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Ask the Doctor: Dr. Ellen Frank on The Role of Circadian and Sleep-wake Factors in Bipolar Disorder
Sept. 23, 2011

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Ask the Doctor: Dr. Ellen Liebenluft on Bipolar Disorder in Adolescents
April 15, 2011

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becoming an advocate coping strategies

Treatments, Services and Supports

Because bipolar disorder is a chronic illness, continuous maintenance to help prevent the reemergence of symptoms is recommended. Providing proper treatment helps most individuals living with bipolar disorder control their mood swings and other symptoms. The management of the illness should include attention to lifestyle, stress management, supports and also medication options. There is no one approach. It is essential to put together a care plan with elements specific to your needs.

If bipolar disorder is left untreated, it tends to get worse and the symptoms can become more pronounced. Recognition and diagnosis of the disorder in its earliest stages is important so that one can receive effective treatment. Effective treatment plans usually include medication, psychotherapy, education, self-management strategies and external supports such as family, friends and formal support groups. Combining these elements and revising the treatment plan based on assessment of an individual's response is the best means of preventing relapse and reducing the severity of symptoms.

Medications

Not everyone responds to medications in the same way. Often, multiple types of medication must be assessed in order to find the one, or ones, that are the most effective for an individual. Some of the types of medication used to treat bipolar disorder are listed below. Information on medications can change. For the most up to date information on use and side effects contact the U.S. Food and Drug Administration (FDA) at www.fda.gov.

Mood-stabilizing medications are often the first choice of medication when treating bipolar disorder. They are referred to as "mood stabilizers" because of their ability to return an individual to usual level of psychosocial functioning. Except for lithium, all of the below "mood stabilizer" medications are known as anticonvulsants.

Generic Name Brand Name
Lithium Eskalith or Lithobid
Valproic Acid (or Divalproex Sodium) Depakote
Lamotrigine Lamictal
Carbamazepine Tegretol

Lithium has been used for more than 50 years for the stabilization and treatment of bipolar disorder. It is typically more effective when administered earlier in the course of the illness. Research has also shown that it is most effective in those individuals with a family history of the illness and in those experiencing the bipolar I swings between mania and depression with a return to normal function between episodes. The use of lithium has proved effective in helping prevent relapse as well as beneficial in the continued treatment of bipolar depression. There is evidence that lithium can lower the risk of suicide but the FDA has not granted approval specifically for this purpose.

Like all medications, lithium treatment produces side effects. The most common unwanted effects vary in intensity with the dose and can be effectively managed. However, for about 30 percent of people who try lithium, it is not tolerable. Lithium side effects may include frequent urination, excessive thirst, weight gain, memory problems, hand tremors, gastrointestinal problems, hair loss, acne and water retention. There are two main side effects of lithium that require monitoring by a simple blood test: 1) hypothyroidism, which can mimic depression, and 2) impaired kidney function, which is less common, but still needs to be monitored.

The FDA has approved valproic acid and carbamazepine for treating mania. These drugs, also approved to treat epilepsy, were found to be as effective as lithium for treating acute mania and may be better than lithium in treating the more complex bipolar subtypes of rapid cycling and dysphoric mania as well as co-morbid substance abuse. As with lithium, valproic acid and carbamazepine may also produce sedation and gastrointestinal distress, but these side effects are generally resolved within the first six months of treatment or with dose adjustment. It is important to monitor liver function on these medications.

Unlike valproate and carbamazepine, Lamotrigine has not shown benefits for treatment of mania but it has approval from the FDA for delaying occurrences of bipolar I disorder. For most people, it produces very few side effects. Lamotrigine does not have FDA approval for treatment of the acute episodes of depression or mania. Studies of lamotrigine for treatment of acute bipolar depression have produced inconsistent results. Lamotrigine can trigger Stevens-Johnson syndrome in some people—eight in 1,000 children and three in 1,000 adults. Stevens-Johnson syndrome is a toxic skin condition that can result in death. Carefully monitor your skin when taking Lamotrigine.

All anticonvulsant medications carry an FDA warning stating that their use may increase the risk of suicidal thoughts or behaviors. Individuals beginning a regimen of anticonvulsant medications for bipolar disorder or other illness should be closely monitored for new or worsening symptoms.

Second-generation antipsychotics (SGAs) are also commonly used to treat the symptoms of bipolar disorder and are often paired with other medications, including mood stabilizers. They are generally used for treating manic or mixed episodes.

Generic Name Brand Name
Olanzapine Zyprexa
Aripiprazole Abilify
Quetiapine Seroqeuel
Risperidone Risperdal
Ziprasidone Geodon
Paliperidone Invega
Asenapine Saphris

These medications are often prescribed to help control acute episodes of mania or depression. At present only quetiapine and the combination of olanzepine and fluoxetine have FDA approval for treatment of bipolar depression. Finding the right preventive/maintenance medicine is not an exact science and is specific to each individual.

Weight gain is a serious clinical concern related to the use of all atypical antipsychotics. Not only can weight gain lead to adult-onset diabetes and cardiovascular diseases, but being overweight is also the leading cause of discontinuing the use of medication.

