What is the best therapy for bipolar depression

APR.

12,

2019

By David J. Miklowitz, Ph.D.

Bipolar disorder (BD) is a condition that is strongly affected by stress. Episodes of mania and depression can be triggered by significant life events, severe family conflicts, turbulent relationships and situations that disrupt sleep/wake rhythms. This is why it’s problematic when treatment is presented as mostly pharmacological. Those with BD function better when they receive medication management from a psychiatrist andregular (weekly or biweekly) psychotherapy sessions.

Therapy can help a person cope with the stress from these external factors, manage their symptoms and improve their relationships. Here are several different forms of therapy that have been found to be effective for BD.

Family-Focused Therapy

Family-focused therapy (FFT) includes both the person with BD and their parents, spouse, or other family members. FFT typically lasts about 12 sessions (depending on the family’s needs) given by a single therapist. Early sessions focus on education about the condition: its symptoms and how they cycle over time, its causes, how to recognize the early warning signs of new episodes, and what to do as a family to prevent the episodes from getting worse. Later sessions focus on communication and problem solving skills, especially to address family conflicts. In many randomized trials conducted by my labs at University of Colorado and UCLA, we have found that people with BD who get FFT and medication after an episode have less severe mood symptoms and better functioning over 1-2 year periods than those who get medications and briefer treatments or case management.

Interpersonal and Social Rhythm Therapy

IPSRT is an individual therapy in which the person with BD keeps daily records of their bed times, wake times, and activities, and the effects of changes in these routines on their moods. The clinician coaches the person on how to regulate their daily routines and sleep-wake cycles as a way to stabilize moods. The person and his/her therapist identify one or more interpersonal problem areas (e.g., conflicts with coworkers; difficulty sustaining friendships) and discuss potential solutions to prevent similar problems from emerging in the future.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is an individual therapy focused on the relationship between a person’s thoughts, feelings and behaviors. CBT teaches people to:

Identify negative assumptions and thinking patterns, and challenge themselves to rehearse more adaptive ways of thinking.

Monitor their activity levels to make sure they are engaged with rewarding aspects of their environment when depressed, and are not overly stretched when manic.

Dialectical Behavior Therapy

Dialectical behavior therapy is a skill-based approach that includes both individual and group therapy. It teaches mindfulness and acceptance skills, such as the ability to experience moment-to-moment thoughts, emotions and their accompanying physical sensations from an observer’s stance, without negative judgment. It also teaches distress tolerance, emotion regulation and interpersonal effectiveness.

Group Psychoeducation

People with BD get together (often accompanied by family members) and are led by a group facilitator (either a psychologist or a trained peer mental health counselor). Some groups are highly structured and follow an educational and skill-training agenda. Others are oriented toward telling one’s story and getting support and suggestions from people who have gone through similar situations. These groups, including those provided by NAMI and the Depression and Bipolar Support Alliance, are quite beneficial to people because they reduce feelings of isolation that often come with mental illness.

Over time, the specific type of therapy may not be as important as the continuity of having a therapist or a group that knows you well and makes you feel comfortable enough to disclose important issues. Along with medications, support from mental health professionals who understand your journey are key to an effective treatment plan and recovery.

David J. Miklowitz is the author of The Bipolar Disorder Survival Guide, 3rdEdition (www.guilford.com/p/miklowitz2), which has just been published by Guilford Press. Check out his website and information about the UCLA Child and Adolescent Mood Disorders program (www.semel.ucla.edu/champ).

We’re always accepting submissions to the NAMI Blog! We feature the latest research, stories of recovery, ways to end stigma and strategies for living well with mental illness. Most importantly: We feature your voices.

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Diagnosis

To determine if you have bipolar disorder, your evaluation may include:

Physical exam. Your doctor may do a physical exam and lab tests to identify any medical problems that could be causing your symptoms.
Psychiatric assessment. Your doctor may refer you to a psychiatrist, who will talk to you about your thoughts, feelings and behavior patterns. You may also fill out a psychological self-assessment or questionnaire. With your permission, family members or close friends may be asked to provide information about your symptoms.
Mood charting. You may be asked to keep a daily record of your moods, sleep patterns or other factors that could help with diagnosis and finding the right treatment.
Criteria for bipolar disorder. Your psychiatrist may compare your symptoms with the criteria for bipolar and related disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Diagnosis in children

Although diagnosis of children and teenagers with bipolar disorder includes the same criteria that are used for adults, symptoms in children and teens often have different patterns and may not fit neatly into the diagnostic categories.

Also, children who have bipolar disorder are frequently also diagnosed with other mental health conditions such as attention-deficit/hyperactivity disorder (ADHD) or behavior problems, which can make diagnosis more complicated. Referral to a child psychiatrist with experience in bipolar disorder is recommended.

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Treatment

Treatment is best guided by a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist) who is skilled in treating bipolar and related disorders. You may have a treatment team that also includes a psychologist, social worker and psychiatric nurse.

