Bipolar disorder is a serious mental illness that can not be treated on your own. However there is a TO DO list to support your treatment regime.

• Always take your medications that your doctor prescribed.
• Do not skip your medications
• Do not take any prescription medication without your doctor’s recommendation
• Always read the warning signs before you use any medication
• Refer to your physician if you feel you’re experiencing an episode.
• Include your family in watching for warning signs of medications.
• Keep away from alcohol and drugs
• Ask for assistance from your family to follow up your treatment

Which specialty treats bipolar disorder?

Number 1 rule: Anyone who is diagnosed with bipolar disorder should be treated under the skilled psychiatrists. Other mental health professionals like, psychiatric social workers, psychologists and psychiatric nurses, can provide help and assistance for supporting the therapy. Prescription medicines should only be prescribed by psychiatrists. Because they are the experts in this field, patients should diagnose and be treated with their guidance.

Supervision of treatment and routine follow-up by a clinician are needed for successful long-term therapy of bipolar disorder. The need for medical monitoring of drug blood levels will vary with the particular pharmacologic agent selected; however, continued supervision is needed to ensure treatment adherence regardless of the particular agent. Routine follow-up visits are used to evaluate the individual’s condition and provide an opportunity to adjust medication as needed.

In general, although nonpharmacologic strategies provide a number of benefits, the efficacy of these approaches can be limited unless the person is willing to adhere to the treatment plan.

When Hospitalization should be considered for patients with bipolar disorder?

Many people with bipolar I disorder are hospitalized at some point during the course of the illness. Affected individuals are often unwilling to enter the hospital voluntarily and may need to be hospitalized to prevent dangerous behavior or consequences to others. For example, those with mania often have a lack of insight into their disorder and do not understand the need for hospitalization.

Hospitalization should be considered under the following circumstances:

• when safety is a question due to suicidal, homicidal, or aggressive impulses or actions
• when severe distress or dysfunction requires around-the-clock care and support
• when there is ongoing substance abuse, to prevent access to drugs
• when the person has an unstable medical condition
• when close observation of the person’s reaction to medications is required.

Patient education should include topics relating to the nature of bipolar disorder, benefits of treatment, consequences of discontinuing or disrupting therapy, expected side effects, and the need to continue medication even when symptoms abate. It is important that patients and their families understand the recurrent nature of bipolar disorder and the need for ongoing treatment. Affected individuals and their families can be taught to recognize early symptoms of mood episodes and the side effects of therapy. They should be encouraged to seek appropriate medical attention when these symptoms occur.

Recognition and acceptance of their illness may be particularly difficult for people who experienced a sense of well-being during previous hypomanias. Some choose to go off their medication in order to regain feelings of hypomania (e.g., exhilaration, creativity). Symptoms of grandiosity can also play a part in nonadherence. People who are not aware of their illness may believe that they do not need to see a doctor or take medication; denial of need is a common reason cited for nonadherence. Others are aware of their disease, but report that they feel good and stop taking their medication.

This approach is particularly useful during acute depression and recovery. During manic episodes, the patient may find it hard to listen to a therapist.

Psychotherapy is used to help a person with bipolar disorder cope with life problems and understand the effects of illness on significant relationships. Individual and/or group counseling can help individuals and their families cope with the effects of manic and/or depressive episodes. The impact of bipolar disorder can include reduced self-esteem, strained relationships, and effects on productivity. Therefore, this is a situation in which the supportive social and familial environment will most likely enhance the person’s outcome; psychosocial support is an essential part of maintenance therapy.

Counseling may be required for patients who have substance-abuse comorbidities. Persons suffering from mood disorders may turn to alcohol and/or drugs in an attempt to self medicate. Alcohol and/or drug abuse impairs judgment and is a factor that can cause nonadherence, leading to unsuccessful treatment.

As with schizophrenia, patient education, psychotherapy, and good patient follow-up are important in increasing adherence to drug therapy and optimizing clinical outcome for people with bipolar disorder. In fact, psychosocial aspects of the treatment of bipolar disorder can be as important as medical treatment. Education, counseling, and supervision can help improve a person’s understanding of the disorder and its treatment, and they are considered part of the overall management program.

