Bipolar Disorder Uncovered

Understanding And Treating Bipolar Disorders

Understanding And Treating Bipolar Disorders

Are You Extremely Happy One Moment and Extremely Sad The Next? Are You On Top Of The World Today And Suddenly Down In The Doldrums Tomorrow? Is Bipolar Disorder Really Making Your Life Miserable? Do You Want To Live Normally Once Again? Finally! Discover Some Highly Effective Tips To Get Rid Of Bipolar Disorder And Stay Happy And Excited Always! Dont Let Bipolar Disorder Ruin Your Life Anymore!

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Married To Mania

This eBook is the key to knowing if you are married to a bipolar spouse, and gives you the keys to what to do about it. Often, being married to a bipolar spouse can be one of the hardest things you go through in your life because emotions in your house can change drastically, and completely without warning. This book gives you the tools to deal with unexpected anger outbursts and guilt that many spouses feel. This book will teach YOU how to deal with feelings of guilt that you may feel towards yourself, even though you have done everything you possibly can to make your marriage work. When you get this eBook, you can order a physical copy of the book and get FREE shipping. Also, you get two bonus eBooks when you order: The Spouse's Guide to Bipolar Disorder Vocabulary, which give you the tools you need to talk to doctors and psychiatrists, and The Bipolar Disorder Rolodex which gives you the latest in bipolar disorder research. It is hard to go through a bipolar marriage without help; now you don't have to.

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Understanding Bipolar Disorder

We believe that the road to health means learning everything you can to help manage your symptoms of bipolar disorder. This book is designed to increase your understanding of bipolar disorder and teach you skills to prolong your periods of wellness. In this chapter, we'll share information about how doctors recognize and diagnose bipolar disorder, the biology of the illness, and other symptoms or disorders you may experience. We'll also dispel a few common myths about bipolar disorder. This chapter will provide key information and establish a common language that will come in handy throughout the rest of the book as we discuss treatment options, illness management, and tools to help provide relief. Bipolar disorder is a biological illness that affects your ability to regulate your mood and leads to feelings of extreme happiness, intense sadness, or heightened irritability. It is considered an illness because, like other medical disorders such as heart disease or diabetes, it occurs...

Description of Bipolar Disorder

Bipolar disorder, also known as manic depression, is a common psychiatric disorder. It is one of several conditions referred to as mood disorders, which are diagnosed based on the occurrence of episodes. Understanding the concept of an episode is important for understanding mood disorders. A mood episode refers to a set of symptoms that occur during the same time period. This simple definition is made more complex because the set of symptoms used to make the diagnosis can include many different combinations of symptoms. For example, mood episodes can be understood much like an episode in a weekly television show. We can think of symptoms like the cast of characters. In this example, mood symptoms are the leading players, but to be recognizable as an episode of a specific show, the presence of other supporting actors is required. Although the entire cast may never be present in the same scene, and some actors may appear in more than one show, we can usually recognize a specific show by...

Bipolar Disorder Not Otherwise Classified

Sive episodes 23, 24 , It is also curious that hypomania mania in association with antidepressant treatment is not even mentioned as a candidate for bipolar disorder not otherwise classified it is simply voted out of existence The intention of these august manuals is apparently to dump them among major depressive disorders.

Types Of Bipolar Disorder

You may have heard treatment providers refer to bipolar disorder with a number bipolar I or II or with the word cyclothymia. This is because there are different types of bipolar disorder. Each is defined by different levels of manic symptoms, and some also include symptoms of depression. We will describe these diagnoses below, but the key differences between the types of bipolar disorder are the severity and duration of symptoms.

The Experience Of Bipolar Disorder Over Time

Bipolar disorder is an episodic, recurrent illness. This means that throughout your life, you might experience symptoms of mania or depression, and then these symptoms will clear and you will experience periods of wellness. Often, this pattern tends to repeat itself. Relapse refers to a new episode after your first episode of mania or depression. Remission or euthymia refers to periods without manic or depressive symptoms. Even if you do everything you can to take care of yourself, you may have relapses. However, they will be less frequent if you take good care of yourself by doing things such as taking your medications, working with your treatment providers, getting enough sleep, and identifying changes in your mood. The goal of treatment is for you to learn how to minimize the chances of having another episode. While there currently is no cure for bipolar disorder, many effective treatments exist (discussed in chapters 3 and 4). Thanks to these treatments, many people who in the...

Toward an Expansion of Bipolar Disorders in DSMV

The work group for mood disorders in DSM-IV and the group developing the ICD-10 classification for mood disorders expanded the concept of bipolar disorders to include bipolar II disorder and rapid cycling into the nomenclature. These two additions were based, at least from the DSM-IV perspective, on sufficient data to warrant their inclusion in the nomenclature. A multi-site data re-analysis was performed to provide validity for the inclusion of rapid cycling 1 . The validity was demonstrated by noting a change in gender frequency as episode frequency increased in bipolar patients. The inclusion of bipolar II disorder was based on a review of the literature involving clinical description, family studies, longitudinal course, biological factors and familial factors differentiating this condition from other forms of bipolar unipolar disorders 2 . Akiskal notes quite correctly that there are still undefined affective conditions lying between the unipolar bipolar distinction. These vary...

In Search for a Definition for Bipolar Disorder

We now lack any objective test that can determine whether an individual has, or does not have, bipolar disorder. Therefore, despite great recent advances in understanding the treatment and phenomenology of bipolar disorder, we are left with the vital and basic questions of a) what is bipolar disorder and b) what is not bipolar disorder. Hagop Akiskal, combining scholarship with an emphasis on clinical pragmatism, addresses these questions. There is no better person for this endeavour, since he has arguably done more than anyone else in the field to change the way in which we think about bipolar disorder. One refreshing and useful feature of Akiskal's review is its emphasis on historical context. It is a common error to overemphasize the cross-sectional view of a patient. The same is true of bipolar disorder as an entity. Bipolar disorder is, we think, an old disease, but it is a relatively new and changing concept. There has been a trend toward viewing bipolar disorder as part of a...

What Causes Bipolar Disorder

Bipolar disorder is likely caused by multiple factors that interact with each other. It often runs in families and there is a genetic component to the disorder. For example, your chances of getting bipolar disorder are higher if your parents or siblings have this disorder. However, even though someone may have inherited the genes for bipolar disorder, there is no guarantee that this person will develop the disorder. A stressful environment or negative life events may interact with an underlying genetic or biological vulnerability to produce the disorder. In other words, some people are born with genes that make it more likely that they will get bipolar disorder. It is not known why some people with these genes develop bipolar disorder and others do not. Often, a stressful event seems to trigger the first episode. Therefore, an individual's coping skills or style for handling stress also may play a role in the development of symptoms. In some cases, drug abuse (e.g., alcohol,...

Broadening the Definition of Bipolar Disorder

Hagop Akiskal has produced an important review, which elucidates well some of the major current issues concerning the diagnosis of bipolar disorder. As with most current debates, Akiskal demonstrates that the issues are hardly new. The tension between sensitivity and specificity between defining the disorder such that it will capture all nuances, while yet maintaining confidence in the validity of the diagnosis is clearly an old one. There remain a variety of disorders which may turn out to be subsyndromal forms of bipolar disorder. On the other hand, they may not. In clinical practice, some of this broadening seems to have already occurred. Here in our corner of the northeastern United States, it seems difficult to find a patient with any sort of chronic psychiatric illness (be it a personality or even a chronic psychotic disorder) who is not already receiving some sort of mood stabilizer. As Akiskal wisely suggests, treatments drive diagnoses, and the availability of a number of new...

Myths About Bipolar Disorder

Now that you've learned the basics about what bipolar disorder is, what it looks like, and what we know about its causes, you have the knowledge to dispel some of the common myths about bipolar disorder and educate others about this illness. Let's take a look at some of these myths. Reality We know that bipolar disorder is a biological illness. It is largely caused by genetics and a chemical imbalance in the parts of the brain that help regulate mood. Bipolar disorder isn't a weakness it's linked to actual biological changes in your body. Myth I'll never be able to reach my goals because I have bipolar disorder. Reality Now that more is known about what causes bipolar disorder and helpful treatments have been developed, people with bipolar disorder often live healthy, fulfilling lives and continue to meet their life goals. Reality Because bipolar disorder is a biological illness, nothing you did caused you to develop symptoms. Although factors like stressful or exciting life events or...

Factors in Coping with Bipolar Disorder

Table 2.3 Protective and Risk Factors in Bipolar Disorder Table 2.3 Protective and Risk Factors in Bipolar Disorder This chapter reviews the medications commonly used to treat bipolar disorder. As an active participant in your treatment, it is important for you to know the purpose as well as the proper dosage, side effects, and schedule for each medication you use. This information makes it easier for you and your doctor to select and adjust medications in a manner that most benefits you. Please discuss your concerns about medication with your physician. Your doctor will be able to help you cope with the side effects or consider alternative treatments.

What Types of Medications are Used to Treat Bipolar Disorder

The following sections describe the four major types of medications used to treat bipolar disorder mood stabilizers, antidepressants, antipsychotics, and antianxiety (anxiolytics). These medications are the main tools for controlling bipolar disorder. Used individually or in combination, these medications provide a way for you to manage your bipolar disorder. Other medication tools also may be used to treat additional symptoms. Drugs often are classified according to the purpose for which they first got approval for use in the United States. Although many drugs are found to have a variety of uses in addition to this first use, the original name sticks. Because of this, doctors often use drugs classified as antidepressants to treat anxiety and drugs called anxiolytics to treat insomnia. For this reason, it is extremely important for you to know the purpose of a medication, not just its name. It helps to try to have a sense of humor with the well-meaning people who may question your...

