Treatment and Outcome

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Treatment And Outcome

The usual treatment for Bipolar I Disorder is lifelong therapy with a mood-stabilizer (either lithium,

carbamazepine, or divalproex / valproic acid) often in combination with an antipsychotic medication.

Usually treatment results in a dramatic decrease in suffering, and causes an 8-fold reduction in suicide

risk. In mania, an antipsychotic medication and/or a benzodiazepine medication is often added to the

mood-stabilizer. In depression, quetiapine, olanzapine, or lamotrigine is often added to the mood-

stabilizer. Alternatively, in depression, the mood-stabilizer can be switched to another mood-stabilizer,

or two mood-stabilizers can be used together. Sometimes, in depression, antidepressant medication is

used. Since antidepressant medication can trigger mania, antidepressant medication should always be

combined with a mood-stablizer or antipsychotic medication to prevent mania.

Research has shown that the most effective treatment is a combination of supportive psychotherapy,

psychoeducation, and the use of a mood-stabilizer (often combined with an antipsychotic medication).

There is no research showing that any form of psychotherapy is an effective substitute for medication.

Likewise there is no research showing that any "health food store nutritional supplement" (e.g., vitamin,

amino acid) is effective for Bipolar I Disorder.

Since a Manic Episode can quickly escalate and destroy a patient's career or reputation, a therapist must

be prepared to hospitalize out-of-control manic patients before they "lose everything". Likewise,

severely depressed, suicidal bipolar patients often require hospitalization to save their lives.

Although the medication therapy for Bipolar I Disorder usually must be lifelong, the majority of bipolar

patients are noncompliant and stop their medication after one year. At 4-year follow-up of bipolar

patients, 41% have a good overall outcome and 4% have died. Women with bipolar disorder lose, onaverage, 9 years in life expectancy, 14 years of lost productivity and 12 years of normal health



Improving Outcomes in Bipolar Disorder

Psychosocial therapies augment medication, but challenges remain.

From Harvard Health Publications

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Although bipolar disorder is diagnosed largely on the basis of whether a manic or hypomanic episode

has occurred, the condition's most painful burden may be depression and disability. In fact, bipolar

disorder is the sixth leading cause of disability worldwide.

Disability is partly a consequence of the high rate of relapse for episodes of both mania and depression.

For example, in a study of people with bipolar disorder type 1, characterized by episodes of mania

(rather than hypomania) with or without depression, researchers followed patients after they suffered amanic or depressive episode. They found that 37% of patients experienced a recurrence of mania or

depression within a year, 60% within two years, and 73% within five years.

Full recovery from a manic or depressive episode if it is achieved may take months, even years.

One study of patients who had been hospitalized for a manic episode and were then followed after

discharge found that 48% of patients recovered from symptoms by the end of a year, but only 24%

returned to normal life functioning. Another study found that aftereffects of a manic episode continued

to affect work, social, and family relations as long as five years later.

Work functioning is a major area of vulnerability. One study found that only 33% of patients with bipolar

disorder worked full-time and 9% worked part-time, while 57% said they were unable to work at all, or

could work only in some type of supportive (sheltered) environment.

Of course, it's important to remember that many people with bipolar disorder eventually rebuild their

lives. But clinicians and patients alike want to find ways to better support and hasten recovery.

Summary points

Recovery may take years for people with bipolar disorder.Depression causes more impairment than mania.

Psychological therapies, combined with medication, help hasten recovery and reduce risk of relapse.

Depression a key factor in disability

Researchers believe that depression is the most significant predictor of disability from bipolar disorder.

Patients generally take longer to recover from a depressive episode than a manic episode, tend to



emerge from a depressive episode with greater impairment, and experience residual symptoms of

depression between clinical episodes. Patients may spend as much as half the year feeling ill due to their

symptoms, with depressive symptoms predominating. Symptoms of bipolar depression tend to

compromise functioning more than symptoms of major depression or dysthymia.

Adding to the challenge, only two medications quetiapine (Seroquel) and an olanzapine-fluoxetine

combination (Symbyax) are specifically approved to treat bipolar depression (compared with nine

medications for mania). And there is growing evidence that using standard antidepressants as an

adjunct to mood-stabilizing medications does not benefit patients with bipolar disorder.

Making matters worse, patients with bipolar disorder like those with other types of chronic illnesses

often take their medications irregularly or stop taking them altogether. According to the research,

anywhere from 18% to 52% of patients with bipolar disorder do not take medications as prescribed.

Finally, in bipolar disorder, the brain's ability to regulate emotion is probably compromised, so stressand conflict, which trigger negative emotions, tend to worsen symptoms, especially depression. Thus

people with bipolar disorder are particularly vulnerable to inadequate social support, traumatic life

events, and hostility or criticism from family members. High levels of neuroticism (a tendency to

overreact or interpret situations negatively) or a dysfunctional cognitive style also increase (or may

underlie) vulnerability.

Psychosocial therapies essential

Psychotherapy and social interventions offer an essential adjunct to drug treatment of bipolar disorder.

A large body of research shows that such therapies, when combined with mood-stabilizing medications,help to alleviate symptoms, increase the number of months a patient feels well, hasten recovery, and

decrease the risk of relapse. The evidence is strongest for four methods: psychoeducation, cognitive

behavioral therapy (CBT), family-focused therapy, and interpersonal and social rhythm therapy.

Psychotherapies are probably useful because they address aspects of recovery that medications alone

do not. Although individual psychotherapies have different theoretical foundations and address

particular challenges, they also have a lot in common. All seek to enlist the patient as an active

participant in recovery by providing information about bipolar disorder and its treatments, educate

patients and families about early signs of relapse, and bolster their coping skills. They also encourage

collaboration between patients, clinicians, and family members. The fact that these therapies tend to

work in multiple ways at once supports the theory that different aspects of recovery from bipolar

disorder need different interventions.

Researchers have begun to evaluate the impact of psychotherapy on social and vocational functioning

aspects of life such as being able to work or sustain supportive relationships that may determine

whether someone will recover fully or become disabled.



