bipolar disorder – treatment – current and future… kurt weber, phd mental health america –...
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Bipolar Disorder – Bipolar Disorder – treatment – current and treatment – current and
future…future…Kurt Weber, PhDKurt Weber, PhD
Mental Health America – Brown CountyMental Health America – Brown CountyBemis International CenterBemis International Center
St Norbert CollegeSt Norbert CollegeMay 13, 2008May 13, 2008
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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
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basicsbasics
treatment plan for bipolar disorder primarily treatment plan for bipolar disorder primarily consists ofconsists of pharmacological intervention (medications)pharmacological intervention (medications) and sometimes psychological therapyand sometimes psychological therapy
psychiatric hospitalizations may be psychiatric hospitalizations may be necessary to safely reach a point of stabilitynecessary to safely reach a point of stability
also treatment options that are less also treatment options that are less common and those that are usually common and those that are usually considered only in extreme circumstances – considered only in extreme circumstances – we’ll discuss them later!we’ll discuss them later!
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medicationsmedications 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
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Psychotherapeutic Psychotherapeutic interventionsinterventions
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
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Inpatient hospitalizationInpatient 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
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Alternative therapies…Alternative therapies…
usually considered only in extreme circumstances Bilateral Cingulotomy Electroconvulsive Therapy Light Therapy
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Review of mental health Review of mental health professionalsprofessionals
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
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psychopharmacologistspsychopharmacologists
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
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psychologistspsychologists 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
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General Practitioners / Primary Care Physicians
well-rounded approach to medicine treating an array of illnesses monitoring patience’s 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
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psychiatric nurse psychiatric nurse practitionerspractitioners
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
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social workerssocial 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 master’s 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
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therapists -- counselorstherapists -- 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
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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
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MedicationsMedications
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
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how to find a psychiatrist how to find a psychiatrist (stolen from about.com)(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.
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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 (I&R) 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.
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before your visit…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.
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considerations for considerations for bipolar medsbipolar meds
1) Does it treat bipolar mania? 2) Does it treat bipolar depression? 3) Does it act prophylactically to
prevent mania and/or depression?
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Mood stabilizersMood 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
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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.
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LithiumLithium 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
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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
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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
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anticonvulsantsanticonvulsants
cann have mood-stabilizing effects may be especially useful for difficult-
to-treat bipolar episodes
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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.
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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
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Newer anticonvulsantsNewer 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
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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
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oxcarbazepine – Trileptal
similar to carbamazepine minimal interactions with other drugs may contribute to hyponatremia slight evidence that it may be anti-
manic and prophylactic
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Atypical antipsychoticsAtypical 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)
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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
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combinationscombinations
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.
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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
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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
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Bipolar depressionBipolar 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.
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pharmacological treatment pharmacological treatment of bipolar depressionof 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
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bipolar maintenancebipolar maintenance
lithium lamotrigine olanzapine aripiprazole
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Mays…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.
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insomniainsomnia
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.
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changes overseen by psychiatrist, of course…
of course, it never happens that a patient changes meds on their own…
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thyroid concernsthyroid 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
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psychosocial psychosocial interventionsinterventions
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
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CBTCBT
Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness
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psychoeducationpsychoeducation
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
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family therapyfamily 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
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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
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of course…of course…
As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.
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dialectical behavior dialectical behavior therapytherapy
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
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DBT continued…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.
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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.
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ECTECT 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
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herbals…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. John’s 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
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omega-3 fatty acidsomega-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
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hospitalizationhospitalization
Advance Psychiatry Directives http://www.bazelon.org/issues/advancedirectives/index.htm
http://bipolar.about.com/od/hospitalization/a/packing.htm
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finally…finally… Treatment Adherence Rates of noncompliance range from 18-
53% if one includes people who occasionally
miss their medications, it is >70% 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