Bipolar disorder is a lifelong condition. Treatment is directed at managing symptoms. Depending on your needs, treatment may include:

Medications. Often, you’ll need to start taking medications to balance your moods right away.
Continued treatment. Bipolar disorder requires lifelong treatment with medications, even during periods when you feel better. People who skip maintenance treatment are at high risk of a relapse of symptoms or having minor mood changes turn into full-blown mania or depression.
Day treatment programs. Your doctor may recommend a day treatment program. These programs provide the support and counseling you need while you get symptoms under control.
Substance abuse treatment. If you have problems with alcohol or drugs, you’ll also need substance abuse treatment. Otherwise, it can be very difficult to manage bipolar disorder.
Hospitalization. Your doctor may recommend hospitalization if you’re behaving dangerously, you feel suicidal or you become detached from reality (psychotic). Getting psychiatric treatment at a hospital can help keep you calm and safe and stabilize your mood, whether you’re having a manic or major depressive episode.

The primary treatments for bipolar disorder include medications and psychological counseling (psychotherapy) to control symptoms, and also may include education and support groups.

Medications

A number of medications are used to treat bipolar disorder. The types and doses of medications prescribed are based on your particular symptoms.

Medications may include:

Mood stabilizers. You’ll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).
Antipsychotics. If symptoms of depression or mania persist in spite of treatment with other medications, adding an antipsychotic drug such as olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris) may help. Your doctor may prescribe some of these medications alone or along with a mood stabilizer.
Antidepressants. Your doctor may add an antidepressant to help manage depression. Because an antidepressant can sometimes trigger a manic episode, it’s usually prescribed along with a mood stabilizer or antipsychotic.
Antidepressant-antipsychotic. The medication Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine. It works as a depression treatment and a mood stabilizer.
Anti-anxiety medications. Benzodiazepines may help with anxiety and improve sleep, but are usually used on a short-term basis.

Finding the right medication

Finding the right medication or medications for you will likely take some trial and error. If one doesn’t work well for you, there are several others to try.

This process requires patience, as some medications need weeks to months to take full effect. Generally only one medication is changed at a time so that your doctor can identify which medications work to relieve your symptoms with the least bothersome side effects. Medications also may need to be adjusted as your symptoms change.

Side effects

Mild side effects often improve as you find the right medications and doses that work for you, and your body adjusts to the medications. Talk to your doctor or mental health professional if you have bothersome side effects.

Don’t make changes or stop taking your medications. If you stop your medication, you may experience withdrawal effects or your symptoms may worsen or return. You may become very depressed, feel suicidal, or go into a manic or hypomanic episode. If you think you need to make a change, call your doctor.

Medications and pregnancy

A number of medications for bipolar disorder can be associated with birth defects and can pass through breast milk to your baby. Certain medications, such as valproic acid and divalproex sodium, should not be used during pregnancy. Also, birth control medications may lose effectiveness when taken along with certain bipolar disorder medications.

Discuss treatment options with your doctor before you become pregnant, if possible. If you’re taking medication to treat your bipolar disorder and think you may be pregnant, talk to your doctor right away.

Psychotherapy

Psychotherapy is a vital part of bipolar disorder treatment and can be provided in individual, family or group settings. Several types of therapy may be helpful. These include:

Interpersonal and social rhythm therapy (IPSRT). IPSRT focuses on the stabilization of daily rhythms, such as sleeping, waking and mealtimes. A consistent routine allows for better mood management. People with bipolar disorder may benefit from establishing a daily routine for sleep, diet and exercise.
Cognitive behavioral therapy (CBT). The focus is identifying unhealthy, negative beliefs and behaviors and replacing them with healthy, positive ones. CBT can help identify what triggers your bipolar episodes. You also learn effective strategies to manage stress and to cope with upsetting situations.
Psychoeducation. Learning about bipolar disorder (psychoeducation) can help you and your loved ones understand the condition. Knowing what’s going on can help you get the best support, identify issues, make a plan to prevent relapse and stick with treatment.
Family-focused therapy. Family support and communication can help you stick with your treatment plan and help you and your loved ones recognize and manage warning signs of mood swings.

Other treatment options

Depending on your needs, other treatments may be added to your depression therapy.

During electroconvulsive therapy (ECT), electrical currents are passed through the brain, intentionally triggering a brief seizure. ECT seems to cause changes in brain chemistry that can reverse symptoms of certain mental illnesses. ECT may be an option for bipolar treatment if you don’t get better with medications, can’t take antidepressants for health reasons such as pregnancy or are at high risk of suicide.

Transcranial magnetic stimulation (TMS) is being investigated as an option for those who haven’t responded to antidepressants.

