Treatment and Medication
The treatment of bipolar disorder is difficult because of the complexity and variability of the disease and its effects on cognition, reason and behavior. The guidelines issued by the American Psychiatric Association for treatment of bipolar disorder recommend a holistic approach, i.e. a combination of pharmacotherapy and psychotherapy in order to relieve acute episodes quickly and efficiently, avoiding the recurrence of episodes, improve interpersonal social function and vocational training, and reduce the incidence suicides.
Pharmacotherapy
The drugs that are commonly used to treat bipolar disorder are summarized in the following table:
Drugs for bipolar disorder
Acute mania / mixed episode
Lithium
Atypical antipsychotics (e.g., olanzapine, risperidone)
Typical antipsychotics (e.g., haloperidol)
Carbamazepine, valporato
Acute bipolar depression
Lithium
Carbamazepine
Antidepressants (combined with mood stabilizers)
Lamotrigine (in addition to mood stabilizers)
Maintenance Therapy
Lithium
Carbamazepine
Antidepressants
Agents in clinical investigation
Atypical antipsychotics (e.g., clozapine, quetiapine, ziprasidone, aripiprazole)
AEDs (e.g., gabapentin, topiramate, zonisamide)
Lithium
Lithium is a well established treatment for bipolar disorder, and is effective for both manic and depressive for. Recent reviews from England and the U.S., including Expert consensus guidelines for 1998, reported that lithium is the first-line therapy for patients with bipolar disorder, and has a response rate of approximately 79%.
Patients who are on lithium therapy they should monitor thyroid function and serum lithium concentration, the lithium dosage should be adjusted to achieve a serum concentration of 0.5-1.2 mEq / l. It usually takes 6 to 8 weeks to get the patient showing therapeutic response to lithium. It is still unclear whether the premature interruption of lithium therapy worsens the course of the disease, and there is evidence that lithium may not be sufficient for the treatment of mixed states and severe mania. Patients who have relatively few lifetime episodes of mood disorders, with symptoms of depression during mania, and without rapid cycling, the best response to treatment is with lithium.
Anticonvulsants
The spectrum of treatment for bipolar disorder was expanded after the introduction of anticonvulsants, which include carbamazepine, and lamotrigine valporato. Patients with rapid cycling or mixed episodes are more likely to benefit from treatment with anticonvulsants than patients with other types of bipolar disorder.
Compared with lithium and placebo, carbamazepine is effective for long-term treatment of bipolar disorder, but their use is approved worldwide for this indication. The results of several studies suggest that carbamazepine has antimanic and antidepressant properties, as monotherapy and in combination with lithium or antidepressants. In a masked study, 53% of depressed patients had a rapid response when added lithium to carbamazepine. Lithium therapy is even greater than carbamazepine, and combination therapy is better than monotherapy, particularly in patients with rapid cycling. This may be due in part to the ability of carbamazepine to induce their metabolism by microsomal enzyme system cytochrome P450.
The valporato is the mood stabilizer prescribed more frequently in the U.S., which is approved for the treatment of acute mania, but only after treatment with lithium and carbamazepine have failed or have not been well tolerated. While not currently used in Europe, its incidence of use is increasing. Valporato effectiveness of the treatment of bipolar disorders is still matter of controversy. A 1994 study confirmed its efficacy in the treatment of mania, but more recent work, conducted in 2000 showed that treatment with valporato no different from placebo in prolonging the period until the recurrence of any episode mood disorders for over 12 months. While larger studies are needed to corroborate or refute these clinical data, currently considered the valporato is more effective for treating mania than depression, but also may have some mild to moderate antidepressant properties.
Lamotrigine is one of the last and new anticonvulsants in bipolar disorder. Has been studied extensively and believes that its effects include inhibition of excitatory amino acids and sodium channel voltage-dependent, blocking serotonin receptor 3. Several studies showed that lamotrigine is effective in treating the depressive phase of bipolar disorder and rapid cycling bipolar disorder. Adverse effects of lamotrigine are similar to those of other anticonvulsants, but with a rate slightly greater headache.
Lamotrigine is not practical to treat the depressive phase of bipolar disorder, which is partly due to the need to increase the dose gradually. It was reported that lamotrigine valporato increases efficiency in bipolar disorder, however, with this dosage there is a risk of rash. To reduce this risk, we recommend the slow adjustment of the dose. On the contrary, when administered concomitantly lamotrigine with carbamazepine, we recommend increasing the dose more quickly. Lamotrigine is emerging as an agent with a high probability for the treatment of bipolar disorder, but more research is needed to clarify its position within the spectrum of treatments.
Antidepressants
Standard antidepressants are effective for the treatment of bipolar I disorder combined with a mood stabilizer. The most frequently recommended antidepressants are selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors (MAOIs) and bupropion.
