The stabilization of a patient with MDI is a long and delicate process that requires close collaboration between the patient and his/her physician, therapist or possibly, the treatment team.
Factors affecting the treatments’ outcome include patients’:
- illness type and course;
- environment (external factors);
- psychological make-up (internal factors);
- response to specific treatments or interventions.
The goal of any intervention is to decrease the instability of the system regulating mood, activity and cognition. The balance of forces affecting this system can be destroyed by a number of events. Like the process of decreasing the swings of a pendulum, it is important to always make small and gentle changes rather than abruptly disturbing the system. Every intervention aimed at decreasing manic symptoms can produce a worsening of depressive symptoms and every antidepressant treatment can worsen manic symptoms. It is also important to keep in mind that MDI is an illness in constant change and that it can respond differently to the same event or treatment at different times.
Several steps are necessary to begin successful treatment of MDI:
- Observation
- Correlation
- Stabilization
- Adaptation
The first step is to recognize the presence of changes of mood, energy and thought, both spontaneous and in response to a precipitant.
The second step is to study the effect of factors like sleep, exercise and diet, on the illness.
The third step is to stabilize mood symptoms by use of appropriate treatment.
The fourth and final step is to adjust to a new level of emotional stability and undo the effects of MDI on self-esteem, as well as family, social and occupational life.
The process is similar to the repair of a car. Let’s imagine that a car is working on three cylinders only and this primary problem has caused, over time, a series of secondary problems.
- The first step involves a survey of the car and how it functions or malfunctions as it is.
- The second step requires careful understanding of the effects of the different variables on the functioning of the car.
- The third step requires fixing the broken cylinder.
- The fourth and final step is the fine-tuning of the engine and of all the minor malfunctions caused by the broken cylinder.
Step 1-OBSERVATION
Observing behavior and mood changes is not easy. Most of the time, rather than observe and describe mood and behavior, we label and judge what we observe. It is also quite difficult to observe one’s own behavior and remain objective.
Events and reactions to events occur constantly, and it is unusual for someone to remember carefully how one behaved or felt just a few days before. Also, patterns of behavior or mood change can be quite difficult to identify if one is not able to observe these changes over extended periods of time.
For all these reasons, it is very useful to keep notes and organize them chronologically. This process is called keeping a mood chart.
Charting changes of mood, physical and mental activity is extremely useful in order to have a clear idea of the severity of the problem. Only careful observation over time can provide evidence that changes of mood or energy are causing problems to the individual. Over time, it becomes clear what areas of one’s life is affected (family, work, finances etc). (Life chart)
If this process is conducted with an experienced clinician, patterns of recurrence of symptoms can be identified. The process of observation can also provide clear targets for treatment interventions by clearly defining baseline functioning and symptoms.
Several areas require monitoring and multiple daily entries are often needed. For instance, one might rate sleep in the morning, while the memory of the last night’s sleep is still fresh in the mind. By lunchtime, one can rate mood, activity and thinking for the morning, and before going to bed take notes on the afternoon and evening hours.
The areas that require observation can roughly be grouped in Mood, Activity and Thinking.
Mood states can change rapidly, spontaneously or in response to an event. The change can be sudden or gradual and the new mood state can last for minutes, hours or days. One should always try to identify the precipitant to a mood change, both external (an event) or internal (a memory or an association).
Activity levels can be observed more easily, as one can better rate productivity, physical energy and endurance, or lack thereof.
Thinking needs to be rated in quantity (many vs. few thoughts), quality (racing vs. sluggish, sharp vs. confused) and focus (good vs. poor concentration, distractibility vs. attention). The quality of our mood affects the content of our thoughts: many thoughts would translate in multiple worries during depression or in many projects and ideas during euphoric hypomania or mania.