Analysing Course of Illness in Bipolar Disorder

Bipolar disorder is usually a lifelong illness, marked by multiple recurrences of mood episodes, persisting prodromal or residual subsyndromal symptoms, comorbid psychiatric disorders, and psychosocial impairment. In reviewing these and other aspects of the illness, Marneros and Brieger have organized their work around the length of follow-up for the many studies they have examined, rightfully giving more weight to findings from studies with a longer observation time. However, it is important to note that, although longitudinal follow-up is necessary for studying the course of illness in recurrent diseases such as mood disorders, what the follow-up data reveal is in large measure a function of the statistical models that are used to analyse the data. Different statistical models vary in their capacity to make full use of follow-up data. Typically, for bipolar disorder, the outcome of interest includes recurrence of mania and major depression, and recovery from these mood episodes....

Outcome in Bipolar Disorder How Much Have We Learned

Bipolar disorder has been known for many centuries, However, our understanding of its course and outcome still remains incomplete. As Marneros and Brieger point out, the main problem has been the snapshot approach taken by both clinicians and researchers when approaching the disorder. The cross-sectional approach is no doubt flawed not only in the prediction of outcome, but also in the selection of treatment. Kraepelin emphasized a longitudinal approach more than a century ago. disorder. Although studies describing the outcome of a first-episode cohort are not new, most contemporary bipolar outcome studies have included multiple episode populations, which are prone to have a poor outcome. Two studies in the United States, however, have focused on first-episode cohorts the McLean Harvard First Episode Mania Study 1, 2 and the University of Cincinnati Study 3 . By assessing a first episode population, confounding factors such as chronicity itself may be controlled, providing more...

Poor Clinical Course and Suicide Risk for Bipolar Disorders

Among the many potential outcome difficulties associated with affective disorders, completed suicide has long been a danger and one often linked to both unipolar and bipolar disorders 1 . Marneros and Brieger cite evidence providing empirical support concerning this danger. The issue of what factors predict risk for suicide in bipolar disorders has not been solved completely, since suicide is a complex behavioural event which can be influenced by many variables, with depression-related factors being among the most prominent ones. There are multiple factors each of which can increase, incrementally, the risk for suicide. There are general predictors of suicide risk which apply to other major disorders and to people of all types. Most of these risk factors also apply to bipolar disorders. Cultural trends and styles within a country can increase risk for suicide. Both hopelessness and hostility have been studied as potential risk factors for suicide. A decline in functioning is also a...

The Role of Seasonal Changes in the Course of Bipolar Disorder

Bipolar disorder was, as Marneros and Brieger remind us in their comprehensive and scholarly review, originally described by Hippocrates some two and a half thousand years ago. It is a sobering thought that, despite all the scientific, clinical and therapeutic advances made since that time, we understand so very little about what determines its course and outcome. All we can say with any confidence is that the more episodes a patient has experienced, the more likely he or she is to have another 1 . Our inability to define reliable and clinically useful prognostic indicators is, I believe, largely due to the lack of objective biological markers to confirm or refute a diagnosis of bipolar disorder. All we have to go on are clinical and demographic features. Another confounding influence has been the recent tendency to subdivide the illness into more and more subcategories, each with its own prognosis. For example, according to DSM-IV, bipolar I disorder can take one of six possible...

Psychotherapy for Bipolar Disorder

This book is designed to provide you and members of your support network with basic information about bipolar disorder and its management. Each of the chapters focuses on a different element of functioning that may influence the course of bipolar disorder. These topic areas information about the disorder, medication use and compliance, stress and schedule management, thinking biases, relationships, communication skills, problem solving, and construction of a treatment contract are the same topic areas that typically receive attention in psychotherapy. Psychotherapy provides a chance to get more help with these or other topics that are relevant for individuals with bipolar disorder. When you choose psychotherapy, it is important to find a therapist who is knowledgeable about bipolar disorder and with whom you are comfortable talking. A good therapist can be a crucial addition to your treatment team. When choosing a therapist, you and your family need to be smart shoppers. Talk with the...

Putative Treatments For Bipolar Disorder

Many drugs are proposed conceptually, or presented in print as effective, in some aspect of treatment of bipolar disorder. Rarely is it possible to assess adequately a drug for bipolar disorder in other than a placebo-controlled, randomized, parallel-group study, enrolling patients who have common illness characteristics at the start of the study. The inherently changing symptomatology of bipolar disorder probably contributes to a greater likelihood of positive open reports in bipolar disorder than most other mental disorders, but ones wherein the improvement reflects inherent changes in symptomatology, rather than an effect of drug. The following drugs have case reports that suggest efficacy in some patients, but have not been tested in the above paradigms, or have had largely negative studies conducted that may have methodological constraints that reduced capacity to identify drug efficacy. Topiramate is a fructopyranose that has been reported as beneficial principally as add-on to...

Bipolar Disorder in Adolescents and Children

Although there has been a lot of controversy about this diagnosis in children, there is increasing evidence that bipolar disorder can affect children. It is estimated that i 1.5 of children have bipolar disorder, and among adults with the disorder, one-third to one-half report that their mood episodes began during childhood or adolescence. The initial episode in children and adolescents is often depression, with onset of mood episodes occurring most frequently in later childhood or early adolescence, although anxiety and other emotional disturbances may be present much earlier. Because bipolar disorder is a genetic illness, the risks for bipolar disorder increase if family members have the disorder, particularly if both parents have the disorder (and may exceed a 50 50 chance).

How Does Bipolar Disorder Present in Children

As with adults, children and adolescents with bipolar disorder can experience symptoms of mania, hypomania, and depression. However, there are important differences among adults and children and adolescents in the types of symptoms that are characteristic of mood episodes. For example, youth with bipolar disorder are more likely to have a form of the disorder that is chronic and rapid-cycling, with

How Is Childhood Bipolar Disorder Treated

The first step to treating this disorder is to obtain a thorough evaluation. The evaluation should be made by a child psychiatrist or child psychologist with expertise in assessing and diagnosing mood disorders in children. The evaluation typically includes speaking with the parent(s), as well as interviewing and observing the child. The evaluation will include a review of the child's current symptoms, a review of his or her history and development, questions about family history, previous treatments, and medical history. Additional forms of assessment such as neuropsychological or psychological testing may be helpful in clarifying other areas of difficulty, although these tests cannot diagnose bipolar disorder.

Bipolar Disorder Pharmacological Treatment Where are We

There have been many systematic reviews of the treatment of bipolar disorder (e.g., 1-3 ). In this excellent review, Bowden has gone further by imposing a scale to measure study quality. In this way, the review allows for an objective assessment of the quality of the studies and presumably the clinical inferences that may be drawn from them. Bowden's review, however, has to be read within the context of three broad conceptual issues, which do not detract from the scholarly nature of his review, but may influence the interpretation of the studies he considers and the conclusions that are drawn. First, a rational, commonly accepted approach to the pharmacological treatment of bipolar disorder is based much more on expert opinion and clinical experience than on evidence derived from rigorous clinical trials. Studies of treatment of all phases of bipolar disorder are woefully inadequate in both quality and quantity as compared with the large dossiers of clinical trial data supporting the...

Challenges for the Experimental Therapeutics of Bipolar Disorder

In his thoughtful overview of contemporary pharmacological treatments for bipolar manic-depressive illness, Charles Bowden raises points calling for further emphasis. First, reasonable criteria for mood stabilization'' should include more than the short-term antimanic effects for which several agents are FDA-approved with research support. Even lithium, the standard mood stabilizer, is FDA-approved only for mania and its recurrences 1 . Evidence of long-term protection, even against mania, remains strikingly limited for agents other than lithium and perhaps carbamazepine 1 . For mood stabilization, controlled trials lasting more than one year are required, particularly in view of the natural average spontaneous recurrence rate in untreated bipolar disorder of about one new episode year 2, 3 . A central problem in experimental therapeutics for bipolar disorder is prevention of recurrences of depression. For most proposed alternatives to lithium, evidence for long-term protection...

Expanding Options to Treat Bipolar Disorder Science Informs Practice

Charles Bowden has done an outstanding job in reviewing a rapidly expanding literature on the treatment of bipolar disorder. Not long ago lithium, advanced by Cade over 50 years ago, was the only medication for this condition. Now, there are many purported pharmacotherapies to alleviate mania, depression, and mixed states, as well as for long-term stabilization of mood. The risk today is that proposed treatments have far outstripped the scientific data underpinning their safe and efficacious use. Bowden begins by observing that psychiatrists in practice may expect too much from a drug labelled mood stabilizer. He recommends that the definition of mood stabilizer require benefit from a drug for one primary aspect of bipolar illness in acute and maintenance-phase treatment, while not worsening any aspect of the illness. This definition more modest than an expectation of total long-term mood stabilization may help set the stage for appropriate polypharmacy, later reviewed by the author....

Pharmacological Treatment of Bipolar Disorder The State of the

Bipolar affective disorder has been described for most of recorded history and ranked high amongst psychiatric disorders in the global burden of disease study 1 . However, it is arguably still under-recognized. Classical epidemiological studies indicate a lifetime prevalence rate of approximately 1 for bipolar I disorder. However, a wider bipolar spectrum'' also exists. This includes bipolar II disorder or major depression with a history of hypomanic episodes and less commonly recognized subsyndromes combining hypomania and minor depression or manic symptoms alone. Jules Angst's longitudinal studies in Zurich recorded high lifetime prevalence rates of this bipolar spectrum 2 . Although the dangers of widening the concept of the bipolar spectrum are clear, it is likely that many cases of bipolar disorder are not recognized as such but may well be diagnosed as unipolar depressive disorder. Many psychiatric researchers have argued for a continuum approach to unipolar major depression and...

