Bipolar disorder:Treatment


 * outcome studies
 * Bipolar disorder: treatment protocols
 * Bipolar disorder: treatment considerations
 * Bipolar disorder: evidenced based treatment
 * Bipolar disorder: theory based treatment
 * Bipolar disorder: team working considerations
 * Bipolar disorder: followup

Treatment of bipolar disorder
There is no cure for bipolar disorder; the emphasis is on management of the symptoms. A variety of medications are used to treat bipolar disorder; many people with bipolar disorder require multiple medications. Some people with bipolar disorder supplement or replace their Western medication with herbal or holistic options. Still, even with optimal medication treatment, many people with the illness have some residual symptoms or relapses of depression or mania. Cognitive therapy may work to lessen the severity of mood swings by recognizing and managing triggering symptoms or events. Interpersonal and Social Rhythm Therapy (ISPRT) emphasizes the regulation of sleep, diet and exercise to prevent episodes, along with teaching coping skills; it is well-documented that sleep disruptions can trigger manic episodes.

Principles
Medications called mood stabilizers are used to prevent or mitigate manic or depressive episodes. Because mood stabilizers are generally more effective at treating mania than bipolar depression, periods of depression are sometimes also treated with antidepressants. However, as stated above, antidepressants carry the risk of inducing mania, especially in bipolar patients who are not taking a mood stabilizer.

In severe cases where the mania or the depression is severe enough to cause psychosis (and recently sometimes in less severe cases as well, although this remains controversial), The antipsychotic drugs may also be used. A new class of "atypical" antipsychotics has also become more widely used for bipolar episodes. The FDA has only approved them for acute episodes, if at all (with the exception of olanzapine, which is approved as a mood stabilizer). Like most doctors, psychiatrists use medication for "off-label" uses, even when such uses are not supported by available research. It is becoming accepted practice to use atypical antipsychotics as mood stabilizers at this point, and there is support in the literature for their effectiveness in mood stabilization.

Some people have reported that antipsychotics cause mania, panic attacks, or psychosis. Any agitation should be reported to the doctor immediately. Antipsychotics also carry a risk of causing tardive dyskinesia, a potentially disfiguring and sometimes irreversible movement disorder that may case the arms, legs, face or head to jerk or twitch. The risk is thought to be proportionate to the length of duration of neuroleptic/antipsychotic use (roughly 5% per year in non-elderly patients) and has recently been linked to an equally high occurrence in both typical and atypical antipsychotics, in contrast to claims of lower risks when the atypicals were introduced. Patients and physicians need to be careful to watch for symptoms of this side effect carefully so that an antipsychotic can be reduced in dosage, or changed to another medication, before the condition progresses. The doctor should, of course, be consulted about any change in dosage. The only antipsychotic with no apparent association with tardive dyskinesia is clozapine.

Medications work differently in each person, and it takes considerable time to determine in any particular case whether a given drug is effective at all, since bipolar disorder is by nature episodic, and patients may experience remissions whether or not they receive treatment. For this reason, neither patients nor their doctors should expect immediate relief, although psychosis with mania can respond quickly to antipsychotics, and bipolar depression can be alleviated quickly with electroconvulsive therapy (ECT). Many doctors emphasize that patients should not expect full stabilization for at least 3-4 weeks (some antidepressants, for example, take 4-6 weeks to take effect), and should not “give up” on a medication prematurely, nor should they discontinue medication with the disappearance of symptoms as the depression may return.

Compliance with medications can be a major problem, because some people as they become manic lose the awareness of having an illness, and they therefore discontinue medications. Patients also often quit taking medication when symptoms disappear, erroneously thinking themselves "cured", and some people enjoy the effects of unmedicated hypomania.

Depression does not respond instantaneously to resumed medication, typically taking 2–6 weeks to respond. Mania may disappear slowly, or it may become depression. Other reasons cited by individuals for discontinuing medication are side effects, expense, and the stigma of having a psychiatric disorder. In a relatively small number of cases stipulated by law (varying by locality but typically, according to the law, only when a patient poses a threat to himself or others), patients who do not agree with their psychiatric diagnosis and treatment can legally be required to have treatment without their consent. Throughout North America and the United Kingdom, involuntary treatment or detention laws exist for severe cases of bipolar disorder and other mental illnesses.