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Are there effective psychosocial treatments for bipolar disorder?





Psychosocial treatments and psychotherapy for bipolar disorder: An overview

Psychosocial treatments are continuing to take a more prominent role in assisting in the mood stability of individuals with bipolar disorder. As an adjunct to pharmacotherapy (medication management of symptoms), family focused treatment strategies and cognitive behavioral therapy have been used to assist in successfully reducing relapse and intervening directly for bipolar depression and hypomanic episodes.

Psychosocial treatments for bipolar disorder are beginning to be recognized more often than in the past by experts as an adjunctive treatment to pharmacotherapy for the treatment and management of bipolar symptoms. Keck et al. (2004) recently found that experts are more consistently recommending psychotherapy and psychosocial interventions for the stages of bipolar disorder when patients are most receptive to interventions, such as when they are in an acute stage or in the maintenance phases of depressive and hypomanic episodes. However, these conclusions were not found when patients were experiencing acute manic or psychotic episodes. Psychological treatments and psychotherapy have also been recommended for the treatment of comorbid conditions such as when the patient has additional medical conditions such as eating or substance use disorders, or anxiety. It has been recommended as a first choice option when the use of medications is limited by comorbid medical conditions such as liver disease, renal conditions, obesity, pregnancy or heart disease.




Bipolar Disorder Psychosocial Treatments:

Some psychosocial treatments and psychotherapeutic interventions have demonstrated effectiveness for relapse prevention and in the earlier stages when the initial symptoms of bipolar disorder begin to occur. Cognitive behavioral therapy designed to treat existing symptoms and prevent relapse, individual cognitive behavioral therapy to treat bipolar depression, psychoeducational interventions and family-oriented interventions to assist in medication compliance and facilitating social support systems have demonstrated some effectiveness. Specific interpersonal related therapy along with interventions to assist with balancing sleep, awake, routine and activity cycles have been studied, although their effectiveness has not been proven at the present time.

The most effective psychosocial treatments seem to focus on some of the same basic principles: (1) Psychoeducation that helps patients to understand the role of medication compliance, and a basic understanding of their disorder as well as factors that aggravate the disorder such as issues related to sleep, regulating lifestyle and stress management; (2) communication and problem-solving training to reduce individual and family stress; (3) improving an understanding of early detection and intervention strategies such as increasing psychotherapy sessions, review of medications and increased family support and assistance. These interventions may be combined with additional cognitive behavioral strategies such as cognitive-restructuring, thought and activity monitoring, and other treatment interventions within an individual, family or group setting.

Cognitive Behavioral Therapy for Bipolar Disorder:

Typical cognitive behavioral therapy may include interventions for depression, balancing sleep and wake cycles and routine management, as well as monitoring of moods with a focus on the early detection of symptoms and initiating intervention. Lam and associates (2003) studied cognitive behavioral treatments and found some strong protective effects associated with the treatments, including a 43.8% relapse rate for individuals participating in cognitive behavioral therapy compared with a 75% rate for individuals from a control group who did not. Additional benefits were also identified in that the actual time spent in manic or depressive episodes was reduced significantly, and fewer days were spent hospitalized for the disorder.

Miklowitz et.al. (2003) found similar success with family interventions. In studies on family focused treatments that focus on psychoeducation for both bipolar patients and their families, along with assisting with communication and problem-solving have been found to be similarly effective. Interventions also included role-playing interventions and rehearsals both within and between sessions. Psychoeducational interventions included discussing risk and protective factors for mood episodes, along with rehearsal and relapse prevention efforts in the early stages of the bipolar episodes. The study by Miklowitz et al. (2003) found that in 21 sessions over a period of nine months of family focused treatments combined with medications, reduced both depression and manic symptoms as well as offered protection against relapse of bipolar episodes. These were compared to alternative interventions which focused on medication treatment along with two sessions of home-based family psychoeducation and crisis intervention over a period of nine months.

In another trial study by Rea et al. (2003), it was found that patients undergoing family focused therapy along with medication management had significantly longer delays in hospitalization and less relapse when compared to individuals undergoing only individual therapy consisting of medication compliance, psychoeducation, family support and problem-solving. Following the delivery of the active psychosocial treatments for a year, the rates of rehospitalization in the family focused therapy experience were only 12% as compared to 60% among the individuals receiving strictly individual therapy.