Specifically for Bipolar Disorder

The pharmacological treatment of bipolar disorder has significantly advanced since the publication in 1990 of the textbook titled Manic-Depressive IUness by Goodwin and Jamison 1 , In this classic textbook, the somatic treatments that were available then for the treatment of bipolar disorder and reviewed included lithium, carbamazepine, neuroleptics, antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) and benzodiazepines. Much of the textbook focused on the many studies that were conducted on lithium, describing it as a major treatment for manic-depressive illness. Little information was available at the time on valproate and other anticonvulsants. No one had envisioned back then the major role that the next generation anticonvulsants and the atypical antipsychotic drugs would have in the treatment of bipolar disorder. However, in spite of that, clearly, the discovery of lithium's efficacy as a mood-stabilizing agent has since revolutionized the treatment of...

Perspectives on the Pharmacological Treatment of Bipolar Disorder

The chapter by Charles Bowden provides a very comprehensive and updated overview of currently available evidence on pharmacological treatments of bipolar disorder. In my commentary, I would like to touch on a few points that I feel are particularly relevant, with emphasis on specific areas of need and priorities for future development. Treatment of refractory mania. For the pharmacological management of treatment-refractory mania, we often have to resort to combination strategies with two mood stabilizers, or combination regimens that would include antipsy-chotic agents, or other agents currently in investigation for the treatment of bipolar disorder 1 . Few controlled studies have directly compared the various alternatives that are commonly utilized in these clinical situations 2 . Among other agents, calcium channel blockers have been examined, but there is very limited evidence in support of their efficacy, although some potentially promising agents in this group have not yet been...

Status and Directions in Drug Treatment of Bipolar Disorder

The review of the pharmacological treatment of bipolar disorder by Bowden is an excellent and sober account of an important topic with increasing clinical relevance. Reviews of this kind are of particular gravity in bipolar A substantial limitation of the field is the absence of a coherent theory of the pathophysiology of this disorder. This is reflected in the array of candidate agents for this disorder with few common pharmacological properties and a wide diversity of mechanisms of action. For instance, with the exception of the serendipitous discovery of lithium, all agents currently in use in the management of bipolar disorder are borrowed from other indications. Greater insight into the pathophysiology of this disorder is therefore essential in order to facilitate rational drug development for the future. A related issue is the assumption that antidepressants trialled in unipolar disorder would necessarily have an equivalent role in the treatment of bipolar depression. Bowden...

Bipolar Disorder A New Field for Rational Polypharmacy

The review provided by Charles Bowden, one of the world's leading experts in the field, is timely and concisely written and summarizes current evidence concerning mood stabilizers as well as antipsychotic medications available for treatment of different states of bipolar disorder. Furthermore, the role of antidepressants in both acute and long-term treatment is critically reviewed. Whereas psychopathologically oriented psychiatrists carefully describe different forms of bipolar disorder, there was a lack of such a description with regard to pharmacotherapy in the past 30 years. One of the main reasons was that only lithium and high-potency or low-potency typical neuroleptics were used for treatment of bipolar disorder. However, with the introduction of new atypical antipsychotics as well as second- and third-generation mood stabilizers, the situation changed and doctors now have different pharma-cotherapeutic options for treatment of pure mania, mixed states and psychotic mania...

Interpersonal Problems in Bipolar Disorder and Their Psychotherapeutic Treatment

All too often clinicians who treat patients with bipolar disorder are provided with expert information regarding psychotropic drugs, but little information on the non-pharmacologic aspects of treatment of this complicated disorder. Mark Bauer provides in lucid and comprehensive fashion a scholarly review of published studies and clinical reports regarding the efficacy and importance of various psychosocial techniques that have been used as part of the treatment of bipolar disorder. These techniques include psychodynamic and psychoanalytically oriented psychotherapy, family and interpersonal interventions, cognitive and behavioural techniques, and psy-choeducation. Each of these has demonstrated efficacy so that clinicians should be aware of their usefulness and importance. I would like to add yet another therapeutic approach that is based on clinical experience treating seriously ill bipolar patients, described in a clinical case report 1 . It has long been apparent to clinicians that...

Childhood ManiaIs it Bipolar Disorder

In their comprehensive review, Shulman et al point out that bipolar disorder frequently begins in youth, and is associated with significant morbidity and mortality. We, therefore, are interested in early identification and treatment to prevent complications. Recently there has been a substantial increase in the frequency of diagnosing children with bipolar disorder, and the use of pharmacotherapies (including mood stabilizers and atypical antipsychotics) to treat children with manic symptoms. While there is some good evidence to support continuity of adolescent mania into adulthood 1,2 , there is a lack of such evidence for preadolescents. A number of authors, including Shulman et a , have discussed this controversy of diagnosis 3, 4 . No doubt there are cases of children with mania who go on to have a typical bipolar disorder in adulthood. But it is also likely there are others who do not. Thus, bipolar children are likely a heterogeneous group. Clearly we have great need for good...

Bipolar Disorder in Children Some Issues of Concern

This extensive and timely review by Shulman and colleagues provides a useful perspective on the effect of gender and age on phenomenology and management of bipolar disorder. We consider here certain issues specific to bipolar disorder in children. Bipolar disorder in the juvenile population is less well studied than in adults. There are several unresolved issues. Most important is the high rate of comorbidity with attention deficit hyperactivity disorder (ADHD). This had led some researchers to suggest that ADHD may be a marker of a very early onset bipolar disorder 1 . However, Indian studies do not report high rates of ADHD 2, 3 . Ascertainment bias and differing clinical characteristics of the samples seem to explain the disparity. While all the previous studies included referred clinical samples, often recruited from clinics well known for treating ADHD children, the Indian patients were largely self-referred and drug-naive. Even a family study 4 , which suggested that ADHD with...

Bipolar Disorder The Need for Treatment Outcome Studies

Shulman et a present a very scholarly and comprehensive review of the empirical literature. It enables the reader to know the current state of the field and, importantly, where there are critical gaps in knowledge. For example, it is painfully clear that treatment outcome studies to evaluate the efficacy of treatments for bipolar disorder (BD) in children, adolescents, and older people are badly needed. Another gap in our knowledge involves the clear delineation of the psychosocial impairments that are associated with bipolar disorder and whether they persist after recovery. It is of considerable clinical importance to know whether bipolar patients who have recovered from the illness are able to return to their premorbid level of psychosocial functioning.

Juvenile Onset Bipolar Disorder Longitudinal Studies Long Overdue

Dr Shulman and colleagues have done a superb and scholarly job in reviewing the relevant literature regarding age and gender effects on the phenomenology and management of bipolar disorder. The most striking aspect of the review is not the details of the literature but the conspicuous paucity of paediatric studies. This is especially alarming given the large and increasing number of children and adolescents who are being treated with mood-stabilizing agents with little data to support or guide the use. Another issue that confounds paediatric bipolar research and treatment is diagnostic uncertainty, particularly the relationship between juvenile-onset bipolar disorder (BD) and attention deficit hyperactivity disorder (ADHD). Whether large numbers of children with BD are being misdiagnosed as ADHD is a raging topic in child psychiatry. The stakes of this debate are compounded by the fact that treatments for BD are generally ineffective for ADHD and treatments for ADHD are generally...

Suicide and Bipolar Disorder in Children and Adolescents

Shulman et al's review presents an interesting theoretical and academic framework for studying the significance of gender and age in the presentation and treatment of bipolar disorder (BD). In this commentary, we would like to examine and elaborate on one particular aspect, that is the issue of suicidality in BD, especially among children and adolescents.

Impact of Development on Diagnosis and Treatment of Bipolar Disorders

Bipolar disorder (BD) is a severe and often chronic condition, which seriously disrupts the lives of children, adolescents and adults by the means of increased rates of suicide attempts and completion, poor academic performance, disturbed interpersonal relationships, increased rates of substance abuse, legal difficulties, and multiple hospitalizations 1, 2 . In spite of its potential to produce significant disability, BD in children has been poorly studied 3, 4 . Antisocial behaviour in bipolar children is a cause of great concern. For example, Pliszka et al found 10 of 50 youths at an urban juvenile detention centre met criteria for mania, another 10 met criteria for major depressive disorder, and one met criteria for bipolar disorder, mixed type. The authors conclude that there is a high rate (42 ) of affective disorders in juvenile offenders 10 .

Childhood Bipolar Disorder

Increasing attention has been paid in the literature to the recognition of bipolar illness that may develop during childhood 46 , although its frequent non-prototypical features or comorbid presentation with other conditions (such as attention deficit hyperactivity disorder) hinder accurate and timely diagnoses. Little information is available on the psychosocial impact of juvenile-onset bipolar disorder with regard to school performance, social development, or longitudinal outcomes. However, data from the National Depressive and Manic-Depressive Association membership survey 18 point to a number of differences in psychosocial outcome following child adolescent onset (before age 20, approximate n 295) and adult onset (after age 20, approximate n 205) bipolar disorder. Notably, child-adolescent onset bipolar disorder was more often associated with school dropout (55 of respondents), financial difficulties (70 of respondents), divorce or marital problems (73 of respondents), alcohol or...

