The key to the treatment of Bipolar Disorder (whether Bipolar I or Bipolar II) remains pharmacological. This is because Bipolar Disorder is a biological condition with a strong genetic component. However, despite good adherence to treatment, many sufferers continue to experience sub-syndromal symptoms if not full episodes of illness. As a consequence, increasing interest is now being paid to the role of psychosocial treatments in ameliorating these symptoms and helping people to adjust to this chronic and relapsing illness. This important aspect is explored in more detail below in Psychological treatments for Bipolar Disorder.
One of the main issues in management for any clinician (GP or Psychiatrist) is helping patients to remain ON medication. The 'stop-start' phenomenon in taking medication is rarely so widespread as occurs for those with Bipolar Disorder. The consequences of this approach are now known to be very detrimental, with increased rates of relapse and often impacting on the actual pattern of episodes, sometimes speeding up cycles of illness. Building a good rapport with the individual, and asking about and dealing with side-effects all assist in this process. Assisting the person to learn about their illness, to take responsibility for it and to aim to work in partnership with their health professional, all help to improve adherence and therefore the prognosis.
The Royal Australian and New Zealand College of Psychiatrists has recently published clinical practice guidelines for the treatment of Bipolar Disorder. A brief overview is provided below. In essence, we focus on the management of those with Bipolar I Disorder, leaving management of Bipolar II Disorder till later.
Pharmacological agents are used in the acute phase of the illness to eliminate the symptoms of mania or depression. They are also used in the maintenance phase - in which their role is to prevent relapse or, at the very least, reduce the frequency and severity of episodes.
| Acute Mania | Acute Bipolar Depression | Mixed Episode | |
|---|---|---|---|
| Lithium (Lithicarb, Quilonum SR) |
Sodium Valproate (Epilim, Valpro) | Most antidepressants | Sodium Valproate (Epilim, Valpro) |
| Carbamazepine (Tegretol, Teril) | Olanzapine* (Zyprexa) |
Lamotrigine (Lamictal) |
|
| Risperidone* (Risperdal, Risperdal Consta) |
Aripiprazole* (Abilify) |
||
| Quetiapine* (Seroquel) |
Solian* (Amisulpride) |
||
* While these newer atypical antipsychotic drugs are commonly used these days, old 'typicals' (e.g. Haloperidol) may also be effective.
In managing acute mania , the table indicates that mood stabilisers (e.g. lithium) or antipsychotic drugs may be used. If the patient is not settling on one such drug class, the use of combination therapy (i.e. mood stabiliser + antipsychotic) may speed up improvement.
In managing acute bipolar depression, narrow action (e.g. SSRI) or dual action (e.g. Avanza or Efexor) antidepressants are preferred (as TCAs and MAOIs may 'switch' the patient to a 'high' - so-called Bipolar III). If the patient does not respond to the antidepressant alone, augmentation with an atypical antipsychotic drug (low dose, and ideally, until the patient is no longer depressed) may be necessary. Together with initiating such antidepressant strategies, a mood stabiliser might also be commenced or, if the patient is already on such medication, have levels checked and dose adjusted as may be required.
These are mainly used as adjunctive treatment to the above, commonly when a person is in hospital, and to control severe agitation or overactivity.
Although strictly a physical therapy and not a medication, it is worth mentioning as ECT plays an important role in treating both acute mania (and psychosis) and severe depression on occasions. ECT may be used when:
In the last few years, a large number of studies have established a strong maintenance role to the atypical antipsychotics, often more powerful than observed for standard mood stabilisers. However, while side-effects associated with our current mood stabilisers are reasonably well known (and may not be trivial), medium and long-term side-effects associated with the atypical antipsychotics in managing Bipolar Disorder I remain to be clarified.
Lamotrigine is another anticonvulsant which has recently caused much interest as a series of studies have found it to be particularly efficacious in the treatment of Bipolar Depression. Depression in Bipolar Disorder can be hard to treat and tends to be less responsive (compared to manic symptoms) to the established mood stabilisers.
