Treatment for Bipolar Disorder Part I: Background and Medications
Bipolar disorder, originally called manic depressive disorder, is a severe psychiatric disorder that vacillates between extreme “ups” (mania, hypomania) and “downs” (depression). The effects of having bipolar disorder can be observed across the patients social and occupational functioning. Often the patient is left isolated from work, friends, and family. Medications have become the first-line treatments for bipolar disorder; however, psychotherapy can offer additional benefits in the ongoing treatment of patients with bipolar disorder. This paper discusses the symptoms and treatment of bipolar disorder focusing on medication treatment. Part II discusses psychotherapy interventions for bipolar disorder such as cognitive behavioral therapy and emotion focused therapy.
Description and Differentiation.
According to the Diagnostic and Statistical Manual of Mental Disorders –Fifth Edition (DSM-5) one’s mood is an all-encompassing and sustained feeling of emotional tone experienced internally by the person and influences the person’s behavior and perception of the world. The term affect refers to the external or outward expression of this inner state (American Psychiatric Association [APA], 2013). Mood disorders are categorized by a loss of that internal sense of control and a sense of distress.
Depressive disorder occurs in the absence of mania or hypomania. When mania or hypomania (a more subdued from of manic behavior) is involved the person is diagnosed with a variant of bipolar disorder or cyclothymia. A manic episode is defined as a distinctive period of an abnormally persistent and elevated, expansive, or irritable mood lasting for a week (unless the patient is hospitalized) and leads to significant impairment in social or occupational functioning (this can include psychotic episodes including hallucinations and delusions; APA, 2013). Hypomania is similar to mania except that the episode is often shorter (but at least four days in duration), there is no psychosis, and the episode does not lead to the same level of social and/or occupational impairment that mania does. Both hypomania and mania result in inflated levels of self-esteem, distractibility, decreased need for sleep, greatly increased mental and physical activity, and an overindulgence in pleasurable or stimulating activities. Bipolar disorder (Bipolar I) is characterized by the presence of one or more manic episodes and sometimes these are interspersed with depressive periods. Bipolar II is characterized by episodes of hypomania and depression (APA, 2013). Cyclothymia is characterized by at least two years of hypomanic symptoms that do not qualify for fit the criteria for mania and depressive symptoms that do not fit the diagnosis of major depression (APA, 2013). For purposes of this paper cyclothymia will not be considered in the discussion of treatment as to keep the paper simple.
Bipolar disorder most often starts with a depressive episode and is a reoccurring disorder. Most bipolar sufferers experience alternating courses of both mania and depression, although there is smaller percentage of those that are afflicted that predominately with manic episodes (APA, 2013). Manic episodes typically have a rapid onset (a few hours to a few days), but can develop over longer periods (weeks). Manic episodes can last as long as three months if not treated, but this is rare. Ninety percent of those who experience a manic episode with have another manic episode within two years. As time goes on the period between manic episodes well shorten, but eventually will stabilize. Bipolar I patients have a poorer prognosis than those with other mood disorders and often are expected to take medication for the course of their lifetime (APA, 2013).
Bipolar disorder appears to occur equally in men and women (whereas depression occurs more often in woman; APA, 2013). Mania occurs more often in men; when it occurs in women it is more likely to present with a mixed picture (mania and depression). Women are more likely to be rapid cyclers, meaning that they are more likely to experience four or more manic episodes in a one year time frame (APA, 2013). The mean age onset for bipolar disorder is around 30 years of age (but can occur as early as five or six years of age or as late as 50 years old in rare cases). The disorder is more common in divorced and single persons, people without a college degree, and there is a slightly higher prevalence of the disorder found in upper socio-economic groups. Many of these demographic factors may relate to the earlier age of onset for bipolar disorder compared to clinical depression (where the mean age of onset is 40 years of age). These factors can be important when considering the course of treatment.
Etiology (Cause) of Bipolar Disorder
The etiology of bipolar disorder is much more speculative than that of clinical depression. Neurotransmitter dysregulation has long been suspected, but the perspective of focusing on a single neurotransmitter or neurotransmitter system has shifted to one that focuses on studying neurobehavioral systems, neuroregulatory systems, and neural circuits (these consist of many neurotransmitters and several different brain systems; Goodwin, 2007). Brain imaging techniques have revealed enlarged brain ventricles, cortical atrophy (degeneration), and widened sulci (the indentations in the “wrinkles” of the brain) indicating that these patients have experienced reduced cortical volume loss. Reduced brain tissue is connected with poorer functioning over all types of disorders. Lesions in the subcortical brain matter (this is the brain tissue below the surface of the brain) in bipolar I sufferers is the most consistent finding of these studies (Goodwin, 2007). The findings from these studies suggest a possible cortical pathology is responsible for bipolar disorder. Genetic studies have also been used to support this assumption as there is a high concordance rate for bipolar disorder in monzygotic (identical) twins (Goodwin, 2007).
