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Bipolar Disorder: A Clinical Information Guide
INTRODUCTION | INCIDENCE & PREVALENCE | CAUSES | DIAGNOSIS | ASSESSMENT | TREATMENT | WHERE TO GO FOR HELP: RESOURCES
Bipolar disorder is psychiatric disorder characterized by wide variations in mood, from mania to depression. When individuals are manic, they have elated or irritable mood and may engage in dangerous and high-risk behaviors such as promiscuous sexual activity, increased spending, violence, and substance abuse. When individuals are depressed, they suffer from sad mood or lack or interest and may exhibit such symptoms as diminished energy, changes in sleep or appetite, lowered self esteem, and thoughts of suicide or death. Bipolar disorder can cause major disruptions in family, social and occupational functioning.
The American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) delineates two subtypes of bipolar disorder. Bipolar I disorder is defined as episodes of mania alternating with episodes of Major Depression. The clinical presentations of this disorder include mania, hypomania, depression, and psychosis. Bipolar II disorder is characterized by recurrent episodes of hypomania and Major Depression. Hypomania is elevated, irritable, or expansive mood without the gross lapses of impulse and judgment common in mania. Hypomanic symptoms can rapidly escalate over a period of days and frequently follow stressful life events.
Bipolar disorder is usually first diagnosed in persons between 18 and 24 years of age (Carlson et al., 1977; Joyce, 1984; Loranger & Levine, 1978; Winokur et al., 1969). Approximately 20% of all bipolar patients have their first episode during adolescence. In the past, developmental variations in presentation, symptomatic overlap with other disorders, and lack of clinician awareness have led to under diagnosis or misdiagnosis in children and adolescents.
It was once believed that schizophrenia was more common than bipolar disorder in youth. Thus, adolescents who presented with psychotic symptoms used to be diagnosed with schizophrenia rather than with bipolar disorder (Bashir et al., 1987; Joyce, 1984; McClellan et al., 1993; Werry et al., 1991). Although clinicians have become increasingly aware of the confusion between early-onset bipolar disorder and schizophrenia, bipolar disorder in youth continues to be under-recognized misdiagnosed (Carlson et al., 1994).
In adults, bipolar disorder is generally an episodic disorder with a variable course (APA, 1994a). The majority of patients with bipolar disorder have multiple episodes. Individuals who are not treated may have ten or more episodes (Goodwill & Jamison, 1990). Episodes tend to come more frequently over time, with the length of cycles (i.e., time from onset of one episode to onset of the next episode) stabilizing after the fourth or fifth episode (Goodwin & Jamison, 1990).
The lifetime prevalence of bipolar disorder is one percent, which compares to a lifetime prevalence of six percent for depression. The prevalence of bipolar disorder does not differ between men and women.
Epidemiological surveys of childhood psychiatric disorders have generally not addressed bipolar disorder (Costello, 1989a). A community school survey of older adolescents (14 to 18 years of age) found the incidence to be approximately one percent (Lewinsohn et al., 1995). Most adolescents in this survey had Bipolar II disorder. The incidence appears to increase after onset of puberty. Despite anecdotal reports of onset prior to 6 years of age, further research is needed to establish whether such cases actually represent bipolar disorder.
Manic symptoms in youth frequently do not persist long enough to meet the one week duration criteria required by DSM-IV (APA, 1994b) to diagnose a manic episode. Therefore, youth are more likely to be diagnosed with either Bipolar II Disorder or Cyclothymic Disorder2, rather than Bipolar I Disorder.
Overall, adult bipolar disorder affects both sexes equally. However, early-onset bipolar disorder (i.e., prior to 13-years-old) is more common in boys than girls. This is consistent with studies of depression in children younger than 12 years of age, where depression is more common in boys than girls (Costello, 1989b).
Patients who are manic or depressed may attempt suicide or homicide. These risks are increased in patients who are psychotic or who have severe depressive symptoms concurrent with mania. The lifetime suicide risk is 15 percent for patients with bipolar disorder; patients at highest risk are young men who are in the early phases of the disorder, who have made previous suicide attempts, or who abuse alcohol.
