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 Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS


Chapter 5 Bipolar Disorder

LEARNING OBJECTIVES FOR

BIPOLAR DISORDER

After reading this section, you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for Bipolar Disorder?
  2. What are the clinical descriptors for Bipolar Disorder?
  3. What are the symptoms common for Bipolar Disorder?
  4. What are the common populations which are treated for Bipolar Disorder?
  5. What are the common treatment settings for Bipolar Disorder?
  6. What are the Evidence Based Practices for treating Bipolar Disorder?
  7. What area the common psychopharmacological treatments for Bipolar Disorder?
  8. What are some common manuals, guideline books and client workbooks for treating Bipolar Disorder?
  9. What are some good references you can use to learn more in-depth information about Bipolar Disorder?

ICD-10-CM Codes for Bipolar in DSM-5

Bipolar Specifiers:

With anxious distress-specify current severity: Mild, Moderate, Moderate-Severe, Severe

With mixed features; With rapid cycling; With melancholic features; With atypical features; With mood-congruent psychotic features; With mood-incongruent psychotic features; With catatonia (use additional code F06.1); With peripartum onset; With seasonal pattern

F31.11 Bipolar I Disorder Current or most recent episode manic  Mild

F31.12 Bipolar I Disorder Current or most recent episode manic  Moderate

F31.13 Bipolar I Disorder Current or most recent episode manic  Severe

F31.2 Bipolar I Disorder Current or most recent episode manic with psychotic features

F31.73 Bipolar I Disorder Current or most recent episode manic in partial remission

F31.74 Bipolar I Disorder Current or most recent episode manic in full remission

F31.9 Bipolar I Disorder Current or most recent episode manic Unspecified

F31.0 Bipolar I Disorder Current or most recent episode hypomanic

F31.73 Bipolar I Disorder Current or most recent episode hypomanic in partial remission

F31.74 Bipolar I Disorder Current or most recent episode hypomanic in full remission

F31.9 Bipolar I Disorder Current or most recent episode hypomanic Unspecified

F31.31 Bipolar I Disorder Current or most recent episode depressed Mild

F31.32 Bipolar I Disorder Current or most recent episode depressed Moderate

F31.4 Bipolar I Disorder Current or most recent episode depressed Severe

F31.5 Bipolar I Disorder Current or most recent episode depressed with psychotic features

F31.75 Bipolar I Disorder Current or most recent episode depressed in partial remission

F31.76 Bipolar I Disorder Current or most recent episode depressed in full remission

F31.9 Bipolar I Disorder Current or most recent episode depressed unspecified

F31.9 Bipolar I Disorder Current or most recent episode unspecified

F31.81 Bipolar II Disorder Specify current or most recent episode: Hypomanic or Depressed. Specify course if full criteria for a mood episode are not currently met in partial remission or In full remission. Specify if full criteria for a mood episode are not currently met: Mild, Moderate, Severe

F31.0 Cyclothymic Disorder Specify if with anxious distress

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed) (DSM-5). Washington, DC: Author.

Laura: Bipolar Disorder


Laura was one of your best clients, she was always dutiful in making all her appointments but she continued to fight you about the need for her to be compliant in taking her lithium and antidepressants prescribed by her psychiatrist to address her Bipolar Disorder. She complained all the time about how the medications affected her negatively, she would not be as creative and involved in her work as graphic artist, she always felt tired and listless when on the meds and she resented that she needed to take those “pills” in order to fit in at home, on the job and in the community. She felt like she was being prejudiced and discriminated against because she needed to be on these meds.


On the other hand Laura admitted that when not taking her medications she was always feeling depressed and down. She said that yes when her mania kicked in she was as creative as any artist in her firm. She said however those times would make it impossible for her to relate appropriately with her co-workers and she would avoid any contact with office mates during her mania creative highs. She always wanted to let her bosses know that her creations they most liked were products of those highs. On the other hand she knew that if she did not get back on her medications for better control she would return to her use of alcohol “to help me chill out” but paying the price for it through DUIs, arguments with friends and other troubles in her apartment complex.


She admits that she is between a rock and a hard place but going back on her meds just feels like a defeat which she is not ready to accept. “So tell me what do you think I should do?”


You take a deep breath and get back to your old mantra: “It is your choice if you stay on your medications, but it also is your responsibility to accept the negative consequences which come from not taking them. It is your choice.”  Amazingly Laura looks up at you and there are tears in her eyes, saying: “I love your support and I know you are there for me and want only the best and I cannot believe that you have not given up on my like all my family members have. So I tell you I will try my best to get back on the wagon as long as you are there for me to help me through the down side of taking those meds.” We agreed we would work together and she made an appointment for her psychiatrist before leaving my office so that she could get back on track again. Prior to her leaving you give her a homework assignment to bring in to your next session.