Summary of Psychosocial and Psychotherapeutic Interventions for Bipolar Disorder:

As reviewed in this article, several psychotherapeutic and psychosocial interventions have been found to be effective as an adjunct to the use of medications for the maintenance and early intervention to reduce the symptoms of bipolar disorder. The common principles involved in utilization of psychosocial treatments and psychotherapy for bipolar disorder focuses on the core belief that effective treatment needs to be a comprehensive, psychoeducational, cognitive behavioral, skill-based program, incorporating the family and social system which is oriented toward the long-term management of this chronic mental health condition.

References:

Keck, D. A., Perlis, R.H., Otto, M.W., Carpenter, D., Docherty, J.P. & Ross, R. (2004). Expert Consensus Guideline Series: Treatment of bipolar disorder. A Postgraduate Medicine Special Report: December, 1-108.

Lam, D. H., Watkins, E. R., Hayward, P., Bright, J., Wright, K., Kerr, et all. (2003). A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder: Outcome of the first year. Archives of General Psychiatry, 60, 145-152.

Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Sudduth, R. L. et.al. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60, 904-912.

Rea, M. M., Thompson, M. C., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial, Journal of Consulting and Clinical Psychology, 71, 482-492.

By Paul Susic Ph.D. Licensed Psychologist



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Bipolar Disorder Medication: Treatments of Choice?




Bipolar Disorder Medication Treatments: Overview

Bipolar disorder medication has been the treatment of choice for several decades now to control the severe and sometimes disabling symptoms of bipolar disorder. Doctors have been prescribing lithium and other mood stabilizers as well as anticonvulsant medications and atypical antipsychotics as the primary treatment for bipolar disorder along with the use of antidepressants and antianxiety medications, to help manage acute episodes as well as for the longer term management and to assist in managing future episodes.

Bipolar disorder medication treatments still rely upon the use of mood stabilizers such as lithium for the acute treatment of both manic and depressive episodes. Lithium has been used now for many decades to manage these moods and to prevent cycling into the other mood state. Doctors also have been known to use the anticonvulsants, antipsychotic medications, antidepressants, antianxiety and even sleep medications to manage the intense manic and depressive episodes as well as some of the associated problems, such as when the bipolar patient has a high level of anxiety or difficulty sleeping.

Mood stabilizers such as Lithium are used to prevent and treat the manic highs and the depressive lows. These medications are used to manage the symptoms so they do not interfere with school, work and with personal relationships. The main mood stabilizing medications are:

Divalproex sodium (Depakote)
Carbamazepine (Tegretol)
Lithium
Lamotrigine (Lamictal)
Valproic acid (Depakene)




Some of these medications are also chategorized as anticonvulsants such as valproic acid, lamotrigine and carbamazepine.

Other medications used to treat bipolar disorder include the atypical antipsychotic medications. These include
Aripiprazole (Abilify)
Risperidone (Risperdal)
Quetiapine fumarate (Seroquel)
Olanzapine (Zyprexa)
Ziprasidone (Geodon)
Loxapine (Loxitand or loxapine inhaler (Adasuve)
Asenapine (Saphris)
Cariprazine (Vraylar)
Lurasidone (Latuda)

If an individual is experiencing insomnia or sleep difficulties in relation to their bipolar symptoms, they may receive prescriptions for antianxiety medications such as benzodiazepines. Some of the more common benzodiazepines include:

Alprazolam (Xanax)
Lorazepam (Ativan)
Diazepam (Valium)
Clonazepam (Klonopin)

Or frequently some of the newer sleep medication such as zaleplon (Sonata) and eszopiclone (Lunesta} will be prescribed as they are believed to cause fewer problems with thinking and memory then the antianxiety medicines, benzodiazepines.

Frequently, the doctor will prescribe the mood stabilizing medication lithium initially, but may also start a medication to also assist with the bipolar depression such as:

Fluoxetine (Prozac) which is combined with olanzapine (Zyprexa) to form a medication referred to as Symbyax
Quetiapine fumarate (Seroquel)
Lurasidone (Latuda) which may be taken either alone or with valproic acid or lithium.