Many youth with bipolar disorder have normal premorbid histories. However, preexisting behavioral problems, including ADHD, conduct disorder, depression, and anxiety are quite common (Carlson, 1990; McClellan et al., 1993; Werry et al., 1991). Ethnic minorities and individuals of lower socioeconomic standing who have bipolar disorder are more likely to be misdiagnosed with schizophrenia than are non-minority individuals or individuals of higher socioeconomic standing Goodwin and Jamison, 1990). Ki1gus et al. (1995) found that psychiatrically hospitalized African-American adolescents were more often diagnosed with organic/psychotic disorders and less often diagnosed with affective/anxiety disorders than Caucasian teenagers.
Most researchers agree that there is no single cause for bipolar disorder-rather, many factors act together to produce the illness. Similar to other mood disorders, the incidence of bipolar disorder is increased in first-degree relatives of persons with the disorder. One study found a 13 percent risk of bipolar disorder among offspring of persons with the disorder. The risk of depression in this study was 15 percent.
Because bipolar disorder tends to run in families, researchers have been searching for specific genes that may increase a person's chance of developing the illness. Studies of identical twins, who share all the same genes, indicate that both genes and other factors play a role in bipolar disorder. If bipolar disorder were caused entirely by genes, then the identical twin of someone with the illness would always develop the illness, and research has shown that this is not the case. But if one twin has bipolar disorder, the other twin is more likely to develop the illness than is another sibling (NIMH Genetics Workgroup, 1998).
Brain-imaging studies are helping scientists learn what goes wrong in the brain to produce bipolar disorder and other mental illnesses (Soares & Mann, 1997, 1997a). Brain-imaging techniques such as magnetic resonance imaging (MRI), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI) suggest that the brains of people with bipolar disorder may differ from the brains of healthy individuals.
To obtain a diagnosis of Bipolar I Disorder, the individual must currently have a manic episode, or must have had an episode in the past. Children and adolescents are diagnosed with bipolar disorder using the same DSM-IV criteria that are used for adults (APA,1994). The symptoms of a manic episode include the following:
1. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
2. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is irritable) and have been present to a significant degree:
· Inflated self-esteem or grandiosity
· Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
· More talkative than usual or pressure to keep talking
· Flight of ideas or subjective experience that thoughts are racing
· Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
· Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
· Excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)
The manic episode must be observable by others and severe enough to cause marked impairment in occupational functioning, social activities, or interpersonal relationships, or require hospitalization.
To obtain a diagnosis of Bipolar II Disorder, the individual must have at least one hypomanic episode. The symptoms of a hypomanic episode are identical to those of a manic episode, except that the period of mood disturbance needs to last only four days, and should not be severe enough to cause marked impairment in social or occupational functioning, or to require hospitalization.
Individuals who present for treatment while in the depressive phase of bipolar disorder (i.e., meeting criteria for Major Depression) may still receive a diagnosis of bipolar disorder, provided that they have experienced a manic or hypomanic episode in the past.
Bipolar Disorder Throughout the Lifespan
Children with mania often present with atypical symptoms (Bowring & Kovacs, 1992). Changes in mood and psychomotor agitation are often erratic, rather than persistent in nature. Hyperactivity is the most common behavioral manifestation of mania in young children. Manic children may also exhibit irritability or temper tantrums. Differential psychiatric diagnoses include attention-deficit hyperactivity disorder, conduct disorder and schizophrenia (Borchardt & Bernstein, 1995; Carlson, 1990; McClellan et al., 1993).
