APA Practice Guidelines

4. Monitor treatment response

cont. from

The psychiatrist should remain vigilant for changes in psychiatric status. While this is true for all psychiatric disorders, it is especially important in bipolar disorder because limited insight on the part of the patient is so frequent, especially during manic episodes. In addition, small changes in mood or behavior may herald the onset of an episode, with potentially devastating consequences. Such monitoring may be enhanced by knowledge gained over time about particular characteristics of a patient's illness, including typical sequence (e.g., whether episodes of mania are usually followed by episodes of depression) and typical duration and severity of episodes.

5. Provide education to the Bipolar patient and to the family

Patients with bipolar disorder benefit from education and feedback regarding their illness, prognosis, and treatment. Frequently, their ability to understand and retain this information will vary over time. Patients will also vary in their ability to accept and adapt to the idea that they have an illness that requires long-term treatment. Education should therefore be an ongoing process in which the psychiatrist gradually but persistently introduces facts about the illness. Over an extended period of time, such an approach to patient education will assist in reinforcing the patient's collaborative role in treating this persistent illness. In this capacity, the patient will know when to report subsyndromal symptoms. Printed material on cross-sectional and longitudinal aspects of bipolar illness and its treatment can be helpful, including information available on the Internet (such as that found in the Medical Library at www.medem.com). Similar educational approaches are also important for family members and significant others. They too may have difficulty accepting that the patient has an illness and may minimize the consequences of the illness and the patient's need for continuing treatment. A list of depressive and bipolar disorder resources, including associations that conduct regular educational meetings and support groups, is provided in Appendix I (p. 37).

6. Enhance treatment compliance

Bipolar disorder is a long-term illness in which adherence to carefully designed treatment plans can improve the patient's health status. However, patients with this disorder are frequently ambivalent about treatment. This ambivalence often takes the form of noncompliance with medication and other treatments, which is a major cause of relapse.

Ambivalence about treatment stems from many factors, one of which is lack of insight. Patients who do not believe that they have a serious illness are not likely to be willing to adhere to long-term treatment regimens. Patients with bipolar disorder may minimize or deny the reality of a prior episode or their own behavior and its consequences. Lack of insight may be especially pronounced during a manic episode.

Another important factor for some patients is their reluctance to give up the experience of hypomania or mania (19). The increased energy, euphoria, heightened self-esteem, and ability to focus may be very desirable and enjoyable. Patients often recall this aspect of the experience and minimize or deny entirely the subsequent devastating features of full-blown mania or the extended demoralization of a depressive episode. As a result, they are often reluctant to take medications that prevent elevations in mood.

Medication side effects, cost, and other demands of long-term treatment may be burdensome and need to be discussed realistically with the patient and family members. Many side effects can be corrected with careful attention to dosing, scheduling, and preparation. Troublesome side effects that remain must be discussed in the context of an informed assessment of the risks and benefits of the current treatment and its potential alternatives.

continue: Promote awareness of stressors and regular patterns of activity and sleep

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Written 4/02. Reviewed: 03/2006