Treatment Options in Bipolar Disorder: Mood Stabilizers

Charles L. Bowden, MD

Medscape Psychiatry & Mental Health eJournal. 1997;2(4) 

In This Article

Addressing Noncompliance

Noncompliance is probably the single most common reason for the failure of Li therapy. The first year after starting Li is a particularly high-risk period for noncompliance.[3] Patients may miss the elevated mood and the good feelings that are part of the disorder. Poor adherence to the drug regimen can also arise as a result of confusion secondary to the illness itself, or even as a side effect of drug treatment. For example, altered cognition, perception, and mood can predispose to noncompliant behavior. Adverse drug effects are also a major reason for noncompliance. Because the impact of noncompliance can be as devastating as that of nontreatment, it is imperative to prevent noncompliance, and to recognize it and intervene when it occurs.[3,7,8]

Accurate diagnosis and aggressive pharmacotherapy are especially important for younger patients, to help them to avoid disruption of social development and compromise of educational and occupational opportunities. Younger patients tend to be less compliant than older patients.[3,7,9]

Since noncompliance is reversible, unlike poor therapeutic response, education and counseling can effect improvement in symptoms. Educating patients about the importance of adhering to an effective drug regimen and making sure they understand the implications of discontinuing therapy are essential.[1,2,3]

Psychological interventions are also necessary for helping patients cope with the potentially devastating changes in self-perception and, often, in their interpersonal relationships.[10,11] Moreover, patients frequently use different criteria to judge treatment success than clinicians do. Such criteria as fewer or no hospitalizations or less need for adjunctive neuroleptics/antidepressant agents or even mood stabilizers represent treatment success for patients. Clinicians, on the other hand, focus on comparative effects of 1 drug over another (eg, differences between Li and anticonvulsants) or on the differences between treated and untreated illness. Day-to-day problems can be as compelling in determining patients' feelings about medications as dramatic differences in symptoms. Whereas the clinician may conclude that a given medication has excellent efficacy, the patient who continues to experience disruptive and upsetting mood swings will interpret the same evidence much more equivocally.[1,2,3]

Psychotherapy is also indicated as an adjunct to medication to help patients understand their illness and the role temperament plays, and to help them deal with issues of control.[10,11] Supportive interventions range from a brief consult with the prescribing physician to formal (individual and/or group) psychotherapy sessions. Indeed, the therapeutic relationship between patient and prescribing physician is often key to the patient's continued adherence to the maintenance regimen. Self-help groups and family counseling are also useful modalities.

Patients must be alerted to the symptoms of impending episodes, such as altered sleep patterns that often precede, accompany, or precipitate mania. They should be counseled to avoid situations that are likely to disrupt sleep and should be encouraged to establish and maintain a regular rhythm for activities of daily living--including meals, exercise, sleeping, and waking. A single night of unexplainable sleep loss should be taken as an early warning of possible impending mania. Not only do patients need to be forewarned about early symptoms, they need to be able to recognize drug side effects in order to address them and consult with their physician about the most appropriate management plan.[1,2,3,7]

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