The main concern when using Lamotrigine is the rare, but serious, side-effect of a Stevens-Johnson-like rash. The risk of this occurring can be reduced by starting at a low dose of 25 mg to 50 mg a day and increasing very gradually by 25-50 mg weekly until a therapeutic dose of around 200 mg has been reached. The patient needs to be informed about the risk of this side-effect, its appearance and what action to take if it occurs. In that event, rapid cessation of the medication is recommended.
One of the concerns about prescribing mood stabilisers for Bipolar Disorder is the need for regular monitoring.
The recommended blood tests that are needed for the different mood stabilisers are shown below.
| Lithium |
|
|---|---|
| Carbamazepine |
|
| Sodium valproate |
|
| Lamotrigine |
|
| Atypical Antipsychotics |
|
It can be helpful to include the patient in this process and encourage joint responsibility for drug level monitoring. The patient should receive copies of all of their blood tests to keep a record at home. If possible, they should be aware what the tests are monitoring, what the numbers mean and obviously what signs would indicate drug toxicity and what to do if this occurs. All of this will help with adherence to the medication and empower the patient to manage his or her own illness.
In the past, it had been thought that psychotherapy had little to offer in the treatment of Bipolar Disorder, as this was an illness that was understood as being primarily a biological illness. Interest in the role of psychological interventions has increased in recent years. There are several reasons for this, including:
Relapse rates after an episode of mania have been reported as being around 50% after one year and between 70-85% after five years. This has led to an increasing number of randomised controlled studies examining the effectiveness of a variety of different interventions. The most useful therapies appear to be psychoeducation, family therapy and cognitive behavioural approaches. While these strategies improve adherence with medication, intervention studies have shown that they have additional benefits. We explore these and others below.
Many of these interventions share key elements, which has made evaluating their individual role more difficult. The common shared themes are:
The types of positive outcomes that have been reported in studies on these interventions include:
It is important to recognise and discuss with patients that these interventions have been found to be effective as adjuncts to and not replacements for medication, which remains the key component to the maintenance treatment of the illness.
Psychoeducational approaches can be delivered (and have been evaluated in randomised controlled trials) as structured interventions delivered as a single package or over several weeks, either individually, or in groups, or for families. The core knowledge that they aim to impart includes:
It is vital therefore that all patients with Bipolar Disorder are assisted to learn as much as they can about the disorder. This is especially important in the first few years after diagnosis to ensure good adherence to treatment and to minimise kindling of the illness by a 'stop-start' approach to medications. Psychoeducation programs don't have to be delivered by 'experts'; a GP can provide very effective interventions by:
Cognitive behaviour therapy for Bipolar Disorder would cover many, if not all, of the following elements:
Studies have found both brief and longer interventions to be useful, although which phase (i.e. manic or depressive) responds best, has been debated. Increasingly, local area mental health services are recognising the importance of this intervention in preventing relapse in people with Bipolar Disorder and some will offer outpatient (as well as inpatient) group programs. If this were not the case in your area, referral, if the patient is willing, to an appropriately experienced Clinical Psychologist would be appropriate.
Several studies have established that patients with Bipolar Disorder who live in environments in which there is a high level of expressed emotion have higher rates or relapse and worse symptom control. Family therapy aims to improve family functioning and teaches a combination of communication skills, problem solving and coping strategies. It will often include psychoeducation about Bipolar Disorder and teach the family/partners skills in recognising early warning signs of relapse. Studies have found that the benefits of such intervention have included:
This was developed in the USA in 2000 and came from a program that was developed for people with unipolar depression. The therapy aims to regulate social and circadian rhythms as well as examine and address any interpersonal problems in the realms of interpersonal conflicts, role disputes and unresolved grief.
The main elements include:
At present it is mostly being delivered through structured programs in research facilities in the United States. There is some debate about whether it is as effective as an adjunct as standard CBT or psychoeducation as described previously.
More attention is increasingly being drawn to the gender differences that occur in the presentation and course of Bipolar Disorder, and how they can impact upon treatment. A full discussion of these differences and treatment issues is out of our scope here but for those interested or specialising in women's health, further reading is suggested from the reference list.