Adolescents are more likely than adults to present with irritability, belligerence, and mixed mood (i.e., mania and depression), rather than simple euphoria. The presentations of adolescents with bipolar disorder are often complicated by psychotic symptoms, including mood-incongruent hallucinations and paranoia and severe deterioration in their behavior (Akiskal et al., 1985; Goodwin and Jamison, 1990). The complex presentation of bipolar disorder in adolescents contributes to under-diagnosis (e.g., Carlson et al., 1994) and high rates of misdiagnosis as schizophrenia (e.g., Carlson, 1990). Further complicating diagnosis of bipolar disorder in adolescents is the fact that reckless behavior, a hallmark symptom of the disorder, must be distinguished from normal childhood boasting, imaginary play, overactivity, and youthful indiscretions.
In children with major depressive disorder, Geller et al. (1994) found that 32% went on to develop either mania or hypomania; 80 percent of them were 12 years old or younger (mean age 11.1 years) at the time of onset of depression. For patients who initially present with depression, some of the risk factors for the development of bipolar disorder include (a) a depressive episode characterized by rapid onset, psychomotor retardation, and psychotic features, (b) a family history of bipolar disorder, and (c) onset of mania or hypomania after treatment with antidepressants (Strober and Carlson, 1982).
Carlson and Cochran (1973) have described three stages in the development of mania:
· Stage I includes euphoria, increased psychomotor activity, and mood lability.
· Stage II includes irritability, racing thoughts, dysphoria, and disorganization.
· Stage III includes deteriorating mental status with significant confusion and psychosis
Studies of primary care patients with mood disorders have repeatedly found certain comorbid conditions. In one study, more than 42 percent of patients meeting criteria for a mood disorder (including bipolar disorder) had lifetime histories of substance abuse. In another study, the frequency of substance abuse was 39 percent in adolescents who had symptoms of bipolar disorder. Another study revealed a high incidence of moderate to severe anxiety disorders in patients who had bipolar disorder.
Assessment for bipolar disorder involves an initial evaluation by a psychiatrist, psychologist, or licensed clinical social worker. This evaluation should involved a thorough clinical interview that in which the clinician gathers information in the following domains:
1. History of present illness -- History of manic and depressive symptoms, psychotic symptoms, and suicidality. The symptoms should represent a significant change from baseline functioning, with associated changes in mental status. Rapidity of onset and precipitating stressors should be noted.
2. Course of illness -- It is helpful to create a life chart to identify cyclical and/or seasonal patterns. It is necessary to assess associated or confounding symptoms, especially substance abuse, organic factors, and behavioral disorders.
3. Family history -- Obtain a thorough family history of mood, anxiety and psychotic disorders, suicidality, impulse control disorders, neurological and medical conditions, and substance abuse.
4. School information -- Obtain information about school functioning, both premorbid and subsequent to the onset of symptoms, either directly or from written reports from teachers, school counselors, and other school personnel.
5. Neuropsychological functioning -- Suspected disabilities in either intellectual functioning, communication abilities, and motor skills should be evaluated to distinguish between bipolar disorder and other diagnoses, and to identify comorbid problems. Psychological testing and speech and language assessments may help to supplement interview data.
Once bipolar disorder is diagnosed, a physical examination should occur. Metabolic, endocrine, or infectious disorders, as well as acute intoxication or withdrawal can present with some of the same symptoms as bipolar disorder, so it is important to rule-out these conditions. In addition, routine laboratory tests such as blood counts, renal and liver functions, thyroid functions, toxicology screen, and a pregnancy test are required before an individual can start psychotropic medications for bipolar disorder. A neurology consultation may also be warranted to rule-out traumatic brain injury.
A diagnosis of bipolar disorder should be considered for any youth whose functioning deteriorates markedly and who exhibits either mood or psychotic symptoms. Using structured and semi-structured diagnostic interviews increases diagnostic accuracy (Carlson et al., 1994). However, even with these instruments, there is still a risk of over-diagnosis in youth with conduct disorder and ADHD (Weller et al., 1995).