For weight and other health management strategies, visit NAMI's Hearts & Minds program at www.nami.org/heartsandminds. Atypical antipsychotics can also cause drowsiness, dizziness when changing positions, blurred vision, rapid heartbeat and skin rashes. All antipsychotic medication carry some risk for causing abnormal involuntary movement disorders and require careful monitoring.

Standard antidepressant medications are sometimes administered to address symptoms of depression in bipolar disorder. However, a recent study funded by the National Institute of Mental Health (NIMH) showed that taking an antidepressant in addition to a mood stabilizer is no more effective that using a mood stabilizer alone for bipolar I.

Generic Name Brand Name
Fluoxetine Prozac
Paroxetine Paxil
Sertraline Zoloft
Bupropion Wellbutrin

These are only some of the many antidepressants that may be prescribed for helping control the depressive symptoms of bipolar disorder, but none has FDA approval specifically for treatment of bipolar depression.

As with anticonvulsants, antidepressant medications also carry an FDA warning. The FDA warning says that patients of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment. Possible side effects to look for are depression that gets worse, suicidal thinking or behavior, or any unusual changes in behavior such as trouble sleeping, agitation or withdrawal from normal social situations.

Psychotherapy and Other Interventions

While medication is one key element in successful treatment of bipolar disorder, psychotherapy, support groups and knowledge about the illness are also essential components of the treatment process. The most useful psychotherapies generally focus on understanding the illness (psychoeducation), learning how to cope and changing ineffective patterns of thinking. One popular type of psychotherapy used for changing these ineffective patterns is Cognitive Behavioral Therapy, or CBT.

Each of these components serves a critical role in helping people recognize the specific factors that can trigger their episodes. It is also important for individuals living with bipolar disorder, and their families, to play active roles in learning about the illness, and in developing and carrying out a treatment plan of the person's choosing. This is known as family-focused therapy.

Recently, the NIMH funded a clinical trial called the Systematic Treatment Enhancement Program for Bipolar Disorder (STEPBD). It showed that several psychotherapy interventions were more advantageous in treating bipolar depression than a threesession intervention teaching collaborative care strategies and directing individuals to self-manage their plans. The three types of psychotherapy examined focused on cognitive strategies, family involvement and schedule and stress regulation.

Electroconvulsive Therapy (ECT)

For severe cases where medication and psychotherapy do not work, ECT may be worth considering. ECT involves the use of short electrical impulses transmitted into the brain. Although ECT is a highly effective treatment for severe depression, manic, or mixed episodes, it is not the first choice in providing treatment. Although ECT still produces some side effects, including some memory loss, modern techniques carried out under general anesthesia are much safer than previously used methods. As with other interventions, the risks and benefits of ECT should be carefully reviewed.

Complementary and Alternative Medicine

CAM refers to alternative forms of medicine that are not considered part of conventional (Western) medicine. In recent years, CAM has become increasingly popular, but no CAM strategy has won FDA approval. While there is still limited data showing support for many CAM practices and some inconsistency in results, there are studies which support the usefulness of CAM strategies that are considered to have minimal if any adverse effects.

One practice that has shown some promise for the treatment and management of bipolar disorder, as well as other mental illnesses, are omega-3 fatty acids, which are commonly found in fish oil. Some researchers hypothesize that omega-3 may be beneficial in treating mental illness because of its ability to protect or support the replenishing of neurons and connections in areas of the brain that are affected by these illnesses.

Treatment for Women

Administering medication and treatment for women living with bipolar disorder can sometimes be difficult. For women who begin taking valproic acid before age 20, there may be an increase in levels of testosterone (a male hormone). This can lead to polycystic ovary syndrome (PCOS). PCOS is a syndrome that causes an imbalance in a woman's female sex hormones. This can result in changes in a woman's menstrual cycle, skin changes, small cysts in the ovaries and other problems. Most of these symptoms will improve after stopping treatment with valproic acid.

Pregnant women and nursing mothers living with bipolar disorder should talk to their doctors about the benefits and risks of all available treatments. The mood stabilizing medications used today can hurt a developing fetus or nursing infant. However, stopping medications, suddenly or gradually, greatly increases the risk that bipolar symptoms will recur during pregnancy, which compounds risk for mother and baby alike.

Treatment for Children

The childhood diagnosis of bipolar disorder has received a great deal of attention and has also generated controversy. Getting a comprehensive evaluation of a child's health and mental health is important before making any psychiatric diagnosis.

In young children, bipolar is most commonly diagnosed at the age of 12. Children who live with bipolar disorder may also have other co-occurring conditions. These can include attention-deficit hyperactivity disorder, posttraumatic stress disorder, learning disabilities and even substance abuse problems. Each of these co-occurring conditions requires a thoughtful and individualized treatment plan. Appropriate treatment for children should include psychotherapy and psychosocial interventions as the first line of treatment before medications are introduced.

Treatment and Culture

African Americans and Latinos are more prone to misdiagnosis, likely due to differing cultural or religious beliefs or language barriers. For anyone who has received a diagnosis of bipolar disorder, it is important to look for a health care professional who understands a person's cultural background and shares the same expectations for treatment.

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