Bipolar Disorder is a chronic mental health disorder which impedes the behavioral activation system in individuals (Hayden, Bodkins, Brenner, Shekhar, Nurnberger, O'Donnell and Hetrick, 2008). To effectively treat it, clincians must diagnose it early and accurately (Rouillon, Gasquet, Garay and Lancrenon, 2011), with as effective treatment approaches as possible (Morriss, 2008). Most importantly, the client must be willing to accept the chronic nature of this condition (Cullen-Drill and Cullen-Dolce, 2008). It is important in the diagnostic and ongoing treatment process that the involved clinicians are always alert to suicidal ideation and willingness to be compliant with treatment (Griel and Kleindienst, 2003). The use of pharmacotherapy is a major EBP in treating Bipolar Disorder, but unfortunately clients are typically non-compliant in taking their medications as directed. All too often these clients are “set up” to expect improvement and have no idea that they are coping with a chronic condition (Gaudino and Miller, 2006). Gaudino and Miller found that a strong alliance between the clients and their prescribing physician impacted improved expectation (2006).


In addition to pharmacotherapy are adjunctive psychotherapy (Milkowitz and Scott, 2009; Steinkuller and Rheineck, 2009) and Cognitive Behavioral Therapy to help the clients better understand the extreme mood swings, their beliefs which lead to non-compliance, distressing intrusive memories which can be derailing, and irrational thinking which keeps clients stuck or unwilling to work on overcoming the impact of their disorder (Wright, Lam and Newsom-Daivs, 2005; Yatham et al., 2005: Mansell, 2007). To increase adherence to the medication regime, clincians have found that psychoeducational efforts which target increased knowledge about the disorder and various risk factors which can derail patients, training on how to alter one’s attitude about the disorder and the treatments involved and what it takes to have successful compliance to the treatment protocals, have increased treatment adherence (Berk, Hallam, Colom, Vieta, Hasty, Macneil and Berk, 2010).


The clinician community has recognized psychoeducation with clients and their families as an effective tool to improve treatment compliance and to reduce the crises which come from unexpected manic episodes or retractive depression (Vieta and Colom, 2004; Grabski, Maczka and Dudek, 2007; Morris, Miklowitz and Waxmonsky, 2007). 

Topics to include in Psychoeducation of Clients and/or Family Members

(Grabski, Maczka and Dudek, 2007)

1. Psychoeducation about Bipolar Disorder

2. What changes in lifestyle are needed to sustain recovery (e.g. reduce substance use)

3. Complying with medication use as medically directed

4. Relapse Prevention: be on look out for signs and symptoms and immediately address the symptoms to get back on track

There are a number of comorbid conditions which exacerbate treating Bipolar Disorder. They are panic, generalized anxiety, substance abuse, personality disorders (Leahy, 2007) and HIV (Badiee, Riggs, Rooney, Vaida, Grant, Atkinson, Moore and HNRP Group, 2012). Clincians have recognized anxiety comorbidity as a major risk due to its contributing to the intensifying of symptoms, contribution to inability to relax enough to recover, over use of substances and increased suicidality (McIntyre, Soczynska, Boltas, Bordbar, Konarski and Kennedy, 2006). Some researchers found that mindfulness-based cognitive therapy (MBCT) helped lessen the state of anxiety for those with Bipolar Disorder over a 12 month followup (Manicavasagar, Mitchell, Ball and Hadzi-Pavlovic, 2013).

Homework assignment for Laura after her first visit


It is important for people who are dealing with Bipolar Disorder to not give into cues for non-recovery and stop taking their prescribed medications and stop doing the healing activities which lessen the desire to get off the medications.

Please read the following directions and work on what they are suggesting:

To lessen the impact of the cues for non‑recovery, you can do the following. Write down which of these suggestions you are willing to do to lessen the impact of cues for non-recovery which are coming your way.

  1. Use thought‑stopping techniques to stop thinking about the cues.
  2. Practice stress‑reduction techniques.
  3. Replace with alternative activities when the cues for non-recovery are more active.
  4. Visualize being successful in the recovered lifestyle and dwell on this visualization.
  5. Avoid the sources of the unhealthy cues
  6. Give the cues less power in your life by committing more energy to the new changes being made.
  7. Use positive self‑talk which encourages you to continue on with the new changes you are making in your life.
  8. Use positive affirmations of who you are, what you can and what you will accomplish in your new recovered lifestyle.
  9. Use pictures or images of yourself in your old, unhealthy lifestyle as a reminder of what you no longer want to return to.
  10. Become very busy with healthy behaviors such as exercise and stress reduction activities so as to not have enough time to dwell on the cues

 

Adapted from: Section 3, Chapter 10 Overcome Cues for Anti-Recovery in: Messina, J.J. (2013).     Self-Esteem Seekers Anonymous-The SEA’s Program of Recovery retrieved at www.coping.us

Another major concern when dealing with Bipolar Disorder is when it appears the client’s condition is treatment resistant.  Because of this there is an identified model of medications which a clinician can utilize to address treatment resistant bipolar depression (Gitlin, 2006). The following chart presents the medication options.