The latest evidence comes from the Systematic Treatment Enhancement Program for Bipolar Disorder

(STEP-BD), a federally funded, multi-site investigation that enrolled patients typical of those treated in

the community, so that the results are clinically relevant. STEP-BD researchers reported in 2007 that

patients who received any of three types of intensive psychotherapy 30 sessions of CBT, family-

focused therapy, or interpersonal and social rhythm therapy delivered over nine months functioned

better overall, had more stable personal relationships, and reported enjoying l ife more, when compared

with patients who received a briefer and less intensive psychoeducation intervention, consisting of three

sessions over six weeks. The three intensive interventions were about equally effective. There was no

effect, however, on ability to work or engage in recreational activities.

Psychoeducation

This type of therapy may be delivered on its own, but it is also a key component of other psychosocial

interventions for bipolar disorder. It is sometimes given in the context of larger programs of collaborative patient care. Psychoeducation can take place on an individual basis or as part of group

therapy.

The goal is to provide social support and share information relevant to bipolar disorder so that a patient

can adapt to living with a chronic illness and find ways to remain stable. Therapy may involve steps to

reduce risk factors for relapse (by identifying and avoiding stressful people and events), to structure the

day and normalize sleep/wake cycles, or to ensure access to emergency medication should symptoms

escalate.

The results of psychoeducation studies are difficult to aggregate because they examine differentcomparison groups. The bulk of the evidence indicates that psychoeducation is effective at reducing

episodes and relapses of mania though not depression.

Cognitive behavioral therapy

Several types of CBT for bipolar disorder exist, adapted from those used to treat unipolar depression.

CBT encourages patients to recognize and change distorted thinking that may contribute to symptoms

(often with the help of written assignments). In bipolar disorder, this involves challenging grandiosity

and unreasonable risk taking, as well as pessimism.

This therapy also encourages patients to enjoy themselves and interact constructively with their

environment, but to avoid the kind of stimulation such as substance use or sleep deprivation that

could trigger a manic episode.



Studies of CBT's effectiveness on bipolar disorder have produced mixed results, and only a few have

evaluated how well this therapy works for bipolar depression. Some researchers believe that CBT may

be most useful for patients who are in the early stages of bipolar disorder or who have milder forms of

the disorder.

Family-focused therapy

Although many different forms of family therapy for bipolar disorder exist, the best studied is family-

focused therapy, developed by psychologists David J. Miklowitz at the University of Colorado and

Michael J. Goldstein at the University of California, Los Angeles.

The therapist educates family members about bipolar disorder so that they can better support a

patient's recovery. Over a period of nine months, clinicians teach the patient and family members how

to recognize emerging symptoms of the disorder and prevent relapse, communicate productively, and

resolve family and other interpersonal conflicts. A problem-solving component focuses on particularaspects of rebuilding a patient's life after an acute episode, such as renegotiating intimate relationships,

determining when it's safe to return to work, and maintaining medication regimens while dealing with

any side effects.

Several randomized controlled trials have concluded that family-focused therapy, combined with

medication, improves medication adherence, stabilizes symptoms, delays relapse, and enhances family

relationships. One study found that 60% of patients who received individual therapy were rehospitalized

within two years, compared with only 12% of those who received family-focused therapy. This therapy is

particularly effective with depressive symptoms and relapses, but it's not clear whether it has the same

effect on manic symptoms and relapses.

Interpersonal and social rhythm therapy

This therapy, developed by psychologist Ellen Frank and colleagues at the University of Pittsburgh,

stresses the importance of establishing regular routines, such as going to bed and getting up at the same

time every day, to avoid triggering a relapse. Therapists also help patients cope with grief over having a

chronic illness. In addition, they focus on how interpersonal relationships affect mood and help patients

renegotiate interpersonal roles in light of the illness.

Studies have reported that this therapy can help patients keep symptoms under control and avoid

relapse, and may speed recovery from depression.



Bipolar Disorder Treatment

Co-occurring Disorders (Dual Diagnosis)

0

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Treatment for bipolar disorder is a comprehensive process of bringing an unmanageable life back under

control. For the millions of Americans suffering through the unpredictable mood swings of bipolar

disorder, effective treatment is crucial in order to reduce and better manage symptoms. Treatment for

bipolar disorder is not a rapid process - it usually requires knowledgeable mental health professionals

and the involvement of the loved ones of the person affected.

What is Bipolar Disorder?

Bipolar disorder is characterized by the cycling of recurrent episodes of mania and depression. Mania

usually refers to periods of elevated mood, such as excitement, irritability, periods of elation, and other

high-energy states. Conversely, bipolar depressive episodes are often characterized by despondency,exhaustion, unexplainable sadness, insecurity, and a general state of melancholy.

Treatment for bipolar disorder is often complicated by the very nature of these mood swings. Often,

those with bipolar disorder feel normal during manic periods- even though they may engage in

irresponsible behavior- and so typically only seek help during depressive episodes. As a result, bipolar

disorder is often misdiagnosed as various forms of depression. Compounding the problem is the fact

that individuals that seek help during manic episodes are often incorrectly assumed to be suffering from

ADD or ADHD.

Because of these complications, many people have suffered with bipolar disorder for as long as a decade

before being diagnosed correctly. However, today there are very effective methods of treating bipolar

disorder that includes a program of education, medication, therapy, lifestyle choices, and the

involvement of loved ones.

Diagnosing Bipolar Disorder

Identifying bipolar disorder begins by ruling out other conditions. This typically involves a thorough

medical exam that will seek to determine if symptoms are being caused by illnesses, injuries, or

imbalances- such as improper use of medications or medications that conflict with one another. Tests

for physical disorders such as thyroid or other glandular conditions are conducted in order to eliminate

physiological causes.

The most important aspect of diagnosing bipolar disorder is a psychological exam. Trained psychiatrists

that specialize in treatment of bipolar disorder will ask potential sufferers questions regarding lifestyle,



manic and depressive episodes, suicidal thoughts or attempts, and will also want to discuss any previous

psychological treatment in order to make as accurate a diagnosis as possible.

