Correct medication choice key to managing bipolar disorder

BIPOLAR DISORDER leads to unusual shifts in mood, energy and activity levels. People experience intense emotional states, cycling between manic episodes, when they are energized and overexcited, and depressive episodes when they are sad and hopeless.

The condition affects approximately 5.7 million American adults, or about 2.6% of the U.S. population aged 18 and older. Symptoms can result in damaged relationships, poor job or school performance and even suicide.

Bipolar disorder often develops in the late teens or early adult years, although some people experience their first symptoms during childhood, and others develop symptoms late in life.

"There's no blood test, no CT scan, no definitive way to diagnose the condition. Instead there is a recurrent behavior pattern," says Kenneth Duckworth, MD, medical director for the National Alliance on Mental Illness (NAMI) and a board member of the American Association of Community Psychiatrists. "Part of the treatment process involves someone coming to accept that they actually have this disorder. Basically, they need to accept the physician's clinical judgment that they do meet the criteria for this condition."

A number of medications are used to treat bipolar disorder:

"Lithium continues to be the standard treatment for bipolar disorder, but antiepileptic drugs such as valproate and carbamazepine are also widely used despite evidence suggesting they are less effective in preventing recurrence," says Mark Abramowicz, MD, editor-in-chief of The Medical Letter on Drugs and Therapeutics, a non-profit newsletter that critically appraises drugs. "Atypical second-generation antipsychotic drugs have received FDA approval for treatment of acute mania or mixed episodes, and for maintenance treatment of bipolar disorder. Lithium is preferred for treatment of depression in bipolar disorder."

Getting the right medicine is an important piece of the puzzle, Dr. Duckworth says.

Providers must consider medicines that patients can tolerate without too many side effects. Patients benefit from a relationship with a professional who can help them understand their condition.

"They need to come to an understanding of what they're living with, and that may take anywhere from six days to six weeks to six years to six decades," he says. "I've had patients who were quite ill, and went to the hospital not believing that they had an illness. Then a year later, they truly 'got it,' and organized their lives to deal with it."

"When someone has bipolar disorder it's especially important to learn from prior experiences," Dr. Duckworth says. "The question is, how quickly can they learn their own pattern? Can they accept feedback from the people who love them? This is a very important challenge for the spouse and other family members who live with someone who has bipolar disorder."

SELF-MANAGEMENT AND CARE

Self-help groups are an important tool to aid people in learning skills they need to manage this condition, particularly valuable because they offer a way to interact with others who are coping with similar problems. NAMI and the Depression and Bipolar Support Alliance offer free self-help support groups.

Typically a psychiatrist is responsible for prescribing medications for bipolar disorder, while a psychiatrist or a mental health therapist may be responsible for ongoing discussions on patient self-management. Relying on a shared medical record and locating providers in the same geographic space will support coordinated care.

Patients with bipolar disorder may self-medicate and develop substance abuse issues. Among all the different psychiatric illnesses, patients with this condition are most likely to also have a substance abuse disorder, so treatment services should be available.

In general, bipolar disorder poses particularly complex treatment issues.

"Every person is unique, and their experience of the illness and response to the medicine is unique. It's a complicated condition, and one size doesn't fit all," Dr. Duckworth says. "A sensible treatment plan includes access to medicines, therapy and support groups."

Elaine Zablocki has been reporting on healthcare for more than 20 years.