Bipolar Disorder How High the Cost

Goldberg and Ernst's review informs us how little we truly know about the economic and social consequences of bipolar disorder, much due to the many variables confounding analyses and interpretation of many of the key studies. In the last decade we have come to appreciate that bipolar disorder is not quite the pristine episodic condition presented in many textbooks. The archetypal patient is no longer the individual who develops a high as a manic defence to some stress and whose mood cycles up and down for several weeks before long quiescent periods of euthymia and normal functioning. We now recognize that bipolar disorder can emerge in adolescence or early adulthood that it is often preceded by protean forme fruste perturbations in childhood that inter-episode periods of normal mood and functioning are probably not the norm and that both the swings and their consequences expose the individual to a range of adverse outcomes. Estimates of the prevalence and consequences of bipolar...

Reducing the Impact of Bipolar Disorder A Developmental Perspective

The devastating impact of bipolar disorder on individuals, families, and our society had become apparent with recent investigations of the phenomenology, neurobiology, treatment and outcome of adults with this illness. Goldberg and Ernst's comprehensive review of the economic and social effects of bipolar disorder provides a useful perspective of future research directions that are necessary to reduce these functional and financial deficits. There are several issues relevant to the field of child and adolescent psychiatry that are worth emphasizing, since primary and secondary prevention of bipolar disorder will ultimately be the responsibility of this specialty. In a retrospective survey, 59 of adult bipolar members of the National Depressive and Manic-Depressive Association reported the onset of their symptoms during childhood or adolescence 1 . Furthermore, in this study, child and adolescent onset bipolar disorder was associated with increased social morbidity, which was...

Broadening the Perspective on Bipolar Disorder Outcome

Goldberg and Ernst have contributed a thorough and incisive review of the enormous economic and psychosocial burden associated with bipolar disorder diagnoses. Unfortunately this field is beset with even more daunting methodologic challenges than traditional research in areas such as treatment efficacy and clinical outcomes. While it is obvious to clinicians, patients and family members that bipolar illness remains difficult to treat and is associated with enormous economic and social consequences, very little is certain concerning the impact of treatment, in particular the effects of long-term treatment on either the illness itself or its associated consequences 1 . In the United States, the National Institute of Mental Health has recognized these issues as an important priority of the mental health research agenda. Among the new initiatives of the Institute has been the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BP), which is a systematic, multisite...

Treatment of Bipolar Disorder

Even when efficacy figures for long-term treatment of bipolar disorder are improved, the everlasting question of treatment effectiveness remains a challenge 3 . Many factors prevent effectiveness figures from reaching the ideals of treatment efficacy. These factors include uncertain diagnostic sub-grouping of bipolar patients, non-compliance among patients and non-compliance among health professionals, the latter subject being heavily understudied 4 .

What is the True Cost of Bipolar Disorder

Much has been and should be made of the findings of The Global Burden of Disease project which revealed that major psychiatric disorders accounted for five of the 10 most common causes of disability worldwide in 1990 1 . Without improved treatment access, adherence and advances, these disorders were projected to remain causes of profound disability well into this century. Among these illnesses, bipolar disorder was ranked as the sixth leading cause. This clearly is bad news. Goldberg and Ernst have compiled their scholarly and encyclopaedic review of the economic and social burden of bipolar disorder from the available studies conducted in this area to date. Notably, they conclude their review with an important call to arms for new research in desperately understudied areas. Epidemiology. Bipolar disorder is a recurrent severe psychiatric disorder that usually begins in late adolescence and early adulthood. Thus, it is commonly a lifelong malady. Epidemiological studies conducted...

Narrowing and Broadening Diagnostic Criteria for Bipolar Disorder Competing Demands of Research and Clinical Practice

Like most psychiatric, and many medical disorders, the diagnosis of a bipolar disorder remains fixed to clinical evaluation, symptom recognition and syndrome definition. Hagop Akiskal provides a comprehensive review of the evolution of this diagnosis during the previous two millennia, particularly the most recent 100 years. Additionally, he proposes a spectrum of bipolar disorders that incorporates broader coverage into primarily depressive states that have typically been included under the rubric of unipolar depression. In the struggle to identify meaningful psychiatric diagnoses, two often competing demands infringe upon the effort. The first of these is the need to develop useful, pragmatic illness descriptions that permit clinicians to label the wide variety of patients that they face each day in their offices. Broad diagnostic guidelines serve the role of helping clinicians develop an initial treatment plan for the many different patients that they see. These diagnostic...

Atypical Psychosis The Other Boundary of Bipolar Disorder

The concept of bipolarity presented by Hagop Akiskal is a good clue for all psychiatrists to find an alternative and effective treatment strategy in patients who might have received a diagnosis of unipolar depression according to classical diagnostic systems. Since nothing should be added to his thorough and well-organized review, I would like to comment on one topic, the other boundary of bipolar disorder, which may be specific to Japan. is close to bouff e d lirante (French traditional diagnosis), Degenerationspsychose (according to Kleist), or zykloide Psychosen (according to Leonhard). These categories are characterized by acute onset, phasic course, complete remission between psychotic episodes, and confusion, just like that observed in mild delirium. Needless to say, these characteristics resemble those of bipolar disorder. Although it is true that some patients having these features should be diagnosed as psychotic disorder not otherwise specified according to DSM-IV, many...

Chronicity Milder Forms and Cognitive Impairment in Bipolar Disorder

Bipolar disorders are severe illnesses, chronic and lifelong. This could be, in their own words, the summary of the excellent review by Marneros and Brieger on the course and prognosis of manic-depressive illness. However, if we look at the way we treat our patients (or the way they accept to be treated), it does not look like we really assume that. In Europe, many psychiatrists would wait until the second or even the third episode before they prescribe prophylactic treatment. Interruption of prophylactic pharma-cotherapy is more the rule than the exception 1 , and even in the context of sophisticated psychoeducational programmes the rate of non-compliance is close to 40 2 . In this commentary we would like to deal with three important issues a) as Marneros and Brieger emphasize, bipolar disorders are associated with high rates of recurrences and impairment treatment, therefore, has to be early and lifelong b) impairment and suicide risk are not exclusive of the most severe forms of...

Subtypes of Bipolar Disorder

There are four subtypes of bipolar disorder Bipolar I, Bipolar II, Cyclothymia, and Bipolar NOS (not otherwise specified). Bipolar disorders bipolar disorder. BiPolar 1 r (luir S at least one manic Bipolar NOS (not otherwise specified) refers to periods of clearly abnormal mood elevation that fail to meet criteria for any of the other subtypes. For example, a person can have some symptoms of mood elevation followed by an episode of depression. Because the symptoms of hypomania were too brief or too few to meet the full criteria for hypomania, the person would not qualify for Bipolar II but would qualify for a diagnosis of Bipolar NOS. Also a person with 4 or even 10 hypomanias but no depressions would be diagnosed as Bipolar NOS. Bipolar NOS is sometimes referred to as Atypical Bipolar disorder. In summary, what distinguishes bipolar disorders from unipolar disorders is the occurrence of episodes of abnormally high, expansive, or irritable mood (e.g., hypomania or mania). Episodes of...

Classification Diagnosis and Boundaries of Bipolar Disorders A Review Hagop S Akiskal

1.2 Toward an Expansion of Bipolar Disorders in DSM-V 1.3 Narrowing and Broadening Diagnostic Criteria for Bipolar Disorder Competing Demands of Research and Clinical Practice 1.4 Is Phenomenological Dissection for Bipolar Disorders Spectrum Possible 1.5 In Search for a Definition for Bipolar Disorder 1.6 What is Disordered in Bipolar Disorders 1.8 Broadening the Definition of Bipolar Disorder 1.11 The Diagnosis of Bipolar Disorder Some Open Issues 79 1.13 Rate of Detection and Care Utilization by People with Bipolar Disorder. Results from the Netherlands Mental Health Survey and Incidence Study Bipolar Disorder 94 CHAPTER 2 PROGNOSIS OF BIPOLAR DISORDER 97 Prognosis of Bipolar Disorder A Review 97 2.1 Studies of Course and Outcome in Bipolar Disorder What is the Real-World Clinical Significance 149 Bipolar Disorder 152 2.3 The Effect of Affective Episodes in Bipolar Disorder 155 2.4 Bipolar Disorder A Longitudinal Perspective 158 in Bipolar Disorder 161 Carolyn L. Turvey Analysing...

Stress Relapse and Disability in Bipolar Disorder

The extent of disability, family disruption and fatality associated with bipolar disorder truly makes it one of the most financially impacting cyclical nature of bipolar disorder, it is difficult to separate in time those events preceding an affective relapse and those stressors that are symptoms of the illness. This is especially difficult with manic episodes. Through a complex model in which psychosocial stresses may lead to a selective activation sequence of gene transcription, Post hypothesizes that significant life stress which precipitates a first mood episode may directly alter gene expression. This, in turn, affects neurotransmission, allowing future episodes to evolve spontaneously. A study of occupational functioning among 130 bipolar and unipolar patients and their relatives 9 supports Post's view while previous research has demonstrated the detrimental effects of bipolar illness on occupational functioning, the ''relationships between bipolar disorder and social adjustment...

