A Review of the Different A Review of the Different Treatments for Bipolar Treatments for Bipolar Disorder, Including Disorder, Including Medications and Medications and PsychotherapyPsychotherapy

Priscilla L. SemmensPriscilla L. Semmens Advanced General Psychology PSY492 Advanced General Psychology PSY492 UD UD Instructor: Jay GreinerInstructor: Jay GreinerOctober 23, 2009October 23, 2009

What is Bipolar What is Bipolar Depression?Depression? Bipolar Disorder (BD) is a serious disability affecting Bipolar Disorder (BD) is a serious disability affecting

many individuals in today’s society. Individuals with many individuals in today’s society. Individuals with BD suffer from severe depression along with manic BD suffer from severe depression along with manic episodes. Some symptoms of depression include episodes. Some symptoms of depression include feeling sad or hopeless, weight loss or weight gain, feeling sad or hopeless, weight loss or weight gain, insomnia or hypersomnia, worthlessness, and suicidal insomnia or hypersomnia, worthlessness, and suicidal thoughts. “Bipolar disorder is a severe and chronic thoughts. “Bipolar disorder is a severe and chronic mental health problem characterized by recurrent mental health problem characterized by recurrent episodes of depression and mania, and high levels of episodes of depression and mania, and high levels of mood symptoms and functioning difficulties during mood symptoms and functioning difficulties during inter-episode periods” (Jones & Burrell-Hodgson, 2008, inter-episode periods” (Jones & Burrell-Hodgson, 2008, p. 1). More people are experiencing symptoms of p. 1). More people are experiencing symptoms of bipolar disorder. bipolar disorder.

StatisticsStatistics

““BD affects an estimated 3.7 % of the United BD affects an estimated 3.7 % of the United State population (Stoner et al., 2007, p. 72) State population (Stoner et al., 2007, p. 72) with a recognized 15% risk of successful with a recognized 15% risk of successful suicide” (Ceron-Litvoc, Soares, Geddes, Litvoc, suicide” (Ceron-Litvoc, Soares, Geddes, Litvoc, & de Lima, 2009, p. 1). “Suicide is the third & de Lima, 2009, p. 1). “Suicide is the third ranking cause of death” (Miklowitz & Taylor, ranking cause of death” (Miklowitz & Taylor, 2006, p. 1). “The annual average suicide rate 2006, p. 1). “The annual average suicide rate in men and women diagnosed with bipolar in men and women diagnosed with bipolar disorder was recently estimated to be more disorder was recently estimated to be more than twenty times that of the general than twenty times that of the general population (0.40%/year versus 0.017%/year)” population (0.40%/year versus 0.017%/year)” (McElroy, Kotwal, Kaneria, & Keck, 2006). (McElroy, Kotwal, Kaneria, & Keck, 2006).

Medications- LithiumMedications- Lithium

Lithium monotherapy is believed to be first-Lithium monotherapy is believed to be first-line pharmacological intercession for treating line pharmacological intercession for treating mania and mixed episodes (Ceron-Litvoc et al., mania and mixed episodes (Ceron-Litvoc et al., 2009). Fountoulakis et al. (2007) state Lithium 2009). Fountoulakis et al. (2007) state Lithium is useful for all phases of BD and it helps with is useful for all phases of BD and it helps with suicide prevention and is more effective suicide prevention and is more effective against mania with a response rate of forty against mania with a response rate of forty percent. Lithium shows effective results with percent. Lithium shows effective results with prevention of manic relapses (Young, 2008). prevention of manic relapses (Young, 2008). Lithium demonstrated evidence to support Lithium demonstrated evidence to support long-term use with reducing manic episodes, long-term use with reducing manic episodes, compared with a placebo, the medication was compared with a placebo, the medication was effective in preventing relapse because of a effective in preventing relapse because of a mood episode (Smith et al., 2007). mood episode (Smith et al., 2007).

Carbamazepine Carbamazepine

Carbamazepine has been suggested as an efficacious Carbamazepine has been suggested as an efficacious treatment for mania and depression and is the only treatment for mania and depression and is the only treatment of bipolar mania approved by the FDA treatment of bipolar mania approved by the FDA (Ceron-Litvoc et al., 2009 & Fountoulakis et al., 2007). (Ceron-Litvoc et al., 2009 & Fountoulakis et al., 2007). Ceron-Litvoc et al., (2009) compared carbamazepine Ceron-Litvoc et al., (2009) compared carbamazepine with lithium in seven trials and the average serum with lithium in seven trials and the average serum intensity of both medications in study was generally intensity of both medications in study was generally parallel. Sixty-two percent of carbamazepine patients parallel. Sixty-two percent of carbamazepine patients and fifty-nine percent lithium patients showed similar and fifty-nine percent lithium patients showed similar anti-manic effects (Ceron-Litvoc et al., 2009). It was anti-manic effects (Ceron-Litvoc et al., 2009). It was suggested that lithium or carbamazepine prescribed suggested that lithium or carbamazepine prescribed alone was effective in short term treatment of mania alone was effective in short term treatment of mania (Ceron-Litvoc et al., 2009). Overall, carbamazepine is (Ceron-Litvoc et al., 2009). Overall, carbamazepine is as effective as lithium in acute manic symptoms, as effective as lithium in acute manic symptoms, however it is not prescribed as much due to drug however it is not prescribed as much due to drug interactions (Young, 2008). interactions (Young, 2008).

