Cognitive-Behavioural Therapy

When someone is diagnosed with Bipolar, there are two types of treatments available. These treatments are called: pharmacological and psychotherapeutic. They usually will work so long as the person is following doctor’s orders.
Pharmacological Therapy –
This type of therapy refers to medicinal use. They are used to control outbursts and mood swings that are caused by mania and depression. Some medicines can also help in controlling severe anxiety attacks. Treatment in this area are divided into five separate categories.
1. – Anti-anxiety medicine and sedatives
Sedatives are several different types. They usually provide relief to the individual with bipolar. It’s used to give the patient the right amount of sleep he needs to get a night’s rest. It can also be used to relieve trepidation and it helps in controlling manic episodes.
Hypnotics, tranquilizers, anxiolytics and benzoduazepines are several well known medications given to patients.
2. – Antidepressants
These are widely prescribed to people who have bipolar disorder. There are several different types of antidepressants including:
A. Atypical antidepressants is one example that is not chemically related to other antidepressant medication. Medicines fitting in this category are: Wellbutrin, Desyrel and Rameron.
B. Monoamine Oxidase Inhibitors or rather known as MAOIs help to disease the symptoms. These category includes: Manerix, Marplan, Nardil and Parnate.
C. Selective Norepinephrine Reuptake Inhibitors or SSRis include Celexa, Paxil, Lexapro, Prozac, Luvox and Zoloft. These help concentrate on a neurotransmitter in the brain.
D. Selective Serotonin – Norepinephrine Reuptake Inhibitors help patient’s who suffer from many of the symptoms that come with bipolar disorder. These do include: Cymbalta and Effexor.
E. Tricyclics antidepressants include: Anafranil, Elavil, Asendin, Norpramin, Aventyl and Adapin.
3.- Antipsychotics
This treatment is commonly referred to as neuroleptic drugs. These can be deemed as major tranquilizers because its mainly used to put patients under sedation. There are three antipsychotic drugs that include atypical, typical and dopamine partial agonists. Drugs that fall into this category are: Symbyax and Tetrabenazine.
4. Mood Stabilizer – These are given to “minister” a person’s mood. THe FDA approved Lithium carbonate and it is the only in the mood stabilizer class. While there are more mood stabilizers in the market, none have been approved by the Food and Drug Administration. There are possibly consequences for using drugs not approved yet by the FDA so it is imperative that people talk with their doctor about their treatment options.
5. Calcium Channel Blockers – These are used in patients to help drop their blood pressure so long as their disease is manageable. It is able to lower heart rate by slowing down the diffusions of electric activity. Three such drugs fall into this category – Dihydropyridine, Phenylalkylamine and Benzonthiazepine.
Psychiatrists should prescribe medications and review treatment of a patient.
The second type of therapy for bipolar disorder is psychotherapy or rather “talk therapy”. This therapy allows the patient to open up and talk about causes that could cause depression. This is also the time to talk about factors to which trigger occurrences of bipolar. If patient is aware of what causes depression events, then they can take steps to avoid certain situations or come up with reasonable solutions to evade the problem.
In psychotherapy… there are two kinds: Interpersonal therapy in which the goal is to help change behavior to have a positive effect with other people and cognitive-behavioral therapy which aims to appraise beliefs and feelings that can alter responses to different scenarios.
The most important thing to remember is patience. Bipolar is treatable though patients often undergo long-term medicinal therapy.