The Diagnosis of Bipolar Disorder Some Open Issues

The thorough and comprehensive review on the diagnosis of bipolar disorders by Hagop Akiskal, one of the leading clinical investigators in the field, leaves no room for new information. Nevertheless it warrants some comments on the main issues he has raised. Since the diagnosis of bipolar disorders is still lacking a solid validation, derived from either an identifiable cause or from objectively measured neurobiological markers, the clinical insightful observation remains the only tool for their recognition and for assessing all those variables that could be utilized for their effective management. One issue that emerges from Akiskal's review is which of the two, the categorical or the dimensional approach, is better fitted for understanding and managing cases with mood disorders and bipolarity in particular. In reviewing diagnostic issues in depressive disorders 1 , we have argued that both approaches have their merits and their limitations. Viewing bipolar disorders as a categorical...

Fdaapproved Medications For Bipolar Disorder

Medications for bipolar disorder work by increasing the function of neurotransmitters, the chemicals in the brain that help regulate mood (discussed in chapter 1). In this section we'll discuss medications approved by the Food and Drug Administration (FDA). The FDA is the U.S. federal agency responsible for ensuring that medications provide benefits and are safe for use by the general public. To be approved by the FDA, a drug must go through several stages of review, including tests comparing the drug to a placebo (a sugar pill) to make sure there's evidence that it works better than not taking medication. you may see advertisements for natural or herbal remedies as substitutions for medications prescribed for bipolar disorder. If you use treatment strategies that haven't been tested, you run a higher risk of having future mood episodes. Using only treatments that have been approved by the FDA will ensure that you're taking medications that researchers have carefully studied and that...

How Does Bipolar Disorder Impact Children

Children with bipolar disorder often experience difficulty at home, at school, and or with peers. Some children with bipolar disorder function well at school but can be very disruptive at home. Because the child's moods and behaviors can be unpredictable, family members may feel stressed and anxious about the child's symptoms. For example, parents will sometimes report that they are walking on eggshells to avoid triggering an emotional explosion. There may also be significant conflict in the family associated with the child's opposi-tionality, aggression, and emotional instability. Children with bipolar disorder also may often exhibit anger and aggression toward their siblings and family pets. Children with bipolar disorder can display a range of functioning at school. Some children do very well academically, socially, and emotionally in the structured setting of school. Some children experience minor difficulties. However, some children experience significant difficulty at school....

Why We Care About the Economic and Social Burden of Bipolar Disorder

Our interest in the economic and social burden of bipolar disorder is not primarily motivated by scientific curiosity. Instead, we hope to use data on the burden of illness to influence public policy and identify priority areas for clinical and quality improvement. Regarding the first of these assumptions, Goldberg and Ernst clearly describe the large economic and social burden associated with bipolar disorder. Costs to the health care system include modest increases in use of general medical services and a large burden of inpatient psychiatric costs and costs due to substance use disorders both of which might be reduced by more appropriate treatment. Social costs include decreased work participation, increased work absenteeism, lost productivity due to suicide, costs associated with crime and the criminal justice system. Major elements of burden that are difficult to express in monetary units include decreased educational attainment, marital instability, and family burden....

The Biology Of Bipolar Disorder

As we stated at the beginning of this chapter, bipolar disorder is a biological illness. Although we know that bipolar disorder results from biological changes, there are currently no medical tests, such as brain scans, blood tests, or genetic tests, that can confirm a bipolar diagnosis or the likelihood of developing the illness. Stressors such as childhood trauma, poor family relationships, and sleep deprivation can bring on or worsen symptoms, but they don't cause bipolar disorder. In this section, we'll discuss the biological changes that are believed to contribute to the development of this illness. Bipolar disorder is an illness related to the chemistry of the brain. Research has shown that among those with bipolar disorder, some neurotransmitters the chemicals that carry information throughout the brain and nervous system don't appear to work properly. Two important neurotransmitters that are disrupted in bipolar disorder are dopamine and serotonin. Dopamine is related to the...

Culture Matters Too in Bipolar Disorder

The biological component of bipolar disorder is unquestionable, as it is the case in most, if not all, mental disorders. Psychosocial aspects are, however, important, although usually neglected, especially in their cultural component. This component is clearly missing in the excellent review of Mark Bauer. It is true that very few studies exist in this field, and this is difficult to understand. As a matter of fact, bipolar disorder is a frequently encountered condition, with a rich behavioural expression. It would be improbable that it does not have an important relationship to culture. This is what we will try to show through two examples.

Specific Psychotherapies for Bipolar Disorder

The past decade has brought welcome research attention to how psychotherapy can help in the management of bipolar disorder. To date, three types of psychotherapy have received prominent attention in research studies family-focused therapy, interpersonal psychotherapy, and cognitive-behavior therapy. We want you to know the brand name of these therapies because they may help you identify therapists who have specialized in the treatment of bipolar disorder and who have adopted a treatment style that has been examined by research. However, it is also important to know that these three types of psychotherapy share many of the same elements of treatment. That is, even though the originators of these treatments come from different theoretical traditions, the elements of treatment they emphasize are very similar. We find this comforting and believe it reflects a shared understanding of what is important for the management of bipolar disorder. Family focused therapy is oriented toward seeing...

School Supports for Children with Bipolar Disorder

Many children and adolescents with bipolar disorder may benefit from additional supports or accommodations at school. Because bipolar disorder is considered a disability under federal law, some children and adolescents with bipolar disorder may qualify for special education services and be eligible for an Individualized Education Plan (IEP). Alternatively, children may be eligible to receive accommodations under a Section 504 plan. Because it can be tricky to navigate the special education system, it is important for parents to educate themselves about their child's eligibility and the services that can be provided. Working closely with school psychologists or guidance counselors, teachers, special education personnel, or school administrators is critical in ensuring that the child receives the appropriate services. In some instances, it may be very helpful to talk with an educational consultant, educational advocate, or educational lawyer who has expertise in special educational...

The Positive Side Of Bipolar Disorder

The media often portrays people with bipolar disorder as being out of control or constantly experiencing symptoms. While this may be true for some individuals, many people with bipolar disorder have full and satisfying lives (Coryell et al. 1998). Even though many people struggle with this illness, about 25 percent of people with bipolar disorder report that their work and social lives are good or better, with as many as 15 percent describing their professional and personal abilities as excellent (Gitlin et al. 1995 Hammen, Gitlin, and Altshuler 2000). Furthermore, when more than three thousand people with bipolar disorder were asked if they would press a button that would eliminate the disorder, about half said no, indicating that this illness has some positive aspects and that people with this diagnosis can live fulfilling lives (Wilson 2006). Indeed, there is evidence that some people with bipolar disorder have exceptional qualities. Among the many notable people believed to have...

What is Disordered in Bipolar Disorders

Mania (euphoric or irritable), the clinical hallmark of bipolar disorder, is usually easy to recognize, whereas the limits of hypomania (the criterion for bipolar type II) with normality and mania proper are much more difficult to ascertain. But what is specific of bipolar disorder is still debated. It is not the symptoms according to Kraepelin 1 , all symptoms can be seen in all mental disorders Pope and Lipinski 2 and Brockington et al 3 found schizophrenic symptoms as frequent in mania as in schizophrenia. It is not the prognosis terrible for Falret 4 , good for Kraepelin 1 , and recently bad for Goldberg and Harrow 5, 6 . Finally, course (which was so important for Falret and Kraepelin) should be dropped completely as a criterion for the classification of endogenous psychoses, according to Angst (quoted in 7 ). The core of the disease is rather the instability and cyclicity of psychic processes, with swerves and switches, larger than normal oscillations of mood (and also)...

And Management of Bipolar Disorder A Review 359

5.1 Heterogeneity of Bipolar Disorder 5.2 Bipolar Disorders in Children and Adolescents Critical Diagnostic Issues for Clinicians 5.3 Emotion, Mood and Bipolar Disorder in Children 408 5.4 Childhood Mania Is it Bipolar Disorder 412 5.5 Bipolar Disorder in Children Some Issues of Concern 414 5.6 Bipolar Disorder The Need for Treatment 5.7 Juvenile Onset Bipolar Disorder Longitudinal 5.8 Development Issues in Bipolar Disorder 5.9 Suicide and Bipolar Disorder in Children and Adolescents 424 Treatment of Bipolar Disorders 428 BIPOLAR DISORDER 441 Bipolar Disorder A Review 441 6.1 What is the True Cost of Bipolar Disorder 468 of Bipolar Disorder 472 Burden of Bipolar Disorder 474 6.6 Bipolar Disorder How High the Cost 482 6.7 Reducing the Impact of Bipolar Disorder 6.8 Stress, Relapse and Disability in Bipolar Disorder 487 James H. Kocsis 6.10 The Current Economic Picture of Bipolar Disorder 6.12 Difficulties in Evaluating the Economics of Bipolar Disorder in Developing Countries 496

Aetiopathogenesis for Bipolar Disorder

Charles Bowden's comprehensive and thoughtful review of the pharmacological treatment of bipolar illness articulates succinctly several fundamental issues and controversies. Not unexpectedly, the issue of What is a mood stabilizer is a central theme. This concept was shaped by lithium and its reported effects for the different phases (acute antimanic, acute antidepressant, and prophylactic against recurrences of mania or depression) of bipolar disorder. However, five decades later, the molecular mechanisms underlying these effects remain incompletely understood, and thus there is no clear knowledge of the biological matrices associated with the processes of mood stabilization. Furthermore, some controlled data and broader clinical experience have questioned lithium's effectiveness in rapid cycling subjects or those with multiple episodes. If we have only a limited understanding of the underlying aetiopatho-physiology of bipolar disorder, we may rightfully question whether the...

