Expert Consensus Treatment Guidelines for Bipolar Disorder:
A Guide for Patients and Families

WHAT IS BIPOLAR DISORDER?

Why is bipolar disorder called an illness?

Everyone has ups and downs in mood-happiness, sadness, and anger are normal emotions and an essential part of everyday life. In contrast, bipolar disorder is a medical condition in which people have mood swings out of proportion, or totally unrelated, to things going on in their lives. These swings affect thoughts, feelings, physical health, behavior, and functioning. Bipolar disorder is not your fault, nor is it the result of a "weak" or unstable personality. It is a treatable medical disorder for which there are specific medications that help most people.

When does bipolar disorder begin?

Bipolar disorder usually begins in adolescence or early adulthood, although it can sometimes start in early childhood or as late as the 40s or 50s. When someone over 50 has a manic episode for the first time, the cause is more likely to be a problem imitating bipolar disorder (e.g., neurological illness or the effects of drugs, alcohol, or some prescription medications).

Why is it important to diagnose and treat bipolar disorder as early as possible?

On average, people with bipolar disorder see 3-4 doctors and spend over 8 years seeking treatment before they receive a correct diagnosis. Earlier diagnosis, proper treatment, and finding the right medications can help people avoid the following:

• Suicide. The risk is highest in the initial years of the illness.
• Alcohol/substance abuse. More than 50% of those with bipolar disorder abuse alcohol or drugs during their illness.
• Marital and work problems. Prompt treatment improves the prospects for a stable marriage and productive work.
• Treatment difficulties. There is evidence that the more mood episodes a person has, the harder it is to treat each subsequent episode and the more frequent episodes may become. (This is sometimes referred to as "kindling"-i.e., once the fire has started and spread, it is harder to put out.)
• Incorrect, inappropriate, or partial treatment. A person misdiagnosed as having depression alone instead of bipolar disorder may incorrectly receive antidepressants alone without anti-manic medication. This can trigger manic episodes and make the overall course of the illness worse.

Is bipolar disorder inherited?

Bipolar disorder tends to run in families. Researchers have identified a number of genes that may be linked to the disorder, suggesting that several different biochemical problems may occur in bipolar disorder (just as there are different kinds of arthritis). However, if you have bipolar disorder and your spouse does not, there is only a 1 in 7 chance that your child will develop it. The chance may be greater if you have a number of relatives with bipolar disorder or depression.

What causes bipolar disorder?

There is no single, proven cause of bipolar disorder, but research strongly suggests that it is often an inherited problem related to a lack of stability in the transmission of nerve impulses in the brain. This biochemical problem makes people with bipolar disorder more vulnerable to emotional and physical stresses. If there is an upsetting life experience, substance use, lack of sleep, or other excessive stimulation, the normal brain mechanisms for restoring calm functioning don't always work properly.

This theory of an inborn vulnerability interacting with an environmental trigger is similar to theories proposed for many other medical conditions. In heart disease, for example, a person might inherit a tendency to have high cholesterol or high blood pressure, which cause gradual damage to the heart's supply of oxygen. During stress, such as physical exertion or emotional tension, the person might suddenly develop chest pain or have a heart attack if the oxygen supply becomes too low. As with heart disease and other medical conditions, treatment for bipolar disorder focuses on taking the right medications and making life-style changes to reduce the risk of mood episodes.

What are the symptoms of bipolar disorder?

Over the course of bipolar disorder, four different kinds of mood episodes can occur:

1. Mania (manic episode). Mania often begins with a pleasurable sense of heightened energy, creativity, and social ease-feelings that can quickly escalate out of control into a full-blown manic episode. People with mania typically lack insight, deny anything is wrong, and angrily blame anyone who points out a problem. In a manic episode, the following symptoms are present for at least 1 week, to the point where the person has trouble functioning in a normal way:

• Feeling unusually "high," euphoric, or irritable (or appearing this way to those who know you well)

Plus at least four (and often almost all) of the following:

• Needing little sleep yet having great amounts of energy
• Talking so fast that others can't follow your thinking
• Having racing thoughts
• Being so easily distracted that your attention shifts between many topics in just a few minutes
• Having an inflated feeling of power, greatness, or importance
• Doing reckless things without concern about possible bad consequences-such as spending too much money, inappropriate sexual activity, making foolish business investments.

