In Behavioral Health, Medication Assisted Treatment (MAT), Practice Guidelines, Psychotherapy, Serious Mental Illness (SMI), Trainings, Treatment

Bipolar Disorder: Making the Shift To a Patient-Centered Approach

What is Bipolar Disorder?

Bipolar disorder (formerly called manic-depressive illness or manic depression) is a mental disorder that is characterized by unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks. The three types of Bipolar disorder are:

  • Bipolar I Disorder defined by manic episodes that last at least 7 days, or by manic symptoms that are so severe that the person needs immediate hospital care. Usually, depressive episodes occur as well, typically lasting at least 2 weeks. Episodes of depression with mixed features (having depressive symptoms and manic symptoms at the same time) are also possible.
  • Bipolar II Disorder— defined by a pattern of depressive episodes and hypomanic episodes, but not the full-blown manic episodes that are typical of Bipolar I Disorder.
  • Cyclothymic Disorder (also called Cyclothymia)— defined by periods of hypomanic symptoms as well as periods of depressive symptoms lasting for at least 2 years (1 year in children and adolescents). However, the symptoms do not meet the diagnostic requirements for a hypomanic episode and a depressive episode (NIMH, 2020).

The following chart from the National Institute of Mental Health (NIMH) describes some of the signs and symptoms experienced by people diagnosed with Bipolar Disorder:

People having a manic episode may: People having a depressive episode may:
Feel very “up,” “high,” elated, or irritable or touchy Feel very sad, “down,” empty, worried, or hopeless
Feel “jumpy” or “wired” Feel slowed down or restless
Have a decreased need for sleep Have trouble falling asleep, wake up too early, or sleep too much
Have a loss of appetite Experience increased appetite and weight gain
Talk very fast about a lot of different things Talk very slowly, feel like they have nothing to say, forget a lot
Feel like their thoughts are racing Have trouble concentrating or making decisions
Think they can do a lot of things at once Feel unable to do even simple things
Do risky things that show poor judgment, such as eat and drink excessively, spend or give away a lot of money, or have reckless sex Have little interest in almost all activities, a decreased or absent sex drive, or an inability to experience pleasure (“anhedonia”)
Feel like they are unusually important, talented, or powerful Feel hopeless or worthless, think about death or suicide

Although no single cause for Bipolar Disorder has been identified, some contributing factors may put people at risk. Those factors include:

  • Brain Structure and Functioning: Some studies indicate that the brains of people with bipolar disorder may differ from the brains of people who do not have bipolar disorder or any other mental disorder.
  • Genetics: Some research suggests that people with certain genes are more likely to develop bipolar disorder. Research also shows that people who have a parent or sibling with bipolar disorder have an increased chance of having the disorder themselves (NIMH, 2020).

Why This Is Important

When properly diagnosed, people with bipolar disorder can lead healthy and active lives. Healthcare providers can play a significant role in accurate diagnosis by conducting a brief screening and referring to a qualified mental health provider. Healthcare providers are likely to see patients who are depressed and an accurate diagnosis is important to avoid misdiagnosis and treatment for major depression since the initial presentation is more often motivated by symptoms of depression rather than mania or hypomania (NIMH, 2020).

What Treatment Is Available?

Treatment can include psychotherapy, medications, or both. One commonly held belief is that medication can stabilize the mood of a person diagnosed with Bipolar Disorder and that is all that is really necessary to manage the disorder. Research shows that medications are not a “silver bullet” for a variety of reasons. According to the NIMH:

  • Medications have side effects and both risks and benefits
  • Medications can interact with other medications
  • Medications must be monitored, and dosage or type of medication may need to be adjusted
  • Medications must be taken consistently and should not be stopped without consulting a healthcare provider