A multimodal treatment plan, combining medications with psychotherapeutic interventions, is needed to address the symptomatology and associated psychosocial difficulties in children and adolescents with bipolar disorder. As in adults, early onset bipolar disorder may represent a lifelong condition that requires ongoing assessment, medication monitoring, and psychosocial interventions. Treatment varies according to the phase of the disorder, with an overall focus on (1) amelioration of acute symptoms, (2) prevention of relapse, (3) reduction of long-term morbidity, and (4) promotion of long-term growth and development. This section focuses primarily on the treatment of manic and hypomanic episodes. Comprehensive treatment should include:
1. Thorough diagnostic assessment -- Acute mania or severe depression (especially psychotic depression) may require hospitalization, depending on the severity and potential danger of the symptomatology, as well as the social supports of the family. Hospitalization may be necessary because of the extensive array of psychiatric and neurological evaluation resources required to complete the initial assessment, and the need for a structured, safe environment.
2. Suicide assessment -- Since this population is at significant risk for attempting suicide, risk factors need to be identified so that they can be addressed in treatment.
3. Evaluation and initiation of medication therapy -- Medication is almost always used to treat bipolar disorder.
4. Psychoeducation -- The patient and family need to learn about bipolar disorder, including the course, prognosis, and recommended treatments.
5. Development of treatment plan -- The plan includes medication management, appropriate psychotherapy and psychoeducational services for the patient, supportive services for the family (e.g., advocacy groups, support groups), appropriate educational and vocational services, and residential services when indicated.
6. Designation of a case manager -- Chronically disabled individuals may need a clinical case manager to coordinate the wide range of services needed.
7. Periodic reassessments -- Patients should be reassessed on a regular basis to ensure the accuracy of diagnosis and measure accomplishment of treatment goals.
Medication
The literature regarding medication treatment for children and adolescents with bipolar disorder is limited. Many of the current recommendations are, therefore, based on studies of adults. Pharmacotherapy is usually instituted to address manic (or mixed) symptoms and depressive symptoms, or to prevent relapse of the disorder. Typically, the first line of treatment for bipolar disorder is an mood stabilizing medication such as lithium. The most common medications and the patterns of prescribing these medications are outlined in this section.
Lithium
Traditionally the agent of first choice in the treatment of bipolar disorder, Lithium has the largest database supporting its efficacy (APA, 1994a). In adults, lithium has been shown to be effective for:
(a) the treatment of acute manic and depressive episodes
(b) prevention of recurrent manic and depressive episodes
(c) reduction of mood instability between episodes
Approximately 80% of patients with bipolar disorder respond to lithium, both for acute mania and depression (APA, 1994a). However, the response rate for mania is quicker (two weeks versus six to eight weeks for depression). Lithium also helps recurrent episodes of both mania and major depression. Discontinuation of long-term lithium therapy increases the risk of relapse, at least in the short term (APA, 1994a). Some patients may develop a more treatment-resistant form of the illness after previously effective lithium treatment has been discontinued (Post et al., 1992).
Youth generally tolerate lithium well and may have fewer side effects than adults (e.g., Alessi et al., 1994), although younger children may be more prone to side effects than older children (e.g., Campbell et al., 1991). Commonly reported adverse reactions include nausea, diarrhea, vomiting, tremor, weight gain, headache, polyuria, polydipsia, enuresis, fatigue, and ataxia (Alessi et al., 1994; Silva et al., 1992; Viesselman et al., 1993).
Lithium can have significant effects on cardiac conduction, including first-degree atrioventricular block, irregular sinus rhythms, and increased premature ventricular contractions. However, serious adverse reactions are rare (Gelenberg & Schoonover, 1991). In children, reversible conduction abnormalities have been reported (Campbell et al., 1972).
Lithium can induce or exacerbate dermatological problems, including acne, which may be a significant concern to adolescent patients (Viesselman et al., 1993).
Lithium may produce a variety of neurological effects, including muscle weakness, tremor (which can be treated with propranolol), lethargy, cognitive blunting, and headaches (Gelenberg and Schoonover, 1991; Viesselman et al., 1993). These are often time-limited and remit quickly. Serious neurotoxicity may develop with higher blood levels, including ataxia, dysarthria, nystagmus, and confusion. With blood levels above 3.0 mEq/L, patients may develop more devastating neurological impairments, including seizures, coma, and death (Gelenberg and Schoonover, 1991).
