Bipolar Disorder – Bipolar Disorder – treatment – current and treatment – current and

future…future…Kurt Weber, PhDKurt Weber, PhD

Mental Health America – Brown CountyMental Health America – Brown CountyBemis International CenterBemis International Center

St Norbert CollegeSt Norbert CollegeMay 13, 2008May 13, 2008

BD is a…

long-term illness that can be effectively treated

currently has no cure staying on treatment, even during

well times, can help keep the disease under control and reduce the chance of having recurrent, worsening episodes

basicsbasics

treatment plan for bipolar disorder primarily treatment plan for bipolar disorder primarily consists ofconsists of pharmacological intervention (medications)pharmacological intervention (medications) and sometimes psychological therapyand sometimes psychological therapy

psychiatric hospitalizations may be psychiatric hospitalizations may be necessary to safely reach a point of stabilitynecessary to safely reach a point of stability

also treatment options that are less also treatment options that are less common and those that are usually common and those that are usually considered only in extreme circumstances – considered only in extreme circumstances – we’ll discuss them later!we’ll discuss them later!

medicationsmedications primary goal of drug treatment is to stabilize

the extreme mood swings of mania and depression

also common for medications to be prescribed for extreme symptoms such as psychosis or co-occurring disorders such as anxiety

generally fall into the following categories Anti-Anxiety and Sedatives Antidepressants Antipsychotics Mood Stabilizers Calcium Channel Blockers

Psychotherapeutic Psychotherapeutic interventionsinterventions

Goals increase compliance of taking medications create bonds with others who have the same

condition reduce negative behaviors learn new coping skills

key types of therapy include Cognitive Behavioral Therapy Dialectical Behavioral Therapy Family/Marriage Counseling Gestalt Therapy Group Therapy Psychoanalytic Therapy

Inpatient hospitalizationInpatient hospitalization

allow specialized staff to monitor patients closely

changing medications as necessary to achieve stabilization

to provide concentrated, frequent sessions of therapy

also vital for those who are struggling with thoughts of suicide

majority of hospital stays are inpatient outpatient programs are becoming more

common

Alternative therapies…Alternative therapies…

usually considered only in extreme circumstances Bilateral Cingulotomy Electroconvulsive Therapy Light Therapy

Review of mental health Review of mental health professionalsprofessionals

Psychiatrists Medical doctors with a specialty in psychiatry

- the branch of medicine that deals with the diagnosis, treatment, and prevention of mental and emotional disorders

formal medical training and licensing several years of specialized training American Board of Psychiatry and Neurology usually the ones who prescribe psychotropic

medications

psychopharmacologistspsychopharmacologists

general practitioners and psychiatrists specialty in the branch of

pharmacology that deals with the study of the actions, effects, and development of psychoactive drugs

often involved in clinical research studies for medications

an excellent resource for those with bipolar disorder due to the complicated medication regimens often required

psychologistspsychologists trained to perform psychological research,

testing, and therapy licensed psychologists have a PhD or PsyD and

have completed a licensure exam many different fields of psychology

e.g., clinical social industrial/organizational child/adolescent cognitive

known for conducting therapy sessions, but many are active researchers

General Practitioners / Primary Care Physicians

well-rounded approach to medicine treating an array of illnesses monitoring patience’s overall health and well-

being BD is most often treated with medications

as a result, it can greatly complicate the treatment of other physical ailments

the involvement of the family doctor in overall healthcare as well as the treatment of this disorder is vital

also physicians can make referrals to other healthcare professionals when needed

psychiatric nurse psychiatric nurse practitionerspractitioners

nurses advance dergee specializing in mental

health often work in psychiatric treatment centers

and hospital units serve as

crisis intervention specialists counselors often monitor treatment progress

may also serve as consultants and teachers

social workerssocial workers

Licensed clinical social workers (LCSW) usually have a degree in social work license to practice at the state level through

completion of a supervision program and state certification exam

Social Workers (MSW) have achieved a master’s degree. most often serve as patient advocates ensuring

access to necessary treatments, assisting with financial aid applications, and securing legal assistance if needed

may also serve as counselors or therapists

therapists -- counselorstherapists -- counselors

many different professionals such as those noted above serve as therapists and counselors

generally conduct therapy sessions individual, family and group

goals of changing behavior learning new skills towards improving

overall mental health

bipolar disorder is much better controlled if treatment is continuous rather than intermittent...

