Bipolar Disorder

Treatments

Systematic Enhancement Treatment Program for Bipolar Disorder (STEP-BD)

Treatment: The program was conducted from 1998-2005 and included 4361 participants across 22 U.S. clinical sites. Patients participated in the program for at least two years. The largest Bipolar Disorder research program ever conducted. The program included three major, randomized control trials in which patients were given mood stabilizers, anti-depressants, and/ or intensive or brief psychotherapy. Psychotherapy types included cognitive-behavioral, interpersonal and social rhythm, and family-focused therapy. In addition, a control group was given psychoeducation on aspects of bipolar disorder. The combination of mood stabilizers with intensive psychosocial interventions yielded the most positive results. However, none of the psychotherapy models were significantly better than the other. Bottom line; there is currently no best treatment for patients suffering from bipolar disorder, although the combination of medication with psychotherapy appears promising.

• Reference: Parikh, S., LeBlanc, S., & Ovanessian, M. (2010). Advancing Bipolar Disorder: Key Lessons From the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). The Canadian Journal of Psychiatry, 55(3), 136-143.
• Submitter: Tim Reynolds

Psychopharmacological and Non-Pharmacological

Treatment Summary: Bipolar Disorder, as with many other mental disorders is difficult to treat effectively. Studies have shown that an effective measure is to be myopic in goal desire (full recovery) while not being myopic in treatment method. An example of forward thinking and forward treatment could be a combination of Lithium and non-pharmacological therapy. When treatments are individualized and not generalized, efficacy is more evident and outcome is more beneficial. Possible Process of treatment: Initial treatment upon occurrence, Maintenance treatment (continuation), Medication – Lithium, Psychotherapy, CBT.

• Reference: http://www.mayoclinic.com/health/bipolar-disorder/DS00356/DSECTION=treatments-and-drugs
• Submitter: N/A

Treatment Summary: Family based treatment concurrent with depression medication has been researched and proved to be effective for bipolar disorders in the United States and foreign countries. Family support, high levels of education and clinical care is associated with effective short term treatment. Family focused therapy (FFT) is a nine month, twenty-one session intervention program and is initiated as soon as the patient stabilizes. FFT involves the patient and other family members. Research has found that family focused treatment is an approach that used a three component approach. These components include psychoeducation, communication skills and problem solving skills necessary for management of the illness. Family therapy provides the structure that helps reduce or delay the number of relapses. A better understanding of the disease by family members provides the most effective treatment and intervention for patients diagnosed with bipolar disorder. Participants in FFT receive instructions and training involving three modules of treatment. These three modules provide training in identifying early warning signs and rehearsal of strategies that can help prevent future episodes, information concerning the interactive roles of stress and vulnerability in reoccurrences and learning about the role of medication and lifestyle management skills. Each module supports the family in developing skills in communication, how to offer positive and negative feedback and strategies for defusing conflicts. Problem solving skills are practiced in order to identify possible solutions to problems that occur as a result of the depression and mania. Family therapy includes the individual and his/her interactions with other family members. Family support, high levels of education and continuous clinical care can help determine a short-term prognosis. Case studies suggest that family focused therapy can be used in treatment along with medication with positive results. More controlled studies are needed to determine if FFT and medication are effective in preventing reoccurrences and help improve the patient’s ability to function.

• Reference: Ozerdem, A., Oguz, M., Miklowitz, D., Cimilli, C. (2009). Family Focused Treatment for Patients with Bipolar Disorder in Turkey: A Case Series. Family Process. 48(3). pp. 417-428. Retrieved from http://web.ebscohost.com.zeus.tarleton.edu:81/ehost/pdf?vid=7&hid=4&sid=e800e034-2794-4158-8a79-081973d8c%40sessionmgr13
• Submitter: N/A

Lamotrigine and Clozapine, Cognitive Behavioral Therapy (CBT)

Treatment Summary: Patient was initially administered a number of medications over many year of treatment, with the most recent being lamotrigine in a combination therapy with sodium valproate in order to control her mixed affective state. The patient remained in this mixed state, with agitation and pressured speech as well as depressive cognitions, for the next several weeks and was subsequently administered clozapine to counteract this state. Once this medication was added, significant improvement in the mental state was evident over the next few weeks. The sodium valproate was gradually lessened to avoid side effects, and the patient was administered a steady dosage of lamotrigine 100 mg and clozapine 150 mg (serum level of clozapine Mg/l). A separate controlled study was done using 103 participants. Some patients were given 12 to 18 sessions of CBT in 6 months with 2 booster sessions in the second 6 months. Both the control group and experimental group all received minimal psychiatric care, including mood stabilizers along with regular psychiatric follow up, which was all the control group received according to the study. Results: Patient was finally discharged in a euthymic state from her in-patient treatment after 3 months. After 5 years of being discharged, she has not had an episode of depression, mania, or hypomania since the dosage listed above was initiated. Clozapine by itself may have been sufficient, but the prophylactic role of lamotrigine in BD as well as the remission of the episodes and the patient’s preference to remain on both medications led to the combination therapy. Patient was able to live a life with a sense of well being, improved interpersonal relationships, and was able to work full-time in a professional capacity. The study on CBT revealed that it significantly reduced bipolar episodes and hospitalizations along with better medication compliance in the group receiving CBT. The control group reported 75% relapse rate in the control group and 44% relapse in the experimental group. The control group also had three times as many days of duration, 88, of bipolar episodes compared to the CBT experimental group of 27 days, and the hospitalization rate for the experimental group was half the amount of the control group.