Bipolar Disorder

Depressed patients often suffer from bipolar disorder, which in the past was called manic-depressive illness. Patients have wide mood swings with manic alternating with depressive episodes. At times, they are extremely happy, talk fast, exhibit a high level of energy, have a reduced need for sleep, have flighty ideas, express grandiosity, elation, have poor judgment, and suffer from excessive aggressiveness and often hostility. In 1817, the Swede Johann Arfvedson discovered the element lithium. Its biological effect is on intracellular influx of sodium during the process of axonal depolarization, which interferes with the synthesis and reuptake of neurotransmitters. In the 1950s, it began to be used in the treatment of bipolar disorder, because it dampens neurotransmission. It enhances the reuptake of dopamine, norepinephrine, and 5-HT into neuronal vesicles, reducing their action. It also reduces release of norepinephrine from synaptic vesicles and inhibits production of cAMP. It...

Introduction The New Bipolar

After relative neglect in the age of melancholy during the 1970s and 1980s, there has been a renaissance of bipolar disorder during the last decade of the 20th century. Major monographs which cover the psychopathology of the illness have been published, beginning with the Goodwin-Jamison encyclopaedic coverage of Manic Depressive Illness 1 , the Marneros and Angst's book on Bipolar Disorders 100 Years After Manic Depressive Insanity 2 and the present author's monograph entitled Bipolarity Beyond Classic Mania 3 . Several volumes deal primarily with biological aspects 4-6 . Two poignant autobiographical accounts 7, 8 have helped in the cause of destigmatizing the illness. Other books have been written to address the needs of patients and their families, while at the same time maintaining a scholarly base 7, 9 . The new bipolar era has also witnessed the development of innovative pharmacological and psychosocial interventions specifically geared for this disorder. Despite these...

US vs International Concepts

The extension of the boundaries of bipolarity is reflected in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders in its 4th edition (DSM-IV) 28 . In this manual, bipolar disorders include bipolar disorder proper (also known as bipolar I), followed by bipolar II, cyclothymia, and bipolar not otherwise specified. This is implicit acceptance of the concept of some sort of a bipolar severity spectrum, contrasted with a depressive disorder spectrum consisting of major depressive disorder, dys-thymia, and depression not otherwise specified. The rubric unipolar disorder'', however, is wisely avoided because of the risk for bipolar transformation of major depressive disorder even after many episodes 2934 , The World Health Organization Classification in its 10th revision (ICD-10) 35 is less committed to the concept of spectrum. Depressive disorders are extensively documented, but again, the term unipolar is avoided. While bipolar disorder is...

Bipolar Depressive Phase And Mixed States Depressive Phase

Like mania, bipolar depression may manifest psychotic symptoms of usually mood-congruent nature 16 . However, delusional and hallucinatory experiences are less common. Stupor, uncommonly observed today, represents the most severe expression of the depressive phase of bipolar disorder. In the elderly, bipolar depression may present as a pseudodementia. Neur-astheniform symptoms 32 with reverse vegetative signs (i.e., atypical depression in the sense of DSM-IV) are more characteristic of juvenile bipolar depressives, particularly adolescents and young adult women. Psychomotor retardation, with or without hypersomnia, is generally considered the hallmark of the uncomplicated depressive phase of bipolar disorder 136 . Onset and offset are often abrupt, though gradual onset over several weeks can also occur. Patients may recover into a free interval or switch directly into mania 137, 138 switching into an excited phase is not infrequently associated with somatotherapy (e.g., ECT, sleep...

Bipolar Subtypes And Their Variants Bipolar I Disorder

Although the sex ratio is 1 1, men experience more manic episodes, and women more depressive and mixed episodes 1 . On average, manic episodes predominate in youth and depressive episodes in later years 48 . A partial exception is the group of secondary manias, which usually occur in association with various cerebral, endocrine, and other systemic medical conditions later in life 165 . Irritable mood tends to prevail in secondary manias 166 . Family history for bipolar disorder, and recurrence or depressive switches, are unusual in these maniform states 165 . The latter features suggest that many such cases do not belong to bipolar I disorder. However, postpartum mania often mixed or schizophreniform in nature should, on the basis of family history and course, be probably classified under bipolar I disorder 167 .

Schizoaffective Disorder

Although current molecular genetic data have revealed intriguing links between some forms of schizophrenia and bipolar disorder 214 , circa 2001, their clinical differentiation does not seem to pose as much trouble as in the past. Clinical differentiation of bipolar disorder from schizoaffective disorder is another matter. According to ICD-10, the concept of schizoaffective disorder should be restricted to recurrent psychoses with full affective and schizophrenic symptoms occurring nearly simultaneously during each episode. Research by the present author 16 has shown that such a diagnosis should not be considered in a bipolar psychosis where mood-incongruent psychotic features can be explained on the basis of one of the following a) affective psychosis superimposed on mental retardation, giving rise to extremely hyperactive and bizarre manic behaviour b) affective psychosis complicated by concurrent cerebral disease, substance abuse, or substance withdrawal, all of which are known to...

Alcohol and Substance Use Disorders

Alcohol may have some therapeutic value in a subgroup of bipolar patients. This can perhaps be inferred from the fact that bipolar disorder following alcohol abuse usually manifests a decade later than bipolar disorder without such abuse 97 however, one cannot rule out the possibility that the protracted use of alcohol may have played a formative influence on the bipolar disorder in such cases. Given the clinical dangers of missing an otherwise treatable disorder, bipolar disorder should be given serious consideration as the primary diagnosis if marked bipolar manifestations continue one month after the period of detoxification. According to Winokur et a 97 , family history of mania can further buttress a bipolar diagnosis in such situations indeed, alcohol, stimulant abuse and mania are often unilineal in such families.

Summary Consistent Evidence

The weight of the reviewed evidence indicates that bipolar disorder is broader than what is included in DSM-IV and ICD-10. It ranges from psychotic extremes to attenuated forms that manifest at the level of disordered temperament. It includes of bipolar disorder. Current data indicate that the modal duration of hypomanic episodes is two days.

Personal Experiences With Mood Episodes

Here are two stories of people who have experienced mood episodes like the ones described above. Like we said before, people's experiences with bipolar disorder are varied. However, the following stories will help give you a better idea of what a mood episode may look like.

What Is the Course of the Disorder

Bipolar disorder can occur at any time but usually begins before age 35. People between the ages of 15 25 have the highest risk of developing this disorder. However, the delay between the first signs and symptoms of the disorder and proper diagnosis and treatment is often 10 years. Approximately one out of eight individuals with bipolar disorder suffer from the rapid cycling form of the disorder (i.e., four or more mood episodes per year). Rapid cycling tends to be more common in women than in men. If a woman experiences an episode of bipolar disorder within four weeks after childbirth, that episode can be designated as having a postpartum onset. Some people also experience a seasonal pattern to bipolar disorder, where most episodes start and end around the same time each year. family members may be tempted to interpret these periods of wellness as evidence that the diagnosis of bipolar disorder was incorrect. Unfortunately, this is seldom the case. Bipolar disorder often has natural...

Common Cooccurring Disorders And Symptoms

Sometimes when you have an illness you may also experience other disorders or symptoms. Two or more disorders that occur at the same time are known as comorbid disorders. Comorbid disorders that tend to occur with bipolar disorder can make it more difficult to manage your symptoms. However, educating yourself about these additional disorders or symptoms can help you prolong periods of wellness. More than 50 percent of people with bipolar disorder experience severe anxiety (Simon et al. 2004). In addition, 60 percent of people with bipolar disorder have recurrent problems with or become addicted to alcohol or drugs at some point in their lifetime (Regier et al. 1990). People with bipolar disorder may have the most severe problems with anxiety, alcohol, or drugs during mood episodes. When you feel manic, you may be particularly vulnerable to excessive drug or alcohol use because of the tendency to get overly involved in pleasurable activities or sensation seeking. Other problems that...

How Prevalent is the Bipolar Spectrum

Hagop Akiskal concisely provides us with a broad overview on what bipolar disorder is and what it is not. His paper dramatically describes the remarkable lack of consensus in the field on what constitutes bipolar disorder in light of very clear and cogent clinical descriptions of mania and depression dating back to the ancient Greeks. Curiously in light of this, the concept of bipolar disorder as a distinct nosologic entity is less than 50 years old. Akiskal notes that the two major official classification systems in the world today, the DSM-IV and the ICD-10, denote a rather restrictive, narrow concept of bipolar disorder. The DSM includes bipolar I, bipolar II, cyclothymia, and bipolar not otherwise specified. ICD-10 includes bipolar I and cyclothymia. I find somewhat surprising that in defining that there is no clear statement of what is the core feature that defines bipolar spectrum. Stated differently, what is it that ultimately determines whether an individual's condition is...

Receiving a Diagnosis and Finding Help

Receiving a diagnosis of bipolar disorder, or any other illness for that matter, is often challenging and may bring up many different emotions. You may feel scared because bipolar disorder is a lifelong illness, or you may feel relieved because you've struggled with symptoms for a long time and now your experiences have a name. A diagnosis is the first step in receiving treatment that will help you take control of your mood and maintain longer periods of wellness. In this chapter, we'll help you prepare to take that first step. We'll provide you with resources to help you find treatment

Finding Professional Help

A variety of helpful resources and professionals are available to provide support for those with bipolar disorder. Some people decide to work with multiple skilled professionals who specialize in various components of their treatment. An example of a treatment team may include a psychiatrist who prescribes medication, a therapist who offers weekly support, and a caseworker who helps coordinate services. An ideal approach is to find treatment providers who already work together, preferably in the same center. This will help ensure that your treatment team works closely together to provide the best care. Often though, the treatment team approach isn't available in a given area, or you may find that you really like one provider who isn't part of a larger team. If members of your treatment team don't work in the same place, it's a good idea to provide written permission for members of your treatment team to talk to each other. This way, they can work collaboratively to provide the best...

