Thursday, November 21, 2019

History, Diagnosis, and Outcomes

The diagnostic precursor to bipolar illness was manic-depressive illness, which was understood to be an episodic disorder, characterized by alternating bouts of depression and mania. This was understood to be a rare disorder, such that were only about 12,750 people in the U.S. hospitalized with this diagnosis in 1955.

The “bipolar” diagnosis first appeared in the third edition of the American Psychiatric Association’s Diagnostic and Statistical Manual. It is defined by the presence of depressive episodes which alternate with manic or hypomanic episodes.

The bipolar diagnosis is split into two types. The main difference is that bipolar I requires manic experiences. Bipolar II requires hypomania instead, and is considered less severe.  A diagnosis of bipolar II may be made even though a person has not required hospitalization (which had been the case for a diagnosis of manic-depressive disorder).

There are many apparent pathways to bipolar. Use of antidepressants to treat a depressive episode increases the risk that a person will experience a manic or hypomanic episode and thus convert to a bipolar diagnosis. Similarly, the use of marijuana and other psychoactive drugs increases the risk that a person will end up diagnosed with bipolar disorder.

According to the medical model promoted by the American Psychiatric Association, bipolar is a chronic brain illness, although there is no accepted  theory of how it develops in the brain, or what the underlying pathology may be.

Bipolar disorder is usually treated with a variety of drugs, including lithium, antiepileptic drugs such as valproate, antidepressants, and neuroleptic tranquilizers (sometimes called “antipsychotics”). Outcomes with this mode of treatment are understood to be poor, with researchers acknowledging that the course of bipolar disorder has worsened in the pharmacological era. The disorder now runs a much more chronic course than it did before the arrival of lithium and the practice of treating patients with two or more drugs at once.


Psychosocial Treatments of Bipolar Disorder

A good overview of the various forms of non-drug treatments for bipolar disorder can be found in the 2018 Canadian guidelines. Unfortunately, most studies on psychosocial treatments only test the interventions as add-ons, so it is unclear how well they would perform without the concurrent use of medication.

I. Psychotherapy

A. Psychoeducation

Usually delivered in a group session, psychoeducation means providing people with information for defining and improving their own mental health. In bipolar disorder treatment, it involves training people to notice their mood shifts, manage stress, cope with mood shifting, and engage in good physical and mental hygiene such as exercise, healthy eating, healthy sleep scheduling, and avoidance of drugs (including caffeine) which might bring on manic episodes. Psychoeducational interventions may also involve meetings with a therapist, readings, online components, and homework assignments.

Psychoeducation appears to be helpful in preventing relapse if it is given when a person is currently healthy and stable. However, it does not appear to help when the person is actually in the midst of a depressive or manic episode.

B. Cognitive-Behavioral Therapy

CBT focuses on identifying and challenging/changing “distorted” or “maladaptive” thoughts (cognitions) about the self and the world. CBT includes homework, in which the client identifies when these thoughts arise, and challenges them in real-time using logic and alternative explanations.

Researchers have found CBT to be effective for both depression and psychosis, but there is still controversy about its use in bipolar disorder. However, it appears to be effective for relapse prevention as well as effective in treating depressive episodes.

A study that added recovery-focused CBT to medication treatment (which incorporates more of the service user’s goals for treatment than standard CBT) found that it helped prevent relapse of both depressive and manic episodes, and enabled a quicker time to recovery, than medication treatment alone.

C. Family-Focused Therapy

Family therapy, in this context, is designed to improve relationships amongst family members, primarily through improved communication and boundary-setting. It is theorized that this intervention can reduce relapse by reducing family stressors and increasing social support. Like CBT, it appears to be effective at preventing relapse, as well as reducing depression. However, it may not be effective at preventing manic episodes or helping reduce manic symptoms.

D. Interpersonal and Social‐Rhythm Therapy (IPSRT)

This intervention is based on the theory that cycles of socialization and sleep are factors causing depressive and manic episodes. The therapy is designed to improve social relationships as well as sleep hygiene and daily scheduling. Unfortunately, multiple studies have found limited or no effect on improving bipolar disorder.

E. Peer Support

Peer support groups are led by people who have the bipolar diagnosis and have experience navigating the mental health system. The intervention is theorized to increase social connectedness and reduce stigma. At least one study has found that peer support groups are just as good as psychoeducation groups at preventing relapse. It’s unlikely that these groups alone are a substantial treatment for specific episodes of depression or mania.


II. Wellness Interventions

 A. Exercise

 Exercise is helpful for improving physical health, and has been researched for improving depression. It may be helpful for reducing the intensity of depressive episodes in bipolar disorder. Unfortunately, very little research has been conducted on exercise interventions for this purpose specifically. One note of concern is that vigorous exercise has also been associated with increased manic episodes.

 B. Yoga

Yoga has also barely been researched as an intervention for bipolar disorder. A study in which people were interviewed about it suggested that it has benefits and risks: it may bring on mania/agitation, or increase depression/lethargy. It appears to be more likely to help relax/calm a person, however.

C. Mindfulness

A review of 13 studies of mindfulness-based cognitive therapy (added to medication) for bipolar disorder found that the intervention improved anxiety, depression, residual mania, and improved cognition and emotion regulation. The results were maintained at 1-year follow-up with some booster sessions.


III. Neutraceuticals

Multiple small studies have investigated various different nutrient/vitamin/herbal remedies for depression and mania, which have been occasionally tested for use in bipolar disorder. Further research needs to be done to clarify these effects. Many of these substances also have the potential to interact negatively with other medications, and can have side effects. A review of the studies can be found here.

A. For reducing mania: a chelated mineral formula, L‐tryptophan, magnesium, folic acid, and branched‐chain amino acids. All of these interventions showed a good effect in small studies, but very little research has been done.

B. For reducing depression: NAC (N-acetyl cysteine), a chelated mineral and vitamin formula, and omega-3 (fish oil) all showed a good effect in small studies.

C. Inositol did not appear to have an effect.

Research compiled by Peter Simons