The psychological evaluation is a crucial part of treatment of bipolar disorder, and often involves family

members and loved ones in order to gain multiple perspectives on the mood and personality of the

apparent sufferer. This is important to ensure that the diagnosis is correct, as bipolar is often

misdiagnosed as depression, schizophrenia, and other mood and personality disorders.

SPECIFIC BIPOLAR DIAGNOSES

Most people diagnosed as bipolar will fall into one of the following categories:

Bipolar I Disorder

Bipolar II Disorder

CyclothymiaThe primary difference between bipolar types I and II is the state of manic episodes. Bipolar I sufferers

cope with the most severe version of the condition, characterized by multiple manic and depressive

episodes. Those with bipolar II suffer from significant depressive episodes, but have experience much

milder periods of mania known as hypomania.

People suffering from cyclothymia have recurrent bouts of both hypomania and mild depression. This

condition is essentially a very mild form of bipolar disorder, but can often develop into bipolar disorder

types I or II if not monitored and treated accordingly.

Diagnosis and treatment of bipolar disorder must be thorough in order to prevent potentially dangerous

misdiagnoses. This is because medications and treatments for other types of conditions and disorders,

such as depression and schizophrenia, can actually worsen bipolar symptoms and increase the likelihood

of suicide. This is an especially important consideration, as nearly one in five sufferers of bipolar

disorder complete suicide. With a proper plan engaged for the treatment of bipolar disorder, this

doesnt have to be the case.

Treatment for Bipolar Disorder

Treatment of bipolar disorder begins with allowing the afflicted person to take back control of their life

through education and self-help. By understanding the condition and its symptoms, a person living with

bipolar disorder can know the difference between their natural selves and the onset of bipolar

symptoms. Identifying these differences and communicating them to family members can help



significantly in managing the disorder, and empowers both the sufferer and family by involving them in

the education and treatment process.

As part of a balanced treatment plan for bipolar disorder, people with bipolar are encouraged to make

healthy lifestyle choices to help control and reduce symptoms. This includes eating a healthy diet,

exercising regularly, and abstaining from harmful activities such as drinking or taking drugs.

Additionally, maintaining a regular sleeping schedule, limiting stressors, and sustaining regular sun

exposure are important as well. Physical and emotional health is strongly linked to the onset and

progression of bipolar disorder. Understanding that these aspects can be controlled is a vital part of an

effective treatment program.

Medication for Bipolar Disorder

Medication is also an integral component to treating bipolar disorder. In order to be effective,

medication must be taken precisely as scheduled; even if no symptoms have been present for sometime. Mood swings may still occur, but will be significantly reduced with effective medication. Seeing a

medical doctor regularly while on any medication is important to monitor any possible physiological

changes or side effects.

Bipolar Disorder Therapy & Support

Ongoing therapy with a professional that specializes in bipolar disorder is another primary part of

treating bipolar. Therapy sessions can be private, or they can involve family members. This often helps

to recognize symptoms or issues that might otherwise be disregarded or not noticed by someone living

with bipolar disorder. Studies have shown that people with bipolar who consistently participate intherapy are happier overall with their lives and treatment and have reduced or less severe manic and

depressive episodes.

Therapy for bipolar disorder is also imperative to determine if medications are working correctly.

Sometimes, therapy and other forms of treatment may succeed so well that medications can be reduced

or eliminated. On the contrary, worsening conditions can be indentified during therapy and medication

can be adjusted accordingly.

There are three primary types of therapy employed to help those with bipolar disorder. They are:

Cognitive/Behavioral Therapy: Explores how thinking affects state of mind and emotions, and focuses on

changing thought patterns that negatively impact a person with bipolar disorder.

Interpersonal Therapy: Helps define and resolve issues in relationships by discussing them candidly,

addressing them proactively, and adhering to a plan for a balanced life rhythm.



Family Focused Therapy: Allows treatment for bipolar disorder to include family and loved ones, who

are often negatively affected by symptoms and unmanageable lifestyles caused by bipolar related

issues.

Supplemental Treatment for Bipolar Disorder

Because bipolar symptoms are often activated or exacerbated by stress, any person living with bipolar

should take part in activities that reduce stress. While this can be something as simple as a daily walk, it

can also include making regular visits to a massage therapist, an acupuncturist, or meditation specialist.

Any self-help form of treatment for bipolar disorder such as these will provide an outlet to release

stress, as well as place control of the condition back into the hands of the sufferer. Knowing that bipolar

is manageable and that steps can be taken now and every day to create a better life while living with

bipolar is perhaps the most important part of a strong, effective, and lasting treatment plan.

Last Updated on Friday, 29 April 2011 13:22



Table showing recommended blood tests

The key to the treatment of bipolar disorder (whether bipolar I or bipolar II) remains pharmacological.

This is because bipolar disorder is a biological condition with a strong genetic component. However,

despite good adherence to treatment, many sufferers continue to experience sub-syndromal symptoms

if not full episodes of illness. As a consequence, increasing interest is now being paid to the role of

psychosocial treatments in ameliorating these symptoms and helping people to adjust to this chronic

and relapsing illness. This important aspect is explored in more detail below.

One of the main issues in management for any clinician (GP or psychiatrist) is helping patients to remain

ON medication. The 'stop-start' phenomenon in taking medication is rarely so widespread as occurs for

those with bipolar disorder. The consequences of this approach are now known to be very detrimental,

with increased rates of relapse and often impacting on the actual pattern of episodes, sometimes

speeding up cycles of illness. Building a good rapport with the individual, and asking about and dealing

with side-effects all assist in this process. Assisting the person to learn about their illness, to take

responsibility for it and to aim to work in partnership with their health professional, all help to improve

adherence and therefore the prognosis.

The Royal Australian and New Zealand College of Psychiatrists has recently published clinical practice

guidelines for the treatment of bipolar disorder. A brief overview is provided below. In essence, we

focus on the management of those with bipolar I disorder, leaving management of bipolar II disorder till

later.

