Left untreated, bipolar disorder tends to become progressively worse over time. Fortunately, many treatments have been shown to improve the course of the disorder. Before reviewing these medications and psychotherapy, there are a few general points to consider:
- The course of bipolar disorders can be quite variable, including episodes of depression, hypomania, mania, mixed states, and “euthymia” (wellness). Therefore, when thinking about treatment one needs to consider both the acute treatment of various mood episodes and maintenance treatments designed to prevent future episodes.
- Because of the importance of preventing future mood episodes, most people with bipolar disorder benefit from continuous treatment. Therefore, doctors are likely to suggest that patients stay on medications even after they recover from an episode.
- Nearly all research studies have been conducted with people with Bipolar I disorder; only a few newer studies have focused on Bipolar II disorder, and even fewer on Bipolar Spectrum disorders. Therefore, doctors treating “softer” forms of bipolar disorder are forced to rely more heavily on their clinical experience and to extrapolate from the Bipolar I research findings. (For more information about bipolar disorder, including the different types of disorders, please click here)
Medications:
Medications are considered essential in the treatment of bipolar disorder. The principle benefits of medication are:
(1) To help control manic symptoms
(2) To alleviate depression
(3) To decrease anxiety
(4) To improve relations with others
(5) To increase one’s confidence
Lithium, a natural salt, was the first medication specifically tested and used for the treatment of bipolar disorder, and continues to be widely used today. Most people with bipolar disorder are on a combination of medications drawn from several different classes, including:
Mood stabilizers: lithium (Eskalith, Lithobid) and anticonvulsant medications, such as valproate (Depakote, Dapakene, Divalproex Na), carbamazepine (Tegretol), lamotrigine (Lamictal) and, less frequently, topimate (Topamax).
Atypical antipsychotics: quetiapine (Seroquel), olanzapine (Zyprexa), risperidone (Risperdal), aripiprazole (Abilify), and ziprasidone (Geodon). Accumulating evidence suggests that many antipsychotics are effective for treating acute mania and for preventing relapse, and in some cases alleviating depression.
Antidepressants: nearly all doctors agree that antidepressants should only be used in combination with a medication with anti-manic properties (a mood stabilizer or antipsychotic medication), and only when depression is severe and unremitting. Some patients clearly benefit from the addition of an antidepressant; for others, antidepressants make their bipolar disorder worse.
General Guidelines for Medication:
- Doctors start patients on a low dose and slowly increase the dose to a level thought to be beneficial (titration). This approach allows ones body to slowly adjust to the new medication. It is important not to make quick judgments about whether a medication can help. Patients may need to see their doctor more frequently when starting a new medication. Patients also need to talk with their doctors if they run out of medication or do not take it for a few days.
- Similarly, to come off of most of these medications, the dose should be tapered (slowly reduced). Stopping abruptly may be medically dangerous, create unpleasant physical symptoms, and/or increase the risk of having a relapse. People should only stop their medication under the supervision of the prescribing doctor.
- All treatments have the potential for side effects (reactions one does not want). Sometimes a side effect can be beneficial. For example, if a medicine makes a person who has trouble sleeping at night drowsy, the doctor may advise taking the medicine at bedtime instead of in the morning. Some side effects go away as one’s body adjusts to the medication, while others can be easily alleviated (e.g., taking medicine with food might alleviate upset stomach).
- It is important to decide whether the benefits of a particular medicine outweigh the costs (side effects). For example, if a medication greatly relieves one’s depression, one might be willing to accept a side effect of a lowered sex drive; at some point, however, the cost of the lowered sex drive may seem to outweigh the benefits of the drug.
- Some medications require laboratory blood tests, either to check the level of the drug in a patient’s blood or to monitor one’s health status. The doctor will order these tests as they are needed.
- Medications may interact with over-the-counter medicines and with herbal remedies and nutritional supplements. Talk with a knowledgeable pharmacist or the prescribing doctor before starting anything new.
- For those who have trouble affording medications, most pharmaceutical companies have Patient Assistance Programs (visit www.needymeds.com). Also, different stores charge different prices for the same drug so shop around at local pharmacies or price compare for on-line pharmacies at www.destinationrx.com.