The incidence of Bipolar I Disorder is the same in men as in women, however it appears that it takes longer for Bipolar Disorder to be recognised in women than in men. Reasons for this include them experiencing more mixed episodes than men, being more likely to experience a rapid-cycling pattern, having higher rates of anxiety disorders (particularly panic disorder and social phobia), and experiencing more depressive episodes than men with Bipolar Disorder.
Recent studies have identified important pharmacokinetic and pharmacodynamic differences between men and women which may impact upon the dosage regimes of medications used in the treatment of Bipolar Disorder, with women likely to require smaller dosages than men. There has been a suggestion that there might be a possible gender difference in response to antidepressants but these are all initial studies (mostly in unipolar depression) and more studies are needed to fully explore this in Bipolar Disorder. Specific important issues for woman in regards to medication include:
Special care needs to be taken for women planning to become pregnant. It is no longer the accepted opinion that women with Bipolar Disorder 'should not' become pregnant nor that all medications need to be ceased. The issues are complex and it is highly recommended that advice from an experienced psychiatrist, ideally involved in women's mental health, is sought.
The post-partum period is a period of maximum risk for a woman with Bipolar Disorder, especially if she ceased the mood stabiliser prior to becoming pregnant. It is therefore vital that medication of some type is used to 'cover' this high-risk period. Valproate and carbamazepine have been considered to be compatible with breastfeeding by the American Academy of Paediatrics despite passing through into breast milk and having some effects on the infant. Again, it is highly recommended that specialist advice be sought at this time.
One of the most important roles in the longer-term management of someone with Bipolar Disorder is recognising the signs and symptoms that herald the onset of a manic or depressive relapse. This 'relapse signature' can vary in its composition from person to person, as can the length of time that the symptoms will appear before a full-blown relapse becomes established. These changes can occur in the person's mood, behaviour and/or their cognitive functioning.
Not all patients with Bipolar Disorder will be able to recognise such early warning signs. Some will switch into mania without warning, losing insight in the process and making preventive action difficult. The majority of people (80%) can, however, recognise such symptoms. A recent paper (Jackson et al, see reference below) reviewed the types of early warning signs that can occur and how easily they were identified by the patient.
The table below summarises that study's findings. It shows the commonest and most easily identified symptoms for both mania and depression at the top of the table and the less frequently identified and experienced symptoms towards the bottom.
| Commonest symptoms | Mania | Depression |
|---|---|---|
 |
Sleep disturbance - commonly needing LESS sleep and not feeling tired (e.g. 3-4 hours a night) | Sleep disturbance - low mood, decreased enjoyment of activities (anhedonia) |
| Psychotic symptoms | Psychomotor symptoms | |
| Mood change | Increased anxiety | |
| Psychomotor symptoms | Appetite change | |
| Appetite changes | Suicidal ideas/intent | |
| Increased anxiety | Sleep disturbance | |
| Least common symptoms | Mania | Depression |
Encouraging patients to use a Daily Mood Graph [PDF, 107KB]can help them to identify such signs indicating that a slip is about to occur. Monitoring over several months can also help them identify triggers to symptoms and therefore help them identify potential 'at risk' times when they need to take more care (for example, overseas travel and disruption to normal sleeping patterns, or a social event in which they may drink more).
The types of early warning signs that occur for the individual patient (changes to mood, behaviour and thinking) for both a manic or depressive episode, should be written down in the medical file and a copy given to the patient to keep. It can be useful to attach to this an agreed 'plan of action' (wellbeing plan) for both the doctor and the patient if these symptoms should occur. Such a plan can be distributed (with permission) to other people involved in the care of the patient (community health staff, local hospital etc) and, very importantly, copies given to supportive individuals that the patient has identified within their social network, such as partners, family members or close friends.