In very severe cases, there may be psychotic symptoms such as hallucinations (hearing or seeing things that aren't there) or delusions (firmly believing things that aren't true)

2. Hypomania (hypomanic episode). Hypomania is a milder form of mania with similar but less severe symptoms and less impairment. In hypomanic episodes, the individual may have an elevated mood, feel better than usual, and be more productive. These episodes often feel good and the quest for hypomania may even cause people to stop their medication. However, all too often there is a severe price to pay for hypomania-either escalation to mania or a crash to depression.

3. Depression (major depressive episode). In a full-blown "major" depressive episode, the following symptoms are present for at least 2 weeks and make it difficult for you to function:

• Feeling sad, blue, or down in the dumps or losing interest in things you normally enjoy

Plus at least four of the following:

• Trouble sleeping or sleeping too much
• Loss of appetite or eating too much
• Problems concentrating or making decisions
• Feeling slowed down or feeling too agitated to sit still
• Feeling worthless or guilty or having very low self-esteem
• Loss of energy or feeling tired all of the time
• Thoughts of suicide or death.

Severe depressions may also include hallucinations or delusions.

4. Mixed Episode. Perhaps the most disabling episodes are those that involve symptoms of both mania and depression occurring at the same time or alternating frequently during the day. You are excitable or agitated as in mania but also feel irritable and depressed, instead of feeling on top of the world.

What are the different patterns of bipolar disorder?

People vary in the types of episodes they usually have and how often they become ill. Some people have equal numbers of manic and depressive episodes; others have mostly one type or the other. The average person with bipolar disorder has four episodes during the first 10 years of the illness. Men are more likely to start with a manic episode, women with a depressive episode. While a number of years can elapse between the first two or three episodes of mania or depression, without treatment most people eventually have more frequent episodes. Sometimes these follow a seasonal pattern (for example, getting hypomanic in the summer and depressed in the winter). A small number of people cycle frequently or even continuously through the year.

Episodes can last days, months, or sometimes even years. On average, without treatment, manic or hypomanic episodes last a few months, while depressions often last well over 6 months. Some individuals recover completely between episodes and may go many years without any symptoms, while others continue to have low-grade but troubling depression or mild swings up and down.

Special terms are used to describe common patterns:

• In Bipolar I Disorder, a person has manic or mixed episodes and almost always has depressions as well. If you have just become ill for the first time and it was with a manic episode, your are still considered to have bipolar I disorder. It is likely that you will go on in the future to have episodes of depression, as well as mania-unless you get effective treatment.
• In Bipolar II Disorder, a person has only hypomanic and depressive episodes, not full manic or mixed episodes. This type is often hard to recognize because hypomania may seem "supernormal," especially if the person feels happy, has lots of energy, and avoids getting into serious trouble. If you have bipolar II disorder, you may overlook hypomania and seek treatment only for your depressions. Unfortunately, if the only medication you receive is an antidepressant, there is a risk that the medication may trigger a "high" or set off more frequent cycles.
• In Rapid Cycling Bipolar Disorder, a person has at least four episodes per year, in any combination of manic, hypomanic, mixed, or depressive episodes. This course pattern is seen in approximately 5%-15% of patients with bipolar disorder. It sometimes results from "chasing" depressions too hard with antidepressants, which may trigger a high, followed by a crash (i.e., you keep going up and down as if on a roller coaster).
• Schizoaffective Disorder: This term is used to describe a condition that in some ways overlaps with bipolar disorder. In addition to mania or depression, there are persistent psychotic symptoms (hallucinations or delusions) during times when mood symptoms are under control. In contrast, in bipolar disorder, any psychotic symptoms that occur during severe episodes of mania or depression end as mood returns to normal.