Psychotherapy:
Psychotherapy is another critical component in treating bipolar disorder and is used in combination with medication. In his book, The Bipolar Disorder Survival Guide, Dr. David Miklowitz, a professor at the University of Colorado and the Director of the Sutherland Center at CU, identifies the following objectives of psychotherapy:
(1) To help make sense of current or past episodes of the disorder
(2) To discuss long-term planning given one’s vulnerability to future episodes
(3) To help a person accept and adapt to a long-term medication regimen
(4) To identify and develop strategies for dealing with stress
(5) To improve one’s functioning in school or the workplace
(6) To deal with social stigmas of the disorder
(7) To improve relationships with others
Research suggests psychotherapy can hasten the recovery time from a bipolar depression, improve functioning and quality of life, increase adherence to medication regimens, decrease hospitalizations, and prevent or delay recurrence of mood episodes. It is important to find the right type of therapy. Depending on where one lives and one’s insurance, there may be many options or few options. Modalities of therapies include:
Individual therapy – Patients meet one-on-one with a therapist. Individual therapies that have been shown in research to be effective for bipolar disorder (Interpersonal and Social Rhythm Therapy, IPSRT; Cognitive Behavior Therapy, CBT; Psychoeducation) tend to be structured and goal-oriented, targeting symptom reduction, relapse prevention and improved quality of life. Psychoeducation appears to be an essential component of effective psychotherapy.
Family and couples therapy – Sometimes bipolar disorder is best treated in a family or couples context. Bipolar disorder generally affects the entire family, and family distress can worsen the disorder while positive family support is a protective factor. Therefore, a therapy that includes the entire family can help all members of the family.
Group therapy/Support groups – Many people with bipolar disorder benefit from participating in therapy or support groups. With this approach people get together to discuss their feelings, experiences and attitudes about bipolar disorder. Dialogue includes discussing which medicines have worked and which have not, therapies that have proven beneficial, challenges with family members or social settings, plus much more. The group leaders can be either mental health professionals (group therapy) or others with bipolar disorder (support groups).
Family support groups – Like people with bipolar disorder, family members often benefit from support groups. Through such groups, family members share experiences, explore strategies for supporting people with the disorder, and discuss the fears, challenges, and frustrations they face in helping others.
Finding the right doctor/therapist:
Following is a list of different types of professionals who may treat bipolar disorders:
Psychiatrists are medical doctors (M.D.) who can prescribe medications, order medical tests and provide psychotherapy.
Psychologists have a doctoral degree (Ph.D. or Psy.D.) and are trained to make diagnoses and provide psychotherapy (individual, family, and/or group). In most states they cannot prescribe medications.
Licensed Clinical Social Workers (LCSW), Licensed Professional Counselors (LPC) and Licensed Marital and Family Therapists (LMFT) have their Masters degree in social work, psychology, counseling or a related field. They are trained to make diagnoses and provide individual, family and group counseling.
Certified Alcohol and Drug Abuse Counselors are counselors with specific clinical training in alcohol and drug abuse.
Psychiatric nurses are licensed registered nurses (R.N.) who have extra training in mental health. Under supervision of medical doctors, they may offer assessments and psychotherapy, and they may help manage medications.
- their medical doctors such as internists, family doctors, and gynecologists can prescribe psychiatric medications. However, many do not have the expert knowledge and extensive experience needed to adequately manage a complicated bipolar disorder.
There are a few things to consider in selecting a mental health provider:
- Find a doctor/therapist who understands the causes, conditions and treatment options that best address bipolar disorders.
- Find a doctor/therapist that you respect and trust and with whom you have a good relationship. Treatment works best when the patient and the doctor/therapist trust and respect one another.
- Make sure different members of the treatment team communicate with each other to coordinate care. This need is particularly true when people go to one doctor for medications and to a second professional for psychotherapy.
- Interview a doctor/therapist before deciding whether to work with him or her. Dr. Miklowitz offers questions to ask a prospective therapist or doctor: (1) Do you regularly work with people with bipolar disorder? (2) How will you integrate your knowledge of the disorder into the treatment? (3) Will the therapist communicate regularly with the physician who is managing the medications?
Other Treatment Components: In addition to medications and psychotherapy, many people with bipolar disorders may benefit from:
- Regular sleep/wake hours, even on weekends
- Regular exercise
- A nutritional program
- Dietary supplements (such as Omega-3 fatty acids)
- Carefully timed light exposure
Doctors/therapists can help patients implement these treatment components.