Bipolar disorder medication treatments and depression:

Due to the predominance of depressive symptoms in bipolar disorder, antidepressants are often combined with mood stabilizers. However, there are significant concerns that the use of antidepressants can trigger manic episodes. These concerns have usually been related to the older antidepressants referred to as tricyclics rather than some of the newer serotonin reuptake inhibitors such as Paxil, Prozac and Zoloft. This risk was identified in a study by Gijsman, Geddes, Rendell, Nolen and Goodwin in 2004 in which it was found that there was a significant risk of the emergence of a manic conversion from depression among patients with a mood or anxiety disorder treated with tricyclic antidepressants, rather than when patients were treated with the SSRI’s. Also, even higher conversion rates from depression to manic episodes were found among younger antidepressant users.

Benzodiazepines and bipolar disorder:

Benzodiazepines have been used at times to reduce agitation and comorbid anxiety as an adjunctive medication treatment for bipolar disorder. However, the actual efficacy of these medicines has not been adequately studied at the present time when used in addition to the mood stabilizing medications.

Normal course of medication treatment for bipolar disorder:

Although mood stabilizers, antidepressants and other adjunctive medications have been used for the treatment of bipolar disorder for many years, the normal course of bipolar disorder continues to be one of relapse of episodes of mania/ hypomania and depression. Studies (Gitlin, Swenson, Heller, and Hammond, 1995) have found one-year relapse rates as high as 40% even while being treated with mood stabilizers. Medication compliance continues to be a major issue with patients with bipolar disorder, with one study (Keck et al., 1998) finding inadequate medication use among approximately one half to two thirds of the patients within one year of initial treatment. Discontinuing the use of medications and the related relapse of bipolar symptoms with these patients is very problematic, especially when these medications have been stopped abruptly. Psychological treatments have been successfully utilized to promote medication compliance and to improve the symptom course of bipolar disorder patients. Overall, psychosocial interventions and psychotherapy have been found to improve the management of long-term bipolar symptoms and assist in relapse prevention.

References:

Gijsman, H.M., Geddes, J.R., Rendell, J.M., Nolen W.A. and Goodwin, G.M. (2004). Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. American Journal of Psychiatry, 161, 1537-1547.

Gitlin, M.J., Swenson, J., Heller, T.L. and Hammen, C. (1995). Relapse and impairment in bipolar disorder. American Journal of Psychiatry, 152, 1635-1640.

Keck, P.E., McElroy, S.L., Strakowski, S.M., West, S.A., Sax, K.W., Hawkins et al (1998). Twelve-month outcome of patients with bipolar disorder following hospitalization for a manic or mixed episode. American Journal of Psychiatry, 155, 646-652.

By Paul Susic Ph.D. Licensed Psychologist


Bipolar Disorder: What is it exactly?




Bipolar Disorder an Overview:

Dipolar disorder, formerly called manic depression is a chronic and very disabling condition. Bipolar disorder is a disorder of instability in mood, behaviors and lifestyle. The main feature of bipolar disorder is a manic episode followed by either another episode of mania at a later point in time, depression or hypomania. In most cases, one or more of these patterns occur repeatedly and chronically over an individual’s lifetime. The overall diagnosis of bipolar disorder is usually bipolar I or bipolar II disorder, with a reference to the most recent episode of “manic, hypomanic or depressed”. Specific symptoms and diagnosis can be found on this website by referring to the bipolar disorder diagnostic pages.

Individuals diagnosed with bipolar disorder may have very different symptom patterns. Some episodic symptom patterns seem to have some balance between episodes of mania, depression and hypomania, while others seem to have predominately one symptom pattern. Some researchers have found that among individuals with bipolar I disorder depressive episodes seem to predominate, with over 3.5 times as many weeks of depression relative to weeks experiencing manic episodes or hypomania. Most bipolar individuals will receive a diagnosis of bipolar disorder I most- recent episode depressed at some point in their mental health history. Individuals with bipolar II disorder, have 38 times more depressive symptoms than hypomanic symptoms.




People diagnosed with bipolar disorder experience tremendous levels of functional impairment in their lives even while maintained on medication. These deficits in functioning are very comprehensive including work-related, academic and interpersonal functioning. Some studies have found that even while maintained on medicine that deficits in functioning continue for as much is five years after the depressive or manic episodes have remitted. Some researchers (Dion, Tohen, and Anthony, 1998) have concluded that 30% of these individuals were unable to work at all and only 21% were able to work at their previous level of functioning following a manic, depressive or hypomanic episode. Similar findings were also found for individuals already on medication for bipolar disorder. Only a small percentage of manic patients seem able to work consistently following hospitalization. Bipolar disorder is also found to be associated with very high levels of marital and family distress, dysfunction and divorce.