Being bipolar and living with the illness means that you should have a bipolar disorder treatment plan in place. This usually begins to be formed from the time that a diagnosis of bipolar disorder is made. Often the bipolar disorder treatment is split into two types – one for treating manic episodes and one for treating depressive episodes. It is essential that this happens so that the person with bipolar disorder is getting the correct bipolar disorder treatment.During a manic episode the bipolar disorder treatment will start with the elimination of any substances that might could the sufferer harm – many will turn to stimulant drugs so they should be removed as they can further alter the mood. Next an assessment should be made to determine whether the best form of bipolar disorder treatment is to hospitalise the sufferer. In particularly extreme manic episodes this can happen to prevent the sufferer from coming to any harm.Then mood stabilising drugs need to be administered as the next phase in the bipolar disorder treatment. Lithium tends to be used at this stage as it is can be a highly effective mood stabiliser. If after a week or so the bipolar sufferer will then be given antipsychotic drugs which should help to stabilise the moods. After this stage of bipolar disorder treatment additional drugs may be prescribed along with any therapy that might be needed. By this point the bipolar sufferer should be quite stable and able to continue with their daily life as usual.During a depressive episode the bipolar disorder treatment is quite similar with lamotrigine or lithium being given to the sufferer initially. If they fail to respond to these many doctors have the opinion that they will have to cope with the depressive episode for as long as it lasts. Strangely antidepressants are not normally included in bipolar disorder treatment plan for depressive episodes as they don’t tend to work very well.Once the bipolar disorder treatment is underway the next step could be to begin cognitive behavioural therapy (CBT) so that the sufferer can start to recognise what triggers their bipolar disorder and learn ways to avoid these triggers. Therapy of this form can be hugely successful if the sufferer is willing to try this type of bipolar disorder treatment. By being able to manage their different moods a bipolar sufferer is helping to reduce the number and severity of depressive and manic episodes. Alternative bipolar disorder treatments are also quite popular with yoga and meditation being two of the most widely used by sufferers around the world. Although there is no known cure for bipolar disorder there are a number of ways that bipolar disorder treatment can help sufferers and there is constant research into finding more ways. It may seem as though there is nothing that can be done for someone who is bipolar but as you can see there are several options that sufferers can try to find which is the best bipolar disorder treatment for them.

It is never easy living with an illness, especially one that can be hard to manage at the best of time and bipolar disorder is such an illness. Bipolar disorder affects the mood of a sufferer to such an extent that living a ‘normal’ life can become virtually impossible. Some of the characteristics of bipolar disorder are that a person with it will have episodes of incredibly intense ‘highs’ or elevated happiness and at times these episodes can result in mania and extreme behaviours. At the opposite end of the scale a person with bipolar disorder will also suffer from extreme ‘lows’ where they are swallowed by feelings of depression, guilt, anxiety and may even have suicidal thoughts.When a person’s mood swings between these two opposites it can make living with bipolar disorder very hard to cope with. In many cases the sufferer feels as though they are the only person who has to live with bipolar disorder and this can be a trigger in itself. It is at these times when it is useful for someone with bipolar disorder to have someone to discuss their feelings with.Often there are also, in between these episodes of feeling high and low the person with bipolar disorder can feel very normal and often it is these times that can cause the most problems. It is at these times when a bipolar disorder sufferer can start to think that they can manage their condition without the need for medication – and some will stop taking what has been prescribed to them. This is very dangerous as this can be the trigger for an episode and without mood stabilising medication the high or low experienced can be incredibly intense and difficult to deal with effectively and safely. Another very useful treatment which is used in addition to medication is psychosocial therapy sessions. These can take the form of cognitive behavioural therapy sessions where the therapist and the patient try to identify ‘triggers’ to a bipolar episode and work on ways to overcome and avoid them. Or they can be family behavioural therapy sessions in which the person with bipolar disorder and the people they live attend and try to work out coping strategies for everyone. This type of treatment can be massively successful when there are other people involved as often they are able to identify when a bipolar disorder sufferer is about to have an episode and can then act accordingly. One thing is for certain, living with bipolar disorder is not easy – but it is more achievable than you might think. As long as a person’s bipolar disorder is kept under control with the correct medication, and any emotional triggers are identified and avoided there is no reason why life cannot continue as normal. Problems occur however when the medication is not taken and the person with bipolar disorder has an additional problem with alcohol or stimulants, both of which can play a large part in the illness and should be avoided.

  

1. Depressive Illness (Unipolar Depression)

 Introduction:

 Very common, rank 4th as a cause of disability worldwide, projected to rank 2nd by 2020. Although effective treatments are available, depression often goes undiagnosed and untreated, often regarded by both patients and physicians as understandable.

Mild depression has a significant morbidity and mortality. Suicide is the leading cause of death in person 20-35 yrs; high percentage (up to 50%) is depression.

