Bipolar Disorder

Conventional Treatment of Bipolar Disorder

Medications, transcranial magnetic stimulation and psychotherapy are beneficial.

Posted Jun 07, 2018

Conventional treatment of bipolar disorder

This post is offered as a concise overview of conventional psychiatric approaches to the treatment of bipolar disorder. Future posts will review the evidence for complementary and alternative therapies for this disorder.

Medications and transcranial magnetic stimulation (TMS)

The American Psychiatric Association endorses the use of different conventional pharmacological agents, including mood stabilizers (e.g. lithium carbonate and valproate), antidepressants, antipsychotics and sedative-hypnotics), to treat bipolar disorder. Antipsychotics are used to treat agitation and psychosis, which occur frequently in acute mania. Sedative hypnotics are prescribed for the severe insomnia that frequently accompanies mania as well as for daytime management of agitation and anxiety. Although antidepressants are not regarded as a first-line treatment of bipolar disorder and may risk 'mania induction,' a significant percentage of bipolar patients must rely on antidepressants to control depressive mood swings.

Repetitive transcranial magnetic stimulation (rTMS) is an emerging treatment of both the acute manic phase and the depressive phase of bipolar disorder and does not risk mania induction; however, findings of controlled trials to date are highly inconsistent. Mania associated with psychosis is approached differently to a mixed episode that includes both manic and depressive symptoms. Antipsychotics are appropriate first-line treatments of the auditory hallucinations that occur during an acute manic episode, while mixed episodes are often managed using a combination of two mood stabilizers or a mood stabiliser and antipsychotic.

Psychotherapy and psychosocial interventions

Psychotherapy and psychosocial interventions in stable bipolar patients may potentially reduce relapse risk by providing psychological support, enhancing medication adherence, and helping patients address warning signs of recurring depressive or manic episodes before more serious symptoms emerge. A review of randomized studies on psychotherapy and psychosocial interventions in combination with medications in bipolar patients concluded that adjunctive psychotherapy reduces symptom severity and improves functioning. Family therapy and interpersonal therapy were most effective in preventing relapse when started following an acute manic or depressive episode. Cognitive behavioral therapy and group psychoeducation were effective strategies for relapse prevention when initiated during stable periods. Psychotherapies and psychosocial interventions emphasizing medication adherence and early recognition of mood symptoms were more effective in preventing recurrences of mania, and cognitive and interpersonal approaches had greater success in preventing depressive relapses.

A specialized psychological intervention called ‘enhanced relapse prevention’ is aimed at recognizing and managing the early warning signs of depressive or manic episodes by improving patients’ understanding of bipolar disorder, enhancing therapist–patient relationships, and optimizing ongoing treatment. A study using qualitative interviews found that both therapists and their bipolar patients believe that enhanced relapse prevention increases awareness of early warning signs of recurring illness, leading to effective changes in medication management and fewer relapses.