even if treatment regimen is followed mood changes can occur and should be

reported immediately to MHP MHP may be able to prevent a full-blown

episode by making adjustments to the treatment plan

MedicationsMedications

recommended that people with bipolar disorder see a psychiatrist for treatment

psychiatric nurse practitioners are also recommended if psychiatry not available, or affordable, or easily obtainable

how to find a psychiatrist how to find a psychiatrist (stolen from about.com)(stolen from about.com)

1. If you have a university within a reasonable driving distance, call their Department of Psychiatry. These psychiatrists are often on the cutting edge of research.

2. If the National Alliance for the Mentally Ill (NAMI) has a branch in your area, get in touch with their offices for a reference. You can also get in touch with their state offices.

3. Join the local chapter of the Depression and Bipolar Support Alliance (formerly NDMDA). This way you can ask individual members for their recommendations and be part of a supportive group at the same time.

4. Phone the psychiatric ward of a hospital in your area and ask the head nurse whom she would see if she needed a psychiatrist.

5. Review the list of approved mental health care providers from your insurance company.

6. Ask your general practitioner and therapist for their recommendations.

7. Scan the yellow pages. Look for certifications such as "Board Certified in Psychiatry" or "Board Certified in Pediatric Psychiatry." Those who specialize in Psychopharmacology may be a good choice.

8. You may want to contact the information and referral (I&R) services of the United Way in your town - particularly if you are in need of financial assistance.

9. Many companies offer employee assistance programs that may be able to provide the names of psychiatrists. Ask your Human Resources Department for information.

10. Call family members and friends for their advice. 11. Telephone the referral service of the hospitals in your

city. 12. Your pastor or rabbi may be able to suggest the names

of appropriate psychiatrists to you.

before your visit…before your visit…

Do you have a strong preference for a male or female doctor? Are the doctor's religious beliefs an issue for you?

Set up your first visit as a short consultation. This will allow you to meet the psychiatrist and his staff without shelling out a lot of money. me may offer a free consultation.

considerations for considerations for bipolar medsbipolar meds

1) Does it treat bipolar mania? 2) Does it treat bipolar depression? 3) Does it act prophylactically to

prevent mania and/or depression?

Mood stabilizersMood stabilizers prescribed to help control bipolar disorder several different types of mood stabilizers

available people with bipolar disorder can continue

treatment with mood stabilizers for extended periods of time

other medications may be added for shorter periods to treat episodes of mania or depression that break through despite the mood stabilizer

The NIMH funded STEP BD research program

after two years of excellent treatment 58% of clients achieve full recovery ~50% will experience a relapse

72% to depression.

LithiumLithium time-honored treatment for manic-depression seems to have a suicide reducing effect that

the other mood stabilizers do not People don't like to take it because it

makes them drink a lot of water and urinate a lot (35%)

causes memory problems (28%) tremor (27%) weight gain (19%) gives them a metallic taste in their mouth can also affect the kidneys and the thyroid

dosed according to blood levels if the lithium level gets too high, death can

result if someone becomes dehydrated, the

lithium level rises with vomiting and diarrhea, confusion, coarse tremor, muscle twitching, slurred speech, and seizures

requires emergency medical attention stopping lithium suddenly may cause a

relapse and increase in suicidality

And… they even know what the mechanism of its

effectiveness! University of Wisconsin researchers found

that lithium exerts a dual effect on receptors for the neurotransmitter glutamate acting to keep the amount of glutamate active

between cells at a stable, healthy level, neither too much nor too little

could be postulated that too much glutamate in the space between neurons causes mania, and too little, depression.