Depression disorder also contributes to higher morbidity and mortality when associated with other physical disorders (e.g. MI) and its successful diagnosis and treatment has been shown to improve both medical and surgical outcomes.

There remains an innate reluctance to consider pharmacological interventions for emotional problems, despite overwhelming evidence of efficacy. Also widespread concern that drugs which improve mood must be addictive, despite evidence to the contrary.

Non compliance remains the major reason for treatment failure and often underestimated (up to 40% of treatment failure due to non-compliance).

Diagnosis:

Slight difference between the ICD-10 and the DSM-IV, however the core symptoms are almost identical:

 Somatic symptoms, also called ‘biological’, ‘melancholic’ or ‘vital’

Psychotic Symptoms:

Severity:

Mild, moderate or severe

Subtypes:

? Melancholic or with somatic symptoms

? With psychotic symptoms

? Under ‘other depressive episodes’:

Indirect presentation

Epidemiology:

Prevalence 2-5%

Lifetime rate 10-20%

Sex Ratio M:F 1:2

It is increasing.

Aetiology:

(Bio-Psycho-Social approach / 3Ps Predisposing, Precipitating and Perpetuating)

 1. Biological and genetic factors:

Lack of Monoamines (Serotonin, Noradrenalin, and possibly Dopamine)

Antidepressant work by increasing the above. SSRI (serotonin reuptake inhibitors e.g. Prozac, Cipralex. TCA (old antidepressant which has severe side effects including cardiac) prevent reuptake of both serotonin and noradrenalin. Other new medications such as Effexor work on all three (low dose ?serotonin, moderate dose? noradrenalin then high dose? dopamine).

Above is oversimplification and other transmitters such as GABA and peptide (e.g vasopressin) are involved. There is also link with abnormalities in regulation of many hormones (stress hormones) such as Cortisol and the Hypothalamic-pituitary-adrenal (HPA) axis. New generation antidepressants (in the making) are to target all of the above.

Twin and family studies have shown that there is a genetic basis to many cases of depression; hence a family history is a significant risk for depression

2. Psychological and social factors:

There is strong evidence that psychological factors (e.g. maternal deprivation or other childhood loss) may predispose to depression. Type of personality is also a risk (obsessive compulsive Personality).Life events such as marital separation, job loss and other stresses also play a role.

Other social risk factors include being at home with young children, unemployment, and lack of close confidants

Differential Diagnosis: 

  

THEREFORE ALWAYS EXCLUDE ORGANICITY AS A PRIMARY CAUSE FOR DEPRESSION.

Course & Prognosis:

Depressive episodes vary from 4-30 wks for mild-moderate cases, to an average of about 6 months for severe cases (25% will last up to 1 yr)

The majority of patients experiencing a depressive episode will have further episodes later in life (risk of recurrence is 30% at 10 yrs, 60% at 20 yrs).Recurrence is greater when there are residual symptoms after remission.

There are good evidence that modern antidepressant treatment impact significantly upon the above, reducing the length of depressive episodes; and if treatment is given long term, the incidence of residual symptoms is less, there are fewer recurrent episodes, and chronicity may be as low as 4%

Mortality suicide 15% (severe) especially requiring hospital admission, overall rate of death is higher than general population with other causes usually due to substance misuse, accidents, cardiovascular disease, respiratory infection and thyroid disorders.

Good prognostic factors: Acute onset, ‘somatic symptoms’. Earlier age of onset

Poor Prognostic Factors: Insidious onset, elderly, residual symptoms, neuroticism, low self confidence, comorbidity (physical or psychiatric. personality disorder), lack of social support

Management & Treatment:  

? History

? MSE (Mental State Examination)

? Physical Examination

? Investigations: Standard test: FBC, ESR, B12/Folate, U&E, LFT, TFT, Glucose, And MSU. Others: EEG, CT/MRI, HIV testing etc (all depends on the history and physical examination. 

?Treatment:

1. Antidepressent: effective in 65-75% of patients. All currently available antidepressant work by increasing the availability of the monoamines (5HT, NA & DA). Many classes are available:

2. Psychotherapy:

CBT (Cognitive-Behavioural Therapy)

IPT (Interpersonal Therapy)

Psychodynamic (Psychoanalysis): lacks evidence based support.