Valproate Valproate

Fountoulakis et al. (2007) states Fountoulakis et al. (2007) states valproate is best treatment for manic valproate is best treatment for manic episodes because it has a more episodes because it has a more robust antimanic effect than lithium robust antimanic effect than lithium in rapid cycling and mixed emotions in rapid cycling and mixed emotions with a response rate of fifty percent with a response rate of fifty percent for acute mania. Valproate showed for acute mania. Valproate showed evidence to support long term use evidence to support long term use with minimizing manic relapses with minimizing manic relapses (Smith et al., 2007). (Smith et al., 2007).

AntipsychoticsAntipsychotics

First generation antipsychotics are considered to be First generation antipsychotics are considered to be the traditional treatment for acute mania and second the traditional treatment for acute mania and second generation antipsychotic do not stimulate depression generation antipsychotic do not stimulate depression (Fountoulakis et al., 2007). Studies support their (Fountoulakis et al., 2007). Studies support their effectiveness in all segments of bipolar illness, either effectiveness in all segments of bipolar illness, either as monotherapy or as an addition to mood stabilizers as monotherapy or as an addition to mood stabilizers (Fountoulakis et al., 2007). Some antipsychotic are (Fountoulakis et al., 2007). Some antipsychotic are Olanzapine, risperidone, quetiapine, ziprasidone and Olanzapine, risperidone, quetiapine, ziprasidone and aripiprazole which have been approved by the FDA for aripiprazole which have been approved by the FDA for the treatment of acute mania” (Fountoulakis et al., the treatment of acute mania” (Fountoulakis et al., 2007). Olanzapine can be taken long term for manic 2007). Olanzapine can be taken long term for manic episodes and preventing relapse because of a mood episodes and preventing relapse because of a mood episode (Smith et al., 2007). episode (Smith et al., 2007).

PsychotherapiesPsychotherapiesPsychoeducation (PE)Psychoeducation (PE) PE aims to offer BD patients with an abstract PE aims to offer BD patients with an abstract

and realistic approach to accepting and dealing and realistic approach to accepting and dealing with the results of their disease and lets them to with the results of their disease and lets them to enthusiastically work together with the enthusiastically work together with the physician in some aspects of treatment (Colom physician in some aspects of treatment (Colom & Vieta, 2004). Several goals of PE are & Vieta, 2004). Several goals of PE are enhancement of adherence, improvement of enhancement of adherence, improvement of illness management skills, the reduction of illness management skills, the reduction of suicide risk and the improvement of social and suicide risk and the improvement of social and occupational function and quality of life (Colom occupational function and quality of life (Colom & Vieta, 2004). “Early detection of & Vieta, 2004). “Early detection of promodromal signs was shown to be efficacious promodromal signs was shown to be efficacious in preventing mania, but not depression, and in in preventing mania, but not depression, and in increasing time to relapse (Colom & Vieta, increasing time to relapse (Colom & Vieta, 2004). 2004).

Family Focused Family Focused TherapyTherapy Miklowitz and Taylor (2006) state the objectives of Miklowitz and Taylor (2006) state the objectives of

Family Focused Therapy (FFT) is to help the family Family Focused Therapy (FFT) is to help the family recognize suicidal behavior, which is a nine month, recognize suicidal behavior, which is a nine month, twenty-one session outpatient intervention that twenty-one session outpatient intervention that involves the patient, their parents, spouse, siblings involves the patient, their parents, spouse, siblings and/or children. FFT is important because families and/or children. FFT is important because families that endure a lot of stress and conflict or poor parent-that endure a lot of stress and conflict or poor parent-child communication and low perceptions of support child communication and low perceptions of support are linked with completed and/or attempted suicides. are linked with completed and/or attempted suicides. Participants of FFT were able to survive the full study Participants of FFT were able to survive the full study duration without the return of depression or mania duration without the return of depression or mania (fifty-two percent) (Miklowitz & Taylor, 2006). In (fifty-two percent) (Miklowitz & Taylor, 2006). In addition, individuals in FFT were less likely to require addition, individuals in FFT were less likely to require hospitalization when they did relapse (Miklowitz & hospitalization when they did relapse (Miklowitz & Taylor, 2006). Taylor, 2006).