HOW IS BIPOLAR DISORDER TREATED?

Stages of Treatment

• Acute treatment phase: Treatment is aimed at ending the current manic, hypomanic, depressive, or mixed episode.
• Preventive treatment: Medication is continued on a long-term basis to prevent future episodes.

Components of Treatment

• Medication: prescribed for nearly all patients during acute and preventive phases.
• Education: crucial in helping patients and families learn how to best manage bipolar disorder and prevent its complications.
• Psychotherapy: helpful for many patients and families in solving problems and dealing with stress; should not be used alone, but rather should be combined with medication (except in special situations such as pregnancy).

MEDICATION

The two most important types of medication used to control the symptoms of bipolar disorder are mood stabilizers and antidepressants. Your doctor may also prescribe other medications to help with insomnia, anxiety, restlessness, or psychotic symptoms.

What are mood stabilizers?

Mood stabilizers are used to improve symptoms during acute manic, hypomanic, and mixed episodes; they may sometimes also reduce symptoms of depression. They are the mainstay of long-term preventive treatment for both mania and depression. Three mood stabilizers are widely used in the United States:

• Lithium (Eskalith, Lithobid, Lithonate, and other brands)
• Valproate (most commonly used as divalproex [Depakote])
• Carbamazepine (Tegretol).

Fortunately, each of the three mood stabilizers has different chemical actions in the body. If one does not work for you, or you have persistent side effects, your doctor can suggest another, or combine two medications at doses you can manage. For all three mood stabilizers, blood tests are used to determine the correct dose and to monitor safety.

Selecting a mood stabilizer for an acute manic episode

The first line drugs for the acute phase treatment of a manic episode are lithium and valproate. In choosing between them, your doctor will take into account whether either of these medicines has worked for you in the past or whether there are particular side effects that might affect your preference. All other things being equal, the initial decision may be based on the subtype of bipolar disorder that you have: experts prefer lithium for patients with euphoric (overly happy) moods and valproate for patients with mixed features (manic episodes with a very unhappy or irritable mood) or for patients who are rapid cyclers.

Acute treatment with lithium or valproate usually helps significantly in a few weeks. However, if the first medication does not work well enough, your doctor may switch you to the other or combine them. Carbamazepine is also useful as a backup, especially for mixed episodes or rapid cycling.

Selecting additional medications for a manic episode

Two types of medications are used for insomnia and agitation during a manic episode:

• Antianxiety medicines such as lorazepam (Ativan) and clonazepam (Klonopin)
• Antipsychotic medicines such as haloperidol (Haldol) and perphenazine (Trilafon).

During acute treatment of mania, you may need one of these to help you sleep and to reduce your mental or physical agitation. Antipsychotic medication is helpful if you have delusions, hallucinations, or severe agitation. These additional medicines may also be needed because it may take a few weeks to get the full effect of mood stabilizers. Fortunately, antianxiety and antipsychotic medicines work rapidly and can be given by mouth or by injection. If you are so severely manic that you don't recognize the symptoms of your illness and refuse medication, injections may literally help save your life by preventing you from acting in impulsive, irrational, or dangerous ways.

Both antianxiety and antipsychotic medicine can cause drowsiness as a side effect. Antipsychotic medicines may also cause muscle stiffness, restlessness, and other side effects. If you have problems with side effects, be sure to tell your doctor, who can adjust the dose or add another medication to help. As you recover, doses of these medicines are usually lowered. They may be discontinued within a few weeks or months.

