Bipolar disorder may be a difficult diagnosis to live with, and finding successful personalized treatments is challenging. Oftentimes, treatment targets shift, patients are non-adherent to medication regimens, and comorbidity rates are extremely high.[1] Unfortunately, bipolar disorder is also associated with high rates of suicide, usually with more lethal means than other mental disorders.[2] Contributing factors to such an association have been reported to be onset of disease at an early age, large number of depressive episodes, comorbid substance use disorders, and hostile and impulsive traits.1 According to Stephen Sobel, Clinical Instructor at the University of California, San Diego, it is usually easier to diagnose bipolar I disorder than it is to diagnose bipolar II, as bipolar I includes episodes of full-blown mania.1 Therefore, Sobel states that psychiatrists should recognize the primary mood state of mania may be irritability rather than euphoria and that symptoms may last fewer than four days, contrary to the DSM-IV diagnostic guidelines.[3]
Bipolar disorder is recognized as a biopsychosocial disorder, with mood-stabilizing medicines creating the backbone of all treatment plans.1 According to Sobel, there are three categories of mood-stabilizing medicines: lithium, antiepileptic agents, and second-generation antipsychotics.1 Oftentimes, a combination of medications is needed to successfully treat manic symptoms.1 For example, either lithium or an antiepileptic paired with an atypical antipsychotic. However, bipolar depression is more difficult to treat than bipolar mania, as it often proves treatment resistance.1 The FDA has approved the medicines Seroquel, Seroquel XR, and Symbyax for the treatment of bipolar depression.1 Patients with bipolar disorder require lifelong treatment, frequently with two or more medications, one to prevent the mania and the other to prevent the depression.1
According to Sobel, the best medicine combination is the one the patient will take regularly, for even effective medicines are not effective if they are not taken regularly.1 Therefore, a strong and trusting patient-physician relationship is needed for a successful decision-making process.1 As maintenance treatment is often necessary for patients, choosing medicines that are tolerable in the long-run are more likely to work out.1 Medicines may need to be adjusted or changed over time, as the illness changes and so does a patient’s lifestyle.1 Sobel states that the following are also factors needed to be taken into consideration when choosing a medicine for bipolar treatment: history of treatment response, family history of treatment response, adverse effects of a drug, drug interactions, pregnancy, and breast-feeding.1
Psychotherapy is the second important aspect of treatment for bipolar disorder.1 Effective psychotherapies include cognitive-behavioral therapy and social rhythm therapy.[4] Psychotherapy focuses on education, comorbidities, medication adherence, and interpersonal relationships.1 Therapy also challenges automatic, distorted and dysfunctional thoughts, helping the patient to change their thinking and to maintain certain social rhythms.1 Involvement of family members is also important.1
Overall, Sobel states that each appointment with a patient with bipolar disorder should focus on changes in their occupational, family, social, and medical health status.1 Therefore, medicine regimens can be evaluated and treatment can be made as effective as possible.1
[1] Sobel, S.V. (2012, August 2). Effective Personalized Strategies for Treating Bipolar Disorder. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/2094000.
[2] Raja M, Azzoni A. Suicide attempts: differences between unipolar and bipolar patients and among groups with different lethality risk. J Affect Disord. 2004;82:437-442.
[3] Akiskal HS, Benazzi F. Optimizing the detection of bipolar II disorder in outpatient private practice: toward a systematization of clinical diagnostic wisdom. J Clin Psychiatry. 2005;66:914-921.
[4] Frank E, Soreca I, Swartz HA, et al. The role of interpersonal and social rhythm therapy in improving occupational functioning in patients with bipolar 1 disorder. Am J Psychiatry. 2008;165:1559-1565.