Medications Used for Bipolar Disorders

Classification

Drug Name (Generic Name)

Lithium

Eskalith and Litobid (Lithium)

Anticonvulsants

Tegretol (Carbamazepine) Depakote (Valproic Acid, Divalproex Sodium)

Neurontin (Gabapentin)

Lamictal (Lamotrigine)

Trileptal (Oxcarbazepine)

Gabitril (Tiagabine)

Topamax (Topiramate)

Lyrica (Pregabalin)

Atypical Antipsychotics * see under schizophrenia

Risperdal (Risperdone)

Zyprexa (Olanzapine)

Seroquel(Quetiapine Fumarate)

Geodon (Ziprasidone)

Abilify (Aripiprazole)  

Invega (Paliperidone Palmitrate)

Clozaril (Clozapine)

With the publication of the DSM-5 in 2013, diagnosing children with Bipolar Disorder will hopefully cease given the DSM-5 provides the diagnosis 296.99 (F34.8) Disruptive Mood Dysregulation Disorder which is listed under the Depressive Disorders. Clinicians cannot diagnose this condition for anyone less than 6 years of age, nor can they diagnose it after 18 years of age. Given this change, earlier work in childhood Bipolar Disorder (Hamrin and Pachler, 2007; Young and Fristad, 2007) must now focus on this new identified disorder.

Online Handouts for Laura to better explain the elements involved in her treatment

  1. TEA System
  2. ALERT System
  3. ANGER System
  4. LET GO System
  5. CHILD System
  6. RELAPSE System

All available online at: www. coping.us at: http://coping.us/seastoolsforrecovery.html

Treatment Workbook for Bipolar Disorder


Basco, M.R. and Rush, A.J. (2005). Cognitive-behavioral therapy for bipolar disorder, Second Edition. New York: The Guilford Press.

 

Ketter, T.A. (2010). Handbook of diagnosis and treatment of bipolar disorders. Washington, DC: American Psychiatric Publishing, Inc.

 

Maj, M., Hagop, S.A., Lopez-Ibor, J.J. and Sartorius, N. (2002). Bipolar disorder. Chichester, West Sussex, England: John Wiley & Sons, Ltd.

 

Messina, J.J. (2013). Tools for coping series: (1) Self-esteem seekers anonymous-The SEA’s program manual; (2) Laying the foundation: Personality traits of low self-esteem; (3) Tools for handling loss; (4) Tools for personal growth; (5) Tools for relationships; (6) Tools for communications; (7) Tools for anger work-out; (8) Tools for handling control issue; (9) Growing down:Tools for healing the inner child; (11) Tools for a balanced lifestyle, retrieved at www.coping.us

 

Miklowitz, D. (2002). Bipolar disorder survival guide: What you and your family need to know. New York: Guilford.

 

Otto, M.W., Reilly-Harrington, N.A., Kogan, J.N., Henin, A., Knauz, R.O. and Sachs, G.S. (2009). Managing bipolar disorder-A cognitive behavioral approach. New York: Oxford University Press.

References on Bipolar Disorder


Badiee, J., Riggs, P. K. Rooney, A.S., Rooney, A.S., Vaida, F., Grant, I., Atkinson, J.H., Moore,

D.J. and HIV Neurobehavioral Research Program (HNRP) Group, 2012). Approaches to identifying appropriate medication adherence asessements for HIV infected individuals with comorbid bipolar disorder. AIDS Patient Care and STDs, 26(7), 388-394. DOI: 10.1089/apc.2011.0447


Berk, L., Hallam, K.T., Colom, F., Victa, E., Hasty, M., Macneil, C. and Berk, M. (2010).

Enhancing medication adherence in patients with bipolar disorder. Human Psychopharmacology: Clinical and Experimental, 25, 1-16. DOI: 10.1002/hup.1081


Cullen-Drill, M. and Cullen-Dolce, D. (2008). Early and accurate diagnosis of bipolar II disorder

leads to successful outcomes. Perspectives in Psychiatric Care, 44(2), 110-119.   


Gitlin, M. (2006). Treatment-resistant bipolar disorder. Molecular Psychiatry, 11(3), 227-240. 


Grabski, B., Maczka, G. and Dudek, D. (2007). The role of psychoeducation in the complex

treatment of bipolar disorder. Archives of Psychiatry and Psychotherapy, 9(3), 35-41. 