Biology and Stress?
In light of the findings that demonstrate a possible biological etiology for bipolar disorder these findings are still complicated by the notion that many neuroimaging studies are performed on chronic patients with a history of medication and drug usage and twin studies are complicated by a dearth of adoption studies (Miklowitz, 2008a). However, few would argue the potential for a strong biological influence and contribution on the expression of bipolar disorder compared to many other disorders such as depression and the anxiety disorders. But a strict overarching biological etiology has not been demonstrated by the research. A long-standing clinical observation is that stressful life events precede rather than follow bipolar and almost all other psychiatric disorders (Alloy et al., 2006). One theory is that traumatic stress might change the brain that alter normal brain functioning. Life events such as the death of a loved one or other stressing events increase the risk of developing depression, which precedes mania in the vast majority of bipolar sufferers (Alloy et al., 2006; Miklowitz, 2008a). There are no single personality factors that are consistently associated with the development of bipolar disorder, but stressful life events could conceivably also interact with innate factors to lead to the expression of the disorder. Therefore, in addition to medications one could hypothesize that psychotherapies that assist with cognitive restructuring and reprocessing of events could assist in the treatment of bipolar disorder (Miklowitz, 2008a).
Medications for Bipolar Disorder
As mentioned above bipolar disorder is viewed as a chronic condition and even though there are a variety of effective treatments available the use of psychotropic medication is often the first-line treatment option. Interestingly, individuals affected with bipolar disorder will often seek out treatment according to what phase of the disorder they currently experience. For example, someone in an initial depressive stage would seek out treatment for depression which could consist of medication or psychotherapy or both. When the patient is in the manic or hypomanic phase of the disorder they often take on the attitude that they do not need medications and if they are on medication they often stop taking them. During these times referrals from family members, employers, or friends get the patient into treatment or the patient acts in such a manner to get themselves involved in the legal system and treatment referrals are made from that venue. If none of this occurs when the person reaches a depressive phase they will often return or seek out treatment (Goodwin, 2007). In any event, actively manic patients can be very difficult to treat. Bipolar patients are also notoriously prone to self-medicate with drugs or alcohol in attempt to relieve their symptoms.
Medication is almost always a part of the treatment course regime for bipolar disorder. The types of medical interventions commonly prescribed for bipolar disorder include the following (Goldberg, 2004; Goodwin, 2007):
- Mood stabilizers. This group includes many of the older medications bipolar such as lithium, which are still reliable and are still well-tolerated by many patients. These were the first-line medication treatments for bipolar disorder at one time but now have been they have largely been replaced by the use of the atypical antipsychotics. Mood stabilizers often have side effects such as lethargy, cognitive issues, diarrhea, and others.
- Atypical antipsychotics. These medications were designed for use with psychotic disorders such as schizophrenia but research indicates that they may provide greater symptom relief for bipolar disorder, but also have more side effects such as tremors, tardive dyskinesia, cognitive problems, sedation, and others.
- Other medications often include the use of antidepressant medications along with an antipsychotic or mood stabilizer and even an anxiolytic (anti-anxiety) medication.
There is no single approach to treating bipolar disorder with medications and psychiatrists typically have to adapt a trial-and-error approach with individual patients until the best overall combination that works with that particular patient is achieved. The use of medication for treating bipolar disorder is often divided into three broad categories:
- In the acute treatment phase the focus is on suppressing current symptoms and continues until the patient is considered to be in remission, which occurs when their symptoms have been significantly are reduced and controlled for a significant time period.
- Continuation treatment is designed to prevent a reoccurrence of the symptoms from the current or from the same depressive or manic episode.
- Maintenance treatment is designed to prevent a recurrence of symptoms after the last episode has been controlled.
There have been numerous studies that have demonstrated that when treated with medications the relapse rates for bipolar disorder are substantially reduced and the overall improvement of symptoms is quite substantial (e.g., Goldberg, 2004). For these reasons medications will continue to be the first-line treatments for bipolar disorder, but this does not mean than psychotherapy cannot be used to help these patients or to assist with their treatment. For bipolar patients in psychotherapy, being on medications is often viewed as a necessary evil. This is because that many patients experience side-effects from mood stabilizers or atypical antipsychotics and yet have to continue to do the work in therapy (as well as their daily routines) in order to adjust and to move forward. Patients, their physicians, and therapists need to be cognizant of the complications of medical interventions such as psychotropic drugs when judging their daily levels of functioning and progress in treatment.
Part Two of this series will discuss the use of psychotherapy in the treatment of individuals with bipolar disorder.