Treatment of Bipolar Disorders

Disclaimer: This article is for educational purposes only. It does not constitute psychological or medical advice and should not be construed to do so.

In a previous article, I described some features of Bipolar disorder. This will expand that somewhat and discuss treatments. First, a few more comments about the nature of mania. Although mania is defined by the activity level and the feelings of euphoria or uncontrollable energy, these are not always the most prominent manifestations or even always present. Instead of euphoria, the individual may be feeling extreme irritability. Instead of great amounts of energy, the individual might merely feel agitated. Personal grandiosity is often, but not always a symptom. However, there is one symptom that is virtually universal to all fully manic states. That is an attention deficit, an inability to concentrate. The hypomanic state is often marked with what feels like a super efficient state of enhanced effectiveness (and sometimes actually is), when the full blown manic condition is present, effective concentration is impossible. Interestingly, attention problems are concomitants of many psychiatric conditions, in fact most. Severely depressed people have trouble concentrating as do highly anxious people. That fact makes it difficult to distinguish a primary attention deficit disorder (ADD) from a secondary symptom of some other disorder (or drug use, for that matter) and leads to over diagnosing of ADD.

The manic individual, though, has an increased activity level, an inability to focus, almost always a high speech pressure in which the words cannot keep up with the often scattered thoughts, and, frequently, a delusional optimism and grandiosity. More often that not, this leads to real trouble. Judgment is shot to hell and buying sprees are common. Out of character, indiscriminate sexual behavior is often a feature, and simply highly risky or bizarre behavior will be undertaken. In my personal experience, I have found manic patients at airports on several occasions. They were taking flights to Washington to advise the president (who needs it) or to buy the Smithsonian. One was following a celebrity, who happened to be an acquaintance of mine, so he and two other so called friends (both physicians) escorted her from the airport (in their car trunk) and dropped her off on my doorstep. The interesting fact in this case is that I was the only one upset about this. The three perpetrators were highly amused and the poor manic lady was perfectly happy -- way too happy. Also, although my so called friends had (collectively) more money than Croesus, I got stuck with getting her back to her home town. So mania is dangerous -- to everyone nearby. As pleasant as the hypomanic path en route to becoming fully manic is to some people, it's not worth the price to most of them. In addition, suicide is an extreme risk in bipolar patients with studies showing a 10 to 15% lifetime suicide rate among sufferers.

Treatment

Treatment of bipolar disorder is primarily medical. Psychological treatments are very valuable adjuncts, and sometimes effective enough alone to help the individual, but they are unable to control the symptoms to any significant degree. Psychological treatments are primarily educational and teaching the person to anticipate the symptoms, take precautions against harmful or risky behavior, and keep in mind that whatever phase they are in, it will pass. That last is of extreme importance in helping reduce the risk of suicide. If the person in a deep depression, or a highly disruptive and uncomfortable mania can have hope that it will pass, the despair and suicide risk are lowered. However, counseling and therapy can only do so much so drug treatment is usually warranted.

As mentioned in the previous article, lithium is still the most efficacious drug. However, there are downsides. Lithium was actually first used as a salt substitute (in the 1940s) for cardiac (or other) patients who were advised to reduce sodium intake. Soon, two things were noticed. One was that it had an unexpected beneficial effects on some psychiatric patients, and two was that several people got seriously ill or died. In 1949 lithium was introduced into psychiatric practice but was not used much in the United States because of its toxicity. Somewhere around 1970, long term studies had demonstrated sufficient efficacy and safety to warrant increased use, particularly in what was called manic depressive psychosis. (Although over the next few years, some brave individuals tried it for nearly any psychiatric disorder you can name -- unsuccessfully for the most part.) It proved extremely effective, more in preventing recurrences of episodes than in curing them, but some effect of reducing ongoing symptoms was also found.

Lithium is a very potentially toxic substance. At therapeutic blood levels, lithium is a safe drug, but there is a very big BUT. At as little as two or three times the therapeutic level, it is very toxic AND it is very easy to achieve unsafe levels even with careful treatment because lithium has several important interactions. Most important is that it is competitive with sodium (table salt) and that suddenly reducing the amount of salt in a diet can increase the lithium concentrations to unsafe levels. The diet of bipolar people is hardly stable and this is a real threat. In addition, lithium levels can be significantly increased by nonsteroidal anti-inflamatory drugs, particularly ibuprophen and naprosyn, as well as diuretics. So lithium levels MUST be carefully monitored as overdose is very difficult to manage, usually requiring dialysis. The first symptoms of overdose are gastrointestinal, including pain and vomiting. Then the central nervous system becomes involved and it progresses to severe tremor, convulsions, and possible death. Although it is often stated that it is free of side effects at therapeutic levels, this isn't always true. Some patients exhibit a fine tremor at usual dose levels. It is not usually disruptive to most people but I don't think I would want my dentist or surgeon on it.

How does it work? The easy answer is "unknown." The real answer is that it is a membrane stabilizer, reducing the activity of serotonin and dopamine (although, interestingly, not nor-epinephrine) through a variety of mechanisms, most of which are undoubtedly (in my mind) related to the replacement of sodium and potassium ions on the cell membranes but the exact mechanism by which it asserts its therapeutic effects is unknown.

Because of the potential toxicity, alternatives to lithium have been actively sought and there are alternative treatment paths. Some anti-convulsant drugs, used in epilepsy, have been shown to have significant therapeutic effects in bipolar disorder, particularly valproic acid and carbamazepine. Valproic acid (Depakote) is somewhat more effective, but has the downside of being toxic to the liver in some people. Carbamazepine (Tegretol) has less possible toxicity, but it is also somewhat less efficacious. Other ways of treating the illness involve treating the separate phases differently. For example, neuroleptics (anti-psychotic) drugs usually have a significant effect on reducing mania and antidepressants can be used for the depressive symptoms. Unfortunately, antidepressants can trigger a switch from depression to mania, but they still have their role in treatment. Most neuroleptics have long term side effects that are undesirable, although many of the newer drugs that are used for schizophrenia have little or no long term problems. Some clinicians recommend tranquilizers, such as the benzodiazepines (Valium, Ativan, etc.) to reduce the agitation of the manic episodes. These drugs, interestingly, are also anticonvulsants but probably have no activity on the underlying bipolar disorder. Their effects are palliative. However, as these anxiolytics (anti-anxiety drugs) can increase euphoria and decrease inhibitions, I think they are generally a bad idea.

In summary, effective drug therapies are available for bipolar disorders, and among the choices, most people with the disorders can be treated. It is also a good idea to include education and supportive psychotherapy as an adjunct to the drug treatment, if only to help the patients and their families understand what to expect.