Treatments for Bipolar disorder

Bipolar Disorder: NIMH (Excerpt)

As an addition to medication, psychosocial treatments—including certain forms of psychotherapy (or "talk" therapy)—are helpful in providing support, education, and guidance to people with bipolar disorder and their families. Studies have shown that psychosocial interventions can lead to increased mood stability, fewer hospitalizations, and improved functioning in several areas.¹³ A licensed psychologist, social worker, or counselor typically provides these therapies and often works together with the psychiatrist to monitor a patient's progress. The number, frequency, and type of sessions should be based on the treatment needs of each person.

Psychosocial interventions commonly used for bipolar disorder are cognitive behavioral therapy, psychoeducation, family therapy, and a newer technique, interpersonal and social rhythm therapy. NIMH researchers are studying how these interventions compare to one another when added to medication treatment for bipolar disorder.

• Cognitive behavioral therapy helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness.
• Psychoeducation involves teaching people with bipolar disorder about the illness and its treatment, and how to recognize signs of relapse so that early intervention can be sought before a full-blown illness episode occurs. Psychoeducation also may be helpful for family members.
• Family 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.
• Interpersonal and social rhythm therapy helps people with bipolar disorder both to improve interpersonal relationships and to regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes.
• As with medication, it is important to follow the treatment plan for any psychosocial intervention to achieve the greatest benefit.

Bipolar Disorder: NIMH (Excerpt)

In situations where medication, psychosocial treatment, and the combination of these interventions prove ineffective, or work too slowly to relieve severe symptoms such as psychosis or suicidality, electroconvulsive therapy (ECT) may be considered. ECT may also be considered to treat acute episodes when medical conditions, including pregnancy, make the use of medications too risky. ECT is a highly effective treatment for severe depressive, manic, and/or mixed episodes. The possibility of long-lasting memory problems, although a concern in the past, has been significantly reduced with modern ECT techniques. However, the 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.²⁰ (Source: excerpt from Bipolar Disorder: NIMH)

Bipolar Disorder: NIMH (Excerpt)

People with bipolar disorder may need help to get help.

• Often people with bipolar disorder do not realize how impaired they are, or they blame their problems on some cause other than mental illness.
• A person with bipolar disorder may need strong encouragement from family and friends to seek treatment. Family physicians can play an important role in providing referral to a mental health professional.
• Sometimes a family member or friend may need to take the person with bipolar disorder for proper mental health evaluation and treatment.
• A person who is in the midst of a severe episode may need to be hospitalized for his or her own protection and for much-needed treatment. There may be times when the person must be hospitalized against his or her wishes.
• Ongoing encouragement and support are needed after a person obtains treatment, because it may take a while to find the best treatment plan for each individual.
• In some cases, individuals with bipolar disorder may agree, when the disorder is under good control, to a preferred course of action in the event of a future manic or depressive relapse.
• Like other serious illnesses, bipolar disorder is also hard on spouses, family members, friends, and employers.
• Family members of someone with bipolar disorder often have to cope with the person's serious behavioral problems, such as wild spending sprees during mania or extreme withdrawal from others during depression, and the lasting consequences of these behaviors.
• Many people with bipolar disorder benefit from joining support groups such as those sponsored by the National Depressive and Manic Depressive Association (NDMDA), the National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA). Families and friends can also benefit from support groups offered by these organizations.

Bipolar Disorder Research at the National Institute of Mental Health: NIMH (Excerpt)

For years, lithium has been the "gold standard" pharmacological treatment for bipolar disorder. When taken regularly, lithium can effectively control mania and depression in many patients and can reduce the likelihood of episode recurrence. (Source: excerpt from Bipolar Disorder Research at the National Institute of Mental Health: NIMH)

Bipolar Disorder Research at the National Institute of Mental Health: NIMH (Excerpt)

Interest in using psychotherapy in combination with medication for bipolar disorder has grown in recent years with the recognition of the continuing high rate of relapse, some of which appears preventable, during pharmacological maintenance treatment. (Source: excerpt from Bipolar Disorder Research at the National Institute of Mental Health: NIMH)

Depression in Children and Adolescents A Fact Sheet for Physicians: NIMH (Excerpt)

The essential treatment of bipolar disorder in adults involves the use of appropriate doses of mood stabilizing medications, typically lithium and/or valproate, which are often very effective for controlling mania and preventing recurrences of manic and depressive episodes. Treatment of children and adolescents diagnosed with bipolar disorder is based mainly on experience with adults, since as yet there is very limited data on the safety and efficacy of mood stabilizing medications in youth. Researchers currently are evaluating both pharmacological and psychosocial interventions for bipolar disorder in young people. (Source: excerpt from Depression in Children and Adolescents A Fact Sheet for Physicians: NIMH)