giant step forward in understanding the biological basis of bipolar disorder

anticonvulsantsanticonvulsants

cann have mood-stabilizing effects may be especially useful for difficult-

to-treat bipolar episodes

divalproex sodium - Depakote

used for mania in bipolar disorder evidence that it works to prevent depression is

not convincing generally has fewer side effects than lithium

patients like it better can cause GI problems, pancreatitis, liver

problems, birth defects, decrease in platelets, and hair loss

some evidence that it may provide prophylaxis for new episodes

new extended release preparation patients will require a higher dose with the extended

release preparation.

carbamazepine - Tegretol

second choice for manic-depression for patients who could not tolerate lithium

requires blood levels sedating can cause an anemia and liver problems too much carbamazepine will cause

sedation and lack of coordination long-acting form has been approved –

Equetro

Newer anticonvulsantsNewer anticonvulsants

lamotrigine - Lamictal shows moderate antidepressant action may be prophylactic for bipolar depression no good evidence for the treatment of

mania Dizziness, diplopia, vomiting, and rash are most

common side effects and are generally mild not to be used in patients under 16 discontinue if they get a rash needs to be increased slowly

topiramate – Topamax

not better than placebo for mania in some reports, 20-50% of people

taking topiramate have lost weight used with clozapine and olanzapine to

reduce weight gain if dose is increased too fast, one may

see cognitive impairment may cause kidney stones and glaucoma

oxcarbazepine – Trileptal

similar to carbamazepine minimal interactions with other drugs may contribute to hyponatremia slight evidence that it may be anti-

manic and prophylactic

Atypical antipsychoticsAtypical antipsychotics being studied as possible treatments for bipolar

disorder. clozapine (Clozaril)

Evidence suggests clozapine may be helpful as a mood stabilizer for people who do not respond to lithium or anticonvulsants.

olanzapine (Zyprexa) Other research has supported the efficacy of olanzapine

for acute mania, an indication that has recently received FDA approval

Olanzapine may also help relieve psychotic depression. risperidone (Risperdal) ziprasidone (Zeldox)

Aripiprazole (Abilify) another atypical antipsychotic

medication used to treat the symptoms of

schizophrenia and manic or mixed (manic and depressive) episodes of bipolar I disorder

combinationscombinations

combinations… Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. 3

G) olanzapine + fluoxetine - Symbyax - This is a combination antipsychotic and antidepressant that is geared toward treating bipolar depression. The antidepressant treats the depression while the atypical antipsychotic stabilizes the mood. Although it is FDA approved for bipolar depression, there is little field data on efficacy or effectiveness.

Children and adolescents with bipolar disorder generally are treated with lithium, but valproate and carbamazepine also are used

Researchers are evaluating the safety and efficacy of these and other psychotropic medications in children and adolescents. some evidence that valproate may lead to

adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20

young female patients taking valproate should be monitored carefully by a physician

Women with bipolar disorder who wish to conceive, or who become pregnant, face special challenges due to the possible harmful effects of existing mood stabilizing medications on the developing fetus and the nursing infant

New treatments with reduced risks during pregnancy and lactation are under study

the benefits and risks of all available treatment options should be discussed with a clinician skilled in this area

Bipolar depressionBipolar depression people with bipolar disorder are at risk of

switching into mania or hypomania, or of developing rapid cycling, during treatment with antidepressant medication mood-stabilizing medications generally are

required, alone or in combination with antidepressants, to protect people with bipolar disorder from this switch.

Lithium and valproate are the most commonly used mood-stabilizing drugs today. However, research studies continue to evaluate the potential mood-stabilizing effects of newer medications.

pharmacological treatment pharmacological treatment of bipolar depressionof bipolar depression

should not be treated with antidepressants alone not clear whether there is any benefit at

all for using them lithium lamotrigine olanzapine olanzapine + fluoxetine

bipolar maintenancebipolar maintenance

lithium lamotrigine olanzapine aripiprazole

Mays…Mays… Of clients who were stable for more than 6

months, only 26% were on lithium alone Lithium alone offers

83% probability against affective relapse at one year 52% at 3 years 37% at 5 years

47% suffer relapse on combination treatment. The best evidence-based treatment for bipolar

maintenance at this time would be lithium plus a second generation antipsychotic

however, 25% will show poor response even to multiple medications.