1. Jackson A, Cavanagh J, Scott J. 'A systematic review of manic and depressive prodromes', J of Affective Disorders 2003; 74: 209-217
2. Mitchell PB, Gould B. 'Bipolar disorder what the GP needs to know', Medicine Today 2004; 5(8):46-52
The management of Bipolar Disorder is often not a straightforward task for a clinician; this commonly reflects the burden that a person carries living with this illness. Despite good adherence to treatment, many people have to manage significant sub-syndromal symptoms, which can have a negative impact on their ability to function, and influence many components such as motivation and drive. Whether these symptoms indicate that treatment is sub-optimal or that this is 'as good as it gets' is a hard balancing act. Against the possible benefits that an increase in dose or a change in medication can bring, there are always the ever-ready negatives of new or increased side-effects (which impact on the individual's sense of wellbeing and functioning in their own right) and the risk of relapse in the case of changing over of medications. In deciding what action to take there are some simple first steps that should be considered.
Often this isn't the case, with the person either taking a lower dose than prescribed or having ceased one or all medications entirely. People with Bipolar Disorder routinely self-medicate and change their medications without their doctor's knowledge. There are a number of possible reasons (some listed below) for this. Obtaining an understanding, from the patient's point of view, of their attitude toward treatment, the problems they have been experiencing and their expectations about treatment, are important steps in regaining good adherence. Adherence can be improved by providing psychoeducation for the person and/or family, talking about fears and plans for the future, and counselling other concerns.
Many people with Bipolar Disorder retain good insight into their illness, at least whilst they are in periods of wellness. However, mania and hypomania lead to a loss of insight, and it is this state that can cause many problems, not only in relation to the patient's compliance with medication, but the possibility of the patient or another person being put at risk as a result. In such situations, a balance needs to be struck between managing your duty of care with the patient's right to confidentiality.
Having a disseminated relapse plan in which the patient has played a role in developing, and which others (i.e. family, partners, community mental health staff) are aware of, can really assist management at these times. Plans that detail in the patient's own words, their signs and symptoms, things they will accept others to tell them and what they will do if told that they need extra treatment, can all help a general practitioner in ensuring that the patient gets the help and intervention that they need.
Sometimes a patient will deny any mood disturbance or that they are unwell but reports from family and partners indicate a gross disruption to their normal level of functioning. These reports need to be taken seriously. Often a patient can present as if "well" for a 5-10 minute interview, whereas those living with them at home are more likely to getting a clearer picture of manic or hypomanic symptoms. A useful operative rule is that the manic/hypomanic patient is always worse than they present or report. Patients can do untold damage (sometimes permanent) to their reputations, their relationships, their financial stability and physical health when in a manic state. When this is the case, it becomes imperative to protect them from such consequences, and use of Mental Health Act and community mental heath teams become warranted.
A general practitioner can ensure that patients with Bipolar Disorder have all of their physical health needs met and are in a key position to coordinate care with other services. As Bipolar Disorder is a chronic relapsing and remitting illness, which can impact negatively on all aspects of a person's functioning (family, friendships, work, finances, personal identity, self esteem and autonomy), a multi-system approach is valuable. It provides a bio-psycho-social framework through which these needs can be addressed.
In areas were there are limited services, a general practitioner can still base management on this approach, and can work with the patient's family and use local social networks and community groups where appropriate. This could include such strategies as linking the person into local Bipolar Disorder/Depression self-help groups, other support groups like AA and Grow, local counsellors, the appropriate local church or spiritual leader.
In areas where services are available, it becomes important for the GP to know what type of service best meets the needs of their patient and how to go about making such a referral. The different types of services and their roles are described briefly below.
It can be useful to discuss your reasons for making any referral with your patient - indicating what you expect the outcome will be. When referring patients to an unknown health practitioner (a new counsellor or private psychiatrist), they need to be told to come back to see you if they feel unhappy to continue, so that they can be referred to someone else. If it's to a local mental health service, make it clear that you need to know what the outcome of their assessment or intervention was, as this can help prevent people from dropping out from under the treatment radar. This becomes especially important when someone presenting is at risk and then acute treatment is vital.
Further information on how to make an effective referral can be accessed here (Download Clinician resource sheet 'Making an Effective Referral' [PDF, 84KB]).
The types of services/individuals that a GP could refer a patient to include those listed below.