Depression in Children and Adolescents A Fact Sheet for Physicians: NIMH (Excerpt)

According to studies conducted in Finland in patients with epilepsy, valproate may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20.³⁹ Increased testosterone can lead to polycystic ovary syndrome with irregular or absent menses, obesity, and abnormal growth of hair. Therefore, young female patients prescribed valproate should be monitored carefully. (Source: excerpt from Depression in Children and Adolescents A Fact Sheet for Physicians: NIMH)

Depression: NIMH (Excerpt)

Lithium has for many years been the treatment of choice for bipolar disorder, as it can be effective in smoothing out the mood swings common to this disorder. Its use must be carefully monitored, as the range between an effective dose and a toxic one is small. If a person has preexisting thyroid, kidney, or heart disorders or epilepsy, lithium may not be recommended. Fortunately, other medications have been found to be of benefit in controlling mood swings. Among these are two mood-stabilizing anticonvulsants, carbamazepine (Tegretol^®) and valproate (Depakote^®). Both of these medications have gained wide acceptance in clinical practice, and valproate has been approved by the Food and Drug Administration for first-line treatment of acute mania. Other anticonvulsants that are being used now include lamotrigine (Lamictal^®) and gabapentin (Neurontin^®): their role in the treatment hierarchy of bipolar disorder remains under study.

Most people who have bipolar disorder take more than one medication including, along with lithium and/or an anticonvulsant, a medication for accompanying agitation, anxiety, depression, or insomnia. Finding the best possible combination of these medications is of utmost importance to the patient and requires close monitoring by the physician. (Source: excerpt from Depression: NIMH)

Medications: NIMH (Excerpt)

The medication used most often to treat bipolar disorder is lithium. Lithium evens out mood swings in both directions--from mania to depression, and depression to mania--so it is used not just for manic attacks or flare-ups of the illness but also as an ongoing maintenance treatment for bipolar disorder.

Although lithium will reduce severe manic symptoms in about 5 to 14 days, it may be weeks to several months before the condition is fully controlled. Antipsychotic medications are sometimes used in the first several days of treatment to control manic symptoms until the lithium begins to take effect. Antidepressants may also be added to lithium during the depressive phase of bipolar disorder. If given in the absence of lithium or another mood stabilizer, antidepressants may provoke a switch into mania in people with bipolar disorder. (Source: excerpt from Medications: NIMH)

Medications: NIMH (Excerpt)

The anticonvulsant valproic acid (Depakote, divalproex sodium) is the main alternative therapy for bipolar disorder. It is as effective in non-rapid-cycling bipolar disorder as lithium and appears to be superior to lithium in rapid-cycling bipolar disorder.² Although valproic acid can cause gastrointestinal side effects, the incidence is low. Other adverse effects occasionally reported are headache, double vision, dizziness, anxiety, or confusion. Because in some cases valproic acid has caused liver dysfunction, liver function tests should be performed before therapy and at frequent intervals thereafter, particularly during the first 6 months of therapy. (Source: excerpt from Medications: NIMH)

Medications: NIMH (Excerpt)

Other anticonvulsants used for bipolar disorder include carbamazepine (Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin), and topiramate (Topamax). The evidence for anticonvulsant effectiveness is stronger for acute mania than for long-term maintenance of bipolar disorder. Some studies suggest particular efficacy of lamotrigine in bipolar depression. At present, the lack of formal FDA approval of anticonvulsants other than valproic acid for bipolar disorder may limit insurance coverage for these medications.

Most people who have bipolar disorder take more than one medication. Along with the mood stabilizer--lithium and/or an anticonvulsant--they may take a medication for accompanying agitation, anxiety, insomnia, or depression. It is important to continue taking the mood stabilizer when taking an antidepressant because research has shown that treatment with an antidepressant alone increases the risk that the patient will switch to mania or hypomania, or develop rapid cycling.⁵ Sometimes, when a bipolar patient is not responsive to other medications, an atypical antipsychotic medication is prescribed. Finding the best possible medication, or combination of medications, is of utmost importance to the patient and requires close monitoring by a doctor and strict adherence to the recommended treatment regimen. (Source: excerpt from Medications: NIMH)

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Book Excerpts: Treatment of Bipolar disorder