Pharmacological agents are used in the acute phase of the illness to eliminate the symptoms of mania or

depression. They are also used in the maintenance phase - in which their role is to prevent relapse or, at

the very least, reduce the frequency and severity of episodes.

Primary medications used in the acute phase of treatment

Acute Mania

Lithium (Lithicarb, Quilonum SR)

Sodium Valproate (Epilim, Valpro)

Carbamazepine (Tegretol, Teril)

Olanzapine* (Zyprexa)

Risperidone* (Risperdal, Risperdal Consta)

Aripiprazole* (Abilify)

Quetiapine* (Seroquel)

Solian* (Amisulpride)

* While these newer atypical antipsychotic drugs are commonly used these days, old 'typicals' (e.g.

Haloperidol) may also be effective.

Acute Bipolar Depression



Most antidepressants

Lamotrigine (Lamictal)

Mixed Episode

Sodium Valproate (Epilim, Valpro)

In managing acute mania , the table indicates that mood stabilisers (e.g. lithium) or antipsychotic drugs

may be used. If the patient is not settling on one such drug class, the use of combination therapy (i.e.

mood stabiliser + antipsychotic) may speed up improvement.

In managing acute bipolar depression, narrow action (e.g. SSRI) or dual action (e.g. Avanza or Efexor)

antidepressants are preferred (as TCAs and MAOIs may 'switch' the patient to a 'high' - so-called Bipolar

III). If the patient does not respond to the antidepressant alone, augmentation with an atypical

antipsychotic drug (low dose, and ideally, until the patient is no longer depressed) may be necessary.

Together with initiating such antidepressant strategies, a mood stabiliser might also be commenced or,

if the patient is already on such medication, have levels checked and dose adjusted as may be required.

Other Treatments

Benzodiazepines ( e.g. diazepam, lorazepam and clonazepam)

These are mainly used as adjunctive treatment to the above, commonly when a person is in hospital,

and to control severe agitation or overactivity.

Electroconvulsive therapy (ECT)

Although strictly a physical therapy and not a medication, it is worth mentioning as ECT plays an

important role in treating both acute mania (and psychosis) and severe depression on occasions. ECT

may be used when:

The patient is unable to take medications because of side-effects.

Concurrent medical conditions make use of medications too risky (including pregnancy).

Other treatments have proven to be ineffective.

The patient is extremely disruptive (e.g. banging head on wall, not sleeping).

The patient is severely medically unwell (e.g. dehydrated or starved) as a consequence of the mood

state.

Medications used for longer-term maintenance therapy in bipolar I disorder

Lithium

LamotrigineSodium Valproate

Carbamazepine

Atypical antipsychotic drugs

In the last few years, a large number of studies have established a strong maintenance role to the

atypical antipsychotics, often more powerful than observed for standard mood stabilisers. However,

while side-effects associated with our current mood stabilisers are reasonably well known (and may not



be trivial), medium and long-term side-effects associated with the atypical antipsychotics in managing

bipolar dDisorder I remain to be clarified.

Lamotrigine is another anticonvulsant which has recently caused much interest as a series of studies

have found it to be particularly efficacious in the treatment of bipolar depression. Depression in bipolar

disorder can be hard to treat and tends to be less responsive (compared to manic symptoms) to the

established mood stabilisers.

The main concern when using Lamotrigine is the rare, but serious, side-effect of a Stevens-Johnson-like

rash. The risk of this occurring can be reduced by starting at a low dose of 25 mg to 50 mg a day and

increasing very gradually by 25-50 mg weekly until a therapeutic dose of around 200 mg has been

reached. The patient needs to be informed about the risk of this side-effect, its appearance and what

action to take if it occurs. In that event, rapid cessation of the medication is recommended. Read more

an information sheet about Lamotrigine-associated rash [PDF, 27KB]

One of the concerns about prescribing mood stabilisers for bipolar disorder is the need for regular

monitoring.

The recommended blood tests that are needed for the different mood stabilisers are shown below.

Lithium

Serum Lithium levels every 3 months. At initiation, may need to be more frequent (weekly) until stable

levels have been reached.

Aim for levels 0.6-0.8 mmol/L

TSH, U&Es and creatine levels every 6-12 months (to exclude hypothyroidism or declining renal function)

Carbamazepine

Serum drug levels every 3 months

Aim for level 17-50 umol/L

Liver function tests every 3-6 months to exclude aplastic anaemia and other haematological dyscrasias

Electrolytes every 3-6 months to exclude hyponatremia

Sodium valproate

Serum drug levels every 3-6 months

Aim for levels 300-700 umol/L

Liver function tests every 3-6 months to exclude hepatotoxicityFull blood count every 3-6 months to exclude thrombocytopenia

Lamotrigine

No regular drug levels or blood tests required.

Slow increase in dose required (25-50 mg increments). Careful monitoring for rash.

Atypical Antipsychotics

Blood sugar and serum lipids every 3-6 months to exclude diabetes and hyperlipidemia



It can be helpful to include the patient in this process and encourage joint responsibility for drug level

monitoring. The patient should receive copies of all of their blood tests to keep a record at home. If

possible, they should be aware what the tests are monitoring, what the numbers mean and obviously

what signs would indicate drug toxicity and what to do if this occurs. All of this will help with adherence

to the medication and empower the patient to manage his or her own illness.

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2. Psychological treatments for bipolar disorder

Psychoeducation

Cognitive Behavioural therapy (CBT)

Family Focused Therapy (FFT)

Interpersonal and Social Rhythm therapy (IPSRT)

In the past, it had been thought that psychotherapy had little to offer in the treatment of bipolar

disorder, as this was an i llness that was understood as being primarily biological. Interest in the role of

psychological interventions has increased in recent years. There are several reasons for this, including:

the increased acceptance of the stress-vulnerability model of bipolar disorder and

the realisation that despite all the advances in psychopharmacology, patients still experience significant

sub-syndromal symptoms and continue to have relapses even if their adherence to medication is high.