Bipolar II is Bipolar

Akiskal also provides a lot of evidence supporting the separation of bipolar II from bipolar I disorder within the broad clinical spectrum of bipolar disorders. Reporting on a significant difference in the distribution of ABO blood group types 5 and in the serum dopamine- -hydroxylase level 6 between bipolar I and bipolar II patients, 20 years ago we concluded that these results indicated a possible genetic difference between these disorders. A few years later our conclusion was corroborated when it was published that levels of dopamine- -hydroxylase activity were controlled by a gene linked to the ABO blood group locus on chromosome 9 7 . These results are also in good agreement with later family studies suggesting the possibility that bipolar I and bipolar II disorders are genetically distinct categories 8 .

The Clinical Spectrum of Mania

In his authoritative review, Akiskal has used the spectrum of mania as the royal road to the field of bipolar disorders. When mapping the manic spectrum Akiskal, the trialblazer, has seen boundaries both in the current classification systems (DSM-IV and ICD-10) and in various rating scales and questionnaires 1 . Thus, the manic symptomatology goes from schizomania at the top to hyperthymia at the bottom. Between these extremes are the other categories from mania to hypomania.

The Bipolar Spectrum

In the realm of bipolar disorders, bipolar II is the most under-recognized variant. The first episode has generally a depressive polarity, frequently with atypical features. To explore subthreshold expressions of mania or hypomania (mania mitigata) in the patient's past history, or to recognize partial manic elements intruded in the depressive symptoms, may be difficult or require a lot of clinical expertise. The prescription of an antidepres-sant in monotherapy is the common choice in this situation. If the patient has a bipolar II disorder, one may predict, on the basis of the available clinical evidence, an unstable and tumultuous course, or a tendency to non-response to antidepressants, or a switch to an excitable state with a mixture of both dysphoric and anxiety symptoms, or an increase of underlying affective dysregulation, or periods with brief hypomanic states or cyclothy-mic episodes, or eventually the full-blown picture of mixed states. bipolar disorder spectrum vs. a more...

Syndromes Symptoms and Spectra

My personal clinical experience of treating bipolar illness includes 27 years of continuous maintenance of an outpatient bipolar clinic with over 150 patients under treatment at any given time, along with innumerable consultations on inpatient stays mostly with mania. This experience agrees with that of Hagop Akiskal to the effect that many mixed syndromes occur, that hyperthymic and dysthymic intermorbid personalities have something to do with the course of illness, that relatives of patients often have bipolar II or cyclothymic syndromes, and that many unusual illnesses that come to me for consultation can be conceptualized as related to bipolar disorder. This much I know, but in the sense that I know how to ride a bicycle. I don't know how to make a bicycle nor do I know how to give detailed instructions to someone else as to how to ride a bicycle. I certainly do not know how my nerves and muscles work to ride a bicycle. A clinician armed with a wide, flexible spectrum concept of...

Definitions And Methodological Issues

There is some confusion in the literature concerning the terms prognosis, course and outcome. The term prognosis actually includes course and outcome. The term course has been used sometimes as an equivalent of outcome, but this is not appropriate, as outcome is only one aspect of course, the endpoint of course in a defined period of time 6, 10 . The course of bipolar disorders (as of any other mental disorder) includes all phenomena which occur after the onset of the illness 11 . The most important features of the course are the following the full symptomatic range on a sufficient number of symptoms to meet syndromal criteria for the disorder. Nevertheless, in bipolar disorder there is the problem of the demarcation of two separate episodes. Concerning rapid cycling, the DSM-IV requires either a switch to a mood state of opposite polarity or a period of remission lasting two months to delineate a new episode. Quite differently, in the Research Diagnostic Criteria (RDC, 17 ), one...

Longterm Naturalistic Studies Table 21 Classical Studies Before 1966

Due to their great number of patients included, the long observation periods, and often an excellent clinical and psychopathological basis, some of the older long-term naturalistic studies on the prognosis of bipolar disorders are very valuable. Nevertheless, they have some obvious shortcomings, as for example the fact that the distinction between bipolar and unipolar illnesses was not always followed. Also, operational criteria or other explicit definitions were not available. Related to this is the fact that since the 1970s especially in North America 21 the concept of schizophrenia has become narrower 22 , and the concept of bipolar disorder broader 23 . It is not always easy to draw a clear demarcation between old and new studies. We decided to use the year 1966 as a turning-point, as in that year the influential studies by Angst 8 and Perris 9 were published, which showed that the Kraepelinian unitary concept for affective disorders was not valid. These two studies supported the...

Anxiolytic Antianxiety Medications

Anxiety and sleeplessness in bipolar disorder. In addition, the benzodiazepines may be used to help control some of the early symptoms of hypomania. All benzodiazepines have the potential to cause physical and psychological dependence or addiction. The potential for abuse seems to be greatest with drugs that produce a quick effect and that are quickly removed from your blood stream, such as alprazolam (Xanax). The potential for abuse seems to be least with benzodiazepines that have a slower effect and spend a longer time in your blood stream, such as clonazepam (Klonopin). Most standard antidepressant medications appear to have excellent effects on reducing anxiety, but they require several weeks of consistent use to become effective and may cause worsening of bipolar disorder in some patients.

During The Appointment

As mentioned earlier, the first time you meet with a treatment provider you'll have to answer important questions about your background and experiences. The information you provide in this session will help your treatment provider learn more about you and determine whether what you describe is consistent with a diagnosis of bipolar disorder. Don't be dismayed if it feels like the initial session doesn't help. It can sometimes take several sessions for a mental health professional to conduct a comprehensive diagnostic interview and carefully collect all the information necessary to make a diagnosis and design a good treatment plan. Although it may not feel like it, the time it takes for care providers to learn about your experiences is an essential component not only of your diagnosis but also of treatment. As mentioned, there are no medical tests (such as brain scans or blood tests) that can confirm a diagnosis of bipolar disorder. Instead, treatment providers will ask you lots of...

Consistent Use of Your Medication

For many individuals, a combination of medications may be used to enhance mood stability. Once your mood stabilizes, there is often the temptation to discontinue medication and to believe that the disorder has been cured. Unfortunately, bipolar disorder is a lifelong condition, one that requires ongoing treatment. We use the analogy of a seatbelt to help underscore the importance of this point. As you know, a seatbelt is a protective device designed to prevent injury in the case of a car accident. Hopefully, that accident never happens, but if it does, you are prepared. In a similar way, taking medications for bipolar disorder protects you from depression and mania. Even when your symptoms feel completely under control, it is important to take your medications regularly. The self-guided care box on page 30 is designed to provide you with opportunities to think through and clarify your goals for using medications as tools to help control your bipolar disorder. Writing out your...

The Pros And Cons Of Taking Medications

It's completely normal to have concerns about long-term medication treatment. As with any illness and treatment, it's important to educate yourself on the pros and cons of taking medications to treat bipolar disorder. The goal of a good medication plan is to maximize benefits (symptom relief) and minimize costs (side effects). Although medications may help you experience fewer symptoms and mood episodes, they may also cause some unwanted side effects, such as weight gain and fatigue, and they may require certain dietary restrictions. As a consumer, it's your job to weigh the costs and benefits and work with your doctor to find the type of medication and dosage that works best for you. Unfortunately, this often takes time and some trial and error. You may have to try a variety of medications before you find the right one.

Medication Monitoring

Monitoring your medication is a good idea to help ensure that you continue to take your medications as prescribed. This is part of making sure that you use the tools that you and your treatment team have selected in the best manner. Chapter 12 provides a form for monitoring your moods and activities to maximize your daily control over your disorder. This form also includes a place to record your use of medications. Research has found that even this simple extra attention to monitoring pill taking helps people stay on track with their daily use of medication. With a little practice at linking pill taking to daily routines, and regular monitoring of moods and medication use, you can maximize the value that medications can have in helping control your bipolar disorder.

Antipsychotic Medications

As discussed in chapter 1, psychotic features (hallucinations or delusions) can be a common experience for people in acute manic or depressive episodes. Antipsychotic medications, which are also called neuroleptic medications, are helpful in reducing psychotic symptoms and lowering irritability, and they can be the fastest way to treat acute manic episodes (American Psychiatric Association 2002). Doctors often prescribe antipsychotic medications when people with bipolar disorder are hospitalized, and some people may continue to use these medications as a maintenance treatment. second-generation antipsychotic medications, which include ris-peridone (brand name Risperdal), olanzapine (brand name Zyprexa), quetiapine (brand name Seroquel), and aripiprazole (brand name Abilify). These medications are more commonly used to treat bipolar disorder than first-generation antipsychotic medications but also tend to be more expensive. Side effects associated with second-generation antipsychotic...

Medications and Pregnancy

Women with bipolar disorder who want to have children should work very closely with family support and health care providers when thinking about conceiving. Careful planning and being well-informed are the keys to successful management of bipolar illness during and after pregnancy. Careful planning can help you best manage bipolar disorder by minimizing symptoms and avoiding risks to your unborn child. First, it is important to never stop taking medications before talking with your prescribing doctor. You also shouldn't make sudden changes to your medication as you consider conception or during pregnancy. Such changes might lead to major side effects, risks to the fetus, and increase your risk for a mood episode. Second, more information than ever is available on medications used to treat bipolar disorder and their impact on the fetus. Contact and carefully plan with your physician which medications provide you with the best balance of mood stabilization and safety for your baby...

