A. Biomedical Therapies: Treatment of bi-polar disorder depends on the specific form of be-havioral disorder at presentation. Lithium carbonate or divalproex represents the preferred initial intervention for the acute manic state, even though 10-14 days may be required before full effect is achieved. A favorable response is reported in 65-75% of bipolar manic patients. Complications are relatively infrequent, but a transient “rebound” depression following resolution of a manic state is not uncommon. Overall response to lithium appears to improve as duration of treatment continues, resulting in a dramatic decrease in morbidity and mortality over the lifetime of the individual. The degree of psychomotor activation and the fragile structure of the treatment alliance in acute mania require that supplemental treatment with faster-acting neuroleptics or benzodiazepines be instituted in most cases. Chronic treatment with neuroleptics is to be avoided, as the risk of tardive dyskinesia is increased in mood disorders.
For patients who do not respond satisfactorily to lithium or divalproex, the anticonvulsant drugs carbamazepine, lamotrigine, or gabapentin may be tried; studies show that these drugs have acute antimanic and possibly antidepressant effects in bipolar illness. Clonazepam and the calcium channel antagonist verapamil have emerged as other empirical alternatives, but these should not be considered agents of first choice. Treatment resistance may require combination therapy. Treatment of the depressive phase of bipolar illness is particularly problematic, as antidepressants may precipitate mania or result in more rapid cycling.
B. Psychosocial Therapies: Some form of psychosocial intervention is almost always indicated in the treatment of bipolar disorder, although its nature and extent will necessarily depend on the degree of disruption of family and financial situations, the baseline character of the individual, and the response to somatic treatment. The nature of the biological contribution to the disorder makes it almost impossible to ascertain in advance what the individual’s ongoing psychosocial needs might be after acute symptoms subside. Some patients with bipolar disorder have infrequent recurrences, experience long symptom-free intervals, and are able to lead productive lives. Others may have a particularly malignant form of the syndrome or may exhibit pathological degrees of denial and lead turbulent lives calling for active psychosocial involvement by the therapist. Manual-based psychoeducational treatments specific to bipolar disorder and employing cognitive-behavioral strategies have recently been developed. Patients with bipolar disorder may also benefit from interventions that help to establish life-style regularity.