This would comprise a team of people covering a specific geographical area. Such a team typically comprises many, but possibly not all, of the following:
These units provide 24-hour emergency assistance and comprise community mental health staffs that have differing backgrounds (i.e. mental health nurses, social workers, and psychologists) supported by psychiatric registrars and team consultant psychiatrists. They can do phone call check ups, and provide emergency assessments in the person's home, local hospital, GP surgery or where ever is appropriate. They can provide short-term case management and referral into community mental health teams.
Accessibility, cost and availability can be an issue and emergency appointments can sometimes be difficult. However, private psychiatrists can offer assessment (45-80 minutes), provide an opinion on the diagnosis of Bipolar Disorder and advise on treatment strategies. In particular, they can oversee initiation of treatment or advise on changes in medication. If requested, they can take key responsibility for the patient's treatment, often working in conjunction with local mental health services if needed. They can facilitate admission into private hospitals or access to their outpatient facilities if required and if the person has the necessary private health cover.
It can be important to distinguish whether the psychologist has specialist training in mental health as a clinical psychologist, as such training ensures experience in specific therapies (Cognitive Behavioural therapy or CBT, Interpersonal Therapy or IPT). Clinical psychologists are likely to have further training in areas such as couple and family therapy and are also more likely to be familiar with the issues around Bipolar Disorder, in particular, the importance of medications.
Social workers operate in a psychosocial model. They can therefore provide advice and assistance with socioeconomic/financial difficulties, providing practical support and assistance to link in with organisations like Centrelink and rehabilitation services like Centacare. They have specific responsibilities in areas which come under specific legislation (e.g. children at risk, domestic violence guardianships orders) and have particular skills in working with families. They play a vital role in the multidisciplinary team, in both the community and hospital mental health setting. If a patient has particular problems in this area it can be useful to identify them up front in the referral and request a social work appointment, especially if you are willing and able to continue to oversee their medical management.
Mental health nurses have numerous skills and work in both the inpatient and community setting. They have both an understanding and training in the medical model of mental illness, as well as psychotherapeutic skills in counselling and in developing and overseeing behavioural rehabilitation programs. They have particular expertise in monitoring mood states of their patients, in monitoring treatment adherence and effectiveness, and promoting physical care. They provide ongoing support to individuals and their families through the development of a therapeutic relationship. Other roles include educator, advocate and case manager.
Occupational therapists are mainly accessible through mental health services but can sometimes be accessed through private rehabilitation companies and some government programs. They can provide a useful role in rehabilitation if someone has been out of work for a long period of time, or if they need assistance or an advocate in return to work after an acute episode. They provide assessments of day to day functioning and living skills, and can develop individual programs to assist a person to improve functioning.
Emerging research is indicating that the rate of Bipolar II Disorder appears to be increasing in the general community. Debate in this area has stimulated further research into Bipolar II and its treatment. Possible real and artefactual causes for the increase in prevalence rates of Bipolar Disorder are listed below.
While cause does not always dictate treatment (e.g. migraine is not due to an insufficiency of aspirin), consideration of possible 'causes' (e.g. genetic, iatrogenic, environmental) can be of some help in treatment options.
One of the problems in being able to make treatment recommendations about Bipolar II disorder is the lack of randomised, double-blind, placebo-controlled trials involving only Bipolar II patients. Currently, recommendations are made on evidence from studies which involve, or are dominated by Bipolar I subjects and therefore the question whether these studies are directly applicable needs to be raised.
In terms of use of lithium, a recent review [2] found support for lithium monotherapy as being effective in maintenance treatment of Bipolar II patients, with fewer hospitalisations and fewer illness episodes compared prior to commencing the lithium. Lamotrigine, an anti-epileptic drug has been found to be effective in the treatment of bipolar depression (both as an augmentation agent and as monotherapy) and has been shown to prevent relapse in Bipolar II patients. As it is the severity and frequency of the depressive episodes, rather than the hypomanic episodes, which present the main challenges in the acute and long-term treatment of Bipolar II Disorder this finding is encouraging for Bipolar II patients. However, due to the difficulty in being able to prescribe lamotrogine on the PBS currently and the need to 'start low and go slow' due to the risk of serious rash, it should not, as yet, be thought of as a first-line approach.