Primary and Adjunctive Drugs

An additional useful distinction is between medications that have primary roles in treatment of, bipolar disorder, vs. those with roles that are per se adjunctive. Primary medications include mood stabilizers, but also include medications that are effective in the manic or depressive phase of the illness. Antipsychotic medications are effectively antimanic. Antidepressant drugs that are approved for major depression are probably effective in alleviating acute bipolar depression, although few have been systematically studied in even one adequate clinical trial. These drugs would qualify as primary treatments. Drugs that are beneficial for component symptoms that are common in, but not diagnostic of, bipolar disorder, plus ones that may augment response to a primary or mood-stabilizing drug are better viewed as secondary, or adjunctive drugs. Examples include supplementation of antidepressant regimens with thyroid medications or other adjuncts such as pindolol or pramipexole. Others are...

Tolerability Drives Drug Selection and Patient Adherence

Although no psychiatrist would employ ineffective medications to treat bipolar disorder, tolerability occupies a more important role in decisions to initiate, or continue, a drug than occurs with most mental disorders. Part of this stems from the excellent efficacy of many treatments for a substantial portion of the bipolar spectrum. Additionally, it is related to the inherent characteristics of bipolar disorder. Evidence of expanded creativity in the arts, sciences, politics and probably most work venues is substantial 14,15 . Bipolar patients have evidence of enhanced educational achievement in first-degree relatives 16 . The bipolar patient expects to be able to operate at a high level of function. I have suggested that a little hyperthymia is not a bad thing, and that psychiatrists sometimes err in overmedicating with mood stabilizers to the point that cognitive dulling occurs. In effect, with this illness, we deal with patients who will often be exquisitely sensitive to...

Methodological Issues

In so far as possible this review takes an evidence-based approach in recommending treatments for bipolar disorder. The levels of evidence are divided into four categories. Category I, also referred to in the final summary as consistent evidence, includes treatments whose efficacy and safety are supported by at least one randomized, double-blind, parallel-group, placebo-controlled study, conducted with a sufficient number of patients that at least one of the major planned analyses provided over a 50 likelihood of identifying a significant difference between groups. Category II has the same criteria as level I, except that no placebo control is required. Category III includes prospective, open trials that employ systematic inclusion and exclusion criteria, utilize behavioural ratings for which raters are trained, and involve a sufficient number of subjects that planned comparisons between two or more groups are possible. These allow comparison, for example, of patients with and without...

Risks With Stopping Medications

Thinking about stopping the use of medications, or even actually stopping, is very common. It's something most people go through even when taking nonpsychiatric drugs, such as medication for high blood pressure. Research has shown that seven out of every ten people with bipolar disorder stop taking their medication at some point, and nine out of every ten seriously consider discontinuing medication treatment (Colom and Vieta 2006). Unfortunately, stopping medication often results in another mood episode, usually within the next six months to one year, and also increases the risk of suicide attempts (Tondo and Baldessarini 2000).

Electroconvulsive Therapy

For some individuals, medications and therapy may be less helpful for treating their symptoms of bipolar disorder. In such cases, doctors sometimes prescribe electroconvulsive therapy (ECT), a medical treatment that involves sending a low-level electric current through the brain for about one minute to induce a small seizure. This is commonly conducted in a hospital under the care of physicians. ECT is usually tried when other treatments don't work, and it can be especially helpful for those experiencing severe depression. Researchers don't fully understand why this treatment works, but it seems to help balance mood and decrease mood symptoms. It is also used to treat acute mania and usually results in rapid improvements without the side effects associated with taking mood stabilizing medications. However, short-term memory loss may occur, which usually lasts only a few short weeks after treatment. If you are interested in learning more about the benefits and side effects of ECT, talk...

Special Situations Sleep

Disturbed sleep is a common, and pathophysiologically important component of bipolar disorder. Persons with bipolar disorder often escalate their interest, elation and energy levels in the evening hours, into the early hours of the next day. It is important to counsel patients regarding this diurnal phase disturbance, but medications are often needed. No systematic studies have been conducted regarding comparative benefits of various strategies. Benzodiazepines are most commonly employed. Benzodiazepines vary along dimensions of speed of onset and half-life. It is best to tailor the drug in a trial-and-error fashion to the patient's unique sleep problems. Some patients may have side effects from benzodiazepines, principally carryover sedation, or less frequently disinhibition of affect and action. In such instances, alternative medications can be used. Despite lack of direct testing for insomnia, gabapentin, at doses of 100 to 400 mg, is often helpful for sleep induction. Although...

Psychosocial Treatments That Work

As discussed in chapter 3, research shows that medication is the most well-s upported and effective treatment for bipolar mania and depression. However, medication is often only one part of the overall treatment for bipolar disorder. And just as it's very helpful to know about current recommendations on medications, it's also important to be informed about other treatments, how they work, and how helpful they are for treating symptoms.

Proven Psychosocial Treatments

Research supports the effectiveness of several psychosocial treatments for bipolar disorder, including psychoeducation, cognitive behavioral therapy, family-focused therapy, and interpersonal and social rhythm therapy. All four of these treatments have been found to decrease symptoms of depression, while psychoeducation seems to be equally effective for decreasing both mania and depression symptoms. All four treatments decrease the chances of hospitalization, and all of them also help people rebuild their social world after a manic episode. However, it is important to remember that medication is still the best and quickest treatment for reducing symptoms of mania and preventing their return. Talk therapies can be used as a supplement to medication.

Pursuit of the Ideal Mood Stabilizer Time to Give Up and Move to Combination Trials

Charles Bowden's authoritative and comprehensive description of the various pharmacotherapies currently being utilized in the medical management of bipolar disorder suggests that we have failed to develop an agent which possesses the capacity to simultaneously stabilize mood from both above and below baseline'' (terms proposed by Terry Ketter, personal communication). In addition, we do not have agents that exert their therapeutic effects quickly and without significant side-effect burden. Our patients find these conclusions demoralizing. We must do better. We must meet this unmet need, and Bowden's review would suggest that we are not going to achieve this goal without informed combination therapy. The available data suggest that lithium remains the gold standard'' in the long-term management of bipolar disorder. However, despite being viewed as our best prophylactic treatment for bipolar disorder, lithium has never been shown with contemporary methodology to prevent both manic and...

What Is the Course of the Illness in Children

At this time, the long-term course of bipolar disorder in children has not yet been determined. However, many adults with bipolar disorder report that their symptoms started in childhood or adolescence, suggesting that the disorder is continuous across development. The few studies that have followed children with bipolar disorder over time suggest that the disorder often follows a waxing and waning course. For example, recent short-term follow-up studies suggest that bipolar disorder in youth tends to be chronic, with long episodes and a high risk for relapse after remission.

Same Data Different Interpretations

There is a pressing need to improve the treatment of bipolar disorders as currently diagnosed. The prevalence estimates in the population have expanded from a lifetime risk of 1 up to 5 , even up to 8 , partly due to the broadened approach of DSM-IV which allows other diagnoses in parallel. The enlarged potential market for new mood stabilizers has understandably been a strong incentive for the pharmaceutical industry, and pharmacological treatment of bipolar disorders has become one of the most frequently presented subjects. Charles Bowden's comprehensive review reflects well the impressive expansion of new, experimental treatments in bipolar disorder. Guy Goodwin 1, 2 , for example, supports a more rigorous definition of mood stabilizers and concludes from a careful meta-analysis that lithium remains the only proven mood stabilizer in bipolar disorder. Based on evidence available to date, Fred Goodwin 3 and Baldessarini and Tondo 4 come to a similar conclusion. Guy Goodwin suggests...

Treatment as Guided by the Dim Light of Evidence

Bipolar disorder is an incurable common disorder that is frequently disabling and can be deadly. While bipolar disorder usually responds to treatment, its course unfolds in chaotic patterns with irregular phases of depression and mood elevation separated by variable periods of partial or complete euthymia. The extreme variability within and between patients is a hallmark of bipolar illness 2 which complicates the process of clinical management and challenges the processes by which clinical research is conducted and results interpreted. Bowden's organizing concepts remind us that bipolar research is indeed handicapped by a lack of consistent definitions. Our field has no clear definition of a mood stabilizer, yet this term is used even in professional discourse without qualification. Any reasonable definition that permits an evidence-based determination of whether a treatment meets criteria for inclusion is an acceptable starting point. Bowden's admonition to divide treatment actions...

Cognitive Behavioral Therapy

Individual therapy can help you stay well and provide support as you learn more about your diagnosis and your particular symptoms. Cognitive behavioral therapy (CBT) is the most carefully studied form of individual therapy for depression and is also effective for treating both depression and mania in bipolar disorder. CBT is a type of talk therapy that focuses on patterns of thoughts, feelings, and behaviors and helping people identify the relationship between those patterns and the symptoms they experience There is also some evidence that CBT is most beneficial for people in the early stages of bipolar disorder. This is one reason it's helpful to educate yourself on treatment options as early as possible (Scott 2001). Additionally, sometimes people use CBT to address other types of difficulties beyond depression and mania, such as managing anxiety, and this is an option you can discuss with your treatment team. Family-focused therapy (FFT) is a type of treatment that combines...