Psychotherapy
Patients with bipolar disorder show a relatively high rate of therapeutic failure rate, estimated at 32-45% of patients treated. The low compliance, combined with high rates of marital conflict, divorce and unemployment associated with bipolar disorder restricts the effectiveness of pharmacotherapy alone. The aim of combining psychotherapy and pharmacotherapy is primarily to increase compliance. In addition, psychotherapy can reduce the amount and duration of hospitalizations and relapses improve social function and quality of life and reduce the risk of patient suicide. There are several psychotherapeutic approaches, appropriate to different stages of the disease, among which we mention psycho education, cognitive behavioral therapy (CBT), family intervention, group therapy and case-specific therapy such as therapy for cases of abuse.
Cognitive-behavioral therapy (CBT)
The aim of CBT is to change the negative thoughts of patient suffering from bipolar disorder. This type of therapy focuses not only on the patient’s behavior but their cognitive world, what he thinks, how he perceives the environment and how to interpret what happens. CBT attempts to change the negative thoughts by teaching the patient to understand how their thinking patterns influence their symptoms, and to modify their thinking and behavior to decrease the likelihood of symptoms. It also provides information on functional difficulties in social related disease, and how to self-manage the development, evolution and severity of the disorder to achieve appropriate therapeutic interventions. He is taught to remove the obstacles to compliance and will provide non-clinical behavioral strategies to deal with the consequences of mania and depression, the best way possible. Are taught strategies to deal with specific symptoms, for example, the patient who has impaired attention span is instructed to reduce noise and overstimulation and concentrate on one thing at a time, and suffering is extreme mania teach relaxation techniques.
Psycho education
Long time ago, doctors recognized the need for better education about bipolar disorder. Providing the patient and family about bipolar disorder, psychotherapy aims to encourage compliance with treatment and dispel the stigma, to persuade against drug abuse and to teach patients to identify symptoms of relapse. The main objective of psycho education is side effects of treatment, disease progression and obstacles on the road to recovery.
The results of research on the efficiency of psycho education are promising. Most interventions result psycho instructive more compliance and fewer hospitalizations and relapses. One study showed a 50% improvement in the performance of lithium treatment and a 60% reduction in the number of hospitalizations.
Family Therapy
In general, the normal marital and family interaction is problematic for patients with bipolar disorder. As a result of strained relations, the patient may suffer more relapses and poorer functional experiences. The goal of family therapy is to educate the patient and family about bipolar disorder aiming at greater compliance, better acceptance of illness by the patient, better functional interaction in social and labor and control of stressors. It enables the family and through the communication aspect of family therapy attempts to reconstruct the functional family after an episode of mood disorder. Family therapy sessions are also trying to address post-traumatic symptoms that can affect the patient and family after an acute attack or period of hospitalization.
Family therapy is divided into three clearly defined stages: stage of evaluation, emphasis on optimizing the communication aspect, and emphasis on problem-solving. Often the family is taught the “exercise of relapse”, which allows you to identify the box of relapse and prepare for the next episode.
Group Therapy
Group therapy is applied to cases of bipolar disorder 10-15 years ago because only bipolar patients were considered unsuitable for this kind of therapy. However, recent studies have shown that group therapy teaches the patient about the treatment compliance, the number of relapses can be reduced by 15% dispelling the stigma of bipolar disorder. In patients who continue combination therapy, group therapy and medication, the evolution of the disease may be less severe than in those receiving only medication, limited in terms of family interaction, marital failure and need for hospitalization again. While it may be difficult to compare the data because of different therapies applied, usually, these data support the application of group therapy for patients with bipolar disorder
Electroconvulsive therapy (ECT)
The TEC is firmly adopted for the treatment of bipolar disorder, supported by a good deal of evidence of its efficacy in the treatment of manic and depressive phases of the disease. It Recently proposed as maintenance therapy for this disease. In a comparative analysis of research studies on the effectiveness of ECT and antidepressants in the treatment of bipolar disorder, they concluded that ECT was more effective in 5 of 7 studies, and more beneficial than tricyclic antidepressants.
ECT should be considered not only a treatment of last resort but also for depressive or manic phase of bipolar disorder any stage, if the patient is satisfied with the progress of treatment. ECT should be considered first-line therapy for critically ill patient, especially delusional or at high risk of suicide. Not recommended lithium treatment during a course of ECT: In some cases it was reported that this combination is neurotoxic. ECT still remains far from his true place in the algorithms of treatment due to current public interest.
New options
Among other therapeutic options that could be beneficial for the treatment of bipolar disorder can include inhibition of neuronal systems of signal transduction by omega-3 fatty acids. A small trial showed a remission significantly longer in patients taking omega-3 fatty acids compared with those taking olive oil. We also investigated the vagus nerve stimulation and tamoxifen as a potential therapeutic interventions and, although preliminary investigations are promising, further clinical data.