Treatment-Resistant Bipolar Disorder - Practical Management

Practical Management

Management of patients with treatment-resistant bipolar disorder is complicated by the need to be vigilant about the possibility of affective switch, as well as the current symptomatology targeted for treatment. Self-reporting may be the only available means of evaluating the patient's illness, yet this subjective information is itself colored by the pathological mood state. In addition, when bipolar disorder is associated with concurrent medical and psychiatric conditions, the treatment process becomes more complex. Using a systematic general approach to evaluation and treatment enables the treating psychiatrists to utilize an array of clinical tools necessary to meet the needs of these patients. These include daily charting of mood and treatments and sequencing treatments at each clinical decision point using a multiphase treatment strategy.

General Treatment Approach
Establish treatment alliance After diagnosing bipolar illness, the single most important element is to establish a therapeutic alliance between patient and psychiatrist. Providing explicit detailed instructions and education about the illness and its treatment and discussing the anticipated problems in management will help establish this alliance.

The psychiatrist should make clear that, for the purpose of treating the mood disorder, the patient and psychiatrist are entering into a partnership. The goals of this alliance are to ensure the patient's safety, to treat acute episodes, to attempt to prevent recurrence, and to maximize the patient's quality of life between episodes. For most patients, these primary goals can be incorporated into an individualized written treatment contract authored by the patient with input from care providers, family, and friends. The contract sets out the parameters by which normal mood, depression, and mood elevation will be assessed and formulates a treatment plan for each phase of the illness. (Sample contracts and directions for writing treatment contracts are available at the Web site of the Harvard Bipolar Research Program, http://www.manicdepressive.org.)

Chart mood and treatments Mood charting aids successful treatment and should be done by both the treating psychiatrist and the patient. All patients should be encouraged to chart their mood, sleep pattern, and treatment on a daily basis. At follow-up, psychiatrists can review the patient's chart and incorporate this information into a monthly mood chart. The data accumulated over time in the mood charts provide a record of typical precipitants, frequency and duration of episodes, and possible seasonality of the illness. Knowledge of the individual patient's mood cycles often enables the psychiatrist to better judge the impact of treatments and determine the most appropriate duration for the continuation phase of treatment.