Treatment of bipolar disorder
Bipolar disorder is one of the psychiatric illnesses that has the most resources for its treatment.
Drugs. Medication is available that help to slow down the euphoria phases, as well as to overcome the depression phase. There are also substances that reduce the frequency and intensity of relapses. None of these medicines are drugs that can lead to dependence. The pharmacological treatment, essential to manage the illness, must be taken for life.
Psychiatric support. It enables confronting the difficulties brought about by the illness with fortitude, to learn to recognise the initial symptoms of a possible decompensation and to know oneself better.
Dietary and sleeping habits. It is recommended to avoid subjecting yourself to stressing situations whenever possible, or to learn strategies to reduce their impact, and to practice some type of sport or exercise.
New treatments. New treatments are being investigated for the disorder; for the manic phase, in order to have new drugs with less side-effects, as well as for the depressive phase. For example, the so-called atypical antipsychotics have shown to be very useful for treating manic or depressive phases (depending on the drug), as well as for the prevention of relapses. Furthermore, they have less side-effects than the older medications. Some drugs that have classically been used as anti-epileptics (valproic acid, lamotrigine, carbamazepine, oxycarbamazepine) have shown to have a very good efficacy for the prevention of the manic as well as the depressive relapses of bipolar disorder.
Lithium has a preventive effect over relapses. Although the body has small amounts of lithium, it has to be increased in patients with bipolar disorder, not because they lack this mineral, but to reinforce the regulatory mechanisms of mood states and to prevent situations of euphoria or depression.
Lithium is an extremely simple substance, which is called an element. However, its use must always be controlled by the doctor, given that it is toxic at high doses. For this reason, those being treated with lithium must have periodic blood tests to monitor its concentration in blood.
Lithium is one of the most effective and safe treatments, besides being the only one that has shown to reduce the risk of suicide.
Mechanism of action of Lithium
Lithium exercises its mood stabilising action through chemical mechanisms that partly correct the changes underlying the disorder. When lithium is ingested, it is absorbed into the gastrointestinal tract without needing to pass through the liver (and, thus, does not pose any risk of hepatotoxicity), and passes into the blood and, from there, arrives at the neurons where it produces changes in the production of certain substances that will effectively regulate the mood alterations. Lithium is one of the most effective and safe treatments in bipolar disorder, besides being the only one that has shown to reduce the risk of suicide.
General considerations to take into account with lithium
Take the medication every day.
Do not stop the treatment, except by medical prescription.
Perform the blood tests requested by the doctor at least twice a year, which may include lithium levels, kidney function, and thyroid function.
Do not reduce the amount of salt in meals or make sudden changes in hydration.
Consult the doctor or, if not available, to temporarily reduce the lithium doses in the following cases:
- Intense diarrhoea
- Frequent vomiting
- High fever
- Do not take the following medications or diuretics without first consulting your doctor (medications used for circulation problems, oedema, fluid retention…)
- Analgesics (medications used to treat pain)
- Non-steroidal anti-inflammatory drugs (medications used for different types of inflammation. Occasionally used for different types of inflammation. Occasionally used in treating influenza)
The need to control the thyroid hormones
The thyroids are glands that are situated in the neck that perform various functions. Among them is to produce a hormone (thyroid hormone) that is involved in the regulation of metabolism of the body. Bipolar disorder in itself is associated with a higher frequency of thyroid changes, but lithium can also lead to changes in the function of this organ. For this reason, it is worthwhile regularly performing a blood analysis in order to determine that the thyroids are functioning correctly.
In patients that take lithium, this blood analysis must be performed at least once a year. The most common change consists of a sub-clinical hypothyroidism, that is to say, a reduction in the capacity of the thyroids to produce thyroid hormone, without showing symptoms or physical discomfort. Sub-clinical hypothyroidism is easy to treat with oral supplements of thyroid hormone, and the lithium does not necessarily have to be withdrawn.
Lithium and its potential interactions with other drugs
The patient on pharmacological treatment with lithium must be especially careful with diuretics (which are given for some cardiac problems, arterial hypertension and, occasionally, in order to lose weight), analgesics, and anti-inflammatory drugs (including aspirin), as well as other drugs. Health staff must always be informed that lithium is being taken before prescribing any treatment and, especially before being subjected to any surgical intervention. Lithium is a safe drug if the indications for its use are followed correctly.