For improving treatment adherence please find below the summary of issues in Psycho-education and Psychotherapy of Bipolar Disorder:

• acceptance of the disease
• adjustment to current life events
• abstention from substance use and abuse
• maintenance of regular sleep habits
• stress management
• discussion of patient’s concerns and questions
• maintenance of appointments
• verbal and written education for patient and family about bipolar disorder
• recognition of early symptoms prior to relapse

Although atypical antipsychotics have a lower incidence of EPS and tardive dyskinesia than typical antipsychotics, as well as better overall tolerability, they are not without side effects. Increases in weight, blood sugar, cholesterol, and triglycerides have brought new issues to light in the treatment of bipolar disorder. Nevertheless, the generally favorable side-effect profile of these agents may improve patient adherence with therapy and thus represent an advance in therapy for severe, chronic disorders, including bipolar disorder. The following atypical antipsychotics may be used in the treatment of bipolar disorder.

Olanzapine (Zyprexa®) is approved for the treatment of acute manic episodes associated with bipolar disorder. The most common side effects associated with olanzapine include somnolence, dizziness, dry mouth, and weight gain. It has a very low incidence of EPS, including tardive dyskinesia. However, there have been reports of the induction of mania.

Although clozapine (Clozaril®) has been proven to show mood-stabilizing properties in people with bipolar disorder who don’t respond to lithium or valproate, it is not considered a first-line therapy in bipolar disorder due to the risk of agranulocytosis.

Risperidone (Risperdal®) has been shown to be effective in acute mania in conjunction with lithium or valproate in some people. Unlike clozapine and olanzapine, risperidone is not associated with significant body weight gain. One difficulty with risperidone is its potent effect on prolactin. Increases in prolactin may cause sexual difficulties in both men and women. In addition, higher doses of risperidone have been associated with the development of extrapyramidal side effects. As noted in the discussion of schizophrenia, different atypical antipsychotics have different efficacy and side-effect profiles. This may result from differences in the pharmacologic properties of specific atypical agents, as well as genetically based differences among patients.

As atypical antipsychotics continue to be developed, their role in the treatment of bipolar disorder will evolve based on results of controlled clinical studies.

Like anxiolytics, antipsychotics are used as adjuvant therapy in the treatment of mania with psychomotor agitation or psychotic features. For example, typical antipsychotic agents may be used to treat the psychosis, aggression, and agitation associated with bipolar disorder. In addition, antipsychotics are often used as first-line agents for these conditions because of their relatively rapid onset of action.

Antipsychotics have been successfully used as an adjunct to lithium and anticonvulsant medications for the treatment of bipolar mania. Current treatment practices for acute mania may include the use of an antipsychotic to quickly manage symptoms. Lithium or anticonvulsants (as mood stabilizers) are added initially or shortly after the symptoms are managed by the antipsychotic. After the acute phase, the antipsychotic is tapered off and the patient is generally maintained on the mood stabilizer.

It is important to remember that Bipolar patients may be at an increased risk for tardive dyskinesia.

As you know, typical antipsychotics are associated with side effects, such as extrapyramidal symptoms (EPS) and the potential for tardive dyskinesia. Other side effects associated with typical antipsychotics include orthostatic hypotension, sedation, anticholinergic and antiadrenergic side effects, sexual dysfunction, and weight gain. One serious adverse reaction is neuroleptic malignant syndrome (NMS). Compared with patients with schizophrenia, patients with bipolar disorder are more sensitive to side effects associated with antipsychotics.

Several controlled studies have shown that haloperidol and chlorpromazine (typical antipsychotics) have efficacy similar to lithium in the treatment of acute mania. However, the side-effect profile of typical antipsychotics, especially EPS, is also a concern if these agents are to be used for long-term treatment of bipolar disorder. With typical antipsychotic agents, there may be a greater potential for tardive dyskinesia in people with affective disorders as compared to those with psychotic disorders.

Valproate (Depakote®) was approved in the United States in 1995 for the treatment of manic episodes associated with bipolar disorder. It is believed that valproate exerts its effect through the inhibition of sodium and/or calcium channels, thereby boosting GABA function and reducing glutamate function. This medication may increase GABA levels and decrease glutamate levels. It has been found to be effective in patients who are unresponsive to lithium. Valproate appears to be more effective than lithium in the treatment of people with mixed or dysphoric mania, rapid-cycling bipolar disorder, or mania with mild depression.

Valproate is associated with significant side effects, although its side-effect profile is more favorable than that of lithium. It may cause mild liver inflammation and may affect the production of platelets; as a result, periodic blood monitoring is required. Rare but potentially serious side effects include hepatic failure and life-threatening pancreatitis.