Bipolar Disorder: Some Basic Information

Bipolar disorder has been estimated to affect about 1% to 2% of the general population. These estimates may be even higher levels when considering the entire bipolar spectrum including cyclothymia.
The initial onset of bipolar disorder seems to be in the late teens to early twenties. People with early onset disorder seem to have a higher level of additional comorbid symptoms, including conditions such as substance abuse and anxiety disorders. Also, early onset patients seem to have a more chronic course, with more episodes of depression and to have a higher likelihood of suicidal behaviors.

Men and women both seem to have about the same likelihood of developing bipolar disorder. However, more women than men seem to have the rapid cycling pattern, which is defined as four or more cycles in a year, as well as being diagnosed with bipolar II disorder more often.

People with bipolar disorder seem to experience comorbidity with several other mental health conditions and disorders. The most common comorbid conditions experienced by individuals with bipolar disorder include panic disorder, social anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder and generalized anxiety disorder. High rates of substance use disorders have been identified in clinical populations as well, with some clinicians believing that the rates may be as high as six times the general population.

The General Course of Bipolar Disorder:

The general course of bipolar disorder is to have repeated manic, depressive and hypomanic episodes that significantly impair an individual’s work and school experiences as well as their personal relationships. Also, these disruptions in functioning may increase the intensity and frequency of the symptoms and episodes. Over the long-term, about three fourths of the individuals who have met the diagnostic criteria for bipolar disorder will have a relapse within a period of 4 to 5 years, with about half having a relapse the following year. As previously mentioned, the residual impairment in functioning seems to continue even in between symptom episodes.

A number of factors seem to be associated with the increased frequency or likelihood of a mood episode. Stressful life and family experiences seem to delay recovery and increase the rate of relapse. It is believed that stressful family experiences and negative interaction patterns are associated with greater relapse rates.

The high level of comorbidity is also associated with a more difficult course. There appears to be significant evidence to support the fact that anxiety and substance use disorders are particularly significant to the appearance, maintenance and relapse of bipolar symptoms and episodes. Clinical experience also seems to confirm that the comorbid existence of anxiety in addition to bipolar disorder is linked to a reduced likelihood of recovery from a mood episode, reduced ability to function in everyday life, greater likelihood of suicide attempts and a reduced ability to respond to some medications. Comorbid substance abuse disorders often cause an individual to experience poor recovery, increase the level of noncompliance with an individual’s medication routine, and increase the frequency of hospitalization. Some individuals may also experience psychotic episodes during depressive episodes resulting in significantly impaired functioning and relapse.

Suicide is also a great concern among individuals with bipolar disorder. Researchers (Brown, Beck, Steer, and Grisham, 2000) have evaluated the course of over 7000 psychiatric outpatients in Pennsylvania diagnosed according to the DSM-IV criteria and found that among the various mental health diagnosis, bipolar disorder patients have the highest level of completed suicides, followed by major depressive disorder and personality disorders. When compared to what are determined to be relatively average psychiatric patients, patients with bipolar disorder seem to have about a 400% higher risk of suicide followed by major depressive disorder which seems to have about 300% higher risk for suicide.

Bipolar Disorder Treatments:

Optimum treatment for bipolar related disorders includes psychotherapy and mood stabilizing medications. Some the primary psychological treatments include psychoeducation, cognitive behavior therapy, family-focused therapy, and interpersonal social rhythm therapy. Lithium and other mood stabilizing medications have had a high rate of success in stabilizing bipolar symptoms and episodes. Individuals who are noncompliant with their medications continue to have very high rates of relapse however.

References:

Brown, G.K., Beck, A.T., Steer, R.A. & Grisham, J.R. (2000) Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68, 371-377.
Dion, G.L.,Tohen, M., and Anthony, W.A., (1998). Symptoms and functioning of patients with bipolar disorder six months after hospitalization. Hospital Community Psychiatry, 39, 652-657.

By Paul Susic Ph.D. Licensed Psychologist



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