Relapse rates after an episode of mania have been reported as being around 50% after one year and

between 70-85% after five years. This has led to an increasing number of randomised controlled studies

examining the effectiveness of a variety of different interventions. The most useful therapies appear to

be psychoeducation, family therapy and cognitive behavioural approaches. While these strategies

improve adherence with medication, intervention studies have shown that they have additional

benefits. We explore these and others below.

Many of these interventions share key elements, which has made evaluating their individual role more

difficult. The common shared themes are:

Education about bipolar disorder

Regularising daily activities

Reducing substance misuse

Enhancing medication adherence

Identifying and managing early warning signs of relapse.The types of positive outcomes that have been reported in studies on these interventions include:

Increased medication adherence

Improved attitudes towards and knowledge about the treatments for bipolar disorder

Decreased number and length of hospitalisations

Improved social functioning



Increased work productivity

Improved sense of well-being

Improved family functioning

Improved marital relationships.

It is important to recognise and discuss with patients that these interventions have been found to be

effective as adjuncts to and not replacements for medication, which remains the key component to the

maintenance treatment of the illness.

Psychoeducation

Psychoeducational approaches can be delivered (and have been evaluated in randomised controlled

trials) as structured interventions delivered as a single package or over several weeks, either

individually, or in groups, or for families. The core knowledge that they aim to impart includes:

The causes of bipolar disorder

The likely course of the illnessInformation on the medications used in treatment, the rationale for them, how to take them and how to

manage side- effects

Recognition of early warning signs of relapse and the role of mood monitoring

Tools to improve self-management of life stressors.

How to deliver psychoeducation in general practice

It is vital therefore that all patients with bipolar disorder are assisted to learn as much as they can about

the disorder. This is especially important in the first few years after diagnosis to ensure good adherence

to treatment and to minimise kindling of the illness by a 'stop-start' approach to medications.

Psychoeducation programs don't have to be delivered by 'experts'; a GP can provide very effective

interventions by:

Using Mood Monitoring as a tool to help monitor patients' symptoms and to assist them in learning to

recognise early warning signs of relapse. You can download a Daily Mood Graph. [PDF, 96KB] We also

provide a sheet patients can use to monitor their progress. (Download our information sheet on

'Monitoring Your Progress' [PDF, 83KB]).

Giving videos to patients, and patients' partners, about the disorder (several good ones have been

produced by various pharmaceutical companies).

Have information sheets for patients and fact sheets available to dowload and distribute (e.g. leaflets in

waiting rooms etc) as well as personally giving them out during a consultation.Recommend appropriate websites like this one and provide information on appropriate books/articles

as well as other resources. See our Reading List.

Encourage questions about medication choices, rationales for using them and provide information

about what side-effects can occur and how to best manage them.

Ask about substance and alcohol use and, if a concern, treat appropriately.

Cognitive Behavioural Therapy (CBT)



Cognitive behaviour therapy for bipolar disorder would cover many, if not all, of the following elements:

Psychoeducation

Relapse prevention

Medication adherence

Stabilisation of social rhythms

Identifying and challenging dysfunctional thoughts and beliefs

Identification and management of stressful life events

Identification of mood instability

Development of skills to modify mood instability.

Studies have found both brief and longer interventions to be useful, although which phase (i.e. manic or

depressive) responds best, has been debated. Increasingly, local area mental health services are

recognising the importance of this intervention in preventing relapse in people with bipolar disorder and

some will offer outpatient (as well as inpatient) group programs. If this were not the case in your area,

referral, if the patient is willing, to an appropriately experienced clinical psychologist would beappropriate.

Family Focused Therapy (FFT)

Several studies have established that patients with bipolar disorder who live in environments in which

there is a high level of expressed emotion have higher rates or relapse and worse symptom control.

Family therapy aims to improve family functioning and teaches a combination of communication skills,

problem solving and coping strategies. It will often include psychoeducation about bipolar disorder and

teach the family/partners skills in recognising early warning signs of relapse. Studies have found that the

benefits of such intervention have included:

Fewer relapse rates

Improved medication adherence

Reduced occurrence of depressive episodes.

Interpersonal and Social Rhythm therapy (IPSRT)

This was developed in the USA in 2000 and came from a program that was developed for people with

unipolar depression. The therapy aims to regulate social and circadian rhythms as well as examine and

address any interpersonal problems in the realms of interpersonal conflicts, role disputes and

unresolved grief.

The main elements include:

Psychoeducation

Social rhythm regulation

Cognitive and behavioural interventions and strategies to manage interpersonal events and problems.



At present it is mostly being delivered through structured programs in research facilities in the United

States. There is some debate about whether it is as effective as an adjunct as standard CBT or

psychoeducation as described previously.

References

Gutierrez M.J., Scott J. 'Psychological treatment for bipolar disorders', Eur Arch Psychiatry Clin Neurosci.

2004; 254:92-98

Patelis-Sotis I. 'Cognitive behavioural therapy: applications for the management of bipolar disorder',

Bipolar disorders 2001; 3:1-10

Lam et al. 'A randomized controlled study of cognitive therapy for relapse prevention for the bipolar

affective disorder: outcome of the first year', Arch. Gen. Psychiatry 2003; 60:145-152

BACK TO TOP

3. Managing women with bipolar disorder

Differences in phenomenology and prognosis

Medications and women with bipolar disorderPregnancy and breast feeding

More attention is increasingly being drawn to the gender differences that occur in the presentation and

course of bipolar disorder, and how they can impact upon treatment. A full discussion of these

differences and treatment issues is out of our scope here but for those interested or specialising in

women's health, further reading is suggested from the reference list.

Differences in phenomenology and prognosis

The incidence of bipolar I disorder is the same in men as in women, however it appears that it takes

longer for bipolar disorder to be recognised in women than in men. Reasons for this include them

experiencing more mixed episodes than men, being more likely to experience a rapid-cycling pattern,

having higher rates of anxiety disorders (particularly panic disorder and social phobia), and experiencing

more depressive episodes than men with bipolar disorder.