One recent study involved 200 adults who were diagnosed with Bipolar I Disorder and received oral antipsychotic medications and who completed a survey about side effects, impact on social functioning, adherence to medication, impact on work, and trade-offs when balancing symptom management and side effects. The study found that 98% of participants experience medication side effects. Some of the most commonly reported include drowsiness or tiredness (83%), lack of emotion (79%), anxiety (79%), dry mouth (76%), and weight gain (76%). 49% of participants said that side effects had a negative impact on job performance and 92% said medication negatively impacted social relationships. Side effects were the most common reason for discontinuing medication for Bipolar Disorder (48%). Of the participants studied, 78% took a single medication, 16% took two medications, and 6% took three or more. While satisfaction with convenience was rated relatively high, overall satisfaction was lower, particularly with those who experienced unpleasant side effects. Nearly two-thirds of participants (66%) reported stopping medications. Of those who stopped taking medication, 51% did so with the agreement of their mental health care provider and 44% did so without agreement of their mental health care provider (Bessonova et al., 2020). Another study of participants diagnosed with Bipolar Disorder I or II found that of 273 participants from a variety of countries, 210 (77%) were adherent and 63 (23%) were less adherent. The adherent trajectory was associated with more motivation, identified by higher rates of daily mood charting, and the less adherent trajectory was associated with more time not euthymic (mood stable). The association of side effects on adherence was not examined (Bauer et al, 2019).

In an invited article about using a patient-centered approach in the treatment of bipolar disorder, one researcher maintains that medication nonadherence in patients diagnosed with Bipolar Disorder may be influenced by a variety of factors, such as the relationship with their healthcare providers, the healthcare system, and people they encounter during the course of their day. They also make decisions about treatment according to personal beliefs, the circumstances of their lives, and how they weigh the benefits of treatment against the disadvantages. Further complicating the decision-making process are their beliefs about medications, family, stigma, and access to treatment (Chakrabarti, 2016). The author argues that the move from an illness centered approach to a patient centered approach is more appropriate and will lead to a better understanding of the best treatment plan for each patient. He also states that “it seems to be the only way forward for both research and clinical practice.”(Chakrabarti, 2016).  As Bipolar Disorder has been shown by numerous studies to have an association between poor adherence and increased risk of relapse, recurrence, and hospital admission, understanding the factors that contribute to medication nonadherence is important (Velligan et al, 2009; Berk et al. 2010; Chakrabarti, S., 2019; Semahegn et al, 2020).

Next Steps

Becoming more familiar with current approaches in the treatment of Bipolar Disorder is the obvious next step for behavioral health providers. The new modalities for treatment are beyond the scope of this blog post and may be a future topic. In the meantime, there are some innovative approaches and tools coming into use and on the horizon. One such approach is the use of a serious game called BIPOLIFE®. The game involves an avatar that teaches those with Bipolar disorder how to regulate mood and energy in everyday life, and a recent study has shown improved attitudes towards medications during the first month of use (Maurin et al, 2019). The authors admit some study limitations, such as small sample size and medication adherence was measured through self-report. The study was funded by Astra Zeneca, a pharmaceutical company. Additional research is needed to fill out a solid knowledge base. A more conventional professional development opportunity might be just the thing while we wait, and CASAT Training has a webinar coming up:

September 15, 2020 Time: 9:00 am – 12:00 PM PST Location: Online

Presenter: Catherine Ann Ness, MA, LCPC, Owner/Clinical Director/Psychotherapist, Affective Counseling

Description: “For too long “take your medication” has been the preferred treatment for clients struggling with Bipolar Disorder. This approach is not sufficient. Clients with Bipolar Disorder continue to rank highest in suicide rates and overall premature deaths.  This statistic is partly to blame by the paucity of information available to practitioners on how to manage clients struggling with Bipolar Disorder. If you are frustrated by the recurrence of mood swings, hospitalizations, lack of treatment compliance or feeling stuck in treating your clients with Bipolar Disorder, this presentation is for you.

There is finally an integrative approach that combines the most promising researched based theories into a cohesive treatment guideline that allows therapy to be catered to an individual’s specific strengths and needs.  Proceeding from a wholistic approach, this treatment goes beyond mood management by evaluating and managing changes in social skills, cognitive functioning, and overall health. Although these considerations are frequently overlooked, they are nonetheless integral to allowing clients to manage their symptoms, increase their level of functioning, and improve their outlook on life.

You will be provided with tangible interventions that are both preventative and sensitive to your client’s current mood state.  In addition, you will be provided with information about differential diagnosis, prognostic indicators, and how to manage co-occurring disorders. This seminar will allow you to go beyond “supportive therapy” and help you assist your clients in regaining control of their mood and life direction.”

