General treatment recommendations

August 1, 2011

The goal of treatment in bipolar disorder is complete remission of symptoms with a return to baseline level of health and functioning. Unfortunately, at this time, there is no “cure” for bipolar disorder, but it is entirely possible for individuals with bipolar illness to experience long periods of freedom from symptoms or with minimal recurrence of mood episodes. Predictors of good outcome include good response to medications, older age at illness onset, good psychosocial supports, absence of comorbid psychiatric and medical conditions, and adherence with treatment.

It is known that psychotherapies may make biological treatments more effective in the management of bipolar illness. Thus, a general recommendation is the use of combined psychotherapy and medication management in optimizing treatment for bipolar disorder. Most studies of psychosocial treatments for bipolar disorder utilize contemporary psychotherapies such as cognitive behavioral therapy, tend to be fairly focused, and are delivered in the context of standard medication treatments. These therapies offer practical techniques for coping with stress, educate patients and families about bipolar illness, and encourage adherence with medication treatment. Types of psychotherapies that have been reported to be particularly beneficial in bipolar illness include family-focused treatment and interpersonal and social rhythm therapy. Psychosocial treatment of bipolar disorder may be delivered in individual, family/couples, or group formats.

The cornerstone of medication treatments in bipolar disorder is mood-stabilizing medication. As bipolar disorder tends to be a chronic, potentially relapsing condition, long-term treatment or prophylaxis treatment with mood-stabilizing medication is generally recommended. The two most commonly used mood-stabilizing medications are lithium carbonate and the anticonvulsant medication valproate (Depakote and others). Other medications that may be utilized in the management of mood episodes in bipolar illness include carbamazepine (Tegretol and others), lamotrigine (Lamictal), and other anticonvulsant compounds. Relatively recently, the atypical antipsychotic medication olanzapine (Zyprexa) received the Food and Drug Administration (FDA) approval for use in bipolar disorder, and use of newer antipsychotic mediations has become increasingly common in the management of bipolar illness.

Regular follow-up with medical care during the prophylaxis (maintenance) phase is extremely important. Choice of mood-stabilizing medication should generally be based upon an individual’s history and clinical status. Both lithium and valproate have proven efficacy as first-line agents. Individuals having a good history of medication response to a particular compound are very likely to have a repeat good response with treatment with this same compound. During maintenance treatment visits, the treating clinician will generally review any occurrence of medication adverse events as well as monitoring of medication levels. Medication blood levels are routinely monitored with lithium, valproate, and carbamazepine. Psychoeducational interventions are typically most effective during the maintenance period, once individuals have achieved some degree of clinical stability. Best results are generally obtained when families or important individuals in the patient’s social support network are engaged in treatment as well.

Individuals with bipolar disorder may develop severe depressive episodes in which substantial functional impairment is seen, and suicide vulnerability becomes an important issue. When this occurs, common treatment strategies involve optimizing mood-stabilizer treatment, addition of additional mood-stabilizing medication, and possible use of antidepressant medications. Families and support individuals should be alerted to possible suicide risks and psychosocial measures implemented as needed. Individuals with suicidal ideation may require hospitalization. Most newer, standard antidepressant drugs appear to be equally efficacious in bipolar depression and choice of agent should be based upon past history and current clinical status.

Less commonly, alternative, nonmedication biological therapies are used for the treatment of bipolar disorder. These include treatments such as electroconvulsive therapy (ECT), rapid transcranial magnetic stimulation (rTMS), and phototherapy/bright light therapy. ECT is a generally safe and effective treatment for depression and mania, which is done under general anesthesia. A brief electrical stimulus is administered via electrodes attached to the scalp, which results in a brief seizure (40-60 s). ECT is often done when individuals are unable to tolerate medication, or when medications have been ineffective. rTMS is a less established, noninvasive procedure in which a brief, nonconvulsive (nonseizure causing) stimulus is used for the treatment of depression. Light therapy involves use of high-intensity light exposure to treat depressive symptoms.

SEE ALSO: Depression, Mood disorders, Schizophrenia


Category: Bipolar Disorders