There is significant debate about the use of antidepressants in Bipolar II disorder with conflicting evidence around their potential to cause cycle acceleration and switching. It is unclear whether the subtype of Bipolar Disorder impacts on the propensity of antidepressants to do this. Many authors suggest caution in their use, preferring still the use of a mood stabiliser in Bipolar II, however, the potential mood stabilising effect of the Selective Serotonin Reuptake Inhibitors (SSRIs) and dual-action antidepressants has led to new research into this area. The Institute's research team published a report in the Journal of Affective Disorders in 2006 supporting the view that the SSRIs are mood stabilisers for those with Bipolar II - in that those on an SSRI compared to placebo had a significant decrease in their depression and also improvement in their 'highs' over the trial. Thus, while antidepressants are usually viewed as contraindicated in managing Bipolar II, the truth may be quite the opposite. The issue will be debated in a book edited by Professor Gordon Parker and to be published by Cambridge University Press in late 2007 ("Bipolar II Disorder: Modelling, Measuring and Managing").
The omega fatty acids are a group of naturally occurring lipids. Lipids are vital for normal brain function and are called 'essential' as they have to come from the diet, as the body cannot manufacture them. There are two main types. 'Omega-3 fatty acid', often called the 'good' fat, is found in high concentrations in particularly cold water or oily fish (like salmon, cod and tuna) as well as from flax seed oil and some nuts. The other, 'Omega-6 fatty acid', is sometimes referred to as the 'bad fat'. This is found primarily in vegetable oils (i.e. corn or sunflower oils). These fatty acids play an important role in neuronal signal transduction, nerve cell membrane integrity and fluidity. The correct balance of these two fatty acids is essential for normal neuronal function.
Interest in the possible role of Omega-3 fatty acids in the treatment of Bipolar Disorder came about through a number of overlapping research area. One was the recognition of the role and function of fatty acids in the brain, and the similarities between their function and the mechanism of action of the mood stabiliser Lithium and the anti-convulsant Sodium Valproate. The other was the observation from large epidemiological studies that countries whose diets which were largely depleted in Omega-3 fatty acids (Western European) had higher rates of coronary heart disease and major depression than those countries with higher rates of Omega-3 consumption (e.g. Japan , where consumption of fish is significantly higher). These findings have lead to randomised, double blind, placebo controlled trials, which have looked at the effect of Omega-3 fatty acids used in conjunction with treatment as usual. Although the numbers of studies so far performed are small, results have been encouraging.
One study found that the addition of 9.6g/day of Omega-3 fatty acid daily led to a significantly longer period of remission in patients with Bipolar Disorder when compared to the placebo group. Another open label study has also reported benefits in using flaxseed oil in bipolar patients.
The dosages have varied in the different studies, especially those looking at the role of Omega-3 fatty acids in Bipolar Disorder and unipolar depression (9.6g day vs. 2g/day). Limited side-effects have been reported, mild ones include having an unpleasant fishy taste and with the higher dosages, loose stools.
It appears from these preliminary studies that Omega-3 fatty acids are likely to be promising additional agents for use in Bipolar Disorder (positive results are also being found in studies in schizophrenia and unipolar depression), especially in light of their high tolerability, low toxicity and lack of drug interactions.
The role of the 'atypical' antipsychotics in the treatment of Bipolar Disorder has now been well established. They have been found to be useful, both as adjuncts to the mood stabilisers and as monotherapy with several randomised, double blind controlled studies now reporting numerous positive effects including improvement in manic symptoms, improvement in depressive symptoms and increased response rates and reduced relapse rates. Their role has been mostly clearly been defined in the acute and maintenance treatment of mania. Side-effects are a concern, especially weight gain, with regular testing of blood glucose and cholesterol recommended. Other side-effects, which can limit their use, include somnolence and sexual dysfunction.
Page last updated: 10-Oct-2008
Depression and Bipolar Disorder Information Australia - Black Dog Institute.
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