Bipolar Disorder

1
Bipolar Disorder treatment current and future

• Kurt Weber, PhD
• Mental Health America Brown CountyBemis
  International Center
• St Norbert College
• May 13, 2008

2
BD is a

• long-term illness that can be effectively treated
• currently has no cure
• staying on treatment, even during well times, can
  help keep the disease under control and reduce
  the chance of having recurrent, worsening episodes

3
basics

• treatment plan for bipolar disorder primarily
  consists of
• pharmacological intervention (medications)
• and sometimes psychological therapy
• psychiatric hospitalizations may be necessary to
  safely reach a point of stability
• also treatment options that are less common and
  those that are usually considered only in extreme
  circumstances well discuss them later!

4
medications

• primary goal of drug treatment is to stabilize
  the extreme mood swings of mania and depression
• also common for medications to be prescribed for
• extreme symptoms such as psychosis or
• co-occurring disorders such as anxiety
• generally fall into the following categories
• Anti-Anxiety and Sedatives
• Antidepressants
• Antipsychotics
• Mood Stabilizers
• Calcium Channel Blockers

5
Psychotherapeutic interventions

• Goals
• increase compliance of taking medications
• create bonds with others who have the same
  condition
• reduce negative behaviors
• learn new coping skills
• key types of therapy include
• Cognitive Behavioral Therapy
• Dialectical Behavioral Therapy
• Family/Marriage Counseling
• Gestalt Therapy
• Group Therapy
• Psychoanalytic Therapy

6
Inpatient hospitalization

• allow specialized staff
• to monitor patients closely
• changing medications as necessary to achieve
  stabilization
• to provide concentrated, frequent sessions of
  therapy
• also vital for those who are struggling with
  thoughts of suicide
• majority of hospital stays are inpatient
• outpatient programs are becoming more common

7
Alternative therapies

• usually considered only in extreme circumstances
• Bilateral Cingulotomy
• Electroconvulsive Therapy
• Light Therapy

8
Review of mental health professionals

• Psychiatrists
• Medical doctors with a specialty in psychiatry -
  the branch of medicine that deals with the
  diagnosis, treatment, and prevention of mental
  and emotional disorders
• formal medical training and licensing
• several years of specialized training
• American Board of Psychiatry and Neurology
• usually the ones who prescribe psychotropic
  medications

9
psychopharmacologists

• general practitioners and psychiatrists
• specialty in the branch of pharmacology that
  deals with the study of the actions, effects, and
  development of psychoactive drugs
• often involved in clinical research studies for
  medications
• an excellent resource for those with bipolar
  disorder due to the complicated medication
  regimens often required

10
psychologists

• trained to perform psychological research,
  testing, and therapy
• licensed psychologists have a PhD or PsyD and
  have completed a licensure exam
• many different fields of psychology
• e.g., clinical
• social
• industrial/organizational
• child/adolescent
• cognitive
• known for conducting therapy sessions, but many
  are active researchers

11
General Practitioners / Primary Care Physicians

• well-rounded approach to medicine
• treating an array of illnesses
• monitoring patiences overall health and
  well-being
• BD is most often treated with medications
• as a result, it can greatly complicate the
  treatment of other physical ailments
• the involvement of the family doctor in overall
  healthcare as well as the treatment of this
  disorder is vital
• also physicians can make referrals to other
  healthcare professionals when needed

12
psychiatric nurse practitioners

• nurses
• advance dergee specializing in mental health
• often work in psychiatric treatment centers and
  hospital units
• serve as
• crisis intervention specialists
• counselors
• often monitor treatment progress
• may also serve as consultants and teachers

13
social workers

• Licensed clinical social workers (LCSW)
• usually have a degree in social work
• license to practice at the state level through
  completion of a supervision program and state
  certification exam
• Social Workers (MSW) have achieved a masters
  degree.
• most often serve as patient advocates ensuring
  access to necessary treatments, assisting with
  financial aid applications, and securing legal
  assistance if needed
• may also serve as counselors or therapists

14
therapists -- counselors

• many different professionals such as those noted
  above serve as therapists and counselors
• generally conduct therapy sessions
• individual, family and group
• goals of
• changing behavior
• learning new skills towards improving overall
  mental health

15

• bipolar disorder is much better controlled if
  treatment is continuous rather than
  intermittent...
• even if treatment regimen is followed
• mood changes can occur and should be reported
  immediately to MHP
• MHP may be able to prevent a full-blown episode
  by making adjustments to the treatment plan

16
Medications

• recommended that people with bipolar disorder see
  a psychiatrist for treatment
• psychiatric nurse practitioners are also
  recommended if psychiatry not available, or
  affordable, or easily obtainable