• Emergency interventions - Fontanel depression
• Treatment - Bipolar disorders
• Treatment - Major depression
• Emergency interventions - Fontanel depression
• Treatment - Bipolar disorders
• Treatment - Depression, major
• Nursing considerations - Fontanel depression

Treatments of Bipolar disorder: Online Medical Books

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Fontanel depression: Emergency interventions
(Handbook of Signs & Symptoms (Third Edition))

If you detect a markedly depressed fontanel, take the infant’s vital signs, weigh him, and check for signs of shock — tachycardia, tachypnea, and cool, clammy skin. If these signs are present, insert an I.V. line and administer fluids. Have size-appropriate emergency equipment on hand. Anticipate oxygen administration. Monitor urine output by weighing wet diapers.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Bipolar disorders: Treatment
(Professional Guide to Diseases (Eighth Edition))

Widely used to treat bipolar disorders, lithium has proved to be highly effective in relieving and preventing manic episodes. It curbs the accelerated thought processes and hyperactive behavior without producing the sedating effect of antipsychotic drugs. In addition, it may prevent the recurrence of depressive episodes; however, it’s ineffective in treating acute depression.

Because lithium has a narrow therapeutic range, treatment must be initiated cautiously and the dosage must be adjusted slowly. Therapeutic blood levels during the active manic period are 0.4 to 1.4 mEq/L. For safety, the level should never exceed 1.5 mEq/L. Therapeutic blood levels must be maintained for 7 to 10 days before the drug’s beneficial effects appear; for this reason, antipsychotic drugs commonly are used in the interim to provide sedation and symptomatic relief. Because lithium is excreted by the kidneys, any renal impairment necessitates withdrawal of the drug.

Anticonvulsants, such as carbamazepine, valproic acid, and clonazepam, are used either alone or with lithium to treat mood disorders. Carbamazepine and divalproex are effective in many patients who are lithium-resistant. Other anticonvulsant drugs have also been used. Electroconvulsive therapy is also effective.

Antidepressants are used to treat depressive symptoms, but they may trigger a manic episode.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Major depression: Treatment
(Professional Guide to Diseases (Eighth Edition))

Depression is difficult to treat, especially in children, adolescents, elderly patients, and those with a history of chronic disease. The primary treatment methods are drug therapy and psychotherapy, particularly cognitive behavioral therapy.

Drug therapy includes tricyclic antidepressants (TCAs) such as amitriptyline, monoamine oxidase (MAO) inhibitors such as isocarboxazid, maprotiline, and trazodone, which has been available for 40 years. A newer class of drugs, the selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, paroxetine, sertraline, bupropion, venlafaxine, and mirtazapine, are equally effective and have more tolerable adverse effect profiles.

TCAs, the most widely used class of antidepressant drugs, prevent the reuptake of norepinephrine or serotonin (or both) into the presynaptic nerve endings, resulting in increased synaptic concentrations of these neurotransmitters. They also cause a gradual loss in the number of beta-adrenergic receptors.

MAO inhibitors block the enzymatic degradation of norepinephrine and serotonin. These agents commonly are prescribed for patients with atypical depression (for example, depression marked by an increased appetite and need for sleep, rather than anorexia and insomnia) and for some patients who fail to respond to TCAs. MAO inhibitors are associated with a high risk of toxicity; patients treated with one of these drugs must be able to comply with the necessary dietary restrictions.

Maprotiline is a potent blocker of norepinephrine uptake, whereas trazodone is an SSRI. The mechanism of action of bupropion is unknown.

Electroconvulsive therapy (ECT) may be considered in particularly severe or drug-resistant depression. Six to 12 treatments are typically needed, although in many cases improvement is evident after only a few treatments. However, ECT has been associated with later short-term memory loss, heart arrhythmias, and seizure activity. Researchers hypothesize that ECT affects the same receptor sites as antidepressants.

Short-term psychotherapy is also effective in treating major depression. Many psychiatrists believe that the best results are achieved with a combination of individual, family, or group psychotherapy and medication. After resolution of the acute episode, patients with a history of recurrent depression may be maintained on low doses of antidepressants as a preventive measure.