Learning Objectives for this training include:

  • Differentiate Bipolar Disorder from similar or comorbid disorders (ADHD, Substance Disorder, Personality Disorders and Schizoaffective Disorder)
  • Learn effective and tangible interventions to prevent mood swings
  • Establish a protocol for clients experiencing extreme mood states
  • Identify prognostic indicators and how this impacts course of treatment
  • Create effective individualized treatment plans based on client’s strengths and personal needs
  • Develop specific strategies to manage Bipolar Disorder and co-occurring Substance Disorders or co-occurring Borderline Personality Disorder

Register for this and other training opportunities at CASAT Training.

Do you have related resources or strategies that you use? Share them in the comments below.

References

Bauer, M., Glenn, T., Alda, M., Bauer, R., Grof, P., Marsh, W., . . . Whybrow, P. C. (2019). Trajectories of adherence to mood stabilizers in patients with bipolar disorder. International Journal of Bipolar Disorders, 7(1), 1-9. doi:10.1186/s40345-019-0154-z

Berk, L., Hallam, K. T., Colom, F., Vieta, E., Hasty, M., Macneil, C., & Berk, M. (2010). Enhancing medication adherence in patients with bipolar disorder. Human Psychopharmacology: Clinical and Experimental, 25(1), 1-16. doi:10.1002/hup.1081

Bessonova, L., Velligan, D. I., Weiden, P. J., O’Sullivan, A. K., Yarlas, A., Bayliss, M., . . . Sajatovic, M. (2020). Antipsychotic treatment experiences of people with bipolar I disorder: Patient perspectives from an online survey. BMC Psychiatry, 20(1), 1-12. doi:10.1186/s12888-020-02767-x

Chakrabarti, S. (2016). Treatment-adherence in bipolar disorder: A patient-centred approach. World Journal of Psychiatry, 6(4), 399. doi:10.5498/wjp.v6.i4.399

Chakrabarti, S. (2019). Treatment attitudes and adherence among patients with bipolar disorder: A systematic review of quantitative and qualitative studies. Harvard Review of Psychiatry, 27(5), 290.

NIMH » Bipolar Disorder. Nimh.nih.gov. (2020). Retrieved 5 August 2020, from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml.

Maurin, K. D., Girod, C., Consolini, J. L., Belzeaux, R., Etain, B., Cochet, B., . . . Olié, D. E. (2020). Use of a serious game to strengthen medication adherence in euthymic patients with bipolar disorder following a psychoeducational programme: A randomized controlled trial. Journal of Affective Disorders, 262, 182-188. doi:10.1016/j.jad.2019.10.008

Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020). Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: A systematic review and meta-analysis. Systematic Reviews, 9(1), 17-18. doi:10.1186/s13643-020-1274-3

Velligan, D. I., Weiden, P. J., Sajatovic, M., Scott, J., Carpenter, D., Ross, R., . . . Expert Consensus Panel on Adherence Problems in Serious and Persistent Mental Illness. (2009). The expert consensus guideline series: Adherence problems in patients with serious and persistent mental illness. The Journal of Clinical Psychiatry, 70 Suppl 4(suppl 4

Blog Post Tags:

Related Blog Posts

Domestic Violence Awareness Month: Responding to the Needs of Those in Treatment and Recovery

What’s in Your Self-care Toolbox?

National Recovery Month: Supporting Sustained, Long-term Recovery – Updated for 2020!

Good News: According to New Research AA Works!

Related Learning Labs

Marijuana

Healthy Aging

Fetal Alcohol Spectrum Disorders (FASD)

Enhancing Outcomes for Reluctant Clients w/ Challenging Issues

Related Resources

Comments
  • Linda W Peterson
    Reply

    Thank you, this is very well written and compelling for enrollment in the course.
    I have a back ground in brain research for the condition of hypoglycemia, with documented EEG data.
    I do believe that this physiological condition, often missed by physicians and mental health workers, can be mislabeled as Bipolar 2 or 3.
    I like the idea of an integrative approach to Bipolar which is one of the most difficult mental health conditions to treat. I would particularly be interested in client involvement in their treatment plan and how to prevent inevitable mood changes.

Leave a Comment

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Contact Us

We're not around right now. But you can send us an email and we'll get back to you, asap.

Not readable? Change text. captcha txt

Start typing and press Enter to search