Step 2-CORRELATION
By observing the effect of several variables on the intensity of symptoms, the individual might begin to recognize that sleep deprivation increases irritability or anxiety or that exercise improves mood and sleep. For many people, the effect of caffeine becomes apparent only when caffeine intake and sleep duration or quality are correlated. Mood changes in relation to changes of sleep pattern or changes of season might come as a surprise and also result in lifestyle changes with beneficial effects. The effect of alcohol and other drugs on mood swings can become apparent over time and might provide the motivation for sobriety.
Step 3-STABILIZATION
Remission of symptoms can be a temporary change in the course of the illness, brought about by treatment or occurring spontaneously. Remission does not mean that the illness is cured, as it can become active again. However, obtaining remission of MDI allows the patient to live a relatively normal life and is the goal of most treatments used.
As MDI manifests with different and sometimes opposite clinical presentations, it is important to distinguish between antimanic, antidepressant and mood-stabilizing treatments. Treatment modalities can be broadly classified as pharmacological and non-pharmacological.
Pharmacological treatments include:
Lithium Salts
Anticonvulsants
Antidepressants
Antipsychotics
Miscellaneous
Non-pharmacological treatments include:
Psychotherapy
Lifestyle
Light treatment
ECT
r-TMS
Lithium salts were first reported to be effective in the treatment of Mania by Cade in 1949. Lithium is effective both as an antimanic and as a mood-stabilizing agent.
The use of Lithium as an antimanic agent often requires doses higher than those required for maintenance treatment. Cade's rapid titration has been recently found to be effective in controlling manic symptoms among inpatients with Mania.
The efficacy Lithium as a maintenance treatment in all forms of MDI has been demonstrated by reduced rates of hospitalization, decrease in frequency and severity of symptoms, improved psychosocial functioning, decreased rate of suicide, and worsening of course of illness after treatment discontinuation.
Anticonvulsants, like Carbamazepine and Valproic Acid and Valproate have been studied and used as antimanic and mood stabilizing agents since the late '70's and early '80's. More recently other anticonvulsants have been used in combination with other treatments for MDI.
Valproic Acid and Sodium Divalproex have been studied as maintenance treatment for patients with Bipolar disorder, and found to be more effective than Lithium in mixed manic states and in some rapid cycling forms of MDI.
The Pharmacological Treatment of Pediatric BD
Controlling the intensity, the duration and the frequency of episodes of MDI usually requires the use of medications. However, psychotherapy can help the patient with MDI learn how to manage their illness.
Several areas of treatment are included in the broad category of psychotherapy:
• Development of insight and self-monitoring of behavior and mood are the most important task of psychotherapy.
• Education about the illness and its treatment is often necessary to create the conditions for treatment compliance and lifestyle changes (sobriety, regular sleep schedule) to help mood stabilization.
• Support and assistance in managing stressful events and in addressing the consequences of MDI on one’s social, occupational, educational and financial life.
One of the most fascinating aspects of MDI is the patients’ lack of awareness of the illness. The medical term for this ‘deficit’ is anosognosia (from the Greek, lack of awareness of one’s illness).
The inability to recognize that changes of mood and behavior are due to an illness is an obstacle to seeking or continuing treatment.
This blind spot is often the cause of confusion and anger among relatives and friends, as it appears to be willful denial of the obvious. In a letter to a patient, a relative wrote:
“It’s all so predictable that it seems impossible you can’t see it. When you’re depressed you insist you’ll never feel better and when you’re manic you insist you’ll never feel depressed again. When you’re depressed, you insist you never had any real friends and when you’re manic you feel that everyone you know is a good friend. When you’re depressed you believe you’re utterly worthless and without redemption. And, when you’re manic you believe you’re God’s gift to mortals.
Why are you unwilling to accept the fact that it is your body, perhaps exacerbated by real events in your life, that throws you into highs and lows? When you’re in a manic phase you persistently condemn Lithium as something totally artificial and hypocritical, yet you eagerly smoke grass.
The reason I feel so utterly convinced that this is biochemical is because your patterns have been so predictable and you live your life swinging from high to low.”
A powerful tool in developing insight is observation and recording of mood and behavior over time. See Observation.