In children, lithium has been reported to alter EEG patterns and to decrease performance on cognitive testing (Alessi et al., 1994). However, at therapeutic blood levels, the impact on overall cognitive functioning does not appear to be significant.
Anticonvulsants
Adult studies have supported the efficacy of the anticonvulsants carbamazepine and valproate for the acute treatment of bipolar disorder (APA, 1994a; McElroy et al., 1992). Greater evidence supports the use of valproate, which was recently approved as a treatment for mania by the U.S. Food and Drug Administration. Some patients who cannot tolerate or do not respond to lithium may respond to anticonvulsants. Anticonvulsants have been used by themselves, together, or in combination with lithium. Indications for their use include rapid cycling or mixed mania, both of which are associated with poor response to lithium (APA, 1994a; McElroy et al., 1992).
Benzodiazepines
Benzodiazepines may be useful for treating agitated manic states (APA, 1994a; Viesselman et al., 1993). These agents, used in conjunction with antimanic agents, are helpful for psychomotor agitation, irritability, and insomnia in acutely manic patients (APA, 1994a; Viesselman et al., 1993). In adults, clonazepam and lorazepam have been most often studied, but no literature is available on their use in children and adolescents with mania (Werry & Arnan, 1993). Benzodiazepines can be adjuncts to antimanic agents for patients with acute mania. However, their long term use in children and adolescents with bipolar disorder should be discouraged, given the lack of supporting research and potential dependency problems.
Neuroleptics
Although neuroleptics are commonly used in clinical practice, no studies have examined the efficacy of neuroleptics for early-onset bipolar disorder. In the adult literature, neuroleptics have been shown to be effective for the treatment of acute mania (Goodwin and Jamison, 1990). However, it is not clear whether the effects of neuroleptics are actually antimanic or due to sedation (Goodwin and Jamison, 1990). Since their effects occur more rapidly than mood stabilizers, they may be useful during the initial phases when patients are highly agitated or psychotic (APA, 1994a). Little evidence indicates that neuroleptics, by themselves, should be used for maintenance treatment of bipolar disorder (APA, 1994a). Some patients whose symptoms do not respond adequately to antimanic agents alone may benefit from a combination of a mood stabilizer with an antipsychotic (APA, 1994a).
The side-effects of neuroleptics dictate close monitoring and periodic reassessment of their ongoing use over the course of therapy (Campbell et al., 1993). Patients with mood disorders may be at greater risk to develop tardive dyskinesia (APA, 1991). In addition, the combination of lithium and neuroleptics has been associated with an increased risk of extrapyramidal side effects and neurotoxicity (Alessi et al., 1994).
Other Antimanic Agents
Clozapine and the other atypical antipsychotic agents (e.g., risperidone), may have mood stabilizing effects in patients with bipolar disorder, including those with psychotic features, mixed episodes, and/or rapid cycling (APA, 1994a). Clozapine was reported to be effective in an adolescent with bipolar disorder (Fuchs, 1994). Other agents with reported efficacy in the adult literature include calcium channel blockers and thyroid hormones (APA, 1994a). Because these agents have not been studied for the treatment of early-onset bipolar disorder, they should only be considered after other medications have been tried.
Antidepressant Medications
A major risk of antidepressant use in bipolar patients is that these medications can induce mania. This risk has been noted with all classes of antidepressant agents (APA, 1994a). Thus, these medications are generally used only as adjuncts to antimanic therapy in patients who have persistent depressive symptoms (Zornberg & Pope, 1993).