• Reference: Bastiampillai, T. J., Reid, C. E., & Dhillon, R. R. (2010). The long-term effectiveness of clozapine and lamotrigine in a patient with treatment-resistant rapid-cycling bipolar disorder. Journal of Psychopharmacology, 24(12), 1834-1836. doi:10.1177/0269881109358202 & Buila, S. (2009). Evidence-Based Research on the Effectiveness of Psychosocial Interventions for Bipolar Disorder. Social Work in Mental Health, 7(6), 572. & Steinkuller, A., & Rheineck, J. E. (2009). A Review of Evidence-Based Therapeutic Interventions for Bipolar Disorder. Journal of Mental Health Counseling, 31(4), 338.
• Submitter: Michael Gunter

Cognitive Behavior Therapy and Medication

Summary of Treatment: Cognitive behavior therapy is used to help treat bipolar disorder.  During the therapy, the focus is on stopping the cycle that allows for bipolar symptoms to get out of control.  The counselor and the client work to stop cognitive and affective symptoms from decreasing the client’s functioning and creating psychosocial problems.  The stress from psychosocial problems can cause a rise in bipolar symptom for the client.  Another focus of cognitive behavior therapy is to help the client to recognize warning signs of the onset of depression or mania.  Psychoeducation is a very important part of therapy.  The counselor needs to inform the client about the disorder, treatments for it, and how the client’s environment, behavior, and mental state will affect the disorder.

Cognitive behavior therapy is effective in helping clients through bipolar disorder, but studies have shown that cognitive behavior therapy along with pharmacotherapy is more effective then cognitive behavior therapy alone.  It may take time for clients to find the right medication and dosage for them.  During the journey for the right medication, it is extremely important that clients keep up and remain going to cognitive behavior therapy.

• Reference: Basco, M. R., Ladd, G., Myers, D. S., & Tyler, D.  (2007). Combining medication treatment and cognitive-behavior therapy for bipolar disorder.  Journal of Cognitive Psychotherapy: An International Quarterly, 21(1), 7-15.
• Submitted by: Erica Copeland

Lithium

Summary of Treatment: Lithium is usually the first line of treatment for the numerous variations of Bipolar 1 and 2.  It works as a mood stabilizer that has been shown to be effective in preventing the reoccurrence of depression and mania.  Lithium stabilizes the neurotransmitters creating a balance of the chemicals released in the brain.  Studies suggest that lithium when combined with lamotrigine or valproate can have an increased beneficial effect than lithium alone.   This medication has a fairly slow onset as it may take 1 to 3 weeks for the treatment to take any effect.  Lithium is typically taken 3 to 4 four times per day.  The preferred administration of this drug is oral.  However, there may be side effects such as: hair loss, swelling of the feet or ankles, gastrointestinal issues, fatigue, and the list goes on.   

• Reference: Malhi, G. S., & Tanious, M. (2011). Optimal Frequency of Lithium Administration in the Treatment of Bipolar Disorder. CNS Drugs, 25(4), 289-298.
• Submitted by: Jason Wells

Electronic Cognitive Behavioral Therapy (e-CBT)

Summary of Treatment: The distinct features of bipolar disorder (BD), particularly type BD two, are depression and hypomania. While cognitive behavioral therapy (CBT) and medication are used together as a resource to treat bipolar, individuals may encounter challenges when seeking in-person CBT services. However, electronic cognitive behavioral therapy (e-CBT) can be a helpful tool for making CBT accessible. Gutierrez et al. (2023) conducted a study to analyze how resourceful e-CBT can be and compared the approach to standard care. In the study, 170 participants from Ontario, Canada, were organized into the control and experimental groups to receive treatment for thirteen weeks. The e-CBT program was conducted in a safe electronic framework in which the participants completed coursework and communicated with mental health professionals. The researchers’ findings suggested that e-CBT was related to minimizing the symptoms and enhancing people’s everyday lives. These findings offer further insight into how e-CBT can be a reliable option that is affordable and helpful for people with BD, type two.

• Reference: Gutierrez, G., Stephenson, C., Eadie, J., Moghimi, E., Omrani, M., Groll, D., Soares, C. N., Milev, R., Vazquez, G., Yang, M., & Alavi, N. (2023). Evaluating the efficacy of web-based cognitive behavioral therapy for the treatment of patients with bipolar II disorder and residual depressive symptoms: Protocol for a randomized controlled trial. JMIR Research Protocols, 12, 46157. DOI: 10.2196/46157
• Submitted by: Heridiann Hernandez Vazquez