Bipolar Disorder: Clinical Management

In my earlier article I started talking about bipolar disorder and its prevalence and causes. Here I would like to continue the topic and talk about the clinical management of the same.

The signs and symptoms of bipolar disorder

There is a need to keep track of the patient’s emotion swings as they suffer from unusually intense emotional swings that occur in distinct periods called as "mood episodes."

Each mood episode is a drastic change from the patient’s baseline behavior. An uncontrollably joyful or excited swing is called as manic episode while extreme sadness or hopelessness is the depressive swing.

Sometimes, a mood episode includes symptoms of both mania and depression. This is called as the mixed state

Manic mood states can be characterized by:

• A long period of feeling "high," or an overly happy or outgoing mood
• Extreme irritability
• Talking very fast, jumping from one idea to another, having racing thoughts
• Being easily distracted
• Increasing activities, such as taking on new projects
• Being overly restless
• Sleeping little or not being tired
• Having an unrealistic belief in one's abilities
• Behaving impulsively and engaging in pleasurable, high-risk behaviors

Depressive mood states can look something like this:

• An overly long period of feeling sad or hopeless
• Loss of interest in activities once enjoyed, including sex
• Feeling tired or "slowed down"
• Having problems concentrating, remembering, and making decisions
• Being restless or irritable
• Changing eating, sleeping, or other habits
• Thinking of death or suicide, or attempting suicide

Bipolar disorder may also be present in a mixed state, in which the person might experience both mania and depression at the same time. In a mixed state, the patient can get very agitated, have trouble sleeping, have changes in appetite, even have suicidal thoughts. People in a mixed state may feel very sad or hopeless while at the same time feel extremely energized, which is a bad combination.

Treatment of bipolar disorder

Bipolar disorder cannot be cured but, can be managed effectively. Treatment is more effective if the patient keeps in regular touch with a doctor and talks openly about his or her concerns and choices. Effective management usually includes medicines and importantly, psychotherapy.

Medications in bipolar disorder

Different medications are used for different aspects of the problem as well as different patients. Not everyone responds to medications in the same way. Regular clinical examination and ‘tweaking’ of the meds and their dosages is very important to decide the most effective medication regime.

It’s very important that a person with bipolar disorder keeps a daily life chart to make a note of daily mood symptoms, treatments, sleep patterns, and life events. This helps the therapists and doctors gain a better understanding of the cycles the patient is going through and tailor their therapy accordingly. Management of bipolar disorders, as for most neuropsychiatric disorders is a marathon with no end, not a race to the finish.

The different medications, used to treat bipolar disorder include mood stabilizers, atypical antipsychotics, and antidepressants.

Mood stabilizers are usually first line drugs in bipolar disorder. Lithium is the prototypically effective mood stabilizer and was first used in the 1970s for treating both manic and depressive episodes. Lithium and its ilk have their own side effects though, including liver and kidney issues. It’s important for a patient on lithium therapy to get their levels checked regularly. The doses need to be tweaked pretty often.

Anti-convulsants can also be used as mood stabilizers. Although they were developed to treat seizures, they can help a lot in bipolar disorder. Valproate and Depakote are examples of anti-seizure medicines used for bipolar disorder.

Atypical antipsychotics can also be used to manage the symptoms of bipolar disorder and many a time they are coupled with antidepressants. Olanzapine, Aripiprazole and Quetiapine have all been used here.

Beyond the drugs: Psychotherapy

Along with medication, psychotherapy allows the patient and their family an understanding of “what comes next” or what to expect and helps the patients monitor their own symptoms leading to quicker reaction times and better management. Behavioral therapy and counseling are the mainstays here.

Although not commonly used, but, Electroconvulsive Therapy (ECT) can be used to manage the patient in cases where the psychotherapy fails.