Electroconvulsive Therapy (ECT)
In adults, electroconvulsive therapy (ECT) is as effective as lithium for the treatment of mania (APA, 1994a; Welch, 1989). Furthermore, it is the most effective therapy available for depression, particularly for patients with psychotic depression or for those nonresponsive or intolerant of medication therapy (APA, 1994a; Welch, 1989). Many patients with bipolar disorder respond quickly to ECT. It is extremely safe as long as modern methods are used (i.e., appropriate anesthesia, alterations in the delivery of the electrical stimulus, the selected use of unilateral treatment, and cardiopulmonary monitoring) (APA, 1994a).
ECT is generally considered the treatment of choice for bipolar disorder in the following clinical situations: (1) pregnancy; (2) catatonia; (3) neuroleptic malignant syndrome, and (4) any other medical condition where more standard medication regimens are contraindicated (APA, 1990). Although the literature is sparse, case reports indicate that ECT is beneficial for children and adolescents with bipolar disorder, including mania, rapid cycling, and depressed phases (Bertagnoli & Borchardt, 1990). Potential side effects include short-term cognitive impairment, anxiety reactions, disinhibition, and altered seizure threshold (Bertagnoli and Borchardt, 1990). Despite its potential efficacy, many centers do not use ECT for patients with early-onset bipolar disorder due to a lack of experience and social stigma.
Psychosocial Treatments
Medications help with the core symptoms of bipolar disorder, but they do not address the associated functional impairment. Thus, a comprehensive multimodal treatment approach combining psychopharmacology with adjunctive psychosocial therapies is almost always indicated for bipolar disorder, especially in children and adolescents.
Patients with bipolar disorder suffer from the psychosocial consequences of past episodes, the ongoing vulnerability to future episodes, and the burdens of adhering to a long-term treatment plan that may involve some unpleasant side effects. In addition, many patients have clinically significant mood instability between episodes. The goals of psychotherapeutic treatments are to reduce distress, improve the patient's functioning between episodes, and decrease the frequency of future episodes. Most patients with bipolar disorder will struggle with some of the following issues:
1) emotional consequences of periods of major mood disorder and diagnosis of a chronic mental illness
2) developmental delays caused by past episodes
3) stigmatization
4) problems regulating self-esteem
5) fears of recurrence and consequent inhibition of normal psychosocial functioning
6) interpersonal difficulties
7) marriage, family, childbearing, and parenting issues
8) academic and occupational problems
9) other legal, social, and emotional problems that arise from reckless or impulsive behavior that may occur during episodes.
Significant issues for family members include the stigma that is frequently associated with mental illness and the need for support and education. Because patients with bipolar disorder often loose judgment in the course of the illness and engage in high-risk behavior, family members may be interacting with the legal system and the health care system simultaneously. Guilt, anger, grief and ambivalence are frequent feelings among family members as they cope with the difficulties. Family members must be educated about the course of bipolar disorder, so that they can cope effectively.
Extrapolating from the adult literature and clinical experience with this population suggests that there are a range of specific psychotherapeutic interventions that may be helpful for some patients. In general, judgments regarding the efficacy of these treatments are based on strong clinical consensus, rather than on formal controlled trials. The individual treatment approaches include psychodynamic, interpersonal, behavioral, and cognitive. In addition, family therapy and group therapy may be helpful for some patients. Formal studies are currently being conducted for many of these treatments in patients with bipolar disorder.
The available psychotherapeutic treatments are discussed as separate entities, even though in practice mental health practitioners commonly use a combination or synthesis of different approaches depending on the patient's needs and preferences.
1) Inpatient family therapy has been applied both in schizophrenia and bipolar disorder. Family treatment is brief (approximately six sessions) and includes a psychoeducational component. Goals include accepting the reality of the illness, identifying and managing stress inside and outside the family and helping the family accept the need for continued treatment after hospital discharge. Systematic study of this approach in patients with bipolar disorder is limited, although there is some evidence that it is helpful for some patients.
2) Behavioral family management is a treatment for patients who have recently been hospitalized for an episode of mania. Behavioral family management is based on a home-centered psychosocial treatment for schizophrenia developed by Falloon. The treatment includes psychoeducation, communication skills training, and problem-solving skills training. Although definitive trials of behavioral family treatment have not been completed, preliminary evidence suggests that behavioral family management/behavioral family treatment in concert with adequate pharmacotherapy leads to a substantial decrease in relapse rates.