Medications for women with bipolar disorder

Recent studies have identified important pharmacokinetic and pharmacodynamic differences between

men and women which may impact upon the dosage regimes of medications used in the treatment of

bipolar disorder, with women likely to require smaller dosages than men. There has been a suggestion

that there might be a possible gender difference in response to antidepressants but these are all initial

studies (mostly in unipolar depression) and more studies are needed to fully explore this in bipolar

disorder. Specific important issues for woman in regards to medication include:

Carbamazepine can induce the metabolism of oral contraceptives through induction of cytochrome

P450 enzymes, particularly CYP3A4, making it less effective.

All 'typical' antipsychotics and risperidone can lead to raised prolactin levels.



The atypical antipsychotics (e.g. quetiapine, clozapine and ziprasidone) can also lead to menstrual

dysfunction but this has been reported at a much lower rate than the 'typicals'.

Most mood stabilising agents have significant teratogenic effects, however, current thinking is that

medication should not be automatically stopped on discovering that the patient is pregnant. The risk to

the foetus needs to be counterbalanced with the risk of relapse in the mother if medication is

discontinued. In particular, rapid discontinuation (<2 weeks) has been linked with high rates of relapse.

Involvement of a specialist is highly recommended.

Pregnancy and breast feeding

Special care needs to be taken for women planning to become pregnant. It is no longer the accepted

opinion that women with bipolar disorder 'should not' become pregnant nor that all medications need

to be ceased. The issues are complex and it is highly recommended that advice from an experienced

psychiatrist, ideally involved in women's mental health, is sought.

The post-partum period is a period of maximum risk for a woman with bipolar disorder, especially if she

ceased the mood stabiliser prior to becoming pregnant. It is therefore vital that medication of some typeis used to 'cover' this high-risk period. Valproate and carbamazepine have been considered to be

compatible with breastfeeding by the American Academy of Paediatrics despite passing through into

breast milk and having some effects on the infant. Again, it is highly recommended that specialist advice

be sought at this time.

References

Leibenluft E. 'Women with bipolar illness: Clinical and Research Issues', Am J Psychiatry 1996; 153:163-

173

Hildebrandt MG, Steyerberg EW, Stage K et al. 'Are gender differences important for the clinical effects

of antidepressants?' Am J Psychiatry 2003; 160:1643-1650Dawkins K. 'Gender differences in psychiatry: epidemiology and drug response', CNS Drugs 1995; 3:393-

407

Ernst C, Goldberg JF. 'The reproductive safety profile of mood stabilizers, atypical antipsychotics and

braid spectrum psychotropics', J Clin Psychiatry 2002; 63 (suppl 4);42-55

Llewellyn A, Stowe ZN, Strader JR Jr. 'The use of lithium and management of women with bipolar

disorder during pregnancy and lactation', J Clin Psychiatry 1998; 59 (suppl 6):57-64

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4. Early warning signs of relapse

One of the most important roles in the longer-term management of someone with bipolar disorder is

recognising the signs and symptoms that herald the onset of a manic or depressive relapse. This 'relapse

signature' can vary in its composition from person to person, as can the length of time that the

symptoms will appear before a full-blown relapse becomes established. These changes can occur in the

person's mood, behaviour and/or their cognitive functioning.





5. Common pitfalls and complications

The management of bipolar disorder is often not a straightforward task for a clinician; this commonly

reflects the burden that a person carries living with this i llness. Despite good adherence to treatment,

many people have to manage significant sub-syndromal symptoms, which can have a negative impact on

their ability to function, and influence many components such as motivation and drive. Whether these

symptoms indicate that treatment is sub-optimal or that this is 'as good as it gets' is a hard balancing

act. Against the possible benefits that an increase in dose or a change in medication can bring, there are

always the ever-ready negatives of new or increased side-effects (which impact on the individual's sense

of wellbeing and functioning in their own right) and the risk of relapse in the case of changing over of

medications. In deciding what action to take there are some simple first steps that should be

considered.

Is the patient taking the medication as prescribed?

Often this isn't the case, with the person either taking a lower dose than prescribed or having ceased

one or all medications entirely. People with bipolar disorder routinely self-medicate and change their

medications without their doctor's knowledge. There are a number of possible reasons (some listed

below) for this. Obtaining an understanding, from the patient's point of view, of their attitude toward

treatment, the problems they have been experiencing and their expectations about treatment, are

important steps in regaining good adherence. Adherence can be improved by providing

psychoeducation for the person and/or family, talking about fears and plans for the future, and

counselling other concerns.

Common reasons for stopping medication

Side-effects which impair functioning - common ones that cause distress being a 'fuzzy headiness', a loss

of creativity and feeling 'flat'.Concern about possible longer-term effects (e.g. 'I don't want to get addicted', or plans to get pregnant).

Advice from friends or relatives that 'You don't need medication', or 'It's dangerous'.

Having a poor understanding about what the medication is supposed to do: 'I've been feeling well for

months, I don't need to take this anymore'

Poor insight. 'I'm not/never have been sick, I don't need to be on medication . It's the medication that's

making me feel ill!'

Dealing with a lack of insight

Many people with bipolar disorder retain good insight into their illness, at least whilst they are in

periods of wellness. However, mania and hypomania lead to a loss of insight, and it is this state that can

cause many problems, not only in relation to the patient's compliance with medication, but the

possibility of the patient or another person being put at risk as a result. In such situations, a balance

needs to be struck between managing your duty of care with the patient's right to confidentiality.

Having a disseminated relapse plan in which the patient has played a role in developing, and which

others (i.e. family, partners, community mental health staff) are aware of, can really assist management

at these times. Plans that detail in the patient's own words, their signs and symptoms, things they will



accept others to tell them and what they will do if told that they need extra treatment, can all help a

general practitioner in ensuring that the patient gets the help and intervention that they need.

