Bipolar disorder has long been misunderstood. A fear of being stigmatized and the thought of taking potentially dangerous medication prevented many from seeking treatment for the highs and lows that often mark the disease once referred to as manic depression.
But a new understanding of the disorder, a new treatment philosophy and a second-generation of medications that are safer and more effective have paved the way for bipolar sufferers to finally seek the help they need.
“I would say the two main things that have change from the standpoint of psychological treatment are the dramatic change to psycho-social treatment that is family-based and the second-generation of antipsychotic medications that are now being used as maintenance drugs,” said Dr. Igor Galynker, director of the Bipolar Family Treatment Center at Beth Israel Medical Center in New York City.
People with bipolar disorder often suffer from extreme highs, causing agitation, elation, mania and bouts of sleeplessness, as well as periods of lows, marked by depression and suicidal thoughts. Some sufferers experience mixed mania, which includes excessive anger, irritability, anxiety and depression.
It’s also a debilitating disease. The World Health Organization said the illness is the sixth-leading cause of disabilities worldwide.
Bipolar disorder affects approximately 5.7 million adult Americans, or about 2.6 percent of the U.S. population age 18 and older, according to the National Institute of Mental Health. The median age of onset for bipolar disorder is 25 years, but the illness can start in early childhood or as late as the 40s and 50s.
The latest generation of bipolar drugs includes aripiprazole, clozapine, olanzapine, quetiapine, ziprasidone and risperidone. These drugs are considered a class of atypical antipsychotics that are FDA approved for the treatment of acute manic and mixed episodes associated with bipolar disorder.
“The second generation antipsychotics work by stabilizing the mood through a combination of two opposing actions: The anti-manic action works on dopamine receptors and the antidepressant action works on the serotonin receptors similar to tricyclic antidepressants,” said Galynker
Dr. Keith Ablow, a psychiatrist and FOX News contributor, said the drugs, which were developed to treat schizophrenia and other psychotic illnesses, block what is believed to be an excessive amount of dopamine produced during the manic phase of bipolar disorder.
“They were repurposed for use in bipolar disorder because of the overall tranquilizing effect they have,” he said. “Some people with bipolar disorder also suffer psychotic symptoms during the manic phase where they are delusional or hear voices or see visions. These drugs can be used also to control those symptoms.”
Although these drugs carry some side effects such as weight gain, sluggishness and digestive upset, they are generally believed to be better tolerated and safer than lithium, a mood stabilizer developed in the 1950s, and anti-seizure medications such as Tegretol and Trileptal, which have been used for several decades and work by controlling the abnormal electrical activity in the brain.
Both lithium and anti-seizure drugs require close monitoring because they have the potential to be toxic, Ablow said.
“I think the major objection to lithium was weight gain, but also its potential for toxicity and kidney problems,” he said.
At one time, it was believed that antidepressants could be used for treating bipolar disorder, but over time their use proved ineffective and potentially dangerous, said Galynker.
“The fact that antidepressants for bipolar depression were not working or harmful was devastating,” he said. “Bipolar is difficult to treat. Some think it’s treatment-resistant. It’s not. But not only do antidepressants not improve bipolar symptoms, they may increase the incidence of mania or cause mixed mania in bipolar individuals.”
Mixing Medication and Therapy
Galynker and Ablow both said that bipolar medication is most effective when used in conjunction with therapy.
“I’m a big proponent of getting to the bottom of what in your life is causing the stress that led to this condition,” Ablow said. “If you’re on powerful psychiatric medications, you also ought to be looking at what else might have set the stage for your condition. I don’t think psychiatric conditions are wholly genetically based. So it’s tremendously important to look at what in your life may be fueling your problems.”
At Beth Israel’s Bipolar Family Treatment Center, Galynker and staff use a family-based approach to treating bipolar disorder.
“The stigma of psychiatric illness starts in the family,” said Galynker. “This is because of legal reasons and tradition. And it’s a kind of mental illness that remains shrouded in secrecy.”
Galynker said the center bases its model on three criteria:
— Chronic illness. Like high blood pressure, diabetes and Alzheimer’s disease, bipolar disorder is a chronic and genetic condition.
“Genetics alone don’t make you become bipolar,” Galynker said. “But it lays the foundation that puts certain people at a higher risk for getting the illness.”
— Open communication. Therapy at the center is family inclusive. Patients sign waivers that allow certain family members, even friends, to have access to their confidential medical records.
“Bipolar people don’t recognize when they’re having a manic episode,” Galynker said. “But their family members and friends, who are often the targets of these episodes, do. This allows a family member to call us and let us know a manic episode is beginning so that we can intervene.”
— Family psychiatry. The center does not require family members and caretakers to receive counseling, but it does follow up with them on a quarterly basis.
“We know that bipolar patients’ caregivers are prone to depression, anxiety and panic attacks,” Galynker said. “We don’t mandate psychotherapy, but a psychiatrist follows up with them to make sure they too are O.K.”
“With bipolar disorder, family involvement is critical,” Galynker added. “The patient would not survive without family intervention.”
Ablow added that with a better understanding of bipolar disorder, therapists can now ensure better treatment for sufferers.
“I think the outlook is definitely better than it was 10 years ago,” he said. “As such, we now know that with treatment a majority of people will get well. And it’s absolutely a reassuring fact that you can now say to (a patient), we can expect to get this under control.”