3) Family therapy and psychoeducation has been tried with patients who have bipolar disorder. Patients who were assigned to family therapy group had lower rates of family separations, greater improvements in level of family functioning, higher rates of full recovery, and lower rates of re-hospitalization for 2 years following family treatment.
4) Cognitive behavioral treatment for patients with bipolar disorder has been developed by Basco and Rush. The goals of the program are to educate the patient regarding bipolar disorder and its treatment, teach cognitive behavioral skills for coping with psychosocial stressors, facilitate compliance with treatment, and monitor the occurrence and severity of symptoms.
5) Support groups -- Many support groups provide useful information about bipolar disorder and its treatment. Patients in these groups often benefit from hearing the experiences of others who are struggling with such issues as denial versus acceptance of the need for medication, problems with side effects, and how to shoulder other burdens associated with the illness and its treatment. Advocacy groups such as the National Depressive and Manic-Depressive Association and the National Alliance for the Mentally Ill have many local chapters that provide both support and educational material to patients and their families.
It is not clear to what extent patients with bipolar and depression are similar in their responsiveness to psychotherapy. However, it seems likely that the following treatments may benefit some patients with bipolar depressive disorders, especially when the depressive episodes seem to be precipitated by psychosocial issues.
1) Psychodynamic psychotherapy aims to clarify the intrapsychic processes that may precipitate or perpetuate mood dysregulation. Once these forces are made conscious, mood regulation difficulties can be anticipated and mastered through the process of insight. Mastery and insight, experienced in the supportive or interpretive relationship with the therapist, permit the patient to overcome some of the negative effects of illness and to prevent future problems.
2) Interpersonal therapy seeks to recognize and explore the ways in interpersonal losses, role disputes and transitions, social isolation, or deficits in social skills contribute to the development and maintenance of depression. There is some evidence in controlled studies that interpersonal therapy without pharmacotherapy is effective in reducing depressive symptoms in the acute phase of less severe depressive episodes (DiMascio, Weissman, Prusoff, Neu, Zwilling, & Klerman, 1979; Elkin, Shea, Watkins, Imber, Sotsky, Collins, Glass, Pilkonis, Leber, Docherty, Fiester, & Parloff, 1989) and that it is especially effective in ameliorating some of the occupational and social aspects of depression (Klerman, DiMascio, Weissman, Prusoff, & Paykel, 1974).
3) Behavior therapy for depression is based on behavior analysis and social learning theory. Some of the techniques used include activity scheduling and self-control therapy, social skills training, and problem solving. Behavior therapy has been reported to be effective in the acute treatment of patients with mild to moderately severe depression, especially when combined with pharmacotherapy (McLean & Hakstian, 1979); Usaf & Kavanagh, 1990; Nezu & Perri, 1989). The utility of behavior therapy in continuation- and maintenance-phase treatment of patients with bipolar depression has not been subjected to controlled studies.
4) Cognitive therapy maintains that irrational beliefs and distorted attitudes toward the self, the environment, and the future perpetuate depression, and that these distorted beliefs may be reversed through cognitive behavior therapy. There is some evidence that cognitive therapy reduces depressive symptoms during the acute phase of less severe forms of depression. No randomized, controlled studies are available on the role of cognitive therapy for bipolar patients in either the acute or maintenance phase of treatment.
5) Specific psycho-therapies for manic episodes -- Management of severe manic episodes poses one of the greatest challenges in psychiatry. While it is generally not beneficial to implement a specific psychotherapy during a manic episode, there are important psychosocial and environmental approaches that may be applied. A plan that sets and enforces clear limits in a firm manner is generally recommended, but may be difficult to implement.