Griel, W. and Kleindienst, N. (2003). Concepts in the treatment of bipolar disorder. Acta

Psychiatrica Scandinavica, 108(418), 41-46. 


Gaudino, B.A. and Miller, I.W. (2006). Patients’ expectancies, the alliance in pharmacotherapy

outcomes in bipolar disorder. Journal of Consulting and Clinical Psychology, 74(4), 671-676. DOI: 10.1037/0022-006X.74.4.671


Hamrin, V. and Pachler, M. (2007). Pediatric bipolar disorder: Evidence-based

psychopharmacological treatments, Journal of Child and Adolescent Psychiatric Nursing20(1), 40-58.


Hayden, E., Bodkins, M., Brenner, C., Shekhar, A., Nurnberger, J., O'Donnell, B., and Hetrick,

W. (2008). A multimethod investigation of the behavioral activation system in bipolar disorder. Journal of Abnormal Psychology, 117(1), 164-170. doi: 10.1037/0021-


Leahy, R. (2007). Bipolar disorder: Causes, contexts, and treatments. Journal of Clinical

Psychology, 63(5), 417-424. doi: 10.1002/jclp.20360 


Manicavasagar, V., Mitchell, P.B., Ball, J.R. and Hadzi-Pavlovic, D. (2013). A randomized 

controlled trial of Mindfulness-based cognitive therapy for bipolar disorder. Acta Psychiatrica Scandinavica, 127, 333-343. DOI: 10.1111/acps.12033


Mansell, W. (2007). An integrative formulation-based cognitive treatment of bipolar disorders:

application and illustration. Journal of Clinical Psychology: In Session, 10(5), 447-461. doi: 10.1002/jclp.20369 


McIntyre, R., Soczynska, J., Bottas, A., Bordbar, K., Konarski, J., and Kennedy, S. (2006).

Anxiety disorders and bipolar disorder: a review. Bipolar Disorders, 8(6), 665-676.


Miklovitz, D.J. and Scott, J. (2009). Psychosocial treatments for bipolar disorder: Cost-

effectiveness, mediating mechanisms, and future directions. Bipolar Disroders, 11, 110-122. 


Morris, C. D., Miklowitz, D. J. and Waxmonsky, J. A. (2007). Family-focused treatment for

bipolar disorder in adults and youth. Journal of Clinical Psychology, 63(5), 433-445. doi: 10.1002/jclp.20359 


Morriss, R. (2008). Implementing clinical guidelines for bipolar disorder. Psychology and

Psychotherapy: Theory, Research and Practice, 81,437-458. DOI:10.1348/147608308X278105


Rouillon, F., Gasquet, I., Garay, R.P. and Lancrenon, S. (2011). Impact of an educational

program on the management of bipolar disorder in primary care. Bipolar Disorders, 13, 318-322. doi: 10.1111/j.1399-5618.2011.00916.x


Steinkuller, A. and Rheineck, J.E. (2009). A review of evidence-based therapeutic interventions

for bipolar disorder. Journal of Mental Health Counseling, 31(4), 338-350. 


Vieta, E. and Colom, F. (2004). Psychological interventions in bipolar disorder: From wishful

thinking to an evidence-based approach. Acta Psychiatrica Scandinavica, 422(110) 34-38. 


Wright, K., Lam, D., Newsom- Davis, I. (2005). Induced mood change and dysfunctional

attitudes in remission bipolar I affective disorder. Journal of Abnormal Psychology, 114 (4), 689-696. doi: 10.1037/0021-843X.114.4.689 


Yatham,L.N, Kennedy, S. H., O'Donovan, C., Parikh, S., MacQueen, G., McIntyre, R., Sharma,

V., Silverstone, P., Alda, M., Baruch, P., Beaulieu, S., Daigneault, A., Milev, R., Young, T., Ravindran, A., Schaffer, A., Connolly, M. and Gorman, C. P. (2005). Canadian network for mood and anxiety treatments (CANMAT) guidelines for the management of patients with bipolar disorder: Consensus and controversies. Bipolar Disorders. 7(3), 5-69. 


Young, M.E. and Fristad, M. A. (2007). Evidence based treatments for bipolar disorder in

children and adolescents. Journal of Contemporary Psychotherapy, 37, 157-164. doi:10.1007/s10879-007-9050-4  

WHERE DO I GO FROM HERE?

CONCERNING BIPOLAR DISORDER

Now that you have read this section, in “Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning Bipolar Disorder in my clinical practice?
  3. Why is it important that I learn more about Bipolar Disorder?
  4. What more do I need to know about this Bipolar Disorder?
  5. Where can I go to obtain more information about Bipolar Disorder?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on Bipolar Disorder?