Bipolar disorder medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Medical therapy

Bipolar disorder cannot be cured, instead the emphasis of treatment is on effective management of acute episodes and prevention of further episodes by use of pharmacological and psychotherapeutic techniques.

Hospitalization may occur, especially with manic episodes. This can be voluntary or (if mental health legislation allows it) involuntary (called civil or involuntary commitment). Long-term inpatient stays are now less common due to deinstitutionalization, although can still occur.[1] Following (or in lieu of) a hospital admission, support services available can include drop-in centers, visits from members of a community mental health team or Assertive Community Treatment team, supported employment [2] and patient-led support groups.

Medication

The mainstay of treatment is a mood stabilizer medication; these comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is lithium ,[3] while almost as widely used is sodium valproate,[4] originally used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder and lamotrigine, which is the first one to be shown to be of benefit in bipolar depression.[5]

Treatment of the agitation in acute manic episodes has often required the use of antipsychotic medications, such as chlorpromazine, olanzapine and thioridazine. More recently, olanzapine has been approved as an effective monotherapy for the maintenance of bipolar disorder.[6] A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis.[7]

The use of antidepressants in bipolar disorder has been debated, with some studies reporting a worse outcome with their use. However, mood stabilizers are of limited effectiveness in depressive episodes.

Other measures

  • Electroconvulsive therapy (ECT) may be used to treat the mania or depressive phase of bipolar disorder if it does not respond to medication. ECT uses an electrical current to cause a brief seizure while the patient is under anesthesia. ECT is the most effective treatment for depression that is not relieved with medications.
  • Transcranial magnetic stimulation (TMS) uses high-frequency magnetic pulses to target affected areas of the brain. It is most often used after ECT.
  • Patients who are in the middle of mania or depressive episodes may need to stay in a hospital until their mood is stable and their behavior is under control.
  • Doctors are still trying to decide the best way to treat bipolar disorder in children and adolescents. Parents should consider the possible risks and benefits of treatment for their children.
  • Support programs and therapies:
  • Family treatments that combine support and education about bipolar disorder (psychoeducation) may help families cope and reduce the odds of symptoms returning. Programs that offer outreach and community support services can help people who do not have family and social support.
  • Important skills include:
  • Coping with symptoms that are present even while taking medications
  • Learning a healthy lifestyle, including getting enough sleep and staying away from recreational drugs
  • Learning to take medications correctly and how to manage side effects
  • Learning to watch for the return of symptoms, and knowing what to do when they return
  • Family members and caregivers are very important in the treatment of bipolar disorder. They can help patients find the right support services, and make sure the patient takes medication correctly.
  • Getting enough sleep is very important in bipolar disorder. A lack of sleep can trigger a manic episode. Therapy may be helpful during the depressive phase. Joining a support group may help bipolar disorder patients and their loved ones.
  • A patient with bipolar disorder cannot always tell the doctor about the state of the illness. Patients often have trouble recognizing their own manic symptoms.
  • Changes in mood with bipolar disorder are not predictable. It it is sometimes hard to tell whether a patient is responding to treatment or naturally coming out of a bipolar phase.
  • Treatments for children and the elderly are not well-studied.

References

  1. Becker T, Kilian R. (2006) Psychiatric services for people with severe mental illness across western Europe: what can be generalized from current knowledge about differences in provision, costs and outcomes of mental health care? Acta Psychiatrica Scandinavica Supplement, 429, 9–16. PMID 16445476
  2. McGurk, SR, Mueser KT, Feldman K, Wolfe R, Pascaris A (2007). Cognitive training for supported employment: 2–3 year outcomes of a randomized controlled trial. Am J Psychiatry. Mar;164(3):437–41. PMID 17329468
  3. Poolsup N, Li Wan Po A, de Oliveira IR. (2000) Systematic overview of lithium treatment in acute mania. J Clin Pharm Ther 25: 139-156 PMID: 10849192
  4. Macritchie K, Geddes JR, Scott J, Haslam D, de Lima M, Goodwin G. (2002). "Valproate for acute mood episodes in bipolar disorder". The Cochrane Database of Systematic Reviews. John Wiley and Sons, Ltd. (2). doi:10.1002/14651858.CD004052. ISSN 1464-780X. 
  5. Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD.(1999) A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group. J Clin Psychiatry 60: 79-88
  6. Now Approved: ZYPREXA for maintenance therapy for bipolar disorder. Official Zyprexa Website.
  7. Tohen, Mauricio (2005). "Olanzapine Versus Lithium in the Maintenance Treatment of Bipolar Disorder: A 12-Month, Randomized, Double-Blind, Controlled Clinical Trial". American Journal of Psychiatry. 162 (7): 1281–1290. 



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