Flexible Models of Care
The educational needs of youth with bipolar disorder must be adequately addressed to help promote long-term academic growth, especially given the high rates of comorbid disruptive behavior disorders. School consultation is often necessary to help develop an appropriate educational environment. Consultation with school personnel can also help alert them to early warning signs of mania or depression. Some youth will need specialized educational programs.
Many youth with bipolar disorder will be chronically impaired, with complicated clinical and social needs. These youth may need an integrated continuum of service that includes case management, intensive community and family support, in-home services, out-of-home care (including respite and specialized foster care), and specialized educational/vocational services. Some youth, either because of the severity of the symptoms or confounding environmental stressors, will need intensive community-based services to continue living in their homes. Consultation may be needed with other community, juvenile justice, and social welfare programs.
In some cases, the severity of the individual's illness or lack of effective response to treatment may necessitate day treatment, residential treatment, or hospitalization. These options should only be considered after less restrictive alternatives have been unsuccessful. Once in a long-term residential setting, the patient's status needs to be reassessed at regular intervals, with the goal of returning to a less restrictive setting when possible.
In seeking help, persons may be directed to physicians, mental health specialists, community mental health agencies, the psychiatric department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, private clinics, self-help groups, pastoral care providers, school counselors, or the local Mental Health Association.
The National Institute of Mental Health provides information on the treatment of children with mental disorders which may be useful to parents. This includes questions on the types of mental illnesses that affect children, risk factors, detecting symptoms, where to obtain help, the diagnostic processes used for children, and the use of psychotropic medications. Information can be obtained by contacting the agency at:
National Institute of Mental Health (NIMH)
Office of Communications and Public Liaison
Information Resources and Inquiries Branch
6001 Executive Blvd., Rm. 8184, MSC 9663
Bethesda, MD 20892-9663
Phone: (301) 443-4513; Fax: (301) 443-4279
Web site: http://www.nimh.nih.gov
The following agencies can also provide useful information concerning bipolar disorder:
Child & Adolescent Bipolar Foundation
1187 Willmette Avenue, PMB #331
Willmette, IL 60091
Phone: (847) 256-8525
Web site: http://www.bpkids.org
Depression and Related Affective Disorders Association (DRADA)
Johns Hopkins Hospital, Meyer 3-181
600 North Wolfe Street
Baltimore, MD 21287-7381
Phone: (410) 955-4647 or (202) 955-5800
Web site: http://www.med.jhu.edu/drada
National Alliance for the Mentally Ill (NAMI)
Colonial Place Three
2107 Wilson Blvd., 3rd Floor
Arlington, VA 22201
Toll-Free: 1-800-950-NAMI (6264)
Phone: (703) 524-7600; Fax: (703) 524-9094
Web site: http://www.nami.org
National Depressive and Manic-Depressive Association (NDMDA)
730 North Franklin Street, Suite 501
Chicago, IL 60610
Toll-Free: 1-800-826-3632
Phone: (312) 642-0049; Fax: (312) 642-7243
Web site: http://www.ndmda.org
National Foundation for Depressive Illness, Inc. (NAFDI)
P.O. Box 2257
New York, NY 10116
Toll-Free: 1-800-239-1265
Web site: http://www.depression.org
National Mental Health Association (NMHA)
1021 Prince Street
Alexandria, VA 22314-2971
Toll-Free: 1-800-969-NMHA (6642)
Phone: (703) 684-7722; Fax: (703) 684-5968
Web site: http://www.nmha.org
1 Sections of this Clinical Information Guide are adapted from the National Institute of Mental Health publication Bipolar Disorder (Publication number 01-3679) and the American Psychiatric Association's Practice Guide for the Treatment of Bipolar Disorder (1994).
2 Cyclothymic Disorder is a psychiatric disorder that is characterized by market shifts in mood between hypomania and depression that do not meet the criteria for either Bipolar disorder or Major Depression.
INTRODUCTION | INCIDENCE & PREVALENCE | CAUSES | DIAGNOSIS | ASSESSMENT | TREATMENT | WHERE TO GO FOR HELP: RESOURCES