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Bipolar Disorder

Best Practices for Identifying and Treating Bipolar Disorder

How to avoid common pitfalls when diagnosing and treating bipolar disorder.

Most estimates suggest that about 2% of adults have bipolar disorder, but depending on the epidemiological data used, some studies put the figure as high as 10%.

There has also been a surge of children diagnosed with bipolar in recent years. The trend has led to earlier and more effective treatment in many cases, but it has also raised concerns about overdiagnosis.

The right diagnostic criteria are key to correctly diagnosing bipolar. Only with a correct diagnosis can you then proceed to recommend treatment. So clinicians must take as much time as necessary to diagnose the disorder, and then follow these best practices for the treatment of bipolar.

Ensure Depression Isn’t Really Bipolar

Between 10 and 40% of patients with bipolar disorder are initially diagnosed with major depressive disorder. Clinicians must critically evaluate all patients with symptoms of a mood disorder, and should not assume that symptoms of depression necessarily mean that depression is the correct diagnosis. Likewise, it’s important to ensure that cyclical depression is not incorrectly diagnosed as bipolar disorder.

Consider Other Diagnoses

In a busy clinical practice, it’s easy to apply rules of thumb to the diagnostic process, leaning heavily on common diagnoses and rough sketches of symptoms. Bipolar can radically alter a person’s life, and a diagnosis can be both reassuring and alarming. The same is true of many other mental health conditions. Clinicians must be mindful that not all symptoms that mimic bipolar are due to bipolar, and that a bipolar diagnosis does not necessarily rule out other diagnoses.

Empirically validated diagnostic criteria are critical to getting an accurate diagnosis. Clinicians must gather a comprehensive symptom history, and consult other sources if possible—especially when a child is involved. Substance use disorders, attention deficit/hyperactivity disorder (ADHD), traumatic brain injuries, personality disorders, and numerous other conditions may mimic bipolar.

Choose the Right Pharmacological Therapy

People with bipolar disorder typically need pharmacological therapy, but choosing the right drug or drug combination often requires some trial and error. Some general principles include:

  • Start with mainline treatments.
  • Start with a low dose, and gradually increase depending on tolerance and response.
  • Don’t add multiple drugs at once.
  • Discuss treatment options with the patient, and actively encourage them to provide feedback.

Monitor for Side Effects and Efficacy

Bipolar relapse rates are high, and the reason for this remains poorly understood. Research indicates that after a year, more than a third of people with well-controlled bipolar will relapse. At two years, relapse rates are above 60%.

Drugs may stop working over time as the body builds tolerance. In some cases, however, patients stop taking their medication either because symptoms have disappeared or because they find side effects intolerable. It’s important to take patient concerns seriously, rather than minimizing the role of side effects or urging patients to simply put up with them. Clinicians must continually re-evaluate patients, even when symptoms have been well-controlled for an extended period of time.

Discuss Psychosocial Aspects of Bipolar

Most patients can cite a specific psychosocial trigger for their first episode of bipolar. A breakup, family trauma, substance use, stress, and other challenges often figure prominently. So while bipolar is a biochemical disorder, it also has deep psychosocial roots. Clinicians should discuss the role of environment, lifestyle, and social life in bipolar, and encourage patients to identify common triggers for mood swings. Patients who are experiencing heightened levels of stress may need more frequent appointments and additional support to manage bipolar symptoms.

Recommend Therapy and Lifestyle Changes

Therapy is critical for the effective treatment of bipolar, for several reasons:

  • Therapy offers psychoeducation that can improve medication compliance.
  • Therapy can help patients better cope with the challenges of bipolar.
  • Therapy may offer useful lifestyle remedies for managing bipolar.
  • Therapy can help friends and family support a loved one with bipolar.
  • Therapy offers immediate support for crises that might trigger a manic or depressive episode.

A healthy lifestyle may also help patients manage the effects of bipolar, including medication side effects such as fatigue and weight gain. Encourage patients to exercise, maintain a regular schedule, participate in social events, pick up a hobby or two, and eat a healthy, balanced diet. When patients are unable to maintain a healthy lifestyle, this may be a sign of worsening bipolar symptoms or socioeconomic barriers to good health.

Actively Involve the Patient in Treatment

The patient is not a passive vessel upon whom to experiment with various treatments. Patients come to treatment with different goals. A successful attorney may have more concerns about side effects that cause brain fog or fatigue, for example, while hyper behavior can disrupt a child’s ability to succeed at school. There is no one size fits all treatment.

Encourage patients to share their treatment goals, to tell you about side effects, and to work with you to find the right treatment. Treatment should be a collaborative undertaking that draws upon the patient’s subjective and objective experiences.

Evaluate Treatment at Regular Intervals

Regularly evaluating treatment efficacy is a key component of successful bipolar treatment. When patients are stabilizing, plan frequent appointments until symptoms improve. Appointments can grow more infrequent with time, but you must continue to re-evaluate treatment, even after years of stability.

References

Ghouse, A. A., Sanches, M., Zunta-Soares, G., Swann, A. C., & Soares, J. C. (2013). Overdiagnosis of bipolar disorder: A critical analysis of the literature. The Scientific World Journal, 2013, 1-5. doi:10.1155/2013/297087

Guzmán, F. (2018, May 11). Bipolar disorder treatment guidelines: A 2018 update. Retrieved from https://psychopharmacologyinstitute.com/guidelines/bipolar-disorder-gui…

Ward, I. (2017, February 15). Best practices for treatment of bipolar disorder. Retrieved from http://www.psychiatryadvisor.com/home/topics/mood-disorders/bipolar-dis…

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