17
how to find a psychiatrist (stolen from about.com)

• 1. If you have a university within a reasonable
  driving distance, call their Department of
  Psychiatry. These psychiatrists are often on the
  cutting edge of research.
• 2. If the National Alliance for the Mentally Ill
  (NAMI) has a branch in your area, get in touch
  with their offices for a reference. You can also
  get in touch with their state offices.
• 3. Join the local chapter of the Depression and
  Bipolar Support Alliance (formerly NDMDA). This
  way you can ask individual members for their
  recommendations and be part of a supportive group
  at the same time.
• 4. Phone the psychiatric ward of a hospital in
  your area and ask the head nurse whom she would
  see if she needed a psychiatrist.
• 5. Review the list of approved mental health care
  providers from your insurance company.

18

• 6. Ask your general practitioner and therapist
  for their recommendations.
• 7. Scan the yellow pages. Look for certifications
  such as "Board Certified in Psychiatry" or "Board
  Certified in Pediatric Psychiatry." Those who
  specialize in Psychopharmacology may be a good
  choice.
• 8. You may want to contact the information and
  referral (IR) services of the United Way in your
  town - particularly if you are in need of
  financial assistance.
• 9. Many companies offer employee assistance
  programs that may be able to provide the names of
  psychiatrists. Ask your Human Resources
  Department for information.
• 10. Call family members and friends for their
  advice.
• 11. Telephone the referral service of the
  hospitals in your city.
• 12. Your pastor or rabbi may be able to suggest
  the names of appropriate psychiatrists to you.

19
before your visit

• Do you have a strong preference for a male or
  female doctor? Are the doctor's religious beliefs
  an issue for you?
• Set up your first visit as a short consultation.
  This will allow you to meet the psychiatrist and
  his staff without shelling out a lot of money. me
  may offer a free consultation.

20
considerations for bipolar meds

• 1) Does it treat bipolar mania?
• 2) Does it treat bipolar depression?
• 3) Does it act prophylactically to prevent mania
  and/or depression?

21
Mood stabilizers

• prescribed to help control bipolar disorder
• several different types of mood stabilizers
  available
• people with bipolar disorder can continue
  treatment with mood stabilizers for extended
  periods of time
• other medications may be added for shorter
  periods to treat episodes of mania or depression
  that break through despite the mood stabilizer

22

• The NIMH funded STEP BD research program
• after two years of excellent treatment
• 58 of clients achieve full recovery
• 50 will experience a relapse
• 72 to depression.

23
Lithium

• time-honored treatment for manic-depression
• seems to have a suicide reducing effect that the
  other mood stabilizers do not
• People don't like to take it because it
• makes them drink a lot of water and urinate a lot
  (35)
• causes memory problems (28)
• tremor (27)
• weight gain (19)
• gives them a metallic taste in their mouth
• can also affect the kidneys and the thyroid

24

• dosed according to blood levels
• if the lithium level gets too high, death can
  result
• if someone becomes dehydrated, the lithium level
  rises with vomiting and diarrhea, confusion,
  coarse tremor, muscle twitching, slurred speech,
  and seizures
• requires emergency medical attention
• stopping lithium suddenly may cause a relapse and
  increase in suicidality

25
And they even know what the mechanism of its
effectiveness!

• University of Wisconsin researchers found that
  lithium exerts a dual effect on receptors for the
  neurotransmitter glutamate
• acting to keep the amount of glutamate active
  between cells at a stable, healthy level, neither
  too much nor too little
• could be postulated that too much glutamate in
  the space between neurons causes mania, and too
  little, depression.
• giant step forward in understanding the
  biological basis of bipolar disorder

26
anticonvulsants

• cann have mood-stabilizing effects
• may be especially useful for difficult-to-treat
  bipolar episodes

27
divalproex sodium - Depakote

• used for mania in bipolar disorder
• evidence that it works to prevent depression is
  not convincing
• generally has fewer side effects than lithium
• patients like it better
• can cause GI problems, pancreatitis, liver
  problems, birth defects, decrease in platelets,
  and hair loss
• some evidence that it may provide prophylaxis for
  new episodes
• new extended release preparation
• patients will require a higher dose with the
  extended release preparation.

