Depression

There is no cure for bipolar disorder, but it responds well to treatment. It is a recurrent, lifelong illness. People suffering from bipolar disorder need long-term psychiatric care to monitor medication, enhance treatment compliance and prevent future episodes. A combination of medication and psychotherapy is optimal.

Treatment aims are to:

• Effectively treat whatever the current (acute) episode is (mania, hypomania or depression).
• Effectively reduce the risk and severity of further episodes with maintenance treatment and support.

Vigilance is the key to preventing relapse. If early symptoms are reported to the doctor when first noticed, adjustments can be made to the treatment plan in order to prevent a “full-blown” episode.

In the maintenance phase, support is needed to continue the use of medication to prevent future episodes. This is often difficult as people feel so much better during these periods.

Medication - Manic episode

In the first instance a good assessment is essential. Medical conditions or drug intoxication need to be excluded before the diagnosis of a manic episode can be made. Commonly an acute episode of mania will require a period of hospitalisation.

Mood stabilizers are the mainstay of the medical treatment. Various drugs have mood stabilizing action. These include Lithium, some drugs used to treat epilepsy (anticonvulsants) and certain antipsychotics. Lithium remains the gold standard for an acute manic episode. As an alternative, the first line option from the anticonvulsant group is Valproate (Epilim), and from the antipsychotic group, Olanzepine (Zyprexa). In episodes where psychotic symptoms are present, antipsychotics are invariably prescribed until symptoms have subsided. Combinations of 2 or more mood stabilisers are commonly used

Benzodiazepines (tranquillisers) may be prescribed to manage agitation, psychosis or dangerous behaviour, while waiting for a mood stabiliser to take effect.

Depression

The depressive phase of bipolar disorder in general does not respond well to anti-depressants when used as a single agent. Moreover, when used without a mood stabilizing drug, antidepressants can trigger a manic or mixed episode. Therefore the first line treatment for a depressive episode remains a mood stabiliser. Anticonvulsants such as Lamotrigine (lamicitn) or antipsychotics such as Quetiapine (seroquel) are used in this context. When antidepressants are used, they are prescribed in conjunction with a mood stabiliser.

Electroconvulsive therapy (ECT)

ECT is a safe and effective treatment for both mania and depression. This is generally reserved for people in hospital and, as such, for more severe episodes.

Maintenance therapy

Acute episodes represent only brief periods in the life of most people with bipolar disorder. To lengthen the time between episodes and minimise the effects of further episodes, the continued use of mood stabilising medication (maintenance therapy) is essential. This may be difficult, as maintenance therapy is needed in periods when people feel well. In this phase, people with bipolar disorder need ongoing psychotherapy to assist with understanding the risks of the illness and minimise early discontinuation.

Patients on lithium need regular blood tests to make sure that there is enough lithium in the body for it to work, but not too much which can be harmful and lead to serious side-effects. This monitoring is done in routine follow-up with a psychiatrist.

Psychosocial support

As bipolar disorder disrupts a person’s life and relationships, psychotherapy can help people regain control and re-establish relationships with others. Support should extend to the family and support structures to help all involved to come to terms with the illness. This also aims to help to motivate people for better treatment compliance.

Support groups

Support groups offer a valuable opportunity to people to meet other people with bipolar disorder and to learn more about the disorder and how to live with it. The Western Cape Bipolar Association can be contacted for a list of support groups in the country. Visit their website at www.bipolar.co.za.

Reviewed by Dr Stefanie van Vuuren, Psychiatrist, MB ChB (Stell), M Med (Psig) (Stell), FC (Psych)SA, (November, 2010)

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