Selecting an antidepressant

Although mood stabilizers by themselves, especially lithium, can sometimes pull you out of a depression, you may also need to take a specific antidepressant medication to treat the depressive episode. However, if given alone, antidepressants can sometimes cause a major problem in bipolar disorder by pushing your mood up too high (causing hypomania, mania, or even rapid cycling). Therefore, in bipolar disorder, antidepressants are given together with a mood stabilizer to prevent an "overshoot."

Antidepressants usually take several weeks to begin showing full effects-so don't get discouraged if you don't feel better right away. Although the first drug tried will work for the majority of patients, it is common to go through two or three trials of antidepressants before finding one that is right for you. While waiting for the antidepressant to work, your doctor may also give you a sedating medication to help with sleep, anxiety, or agitation. After you recover from the depression, your doctor will help you decide whether to taper off the antidepressant.

Many types of antidepressants are available with different chemical mechanisms of action. All can be effective, but most experts consider the following two types to be first choices in bipolar disorder:

• Bupropion (Wellbutrin)
• Selective serotonin reuptake inhibitors: fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft).

If these do not work, or if they cause unpleasant side effects, the other choices are:

• Mirtazapine (Remeron)
• Monoamine oxidase inhibitors: phenelzine (Nardil), tranylcypromine (Parnate). These may be very effective if other drugs do not help, but also require you to stay on a special diet to avoid dangerous side effects. (Your doctor will give you a list of foods and medications to be avoided).
• Nefazodone (Serzone)
• Tricyclic antidepressants: amitriptyline (Elavil), desipramine (Norpramin, Pertofrane), imipramine (Tofranil), nortriptyline (Pamelor). Tricyclics may be more likely to cause side effects, or to set off manic episodes or rapid cycling.
• Venlafaxine (Effexor).

Electroconvulsive therapy

Although electroconvulsive therapy (ECT) has had a lot of unfair publicity, it can be a life-saver and is often the safest and most effective treatment for psychotic depression. ECT may also be needed if you are severely ill and cannot wait for medicines to work, if you have had several unsuccessful trials of antidepressant medications, or if you have medical conditions or pregnancy that make drug therapy less safe. Remember ECT is much safer and more comfortable than it has been portrayed in Hollywood movies and can be remarkably effective. Like all treatments, ECT has potential side effects. Although there is usually short-term memory disturbance, most ECT patients feel that the benefits far outweigh the prospect of suffering from long-term severe, unremitting depression.

About hospitalization

Treatment in the hospital is sometimes needed but is usually brief (1-2 weeks). Hospitalization can be essential to prevent self-destructive, impulsive, or aggressive behavior that the person will later regret. Manic patients often lack insight that they are ill and require hospitalization. Research has shown that after recovery, most manic patients are grateful for the help they received, even if it was given against their will at the time. During depression, hospitalization may be needed if a person becomes very suicidal. Hospitalization is also used for individuals who have medical complications that make it harder to monitor medication and for people who cannot stop using drugs or alcohol. Remember, early recognition and treatment of manic and depressive episodes can lower the chances of hospitalization.

Medication for lifetime prevention

Successful management of bipolar disorder requires a great deal from patients and families. There will almost certainly be many times when you will be sorely tempted to stop your medication because 1) you feel fine, 2) you miss the highs, or 3) you are bothered by side effects. If you stop your medication, you probably won't have an acute episode immediately in the next days or weeks, but eventually you will probably have a relapse. Don't forget the kindling model, which suggests that each episode worsens your chances of having a smooth long-term course.

Sometimes the diagnosis is uncertain after a single episode and it is possible to taper the medication after about a year. However, if you have had only one episode of mania but have a very strong family history (suggesting you may have inherited the disorder), or if the episode was so severe that it almost ruined your life, you should strongly consider taking medication for several years if not for life. If you have had two or more manic or depressive episodes, experts strongly recommend taking preventive medication indefinitely.

How often does preventive medication work? What if I start to feel symptoms?