insomniainsomnia

high-potency benzodiazepine medication clonazepam (Klonopin) lorazepam (Ativan) may be helpful to promote better sleep may be habit-forming best prescribed on a short-term basis

Other types of sedative medications, such as zolpidem (Ambien), are sometimes used instead.

changes overseen by psychiatrist, of course…

of course, it never happens that a patient changes meds on their own…

thyroid concernsthyroid concerns people with bipolar disorder often have

abnormal thyroid gland function important that thyroid levels are carefully

monitored by a physician rapid cyclers tend to have co-occurring

thyroid problems and may need to take thyroid pills in addition to their medications for bipolar disorder

lithium treatment may cause low thyroid levels in some people, resulting in the need for thyroid supplementation

psychosocial psychosocial interventionsinterventions

can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas

licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient s progress

number, frequency, and type of sessions should be based on the treatment needs of each person.

common interventions include cognitive behavioral therapy psychoeducation family therapy interpersonal and social rhythm therapy

CBTCBT

Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness

psychoeducationpsychoeducation

teaching people with bipolar disorder about the illness and its treatment how to recognize signs of relapse so that

early intervention can be sought before a full-blown illness episode occurs

may be helpful for family members

family therapyfamily 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

Interpersonal and social rhythm therapy

helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines

may help protect against manic episodes

of course…of course…

As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

dialectical behavior dialectical behavior therapytherapy

DBT is now being used in many settings as a viable therapy for the treatment of bipolar disorder

Treatment in DBT has four parts Individual Therapy Telephone Contact Therapist Consultation - good communication between

group therapist and individual therapist is essential to the successful outcome of DBT

Skills Training - Conducted by a behavioral technician or another therapist usually in a group context

focus is on learning and practicing adaptive skills, not personal or specific complaints of the clients

any specific or personal issues are redirected to be discussed in individual therapy

DBT continued…DBT continued… Core Mindfulness Skills - These are derived from

Buddhist meditation techniques to enable the client to become aware of the different aspects of experience and to develop the ability to stay with that experience in the present moment. - Treatment lasts for about 2 -3 weeks.

Interpersonal Effectiveness Skills - These focus on effective ways of achieving one's objectives with other people: to ask for what one wants effectively, to say no and be taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people (comparable to assertiveness training). - Treatment lasts for about 8 weeks.

Emotion Modulation Skills - These skills are ways of coping with intense emotional experiences and their causes. They also allow for an adaptive experience and expression of intense emotions. - Treatment lasts for about 8 weeks.

Distress Tolerance Skills - These include techniques for putting up with, finding meaning for, and accepting distressing situations if there is no conceivable solution at present. - Treatment lasts for about 8 weeks.

ECTECT if other interventions prove ineffective, or work too

slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered

ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes

possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques

potential benefits and risks of ECT, and of available alternative interventions, should be carefully reviewed and discussed with individuals considering this treatment and, where appropriate, with family or friends

herbals…herbals…

not been well studied little is known about their effects on bipolar disorder FDA does not regulate their production

different brands of these supplements can contain different amounts of active ingredient

Before trying herbal or natural supplements, it is important to discuss them with your doctor evidence that St. John’s wort can reduce the

effectiveness of certain medications may cause a switch into mania in some individuals

with bipolar disorder, especially if no mood stabilizer is being taken

omega-3 fatty acidsomega-3 fatty acids

found in fish oil being studied to determine their

usefulness, alone and when added to conventional medications, for long-term treatment of bipolar disorder

hospitalizationhospitalization

Advance Psychiatry Directives http://www.bazelon.org/issues/advancedirectives/index.htm

http://bipolar.about.com/od/hospitalization/a/packing.htm

finally…finally… Treatment Adherence Rates of noncompliance range from 18-

53% if one includes people who occasionally

miss their medications, it is >70% Clients have limited insight not denial or wish to distort the facts something in the illness that distorts the way

clients see themselves and the world. Regardless, the best predictor of a poor

outcome is poor treatment adherence