APA Practice Guidelines

7. Promote awareness of stressors and regular patterns of activity and sleep

cont. from

Patients and families can also benefit from an understanding of the role of psychosocial stressors and other disruptions in precipitating or exacerbating mood episodes. Psychosocial stressors are consistently found to be increased before both manic and depressive episodes. Although this relationship was previously thought to hold true only for the first few episodes of bipolar disorder, more recent studies have found that stressors commonly precede episodes in all phases of the illness. Social rhythm disruption with disrupted sleep/wake cycles may specifically trigger manic (but not depressive) episodes. Of course, some episodes may not be associated with any discernible life events or stressors. Clinically, the pharmacological management of manic or depressive episodes does not depend on whether stressors preceded the episode. However, patients and families should be informed about the potential consequences of sleep disruption on the course of bipolar disorder. To target vulnerable times and to generate coping strategies for these stressors, the unique association between specific types of life stressors and precipitating episodes for each patient should also be addressed. It is similarly important to recognize distress or dysfunction in the family of a patient with bipolar disorder, since such ongoing stress may exacerbate the patient's illness or interfere with treatment.

Patients with bipolar disorder may benefit from regular patterns of daily activities, including sleeping, eating, physical activity, and social and emotional stimulation. The psychiatrist should help the patient determine the degree to which these factors affect mood states and develop methods to monitor and modulate daily activities. Many patients find that if they establish regular patterns of sleeping, other important aspects of life will fall into regular patterns as well.

8. Work with the patient to anticipate and address early signs of relapse

The psychiatrist should help the patient, family members, and significant others recognize early signs and symptoms of manic or depressive episodes. Such identification can help the patient enhance mastery over his or her illness and can help ensure that adequate treatment is instituted as early as possible in the course of an episode. Early markers of episode onset vary from patient to patient but are often usefully predictable across episodes for an individual patient. Many patients experience changes in sleep patterns early in the development of an episode. Other symptoms may be quite subtle and specific to the individual (e.g., participating in religious activities more or less often than usual). The identification of these early prodromal signs or symptoms is acilitated by the presence of a consistent relationship between the psychiatrist and the patient as well as a consistent relationship with the patient's family. The use of a graphic display or timeline of life events and mood symptoms can be very helpful in this process. First conceived by Kraepelin and Meyer and refined and advanced by Post et al., a life chart provides a valuable display of illness course and episode sequence, polarity, severity, frequency, response to treatment, and relationship (if any) to environmental stressors. A graphic display of sleep patterns may be sufficient for some patients to identify early signs of episodes.

9. Evaluate and manage functional impairments

Episodes of mania or depression often leave patients with emotional, social, family, academic, occupational, and financial problems. During manic episodes, for example, patients may spend money unwisely, damage important relationships, lose jobs, or commit sexual indiscretions. Following mood episodes, they may require assistance in addressing the psychosocial consequences of their actions.

Bipolar disorder is associated with functional impairments even during periods of euthymia, and the presence, type, and severity of dysfunction should be evaluated (33-35). Impairments can include deficits in cognition, interpersonal relationships, work, living conditions, and other medical or health-related needs (36,37). Identified impairments in functioning should be addressed. For example, some patients may require assistance in scheduling absences from work or other responsibilities, whereas others may require encouragement to avoid major life changes while in a depressive or manic state. Patients should also be encouraged to set realistic, attainable goals for themselves in terms of desirable levels of functioning. Occupational therapists may be helpful with addressing functional impairments caused by bipolar disorder.

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Written 4/02. Reviewed: 03/2006