Mood stabilizers (lithium, valproate, carbamazepine) are the core of prevention. About one in three people with bipolar disorder will be completely free of symptoms by taking mood stabilizing medication for life. Most people experience a great reduction in how often they become ill or in the severity of each episode. Don't be discouraged if you occasionally feel that you might be going into a manic or depressive episode. Always report changes to your doctor immediately, because adjustments in your medicine at the first warning signs can usually restore a normal mood. Sometimes it just takes a slight increase in the blood level of your mood stabilizer, or other medicines may need to be added. Medication adjustments are usually a routine part of treatment (just as insulin doses are changed from time to time in diabetes). Never be afraid to report changes in symptoms-they usually don't require any very dramatic change in treatment and your doctor will be eager to help.

Take your medicine as directed even if you have felt better for a long time.

Sometimes people who have felt well for a number of years hope that the bipolar disorder has gone away and that they don't need medicine anymore. Unfortunately, the medications do not "cure" bipolar disorder. Stopping them even after many years of good health can lead to a disastrous relapse, sometimes within a few months. Generally, the only times you should seriously think of stopping preventive medication are if you want to become pregnant or have a serious medical problem that would make the medicines unsafe. Even these may not be absolute reasons to stop. Always talk these situations over carefully with your doctor. If you are going to stop, it is important to taper the medicines very slowly (over weeks to months).

Tell your doctor right away about any side effects you have.

Some people have different side effects than others and one person's side effect (e.g., unpleasant sleepiness) may actually help another person (e.g., someone who suffers from insomnia). The side effects you may get from medication depend on:

• The type and amount of medicine you take
• Your body chemistry (including water loss due to hot weather)
• Your age
• Other medicines you are taking
• Other medical conditions you have.

At least half of those who take mood stabilizers have side effects (See table below). These are especially common if high doses and a combination of medicines are needed during the acute phase of treatment. Lowering doses and decreasing the number of medicines usually helps, but some people may have severe enough side effects to require a change of medicine. Side effects tend to be worse early in the treatment, but some people who have taken lithium for 20 years or longer with good results develop problems with side effects or toxicity as they become older. Fortunately, valproate or carbamazepine are often excellent alternatives as long the switch is made gradually. Valproate appears to cause the fewest side effects during long-term treatment.

If side effects are a problem for you, there are a number of approaches your doctor may suggest:

• Reducing the amount of medicine you take
• Trying a different medicine to see if there are fewer or less bothersome side effects
• Taking your medicine at night.

Remember: Changing medicine is a complicated decision. It is dangerous to make changes in your medicine on your own!

EDUCATION

You and your family or loved ones will benefit by learning as much as possible about how to live with bipolar disorder. Here are the most commonly asked questions about lifestyle changes:

Is there anything I can do to help my disorder?

Absolutely yes. First, become an expert on your illness. Since bipolar disorder is a lifetime condition (like many other medical disorders such as diabetes), it is essential that you and your family or others close to you learn all about it and its treatment. Read books, attend lectures, talk to your doctor or therapist, and consider joining a chapter of the Depressive and Manic-Depressive Association or the National Alliance for the Mentally Ill near you to stay up to date and learn from others how to manage day-to-day life and your medications. Being an informed patient is the surest path to success.

You can help reduce the minor mood swings and stresses that sometimes lead to more severe episodes by paying attention to the following:

• Maintain a stable sleep pattern. Go to bed around the same time each night and get up about the same time each morning. Disrupted sleep patterns appear to cause chemical changes in your body that can trigger mood episodes. If you have trouble sleeping, or are sleeping too much, be sure to tell your doctor. If you have to take a trip where you will change time zones and might have jet lag, get advice from your doctor.
• Maintain a regular pattern of activity. Don't be frenetic or drive yourself impossibly hard.
• Do not use alcohol or illicit drugs. These chemicals cause an imbalance in how the brain works. This can, and often does, trigger mood episodes and interferes with your medications. You may sometimes find it tempting to use alcohol or illicit drugs to "treat" your own mood or sleep problems-but this almost always makes matters worse. If you have a problem with substances, ask your doctor for help and consider self-help groups such as Alcoholics Anonymous.
• Be very careful about "everyday" use of small amounts of alcohol, caffeine, and some over-the-counter medications for colds, allergies, or pain. Even small amounts of these substances can interfere with sleep, mood, or your medicine. It may not seem fair that you have to deprive yourself of a cocktail before dinner or morning cup of coffee, but for many people this can be the "straw that breaks the camel's back."
• Support from family and friends can help a lot. However, you should also realize that it is not always easy to live with someone who has mood swings. If all of you learn as much as possible about bipolar disorder, you will be better able to help reduce the inevitable stress and mutual criticisms that the disorder can cause. Even the "calmest" family will sometimes need outside help in dealing with the stress of a loved one who has continued symptoms. Ask your doctor or therapist to help educate both you and your family about bipolar disorder. Family therapy or joining a support group can be very helpful.
• Try to reduce stress at work. Of course, you want to do your very best at work, but always remember that avoiding relapses is job #1 and in the long run will increase your overall productivity. Try to keep predictable hours that allow you to get to sleep at a reasonable time. If mood symptoms interfere with your ability to work, discuss with your doctor whether to "tough it out" or take time off. How much to discuss openly with employers and coworkers is ultimately up to you. If you are unable to work, you might have a family member tell your employer that you are not feeling well and that you are under a doctor's care and will return to work as soon as possible.

What are the early warning signs of a new mood episode?

Early signs of a mood episode differ from person to person and are different for mood elevations and depressions. The better you are at spotting your own early warning signs, the faster you can get help to prevent a full-blown episode. Each person gets to know certain inner feelings that indicate when a mood change is developing. Slight changes in mood, sleep, energy, self-esteem, sexual interest, concentration, willingness to take on new projects, thoughts of death (or sudden optimism), and even changes in dress and grooming, may be early warnings of an impending high or low. Pay special attention to a marked change in your sleep pattern, since this is a common clue that trouble is brewing. Since loss of insight may be an early sign of an impending mood episode, don't hesitate to ask your family to watch for early warnings that you may be missing.

What should you do when you feel like quitting your treatment?

It is normal to have occasional doubts and discomfort with treatment. Be sure to discuss all your concerns and any discomforts with your doctor, therapist, and family. If you feel a treatment is not working or is causing unpleasant side effects, tell your doctor-don't stop or adjust your medication on your own. Symptoms that come back after stopping medication are sometimes much harder to treat. You and your doctor can work together to find the best and most comfortable medicine for you. Also, don't be shy about asking for a second opinion from another clinician. Consultations can be a great help.

How often should I talk with my doctor?

During acute mania or depression, most people talk with their doctor at least once a week, or even daily, to monitor symptoms, medication doses, and side effects. As you recover, contact becomes less frequent; once you are well, you might see your doctor for a quick review every few months.

Regardless of scheduled appointments or blood tests, call your doctor if you have:

• Suicidal or violent feelings
• Changes in mood, sleep, or energy
• Changes in medication side effects
• A need to use over-the-counter medications such as cold medicine or pain medicine
• Acute general medical illnesses or a need for surgery, extensive dental care, or changes in other medicines you take.

How can I monitor my own treatment progress?

Keeping a mood chart is a good way to help you, your doctor, and your family manage your disorder (see the sample chart below). This is a diary in which you keep track of your feelings, activities, sleep patterns, medication and side effects, and important life events. Often just a quick daily entry about your mood is all that is needed. Many people like using a simple, visual scale- from the "most depressed" to the "most manic" you ever felt, with "normal" being in the middle. Noticing changes in sleep, stresses in your life, and so forth, may help you identify what are the early warning signs of mania or depression for you. Keeping track of your medicines over many months or years will also help you figure out which ones work best for you.