28
carbamazepine - Tegretol

• second choice for manic-depression for patients
  who could not tolerate lithium
• requires blood levels
• sedating
• can cause an anemia and liver problems
• too much carbamazepine will cause sedation and
  lack of coordination
• long-acting form has been approved Equetro

29
Newer anticonvulsants

• lamotrigine - Lamictal
• shows moderate antidepressant action
• may be prophylactic for bipolar depression
• no good evidence for the treatment of mania
• Dizziness, diplopia, vomiting, and rash are most
  common side effects and are generally mild
• not to be used in patients under 16
• discontinue if they get a rash
• needs to be increased slowly

30
topiramate Topamax

• not better than placebo for mania
• in some reports, 20-50 of people taking
  topiramate have lost weight
• used with clozapine and olanzapine to reduce
  weight gain
• if dose is increased too fast, one may see
  cognitive impairment
• may cause kidney stones and glaucoma

31
oxcarbazepine Trileptal

• similar to carbamazepine
• minimal interactions with other drugs
• may contribute to hyponatremia
• slight evidence that it may be anti-manic and
  prophylactic

32
Atypical antipsychotics

• being studied as possible treatments for bipolar
  disorder.
• clozapine (Clozaril)
• Evidence suggests clozapine may be helpful as a
  mood stabilizer for people who do not respond to
  lithium or anticonvulsants.
• olanzapine (Zyprexa)
• Other research has supported the efficacy of
  olanzapine for acute mania, an indication that
  has recently received FDA approval
• Olanzapine may also help relieve psychotic
  depression.
• risperidone (Risperdal)
• ziprasidone (Zeldox)

33

• Aripiprazole (Abilify)
• another atypical antipsychotic medication
• used to treat the symptoms of schizophrenia and
  manic or mixed (manic and depressive) episodes of
  bipolar I disorder

34
combinations

• combinations Anticonvulsant medications may be
  combined with lithium, or with each other, for
  maximum effect. 3
• G) olanzapine fluoxetine - Symbyax - This is a
  combination antipsychotic and antidepressant that
  is geared toward treating bipolar depression. The
  antidepressant treats the depression while the
  atypical antipsychotic stabilizes the mood.
  Although it is FDA approved for bipolar
  depression, there is little field data on
  efficacy or effectiveness.

35

• Children and adolescents with bipolar disorder
  generally are treated with lithium, but valproate
  and carbamazepine also are used
• Researchers are evaluating the safety and
  efficacy of these and other psychotropic
  medications in children and adolescents.
• some evidence that valproate may lead to adverse
  hormone changes in teenage girls and polycystic
  ovary syndrome in women who began taking the
  medication before age 20
• young female patients taking valproate should be
  monitored carefully by a physician

36

• Women with bipolar disorder who wish to conceive,
  or who become pregnant, face special challenges
  due to the possible harmful effects of existing
  mood stabilizing medications on the developing
  fetus and the nursing infant
• New treatments with reduced risks during
  pregnancy and lactation are under study
• the benefits and risks of all available treatment
  options should be discussed with a clinician
  skilled in this area

37
Bipolar depression

• people with bipolar disorder are at risk of
  switching into mania or hypomania, or of
  developing rapid cycling, during treatment with
  antidepressant medication
• mood-stabilizing medications generally are
  required, alone or in combination with
  antidepressants, to protect people with bipolar
  disorder from this switch.
• Lithium and valproate are the most commonly used
  mood-stabilizing drugs today. However, research
  studies continue to evaluate the potential
  mood-stabilizing effects of newer medications.

38
pharmacological treatment of bipolar depression

• should not be treated with antidepressants alone
• not clear whether there is any benefit at all for
  using them
• lithium
• lamotrigine
• olanzapine
• olanzapine fluoxetine

39
bipolar maintenance

• lithium
• lamotrigine
• olanzapine
• aripiprazole

40
Mays

• Of clients who were stable for more than 6
  months, only 26 were on lithium alone
• Lithium alone offers
• 83 probability against affective relapse at one
  year
• 52 at 3 years
• 37 at 5 years
• 47 suffer relapse on combination treatment.
• The best evidence-based treatment for bipolar
  maintenance at this time would be lithium plus a
  second generation antipsychotic
• however, 25 will show poor response even to
  multiple medications.

41
insomnia

• high-potency benzodiazepine medication
• clonazepam (Klonopin)
• lorazepam (Ativan)
• may be helpful to promote better sleep
• may be habit-forming
• best prescribed on a short-term basis
• Other types of sedative medications, such as
  zolpidem (Ambien), are sometimes used instead.

42

• changes overseen by psychiatrist, of course
• of course, it never happens that a patient
  changes meds on their own
• ?

