Treatment of bipolar affective disorder: medication and psychotherapy

The first step in the treatment of bipolar disorder is to confirm the diagnosis of mania or hypomania and to define the phase in which the patient's mood is. The therapeutic approach for hypomania, mania, depression, or euthymia varies considerably.

In the management of the acute phase, the primary goal is to ensure the safety of the patient and those in the vicinity. All of this must be done with minimal side effects.

In managing long-term mood stabilization, the main priority is to prevent recurrence of episodes and to ensure sufficient efficacy with minimal burden on the body.

Treatment is best led by a physician who specializes in the diagnosis and treatment of mental health conditions (psychiatrist) and who is experienced in treating bipolar and related disorders. The therapeutic team also includes a psychologist, social worker, and psychiatric nurse.

Medication treatment

Bipolar disorder requires lifelong treatment with medication. This is true even during periods when the patient is feeling better.

People who skip maintenance treatment are at high risk of symptom recurrence. Mild mood changes can quickly turn into full-blown mania or depression.

• Mood stabilisers

Patients usually need medication to stabilise mood, to control manic or hypomanic episodes. Examples of mood stabilisers include lithium, valproic acid, divalproex sodium, carbamazepine and lamotrigine.

• Antipsychotics

If symptoms of depression or mania persist despite treatment with other medications, an antipsychotic should be added. Examples of drugs used include olanzapine, risperidone, quetiapine, aripiprazole, and others.

It is possible to take one of these drugs alone or with a mood stabilizer in combination.

• Antidepressants

To help manage depression, your doctor may add an antidepressant to your treatment. Because an antidepressant can sometimes trigger a manic episode, it is usually prescribed along with a mood stabilizer or antipsychotic.

• Antidepressant-antipsychotic

Some medications are available directly in combination. For example, the combination of the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a treatment for depression and a mood stabilizer.

• Anti-anxiety medication

Benzodiazepines can help with anxiety and improve sleep. They are usually used for a short time.

• Finding the right medicine

Finding the right medication or medications often requires some trial and error. If one doesn't work well, several others need to be tried.

This process requires patience. Some medicines take weeks or months to take full effect. Generally, only one medicine is changed at a time.

The doctor will decide which medications are effective to relieve symptoms with the least bothersome side effects.

• Side effects

Mild side effects usually start to improve when the right medication and doses are found that are effective enough and the body can adjust to them.

The patient should never make changes in the dosage of medication on his or her own. He or she should never stop taking the medication on his or her own. If he or she stops taking it, withdrawal symptoms may occur or the symptoms of the disease may worsen or return.

The patient may become very depressed, suicidal or go into a manic or hypomanic episode after sudden withdrawal.

• Medication and pregnancy

Some medications for bipolar disorder are associated with a higher incidence of birth defects. They may also pass through breast milk to the baby.

Some medications, such as valproic acid and divalproex sodium, should not be used during pregnancy.

If hormonal contraceptives are used along with certain medications for bipolar disorder, they may lose their effectiveness.

Every woman should discuss treatment options with her doctor before planning to become pregnant.

Day care

This is a day treatment program that the patient attends every day. Thus, he or she does not need to be hospitalized. Such programs provide the support and counseling that patients need but are not stressed by the need to spend the night in a hospital setting.

Hospitalization

If a patient is behaving dangerously to himself or herself or those around him or her, is suicidal, or has become "detached" from reality and is psychotic, the doctor will order hospitalization. In such cases, this may be against the patient's wishes.

Psychiatric treatment in a hospital helps to maintain the safety of the patient, his surroundings and stabilize his mood, whether it is manic or a major depressive episode.

Psychotherapy

The primary treatment for bipolar disorder involves medication and psychological counselling, i.e. psychotherapy.

Psychotherapy is an important part of the treatment of bipolar disorder. It is provided in an individual, family or group setting.

There are several types of therapy:

• Interpersonal and Social Rhythm Therapy - Focuses on stabilizing daily rhythms such as sleep, wakefulness, and mealtimes. Consistency and so-called routines allow for better control of moods.
• Cognitive Behavioral Therapy - It focuses on identifying unhealthy and negative beliefs about oneself and one's environment and replacing them with healthy and positive ones. It also helps identify triggers of bipolar episodes. It teaches effective strategies for coping with stress and managing unpleasant situations.
• Psychoeducation - It involves learning about bipolar disorder. It helps the patient and his family to understand the condition, get the best support, identify problems, create a plan to prevent relapse and stick to treatment.
• Family-centered therapy - Family support and communication is very important when trying to keep a treatment plan. It also teaches loved ones to recognize and manage the warning signs of mood changes.

Other treatment options

In addition to medication, there are complementary treatments. Their use depends on the patient's response to treatment.

Electroconvulsive treatment

During electroconvulsive therapy, electrical currents are passed through the brain to deliberately induce a brief seizure.

It is thought that these discharges cause changes in the chemical processes in the brain. These can reverse the symptoms of certain mental illnesses.

Electroconvulsive therapy is used in the treatment of bipolar disorder when the patient does not improve with medication or cannot take antidepressants for medical reasons, such as pregnancy.

It can also be used in the acute phase of a flare-up, when there is a high risk of suicide, for example.

Transcranial magnetic stimulation

Transcranial magnetic stimulation is a relatively new treatment that is still being explored as a treatment option for those people who have not responded to antidepressants.

Treatment for children and adolescents

Treatment for children and adolescents is generally decided on an individual, case-by-case basis, depending on symptoms, medication side effects, and other factors.

Treatment usually includes:

• Medications

Children and teens with bipolar disorder are often prescribed the same types of medications used for adults.

However, we know much less about the safety and effectiveness of these medications in pediatric patients because there are far fewer pharmacostudies and research studies done on pediatric patients.

• Psychotherapy

Early initiation of psychotherapy and long-term treatment can help prevent recurrence of symptoms. Psychotherapy helps children and adolescents establish routines, solve learning problems, manage social problems, and strengthen family ties and communication with others.

Not infrequently, psychotherapy is also needed to treat substance abuse problems, which are not rare in older children and adolescents with bipolar disorder.

• Psychoeducation

Psychoeducation involves "learning" about the symptoms of bipolar disorder. It is very important for the family of a patient with this disorder to learn about how their behavior may differ from that of their peers.

• Support

Working with teachers and school counsellors, and support from family and friends is essential to achieve mood stabilisation in a young person.