What can families and friends do to help?

If you are a family member or friend of someone with bipolar disorder, become informed about the patient's illness, its causes, and its treatments. Talk to the patient's doctor if possible. Learn the particular warning signs for how that person acts when he or she is getting manic or depressed. Try to plan, while the person is well, for how you should respond when you see these symptoms. You will be thanked later!

• Encourage the patient to stick with the treatment, see the doctor, and avoid alcohol and drugs. If the patient has been on a certain treatment for an extended period of time with little improvement in symptoms or has troubling side effects, encourage the person to ask the doctor about other treatments or getting a second opinion. Offer to come to the doctor with the person to share your observations.
• If your loved one becomes ill with a mood episode and suddenly views your concern as interference, remember that this is not a rejection of you-it is the illness talking.
• Learn the warning signs of suicide. Take any threats the person makes very seriously. If the person is "winding up" his or her affairs, talking about suicide, frequently discussing methods of follow-through, or exhibiting increased feelings of despair, step in and seek help from the patient's doctor or other family members or friends. Confidentiality is important but does not stack up against the risk of suicide. Call 911 or a hospital emergency room if the situation becomes desperate. Encourage the person to realize that suicidal thinking is a symptom of the illness. Always stress that the person's life is important to you and to others and that his or her suicide would be a tremendous burden and not a relief.
• With someone prone to manic episodes, take advantage of periods of stable mood to arrange "advance directives"-plans and agreements you make with the person when he or she is stable to try to avoid problems during future episodes of illness. You should discuss and set rules that may involve safeguards such as withholding credit cards, banking privileges, and car keys. Just like suicidal depression, uncontrollable manic episodes can be dangerous to the patient. Hospitalization can be life-saving in both cases.
• If you are helping care for someone at home, try, if possible, to take turns "checking in" on a patient's needs so that the patient doesn't overburden one family member or friend.
• When patients are recovering from an episode, let them approach life at their own pace, and avoid the extremes of expecting too much or too little. Don't push too hard. Remember that stabilizing mood is the most important first step towards a full return to function. On the other hand, don't be overprotective. Try to do things with them, rather than for them, so that they are able to regain their sense of self-confidence.
• Treat people normally once they have recovered, but be alert for telltale symptoms. If there is a recurrence of the illness, you may notice it before the person does. In a caring manner, indicate the early symptoms and suggest a discussion with the doctor.
• Both you and the patient need to learn to tell the difference between a good day and hypomania, and between a bad day and depression. Patients taking medication for bipolar disorder, just like everyone else, do have good days and bad days that are not part of their illness.
• Take advantage of the help available from support groups.

PSYCHOTHERAPY

Psychotherapy can play an important role in reducing the stresses that can trigger manic and depressive episodes. Psychotherapy is much more likely to be helpful for depression than mania, since patients in a manic phase often have trouble retaining what they learn.

Types of psychotherapy

Three types of psychotherapy appear to be particularly useful for depression and may also help during recovery:

• Behavioral therapy focuses on behaviors that can increase or decrease stress and ways to increase pleasurable experiences that may help improve depressive symptoms.
• Cognitive therapy focuses on identifying and changing the pessimistic thoughts and beliefs that can lead to depression.
• Interpersonal therapy focuses on reducing the strain that a mood disorder may place on relationships.

Psychotherapy can be individual (only you and a therapist); group (with other people with similar problems); or family. The person who provides therapy may be your doctor or another clinician (e.g., a social worker, psychologist, nurse, or counselor) who works in partnership with your doctor.

How to get the most out of psychotherapy

• Keep your appointments.
• Be honest and open.
• Do the homework assigned to you as part of your therapy.
• Give the therapist feedback on how the treatment is working.

During depression, psychotherapy usually works more gradually than medication and may take 2 months or more to show its full effects. However, the benefits may be long lasting. Remember that people can react differently to psychotherapy, just as they do to medicine.