43
thyroid concerns

• people with bipolar disorder often have abnormal
  thyroid gland function
• important that thyroid levels are carefully
  monitored by a physician
• rapid cyclers tend to have co-occurring thyroid
  problems and may need to take thyroid pills in
  addition to their medications for bipolar
  disorder
• lithium treatment may cause low thyroid levels in
  some people, resulting in the need for thyroid
  supplementation

44
psychosocial interventions

• can lead to increased mood stability, fewer
  hospitalizations, and improved functioning in
  several areas
• licensed psychologist, social worker, or
  counselor typically provides these therapies and
  often works together with the psychiatrist to
  monitor a patient s progress
• number, frequency, and type of sessions should be
  based on the treatment needs of each person.
• common interventions include
• cognitive behavioral therapy
• psychoeducation
• family therapy
• interpersonal and social rhythm therapy

45
CBT

• Cognitive behavioral therapy helps people with
  bipolar disorder learn to change inappropriate or
  negative thought patterns and behaviors
  associated with the illness

46
psychoeducation

• teaching people with bipolar disorder
• about the illness and its treatment
• how to recognize signs of relapse so that early
  intervention can be sought before a full-blown
  illness episode occurs
• may be helpful for family members

47
family therapy

• uses strategies to reduce the level of distress
  within the family that may either contribute to
  or result from the ill person s symptoms

48
Interpersonal and social rhythm therapy

• helps people with bipolar disorder both to
  improve interpersonal relationships and to
  regularize their daily routines
• may help protect against manic episodes

49
of course

• As with medication, it is important to follow the
  treatment plan for any psychosocial intervention
  to achieve the greatest benefit.

50
dialectical behavior therapy

• DBT is now being used in many settings as a
  viable therapy for the treatment of bipolar
  disorder
• Treatment in DBT has four parts
• Individual Therapy
• Telephone Contact
• Therapist Consultation - good communication
  between group therapist and individual therapist
  is essential to the successful outcome of DBT
• Skills Training - Conducted by a behavioral
  technician or another therapist usually in a
  group context
• focus is on learning and practicing adaptive
  skills, not personal or specific complaints of
  the clients
• any specific or personal issues are redirected to
  be discussed in individual therapy

51
DBT continued

• Core Mindfulness Skills - These are derived from
  Buddhist meditation techniques to enable the
  client to become aware of the different aspects
  of experience and to develop the ability to stay
  with that experience in the present moment. -
  Treatment lasts for about 2 -3 weeks.
• Interpersonal Effectiveness Skills - These focus
  on effective ways of achieving one's objectives
  with other people to ask for what one wants
  effectively, to say no and be taken seriously, to
  maintain relationships and to maintain
  self-esteem in interactions with other people
  (comparable to assertiveness training). -
  Treatment lasts for about 8 weeks.

52

• Emotion Modulation Skills - These skills are ways
  of coping with intense emotional experiences and
  their causes. They also allow for an adaptive
  experience and expression of intense emotions. -
  Treatment lasts for about 8 weeks.
• Distress Tolerance Skills - These include
  techniques for putting up with, finding meaning
  for, and accepting distressing situations if
  there is no conceivable solution at present. -
  Treatment lasts for about 8 weeks.

53
ECT

• if other interventions prove ineffective, or work
  too slowly to relieve severe symptoms such as
  psychosis or suicidality, electroconvulsive
  therapy (ECT) may be considered
• ECT is a highly effective treatment for severe
  depressive, manic, and/or mixed episodes
• possibility of long-lasting memory problems,
  although a concern in the past, has been
  significantly reduced with modern ECT techniques
• potential benefits and risks of ECT, and of
  available alternative interventions, should be
  carefully reviewed and discussed with individuals
  considering this treatment and, where
  appropriate, with family or friends

54
herbals

• not been well studied
• little is known about their effects on bipolar
  disorder
• FDA does not regulate their production
• different brands of these supplements can contain
  different amounts of active ingredient
• Before trying herbal or natural supplements, it
  is important to discuss them with your doctor
• evidence that St. Johns wort can reduce the
  effectiveness of certain medications
• may cause a switch into mania in some individuals
  with bipolar disorder, especially if no mood
  stabilizer is being taken

55
omega-3 fatty acids

• found in fish oil
• being studied to determine their usefulness,
  alone and when added to conventional medications,
  for long-term treatment of bipolar disorder

56
hospitalization

• Advance Psychiatry Directives http//www.bazelon.o
  rg/issues/advancedirectives/index.htm
• http//bipolar.about.com/od/hospitalization/a/pack
  ing.htm

57
finally

• Treatment Adherence
• Rates of noncompliance range from 18-53
• if one includes people who occasionally miss
  their medications, it is gt70
• Clients have limited insight
• not denial or wish to distort the facts
• something in the illness that distorts the way
  clients see themselves and the world.
• Regardless, the best predictor of a poor outcome
  is poor treatment adherence