Bipolar Disorder: Exploring Treatment Options – Part 3 of 3
by David Mintz, MD, team leader and staff psychiatrist at the Austen Riggs Center
It is harmful to leave bipolar disorder untreated. Not only are there the acute risks of untreated mania (interpersonal chaos, financial and occupational problems, health consequences, and the risk of suicide), but there is also evidence that each manic episode increases the likelihood of successive manic episodes, leading to a long-term worsening of the illness. Optimal treatment of bipolar disorder most often involves certain lifestyle changes, consistent use of mood-stabilizing medications, and psychotherapy.
Everyone should attempt to adopt a healthy lifestyle, but this is especially important for patients with bipolar disorder. Regular sleep routines are key, as sleep disruption or sleep deprivation commonly destabilizes moods in bipolar disorder. Avoiding substances of abuse and excessive alcohol also promotes stable moods. A healthy diet and regular exercise may contribute to improved sleep, better mood, and can counteract weight gain associated with some medical treatments of bipolar disorder. It is also crucial for patients with bipolar disorder to learn to recognize and manage stress. Stressful life events are a major predictor for bipolar relapse, even when patients adhere to their prescribed medications. Patients with bipolar disorder may also be quite sensitive to the stress levels in their families. Distressed families lead to worse outcomes for patients with bipolar disorder, so interventions that promote the healthy functioning of families may be useful.
Medications are an important part of the treatment of most people with bipolar disorder, and especially of those with more severe forms of the illness. Common treatments include mood stabilizers (Lithium, Depakote, Tegretol, Lamictal, Trileptal, and others) and atypical neuroleptics (Risperdal, Zyprexa, Seroquel, Geodon, Abilify, and others). Often, patients with bipolar disorder may require combinations of medications (polypharmacy) to adequately control symptoms of mania or depression. Sometimes antidepressants are added in order to help manage the depressive phase of the illness, but this is controversial, as evidence suggests that, for the average patient with bipolar disorder, antidepressants are likely to destabilize mood and exacerbate mood swings and manias. Natural treatments such as high dose fish oil (ω-3 fatty acids) may also help improve and stabilize moods.
Medication alone is less helpful to patients with bipolar disorder than a combination of medication and psychotherapy. Anecdotal and research, evidence suggests that psychotherapy benefits these patients in a number of ways. In the largest study of its kind, researchers found that patients in psychotherapy (either cognitive-behavioral therapy, psychodynamic psychotherapy with a focus on relationships and social rhythms, or family therapy) had significantly better outcomes than patients receiving medications alone. Bipolar patients in psychotherapy experienced the greatest increases in treatment adherence, and the greatest reductions in relapse and re-hospitalization rates. These patients got well faster and stayed well longer.
Two related factors which frequently complicate the treatment of bipolar disorder are medication non-adherence and impaired insight into illness. Patients may resist treating their bipolar disorder because the euphoria associated with mania is, at least for a while, quite pleasurable and reinforcing. However, even when returned to a normal mood, patients frequently continue to exhibit an impaired ability to recognize that they have an illness that operates beyond their conscious control. Psychodynamic therapies, cognitive-behavioral therapies, and family psychoeducational treatments have all been shown to improve medication adherence in patients with bipolar disorder.
Insight oriented psychotherapy may help patients to use medications in more healthy and responsible ways by helping them to more accurately appreciate their strengths and limitations, to understand specific vulnerabilities and triggers for illness, to recognize the toll that their illness has taken on themselves and those around them, and to acknowledge, bear, and put in perspective the grief associated with the recognition that one has a significant illness. In the post-manic phase, psychotherapy and its context of a trusting therapeutic relationship may help patients face the grief, shame, and remorse often experienced in the wake of a manic episode. In the long term, patients with bipolar disorder may have to develop not only insight into illness, but also insight into health. In these situations, patients who have experienced the frightful loss of control associated with mania and who recognize that they have an illness may come to mistrust themselves, fearing that experiences of joy or excitement are simply manifestations of illness. Psychotherapy may provide a space in which patients can develop comfort with these feelings while learning to recognize the difference between healthy joy and manic euphoria.