3. Combination of the above may act synergistically

4. Augmentation (Evidence for lithium and mood stabilisers).

5. ECT: May be considered as first-line therapy when there are severe biological features (significant weight loss) or marked aggression, retardation or suicide risk, psychotic features are prominent.. Consent needed, main risk due to anaesthesia, safe, no aboslolue contraindication.

6. Psychosurgery only in exceptional circumstances when all other fails. Employ stereo tactic method using MRI.

7. Others: Light Therapy, rTMS (repetitive transcranial magnetic stimulation, Magneto-Convulsion Therapy (MCT), Vagus Nerve Stimulation(VNS)

2. Bipolar Illness (Manic-depression):

Diagnosis:

Mania (Bipolar I): A distinct period of abnormally and persistently elevated, expansive, or irritable mood, with 3 (or more) symptoms. lasting 1 week or less if admission is required.

Clinical Features:

Psychotic symptoms: 

Hypomania (BPII): 4 days and symptoms less severe and does not interfere with social or occupational function

Epidemiology:

Life time prevalence 3-1.5%

M=F (except Rapid Cycling i.e. more than 4 episodes a year)

Age mean 21yrs, males earlier than females.

Aetiology:

(Bio-Psycho-Social-/ 3Ps Predisposing, Precipitating and Perpetuating)

(Patient must have the genetic predisposability)

Genetic 1st degree relatives are more likely to develop the condition (10-15%). Children of a parent with bipolar disorder have 50% chance of developing a psychiatric disorder (genetic liability appears shared for schizophrenia, schizoaffective, and Bipolarity).

MZ twins 33-90%, DZ twins 25%

Neurotransmitters NA, DA, 5HT and glutamine

HPA axis stress hormones.

Differential Diagnosis:

As in depression exclude organicity (secondary mania)

Medication that may induce mania:

Antidepressant

Other psychotropic medications

Anti Parkinson medications

Cardiovascular medications

Respiratory drugs

Anti infection

Analgesic

Gastrointestinal drugs

Steroids

Others: interferons, cyclosporine, baclofen

Course & Prognosis:

Extremely variable.1st episodes may be hypomanic, manic, mixed or depressive. This may be followed by many years without further episodes, but the length of time between subsequent episodes may begin to narrow. There is often a 5-10 years interval between age of onset and treatment. Depression is much more common to be first, mania can present even at later life (>50).

Mortality and morbidity rates are high, in term of lost work, productivity, effect on marriage (much higher divorce rate). Attempted suicide up to 40% and completed up to 10%

Within the first 2 years of 1st episode, 50% will experience another episode.

Poor prognostic factors: Poor compliance, Unemployment, substance misuse, psychotic features, male, mixed state, rapid cycling.

Good prognostic factors: Mania episode of short duration, later age of onset, good response treatment, and few comorbidity physical problems.

Management & Treatment:

(Bio-psycho-social approach again!!)

Same as depression in term of assessment

  ?First line treatment:

  

Lithium, Antipsychotic, ECT, BDZ (for acute episode).

  ?Second line:

Anticonvulsant: Valproate and Carbamazepine

  ?Psychotherapeutic interventions:

 Most patients will struggle with some of the following issues:

Some selected intervention:

Cognitive Behavioural Therapy (CBT) time limited, with specific aims: educate the patient about bipolar disorder and its treatment, teach cognitive behavioural skills for coping with psychosocial stressors and associated problems, facilitate compliance with treatment and monitor the occurrence of symptoms (relapse signature)

Family Therapy

Support Groups

 

 

References

.1.    Stevens L, Rodin I. Psychiatry: An illustrated colour text, Churchill Livingstone 2001

•2.    Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006

•3.    Guthrie E & Creed F. Seminars in Liaison Psychiatry. Royal college of Psychiatrist 2007

•4.    World Health Organization (WHO). ICD-10 Classification of mental and behavioural disorders. Churchill Livingstone

•5.    American Psychiatric Association (APA). DSM-IV-TR. Fourth Edition Text Revision. APA Publication

•6.    King D. Seminars in clinical psychopharmacology. Second Edition 2004. Royal College of Psychiatrists