Other Anticonvulsants:

Carbamazepine (Tegretol®, Carbatrol®) appears to have a profile similar to valproate. It is not approved for use in bipolar disorder, but is used as a mood stabilizer. This medication may act by enhancing GABA function through actions on sodium and/or potassium channels. Carbamazepine is effective in both euphoric and mixed manic states. Carbamazepine is associated with aplastic anemia and agranulocytosis (black box warnings). As with valproate, treatment with carbamazepine is associated with sedation and gastrointestinal side effects and requires periodic blood testing. When utilized with other medications, the potential for significant drug interactions exists due to carbamazepine’s induction of liver enzymes.

At this time, lamotrigine (e.g., Lamictal®, Glaxo Wellcome) is not indicated for bipolar disorder, but it has been used as a mood stabilizer. It is believed that lamotrigine inhibits glutamate release through the inhibition of sodium channels. Lamotrigine has the most data to support its possible use in abating the depressive phase of bipolar disorder. Lamotrigine is associated with a rare but serious rash as side effect (a black box warning). Other side effects include dizziness, headaches, and difficulties with vision.

Gabapentin (e.g., Neurontin®, Parke-Davis) is being evaluated for use in bipolar disorder. This medication may increase GABA levels and decrease glutamate levels. Gabapentin appears to be very well tolerated, and it does not appear to interact with other psychotropic medications. Gabapentin may be effective as an adjunctive agent; however, studies to date have failed to show efficacy in bipolar disorder. Side effects include somnolence, dizziness, and fatigue.

Topiramate (Topamax®) is another anticonvulsant that has been investigated for the treatment of bipolar disorder, especially acute mania. Its mechanism of action appears to be to increase GABA levels and decrease glutamate levels. Topiramate is gaining more use in bipolar patients due to its potential to cause weight loss. It is increasingly used as an adjunct to improve efficacy and to reduce weight gain induced by other agents used to treat bipolar disorder.

Lithium has long been considered the mainstay of pharmacologic therapy for bipolar disorder. In the United States, it was approved in 1970 for the management of acute mania and in 1974 for maintenance therapy. Lithium continues to be used globally for the treatment of bipolar disorder, for both acute and maintenance therapy. Its mechanism of action is unknown, but is believed to involve the modification of second-messenger systems.

However, lithium has numerous disadvantages. When used as monotherapy, lithium is associated with a poor response rate. Lithium appears to be most effective for individuals with “euphoric” or “pure” mania, mild mania, and people with a family history of response. However, people with more severe mania, psychotic mania, mixed mania, rapid cycling, or comorbid substance abuse tend to respond poorly. In addition, many people undergoing long-term treatment develop a resistance to lithium. Furthermore, lithium has a very narrow therapeutic window; patients who exceed the recommended blood concentration of lithium may experience lithium toxicity. Moreover, lithium has an unfavorable side-effect profile.

The consensus guidelines for bipolar disease are prepared by a panel of psychiatrists who are experts in their field. These experts completed a survey concerning psychopharmacologic interventions used in specific clinical situations. The guidelines, reflecting the aggregate opinions of panel members, lay out a recommended treatment approach.

The 2000 consensus guidelines for the pharmacologic treatment of bipolar disorder make the following key points:

• Mood stabilizers are the treatment of choice for patients with bipolar disorder.
• If monotherapy fails, combination therapy should be used.
• Bipolar disorder is a chronic illness.
• Adjunctive use of atypical antipsychotics is recommended for mania or depression with psychosis — this may change with emerging data and clinical experience.
• Antidepressants may be used in conjunction with a mood stabilizer to treat concomitant depressive disorders.

It is important to note that recent studies suggest that atypical antipsychotics, in addition to their benefits in reducing psychotic symptoms, may play a role as mood stabilizers.

A variety of medications are used to treat bipolar disorder. They include:

• medications used as mood stabilizers (e.g., lithium, certain anticonvulsants)
• medications used to treat psychotic symptoms (antipsychotics)
• medications used to treat other specific symptoms, such as anxiety and insomnia (benzodiazepines and sedative hypnotics)

In general, lithium and certain anticonvulsants are used as first-line treatment for acute manic episodes and as maintenance therapy.

Antipsychotics are used as adjunctive therapy in severe cases where psychosis is present or as a sedative to treat insomnia, anxiety, and agitation. In addition, recent research has indicated a role for the newer atypical antipsychotics as mood stabilizers.

Benzodiazepines are anxiolytic (antianxiety) drugs that can be used as adjuvant therapy for people with agitation or insomnia.

Antidepressants may be used in combination with a mood stabilizer for treatment of major depressive episodes. However, antidepressants must be used with care. If bipolar depression is misdiagnosed as unipolar depression, the use of antidepressants alone may induce mania or rapid cycling.