Sometimes a patient will deny any mood disturbance or that they are unwell but reports from family

and partners indicate a gross disruption to their normal level of functioning. These reports need to be

taken seriously. Often a patient can present as if "well" for a 5-10 minute interview, whereas those living

with them at home are more likely to getting a clearer picture of manic or hypomanic symptoms. A

useful operative rule is that the manic/hypomanic patient is always worse than they present or report.

Patients can do untold damage (sometimes permanent) to their reputations, their relationships, their

financial stability and physical health when in a manic state. When this is the case, it becomes

imperative to protect them from such consequences, and use of Mental Health Act and community

mental heath teams become warranted.

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6. Who else to involve in management?Community Mental Health Service

Crisis Team

Private consultant psychiatrist

Psychologists

Social workers

Community mental health nurse

Occupational therapist

A general practitioner can ensure that patients with bipolar disorder have all of their physical health

needs met and are in a key position to coordinate care with other services. As bipolar disorder is a

chronic relapsing and remitting illness, which can impact negatively on all aspects of a person's

functioning (family, friendships, work, finances, personal identity, self esteem and autonomy), a multi-

system approach is valuable. It provides a bio-psycho-social framework through which these needs can

be addressed.

In areas were there are limited services, a general practitioner can still base management on this

approach, and can work with the patient's family and use local social networks and community groups

where appropriate. This could include such strategies as linking the person into local bipolar

disorder/depression self-help groups, other support groups like AA and Grow, local counsellors, the

appropriate local church or spiritual leader.

In areas where services are available, it becomes important for the GP to know what type of service best

meets the needs of their patient and how to go about making such a referral. The different types of

services and their roles are described briefly below.



It can be useful to discuss your reasons for making any referral with your patient - indicating what you

expect the outcome will be. When referring patients to an unknown health practitioner (a new

counsellor or private psychiatrist), they need to be told to come back to see you if they feel unhappy to

continue, so that they can be referred to someone else. If it's to a local mental health service, make it

clear that you need to know what the outcome of their assessment or intervention was, as this can help

prevent people from dropping out from under the treatment radar. This becomes especially important

when someone presenting is at risk and then acute treatment is vital.

Further information on how to make an effective referral can be accessed here (Download clinician

resource sheet 'Making an Effective Referral' [PDF, 84KB]).

The types of services/individuals that a GP could refer a patient to include those listed below.

Community Mental Health Service

This would comprise a team of people covering a specific geographical area. Such a team typicallycomprises many, but possibly not all, of the following:

Clinical psychologist

Community mental health nurses

Consultant psychiatrist

Occupational therapists

Social workers

Psychiatric registrars.

Crisis Team

These units provide 24-hour emergency assistance and comprise community mental health staffs that

have differing backgrounds (i.e. mental health nurses, social workers, and psychologists) supported by

psychiatric registrars and team consultant psychiatrists. They can do phone call check ups, and provide

emergency assessments in the person's home, local hospital, GP surgery or where ever is appropriate.

They can provide short-term case management and referral into community mental health teams.

Private consultant psychiatrist

Accessibility, cost and availability can be an issue and emergency appointments can sometimes be

difficult. However, private psychiatrists can offer assessment (45-80 minutes), provide an opinion on the

diagnosis of bipolar disorder and advise on treatment strategies. In particular, they can overseeinitiation of treatment or advise on changes in medication. If requested, they can take key responsibility

for the patient's treatment, often working in conjunction with local mental health services if needed.

They can facilitate admission into private hospitals or access to their outpatient facilities if required and

if the person has the necessary private health cover.

Read more about psychiatrists



Psychologists

It can be important to distinguish whether the psychologist has specialist training in mental health as a

clinical psychologist, as such training ensures experience in specific therapies (Cognitive Behavioural

Therapy or CBT, Interpersonal Therapy or IPT). Clinical psychologists are likely to have further training in

areas such as couple and family therapy and are also more likely to be familiar with the issues around

bipolar disorder, in particular, the importance of medications.

Read more about psychologists

Social workers

Social workers operate in a psychosocial model. They can therefore provide advice and assistance with

socioeconomic/financial difficulties, providing practical support and assistance to link in with

organisations like Centrelink and rehabilitation services like Centacare. They have specific

responsibilities in areas which come under specific legislation (e.g. children at risk, domestic violenceguardianships orders) and have particular skills in working with families. They play a vital role in the

multidisciplinary team, in both the community and hospital mental health setting. If a patient has

particular problems in this area it can be useful to identify them up front in the referral and request a

social work appointment, especially if you are willing and able to continue to oversee their medical

management.

Community mental health nurse

Mental health nurses have numerous skills and work in both the inpatient and community setting. They

have both an understanding and training in the medical model of mental illness, as well as

psychotherapeutic skills in counselling and in developing and overseeing behavioural rehabilitationprograms. They have particular expertise in monitoring mood states of their patients, in monitoring

treatment adherence and effectiveness, and promoting physical care. They provide ongoing support to

individuals and their families through the development of a therapeutic relationship. Other roles include

educator, advocate and case manager.

Occupational therapist

Occupational therapists are mainly accessible through mental health services but can sometimes be

accessed through private rehabilitation companies and some government programs. They can provide a

useful role in rehabilitation if someone has been out of work for a long period of time, or if they need

assistance or an advocate in return to work after an acute episode. They provide assessments of day to

day functioning and living skills, and can develop individual programs to assist a person to improve

functioning.

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7. Emerging new treatment approaches

Increasing prevalence of bipolar II

Role of mood stabilisers in bipolar II

Role of the antidepressants in bipolar II

Omega-3 fatty acids

Atypical antipsychotics as mood stabilisers

Increasing prevalence of bipolar II disorder

Emerging research is indicating that the rate of bipolar II disorder appears to be increasing in the general

community. Debate in this area has stimulated further research into bipolar II and its treatment.

Possible real and artefactual causes for the increase in prevalence rates of bipolar disorder are listed

below.

Possible artefactual causes

Changes to how diagnostic criteria are applied. Using the current DSM-IV 'hard' criterion of hypomanic

symptoms needing to be present for a minimum of 4 days led to a prevalence rate of 5.3%, where asusing 'soft' criteria yielded a prevalence rate of 11% in a Zurich study by ANGST.

