrigine) alone (or with an antimanic agent) or Symbyax should be initiated. If one fails to respond to these two strategies the addition of Seroquel (quetiapine) or lithium may be recommended. Failing that, an additional antimanic agent plus an SSRI, buproprion, or Effexor (venlafaxine) may be added. Electroconvulsive therapy (ECT) is considered for more refractory cases (as well as for refractory mania).

Trials of nontraditional medications such as calcium channel blockers, stimulants, or thyroid hormone should be considered in conjunction with all of the above when symptoms cannot be adequately controlled.

This is known as rational polypharmacy, as medications from different classes with different actions are added that may have a synergistic effect to improve mood stability.

Leslie’s comments:

This is difficult because each prescriber has a different theory on what makes the best combination of medication. I have been on so many different medications trying to get it“right.” It can become very disheartening to try a medication, take the time to build up to a therapeutic dose, and then realize that either it’s not working or the side effects cannot be tolerated. Sometimes I have felt like a guinea pig trying these medications but, in the end, it does pay off because when you find the right medications, the disorder is manageable. Right now I am on an antidepressant, a mood stabilizer, and an atypical antipsychotic. This seems to be a good combination for me.

Terms:

ECT - electroconvulsive or shock therapy

Benzodiazepine - a drug that is part of a class of medication with sedative and anxiolytic effects.  Drugs in this class share a common chemical structure and mechanism of action.

Placebo - an inert substance that when ingested causes absolutely no physiological process to occur but may have psychological effects.

Off-label - prescribing of a medication for indications other than those outlined by the Food and Drug Administration (FDA)

Rational polypharmacy - the practice of combination medication therapy with consideration of the clinical effects, adverse effects, drug interactions, and relation between effective and toxic drug levels, as well as with an understanding of the mechanisms of action of each agent.

 

 

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(35) Bipolar Disorder

Women's Sexuality and Bipolar Disorder

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What are the side effects of medication for bipolar disorder?

Side effects can occur with all medications, not just psychotropic medications. In bipolar disorder however, medications are taken for long periods, so some side effects may not be tolerable because of the duration of treatment required. Side effects vary both within a class of medications and between classes, although the group of atypical antipsychotics have more similar side-effect profiles than the group of anticonvulsants, for example.

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