Treatment in children and teenagers

Treatments for children and teenagers are generally decided on a case-by-case basis, depending on symptoms, medication side effects and other factors. Generally, treatment includes:

Medications. Children and teens with bipolar disorder are often prescribed the same types of medications as those used in adults. There’s less research on the safety and effectiveness of bipolar medications in children than in adults, so treatment decisions are often based on adult research.
Psychotherapy. Initial and long-term therapy can help keep symptoms from returning. Psychotherapy can help children and teens manage their routines, develop coping skills, address learning difficulties, resolve social problems, and help strengthen family bonds and communication. And, if needed, it can help treat substance abuse problems common in older children and teens with bipolar disorder.
Psychoeducation. Psychoeducation can include learning the symptoms of bipolar disorder and how they differ from behavior related to your child’s developmental age, the situation and appropriate cultural behavior. Understanding about bipolar disorder can also help you support your child.
Support. Working with teachers and school counselors and encouraging support from family and friends can help identify services and encourage success.

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Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

You’ll probably need to make lifestyle changes to stop cycles of behavior that worsen your bipolar disorder. Here are some steps to take:

Quit drinking or using recreational drugs. One of the biggest concerns with bipolar disorder is the negative consequences of risk-taking behavior and drug or alcohol abuse. Get help if you have trouble quitting on your own.
Form healthy relationships. Surround yourself with people who are a positive influence. Friends and family members can provide support and help you watch for warning signs of mood shifts.
Create a healthy routine. Having a regular routine for sleeping, eating and physical activity can help balance your moods. Check with your doctor before starting any exercise program. Eat a healthy diet. If you take lithium, talk with your doctor about appropriate fluid and salt intake. If you have trouble sleeping, talk to your doctor or mental health professional about what you can do.
Check first before taking other medications. Call the doctor who’s treating you for bipolar disorder before you take medications prescribed by another doctor or any over-the-counter supplements or medications. Sometimes other medications trigger episodes of depression or mania or may interfere with medications you’re taking for bipolar disorder.
Consider keeping a mood chart. Keeping a record of your daily moods, treatments, sleep, activities and feelings may help identify triggers, effective treatment options and when treatment needs to be adjusted.

Alternative medicine

There isn’t much research on alternative or complementary medicine — sometimes called integrative medicine — and bipolar disorder. Most of the studies are on major depression, so it isn’t clear how these nontraditional approaches work for bipolar disorder.

If you choose to use alternative or complementary medicine in addition to your physician-recommended treatment, take some precautions first:

Don’t stop taking your prescribed medications or skip therapy sessions. Alternative or complementary medicine is not a substitute for regular medical care when it comes to treating bipolar disorder.
Be honest with your doctors and mental health professionals. Tell them exactly which alternative or complementary treatments you use or would like to try.
Be aware of potential dangers. Alternative and complementary products aren’t regulated the way prescription drugs are. Just because it’s natural doesn’t mean it’s safe. Before using alternative or complementary medicine, talk to your doctor about the risks, including possible serious interactions with medications.

Coping and support

Coping with bipolar disorder can be challenging. Here are some strategies that can help:

Learn about bipolar disorder. Education about your condition can empower you and motivate you to stick to your treatment plan and recognize mood changes. Help educate your family and friends about what you’re going through.
Stay focused on your goals. Learning to manage bipolar disorder can take time. Stay motivated by keeping your goals in mind and reminding yourself that you can work to repair damaged relationships and other problems caused by your mood swings.
Join a support group. Support groups for people with bipolar disorder can help you connect to others facing similar challenges and share experiences.
Find healthy outlets. Explore healthy ways to channel your energy, such as hobbies, exercise and recreational activities.
Learn ways to relax and manage stress. Yoga, tai chi, massage, meditation or other relaxation techniques can be helpful.

Preparing for your appointment

You may start by seeing your primary care doctor or a psychiatrist. You may want to take a family member or friend along to your appointment, if possible, for support and to help remember information.

What you can do

Before your appointment, make a list of:

Any symptoms you’ve had, including any that may seem unrelated to the reason for the appointment
Key personal information, including any major stresses or recent life changes
All medications, vitamins, herbs or other supplements you’re taking, and the dosages
Questions to ask your doctor

Some questions to ask your doctor may include:

Do I have bipolar disorder?
Are there any other possible causes for my symptoms?
What kinds of tests will I need?
What treatments are available? Which do you recommend for me?
What side effects are possible with that treatment?
What are the alternatives to the primary approach that you’re suggesting?
I have these other health conditions. How can I best manage these conditions together?
Should I see a psychiatrist or other mental health professional?
Is there a generic alternative to the medicine you’re prescribing?
Are there any brochures or other printed material that I can have?
What websites do you recommend?

Don’t hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your doctor may ask:

When did you or your loved ones first begin noticing your symptoms?
How frequently do your moods change?
Do you ever have suicidal thoughts when you’re feeling down?
Do your symptoms interfere with your daily life or relationships?
Do you have any blood relatives with bipolar disorder or depression?
What other mental or physical health conditions do you have?
Do you drink alcohol, smoke cigarettes or use recreational drugs?
How much do you sleep at night? Does it change over time?
Do you go through periods when you take risks that you wouldn’t normally take, such as unsafe sex or unwise, spontaneous financial decisions?
What, if anything, seems to improve your symptoms?
What, if anything, appears to worsen your symptoms?