Improved detection of bipolar disorder in the community, related to destigmatisation of mood disorders

with more people presenting for treatment.

Widened definition of bipolar disorder, with broadening of the spectrum of bipolar disorders risking

inclusion of mood swings that are not truly bipolar conditions.

Possible real causes

Genetic changes within the population

Impact of environmental changes such as:

Increased use of stimulants in the general population

Increased use of antidepressant medications reflecting their possible capacity to cause switching

Reduced levels of omega-3 fatty acids in the diet of the general population.

While cause does not always dictate treatment (e.g. migraine is not due to an insufficiency of aspirin),

consideration of possible 'causes' (e.g. genetic, iatrogenic, environmental) can be of some help in

treatment options.

One of the problems in being able to make treatment recommendations about bipolar II disorder is the

lack of randomised, double-blind, placebo-controlled trials involving only bipolar II patients. Currently,

recommendations are made on evidence from studies which involve, or are dominated by bipolar I

subjects and therefore the question whether these studies are directly applicable needs to be raised.

Role of mood stabilisers in bipolar II

In terms of use of lithium, a recent review [2] found support for lithium monotherapy as being effective

in maintenance treatment of bipolar II patients, with fewer hospitalisations and fewer illness episodes

compared prior to commencing the l ithium. Lamotrigine, an anti-epileptic drug has been found to be

effective in the treatment of bipolar depression (both as an augmentation agent and as monotherapy)



and has been shown to prevent relapse in bipolar II patients. As it is the severity and frequency of the

depressive episodes, rather than the hypomanic episodes, which present the main challenges in the

acute and long-term treatment of bipolar II disorder this finding is encouraging for bipolar II patients.

However, due to the difficulty in being able to prescribe lamotrogine on the PBS currently and the need

to 'start low and go slow' due to the risk of serious rash, it should not, as yet, be thought of as a first-line

approach. Read more an information sheet about Lamotrigine-associated rash [PDF, 27KB]

Role of the antidepressants in bipolar II

There is significant debate about the use of antidepressants in bipolar II disorder with conflicting

evidence around their potential to cause cycle acceleration and switching. It is unclear whether the

subtype of Bipolar Disorder impacts on the propensity of antidepressants to do this. Many authors

suggest caution in their use, preferring still the use of a mood stabiliser in bipolar II, however, the

potential mood stabilising effect of the Selective Serotonin Reuptake Inhibitors (SSRIs) and dual-action

antidepressants has led to new research into this area. The Institute's research team published a report

in the Journal of Affective Disorders in 2006 supporting the view that the SSRIs are mood stabilisers for

those with bipolar II - in that those on an SSRI compared to placebo had a significant decrease in their

depression and also improvement in their 'highs' over the trial. Thus, while antidepressants are usually

viewed as contraindicated in managing bipolar II, the truth may be quite the opposite. The issue is

debated in a book by Professor Gordon Parker and published by Cambridge University Press, 2008,

"Bipolar II Disorder: Modelling, Measuring and Managing".

Omega-3 fatty acids (fish oils)

The omega fatty acids are a group of naturally occurring lipids. Lipids are vital for normal brain function

and are called 'essential' as they have to come from the diet, as the body cannot manufacture them.

There are two main types. 'Omega-3 fatty acid', often called the 'good' fat, is found in highconcentrations in particularly cold water or oily fish (like salmon, cod and tuna) as well as from flax seed

oil and some nuts. The other, 'omega-6 fatty acid', is sometimes referred to as the 'bad fat'. This is found

primarily in vegetable oils (i.e. corn or sunflower oils). These fatty acids play an important role in

neuronal signal transduction, nerve cell membrane integrity and fluidity. The correct balance of these

two fatty acids is essential for normal neuronal function.

Interest in the possible role of omega-3 fatty acids in the treatment of bipolar disorder came about

through a number of overlapping research area. One was the recognition of the role and function of

fatty acids in the brain, and the similarities between their function and the mechanism of action of the

mood stabiliser lithium and the anti-convulsant sodium valproate. The other was the observation fromlarge epidemiological studies that countries whose diets which were largely depleted in omega-3 fatty

acids (Western European) had higher rates of coronary heart disease and major depression than those

countries with higher rates of omega-3 consumption (e.g. Japan , where consumption of fish is

significantly higher). These findings have lead to randomised, double blind, placebo controlled trials,

which have looked at the effect of omega-3 fatty acids used in conjunction with treatment as usual.

Although the numbers of studies so far performed are small, results have been encouraging.



One study found that the addition of 9.6g/day of Omega-3 fatty acid daily led to a significantly longer

period of remission in patients with bipolar disorder when compared to the placebo group. Another

open label study has also reported benefits in using flaxseed oil in bipolar patients.

The dosages have varied in the different studies, especially those looking at the role of omega-3 fatty

acids in bipolar disorder and unipolar depression (9.6g day vs. 2g/day). Limited side-effects have been

reported, mild ones include having an unpleasant fishy taste and with the higher dosages, loose stools.

It appears from these preliminary studies that omega-3 fatty acids are likely to be promising additional

agents for use in bipolar disorder (positive results are also being found in studies in schizophrenia and

unipolar depression), especially in light of their high tolerability, low toxicity and lack of drug

interactions.

'Aypical' antipsychotics as mood stabilisersThe role of the 'atypical' antipsychotics in the treatment of bipolar disorder has now been well

established. They have been found to be useful, both as adjuncts to the mood stabilisers and as

monotherapy with several randomised, double blind controlled studies now reporting numerous

positive effects including improvement in manic symptoms, improvement in depressive symptoms and

increased response rates and reduced relapse rates. Their role has been mostly clearly been defined in

the acute and maintenance treatment of mania. Side-effects are a concern, especially weight gain, with

regular testing of blood glucose and cholesterol recommended. Other side-effects, which can limit their

use, include somnolence and sexual dysfunction.



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