Anti-epileptics (or mood stabilisers). This drug group is essentially used during the maintenance phase in order to prevent relapses and, in some circumstances, in acute manic (valproic acid) and depressive (lamotrigine) phases.
The choice of one or other depends on the tendency to relapse into one or other episode, the experience with other drugs, and the adverse effects profile. They are generally well-tolerated drugs, but their levels need to be routinely measured in blood to ensure that they are in the therapeutic range. The risk of intoxication is a lot lower than with lithium. Some of the precautions that have to be taken with some of them are, skin reactions, which although exceptional, require seeing a doctor immediately.
Typical and atypical antipsychotics. They are a family of drugs that have shown to be useful in another illness, schizophrenia, and in the manic phase of bipolar disorder (although some are also useful for depression and the prevention of relapses). Some patients seem to benefit from a maintenance treatment with one of these drugs, generally combined with mood stabilisers (such as lithium or some anti-epileptics).
In general, the atypical antipsychotics (such as clozapine, risperidone, olanzapine, quetiapine, amisulpride, ziprasidone, paliperidone, asenapine, or aripiprazole) are much less prone than the classic antipsychotics (haloperidol) of presenting with neurological-type side effects such as, for example, Parkinsonism, but they are also not exempt from undesirable effects like sedation or increase in weight. Some antipsychotics, such as quetiapine, have also shown to have antidepressant and mood stabiliser effects.
Antidepressants. As it name suggests, this drug group exercises its effect on neurotransmitters that improve mood, increasing its availability in the brain (serotonin, noradrenaline, dopamine, etc.).
The antidepressants are classified according to the neurotransmitter that they affect:
- Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine, paroxetine, sertraline, and others, have an effect on serotonin.
- Serotonin and noradrenaline reuptake inhibitors (SNRIs), such as venlafaxine, duloxetine, or desvenlafaxine, exercise their effect on serotonin as well as noradrenaline.
However, outside the depressive phases, in the case of bipolar disorder, the neurotransmitters can be detrimental as they can tip the balance and equilibrium of the brain towards a manic episode.
As bipolar disorder requires a natural genetic-based predisposition, in principal the antidepressants do not cause mania in everybody that takes them. However, the treatment of a depressive phase in a bipolar patient with antidepressants, can, to some extent, increase the risk of changing to a mania, particularly if the patient does not follow treatment with a stabiliser or an antipsychotic.
For that reason, in general, it is not advised to prescribe antidepressant for mild or reactive depressive phases—in those that follow, for example, bad news or a personal problem— but much better to reserve them for moderate or severe depressions, in which the advantages of the treatment outweigh the possible disadvantages or risks.
Psychotherapy, provided that it is given by a specialist, tries to teach the patient with bipolar disorder to live better with their illness, by accepting it better, to correctly regulate their schedules, to detect the symptoms of each phase before it is too late in order to prevent relapses, and to treat specific episodes—particularly all depressive phases.
There are currently several studies that demonstrate the efficacy of cognitive-behavioural therapy and psycho-education of the patient and the family in the approach to bipolar disorders, but there is no evidence that any of the other approaches are effective. On the other hand, it should be underlined that psychotherapy must always complement the medication and never replace it.
Electroconvulsive therapy (ECT), called electric shock, has stopped being an indiscriminate and ethically questionable tool, to becoming, as certain studies have demonstrated, a safe and effective technique that, as practiced today with anaesthesia and pulsed current, helps to treat severe cases or those that do not respond effectively to conventional treatment.
It is the treatment of choice in pregnant patients with bipolar disorder. ECT acts as an anti-epileptic, that triggers a convulsion (that is only visible in the electro-encephalogram (EEG) at the time it is applied), and leads to a refractory period in which some changes are produced.
Phototherapy is a treatment that uses light. Thus said, it seems very natural, ecological, or even magical. The reality is that many studies have rigorously and scientifically demonstrated that intense light causes significant emotional changes and can have a therapeutic effect on people that suffer from the so-called “seasonal affective disorder”.
This consists of apathetic depressions with the arrival of winter and moderate hyperactivity/euphoria phases in the summer season. Some patients with bipolar disorder have this specific form of the illness and may benefit from treatment with special lamps with very intense white light that should be used daily, preferably in the morning, during the season with less light (that is to say, winter). This treatment must be monitored by a psychiatrist.
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