Depression may be experienced differently by members of different cultures. For instance, in some Asian cultures, there are more somatic manifestations of depression than overt psychologic signs or symptoms.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Fontanel depression: Emergency interventions
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you detect a markedly depressed fontanel, take vital signs, weigh the infant, and check for signs of shock—tachycardia, tachypnea, and cool, clammy skin. If these signs are present, insert an I.V. line and administer fluids. Have size-appropriate emergency equipment on hand. Anticipate oxygen administration. Monitor urine output by weighing the wet diapers.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Bipolar disorders: Treatment
(Handbook of Diseases)

Specific symptom clusters are treated empirically. Antidepressants and low-dose antipsychotic drugs are helpful for those with cluster A type symptoms (paranoid and schizoid types). Anticonvulsant mood stabilizers and monamine oxidase inhibitors are helpful for those showing marked mood reactivity, behavioral dyscontrol, and rejection hypersensitivity.

Anticonvulsants — such as carbamazepine, valproic acid, and clonazepam — are used either alone or with lithium to treat mood disorders. (See Preventing complications of lithium therapy.) Carbamazepine, a potent antimanic drug, is effective in many lithium-resistant patients.

Antidepressants are used to treat depressive symptoms, but they may trigger a manic episode.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Depression, major: Treatment
(Handbook of Diseases)

Depression is difficult to treat, especially in children, adolescents, elderly patients, and those with a history of chronic disease. The primary treatment methods are drug therapy, electroconvulsive therapy (ECT), and psychotherapy.

Drug therapy

In depression, drug therapy includes tricyclic antidepressants (TCAs) such as amitriptyline, serotonin reuptake inhibitors such as fluoxetine, and monoamine oxidase (MAO) inhibitors, such as isocarboxazid, maprotiline, and trazodone.

❑ The most widely used class of antidepressant drugs, TCAs prevent the reuptake of norepinephrine or serotonin (or both) into the presynaptic nerve endings, resulting in increased synaptic concentrations of these neurotransmitters. They also cause a gradual loss in the number of beta-adrenergic receptors.

❑ After resolution of the acute episode, patients with a history of recurrent depression may be maintained on low doses of antidepressants as a preventive measure.

❑ Selective serotonin reuptake inhibitors, including fluoxetine, paroxetine, and sertraline, are increasingly becoming the drugs of choice. They are effective and produce fewer adverse effects than the TCAs; however, they’re associated with sleep and GI problems and alterations in sexual desire and function.

❑ MAO inhibitors block the enzymatic degradation of norepinephrine and serotonin. These agents are commonly prescribed for patients with atypical depression (for example, depression marked by an increased appetite and need for sleep, rather than anorexia and insomnia) and for some patients who fail to respond to TCAs.

MAO inhibitors are associated with a high risk of toxicity; patients treated with one of these drugs must be able to comply with the necessary dietary restrictions. Conservative doses of an MAO inhibitor may be combined with a TCA for patients refractory to either drug alone.

Maprotiline is a potent blocker of norepinephrine uptake, whereas trazodone is a selective serotonin uptake blocker. The mechanism of action of bupropion is unknown.

ECT

When a depressed patient is incapacitated, suicidal, or psychotically depressed, or when antidepressants are contraindicated or ineffective, ECT is commonly the treatment of choice. Six to 12 treatments usually are needed, although improvement is usually evident after only a few treatments. Researchers hypothesize that ECT affects the same receptor sites as antidepressants.

Psychotherapy

Short-term psychotherapy is also effective in treating major depression. Many psychiatrists believe that the best results are achieved with a combination of individual, family, or group psychotherapy and medication. Therapeutic interventions focus on identifying the patient’s negative thoughts and interpretations and substituting adaptive responses.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Fontanel depression: Nursing considerations
(Nursing: Interpreting Signs and Symptoms)

▪ Monitor the infant's vital signs and level of consciousness.

▪ Monitor intake and output and watch for signs of worsening dehydration.

▪ Obtain serum electrolyte values to check for an increased or decreased sodium, chloride, or potassium level.

▪ If the infant has mild dehydration, provide small amounts of clear fluids frequently or provide an oral rehydration solution.

▪ If the infant can't ingest sufficient fluid, begin I.V. parenteral nutrition.

▪ If the patient has moderate to severe dehydration, provide rapid restoration of extracellular fluid volume to treat or prevent shock.

▪ Continue to administer I.V. solution with sodium bicarbonate added to combat acidosis. As renal function improves, administer I.V. potassium replacements.

▪ When the infant's fluid status stabilizes, begin to replace depleted fat and protein stores through diet.

▪ Obtain urinalysis for specific gravity and, possibly, blood tests to determine blood urea nitrogen and serum creatinine levels, osmolality, and acid-base status.

Patient teaching

▪ Explain all procedures and treatments to the infant's parents.

▪ Provide emotional support.

▪ Explain ways to prevent dehydration.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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