Cognitive Behavioral Cognitive Behavioral TherapyTherapy The therapeutic approach of CBT is the development of The therapeutic approach of CBT is the development of

cognitive and behavioral skills to understand and monitor cognitive and behavioral skills to understand and monitor links between mood and behavior to facilitate detection of links between mood and behavior to facilitate detection of early warning signs for mania and depression, acceptance early warning signs for mania and depression, acceptance skills to reduce risk of relapse, stability in sleep pattern, and skills to reduce risk of relapse, stability in sleep pattern, and moderation of achievement behavior (Jones & Burrell-moderation of achievement behavior (Jones & Burrell-Hodgson, 2008). In addition, Slee et al. (2007) states that Hodgson, 2008). In addition, Slee et al. (2007) states that BD patients are taught cognitive behavioral concepts, BD patients are taught cognitive behavioral concepts, emotion regulation, interpersonal effectiveness, distress emotion regulation, interpersonal effectiveness, distress tolerance, core mindfulness and self-management skills with tolerance, core mindfulness and self-management skills with CBT. Colom and Vieta (2004) found between forty and CBT. Colom and Vieta (2004) found between forty and seventy-five percent of patients had improved with CBT seventy-five percent of patients had improved with CBT (Colom & Vieta, 2004). Overall, CBT showed an (Colom & Vieta, 2004). Overall, CBT showed an improvement in the adoption of self-control skills by the end improvement in the adoption of self-control skills by the end of the therapy (Jones & Burrell-Hodgson, 2008). “The of the therapy (Jones & Burrell-Hodgson, 2008). “The ultimate aim is to provide a framework that encourages ultimate aim is to provide a framework that encourages practitioners to look for these mechanisms of change in the practitioners to look for these mechanisms of change in the context of their work with BD patients” (Slee et al., 2007, p. context of their work with BD patients” (Slee et al., 2007, p. 180). 180).

ISPRTISPRT

ISPRT is a treatment aimed to maintain regular daily ISPRT is a treatment aimed to maintain regular daily activities and stability in personal relationships for BD activities and stability in personal relationships for BD patients (Colom & Vieta, 2004). IPSRT is based on the patients (Colom & Vieta, 2004). IPSRT is based on the suggestion that interferences in every day routines suggestion that interferences in every day routines and problems in interpersonal relationships can result and problems in interpersonal relationships can result in return of the manic and depressive episodes (Colom in return of the manic and depressive episodes (Colom & Vieta, 2004). During treatment, therapist’s will help & Vieta, 2004). During treatment, therapist’s will help the BD patient recognize how change in daily routines the BD patient recognize how change in daily routines can affect their moods, how to handle stressful can affect their moods, how to handle stressful situations and maintain positive relationships with situations and maintain positive relationships with people. people. IPSRT experience less depressive slips, earlier IPSRT experience less depressive slips, earlier revitalization from depression and fewer threshold revitalization from depression and fewer threshold depressive symptoms, helps with bipolar suicide and depressive symptoms, helps with bipolar suicide and prodomal indicators revealed to be successful in prodomal indicators revealed to be successful in preventing mania (Colom & Vieta, 2004). preventing mania (Colom & Vieta, 2004).

After reviewing the literature, I have found there are After reviewing the literature, I have found there are various types of treatment for BD patients. The various types of treatment for BD patients. The treatments include medication and psychotherapy. I treatments include medication and psychotherapy. I believe the best treatment for BD patients would be believe the best treatment for BD patients would be lithium along with a combination of FFT and PE. The lithium along with a combination of FFT and PE. The medication acts as a mood stabilizer. “Lithium medication acts as a mood stabilizer. “Lithium prophylaxis combined with supportive care prophylaxis combined with supportive care management has been shown to reduce suicide risk management has been shown to reduce suicide risk in bipolar patients and is a first line treatment for in bipolar patients and is a first line treatment for patients exhibiting suicidal risk” (Rizvi & Zaretsky, patients exhibiting suicidal risk” (Rizvi & Zaretsky, 2007, p. 500). FFT will help the patient and their 2007, p. 500). FFT will help the patient and their family reduces suicide attempts. The application of family reduces suicide attempts. The application of FFT that is specific to suicide risk and behaviors is FFT that is specific to suicide risk and behaviors is pertinent (Rizvi & Zaretsky, 2007). pertinent (Rizvi & Zaretsky, 2007).

ReferencesReferences

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