SUPPORT GROUPS

Support groups are an invaluable part of treatment. These groups provide a forum for mutual acceptance, understanding, and self-discovery. Participants develop a sense of camaraderie with other attendees because they have all lived with mood disorders. People new to mood disorders can talk to others who have learned successful strategies for coping with the illness.

National Depressive and Manic-Depressive Association (National DMDA)

Founded in 1986 by and for persons with depressive illnesses and their families, National DMDA is the largest illness-specific, patient-run organization in the nation. A nonprofit corporation, National DMDA is guided by a Scientific Advisory Board of some 60 distinguished researchers and practicing mental health professionals; a national Board of Directors comprised of patients and family members; and a grassroots network of 275 chapters throughout the United States, Canada, and countries overseas.

Support groups are a major function of local DMDA chapters. The groups have medical advisors and appointed facilitators, most of them patients or family members. Some chapters have lending libraries, fund-raisers, newsletters, and organized activities ranging from seminars to softball games.

The mission of National DMDA is to educate patients, families, professionals and the public concerning the nature of depressive and manic-depressive illnesses as medical diseases; to foster self-help for patients and families; to eliminate discrimination and stigma; to improve access to care; and to advocate for research toward the elimination of these illnesses.

National DMDA operates a bookstore, publishes a newsletter, holds conventions and conferences, has a National Speakers Bureau, and participates in national campaigns. To find out if there is a DMDA chapter or support group in your area or to learn more about National DMDA, call or write:

Other organizations

These other organizations have local chapters and can also help you locate support groups and information:

FOR MORE INFORMATION

National DMDA distributes free the booklet A Guide to Depressive and Manic-Depressive Illness: Diagnosis, Treatment and Support, along with a National DMDA bookstore catalog and chapter directory. The publications listed below also provide more information on bipolar disorder. Most are available from the National DMDA bookstore. To order these materials, call 800-82-NDMDA.

Medical information about bipolar disorder:

Cognitive-Behavioral Therapy for Bipolar Disorder. Basco MR and Rush AJ. Guilford, 1996.

The Depression Workbook: A Guide for Living with Depression and Manic Depression. Mary Ellen Copeland, MS. Newharbinger Publications, Inc., 1992.

Depressive Illness: The Medical Facts, the Human Challenge. National DMDA, rev. 1996.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). American Psychiatric Association, 1994.

Everyone Needs a Hand to Hold On To (18-minute video produced for National DMDA; comes with a discussion guide) 1995.

Living with Manic-Depressive Illness: A Guidebook for Patients, Families and Friends. National DMDA, available in early 1997. Comprehensive, fully updated 60-page guide to the illness.

Manic-Depressive Illness. Frederick K. Goodwin, MD, and Kay Redfield Jamison, PhD. Oxford University Press, 1990.

Structured Group Psychotherapy for Bipolar Disorder: The Life Goals Program. Bauer M and McBride L. Springer, 1996.

Dark Glasses and Kaleidoscopes: Living with Depression and Manic Depression (video); to be released in 1996.

Outstanding books by people with bipolar disorder or depression:

The Beast: A Reckoning with Depression. Tracy Thompson. G.P. Putnam's Sons, 1995.

A Brilliant Madness: Living with Manic-Depressive Illness. Patty Duke and Gloria Hockman. Bantam Books, 1992.

Call Me Anna: The Autobiography of Patty Duke. Patty Duke and Kenneth Turan. Bantam, 1987.

Darkness Visible: A Memoir of Madness. William Styron. Random House, 1990.

On the Edge of Darkness: Conversations About Conquering Depression. Kathy Cronkite. Doubleday, 1994.

An Unquiet Mind: A Memoir of Moods and Madness. Kay Redfield Jamison, PhD. Alfred A. Knopf, 1995.

Undercurrents: A Therapist's Reckoning With Her Own Depression. Martha Manning. Harper Collins, 1994.

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