• Treatment-refractory mania: Mania without remission despite 6 weeks of adequate therapy with at least two antimanic agents used together (lithium, antipsychotic, anticonvulsant, etc.) in the absence of antidepressants or other mood-elevating agents.
• Treatment-refractory bipolar depression: Depression without remission despite two adequate antidepressant treatment trials including at least one augmentation strategy.
• Treatment-refractory mood cycling: Continued cycling despite maximal tolerated lithium combined with valproate and/or carbamazepine for a period of three times the cycle length and not less than 6 months in the absence of antidepressants or other cycle-promoting agents.
• Recovery from acute episode: A period of at least 8 weeks with sustained remission of mood symptoms. During the first 8 weeks of recovery, remission is characterized by no more than 1 day in any week with significant mood abnormality (depression, lack of interest, irritability, expansiveness, euphoria), no more than two neurovegetative symptoms, and an Axis V (Global Assessment of Functioning) rating above 60.
Fortunately, the vast majority of acute episodes appear to be treatment-responsive.
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.
1.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 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.
2.Mood charting..
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.
3. Review and re-evaluation:
Review and, if indicated, order further neuropsychiatric evaluation
Medication nonresponse may be due to other medical problems. Treatment resistance therefore calls for a review of the neuropsychiatric workup and additional studies if needed to determine if there is an organic cause of the nonresponse.
Mixed episodes may arise spontaneously (simple), or they may result from the co-occurrence of a primary mood disorder and a secondary neuropsychiatric condition. The most common conditions affecting treatment outcome are alcohol/substance abuse, migraine headaches, nonparoxysmal electroencephalogram (EEG) abnormalities, ADHD, bulimia, thyroid disorders, and autoimmune disorders such as systemic lupus erythematosus and multiple sclerosis. Treatment of such secondary neuropsychiatric conditions may enhance the treatment of the mixed state..
To rule out general medical and neuroendocrine disease, appropriate physical examination and laboratory workup should be carried out if necessary. Thyroid disease appears to be common among patients, both as a preexisting condition and as a consequence of treatment (especially with lithium or carbamazepine). Given the association between thyroid disease and treatment-refractory conditions such as rapid cycling and mixed states, evaluation and optimization of thyroid status may be a key to improving treatment response. Unfortunately, practical management guidelines for thyroid function remain controversial because laboratory measures may vary widely and still be within the normal range. In light of this, use of a thyroid preparation for optimization of thyroid function could be recommended in two situations: 1) to achieve a normalization of thyroxine, free T4, or thyroid-stimulating hormone if these values are outside the normal range; or 2) to reestablish baseline thyroid function, if on repeated measurement one of these values has changed by 50% or more during the course of the illness, even while remaining within normal limits.
Eliminate cycle-promoting agents Data from several studies show that the elimination of antidepressants from the treatment regimen may be the single most successful intervention for rapid cycling .
These data also suggest that antipsychotics may promote cycling. Some patients improve when they discontinue antipsychotics. Discontinuation of antidepressants can have salutary effects on the cycle rate of non-rapid-cycling bipolar illness.
Reduction of stimulants (including caffeine) and bronchodilators (e.g., albuterol, theophylline) also appears to be beneficial.
4.Encourage good mood hygiene
Improvement in treatment outcome can be achieved in some cases by educating the family and patient about the nature of the mood disorder and principles of good mood hygiene. Although studies associating the onset of episodes with environmental events demonstrate little correlation beyond the earliest episodes, many patients are able to use simple strategies to lessen conflict or avoid precipitants.
Encouraging the patient to maintain a stable sleep-wake schedule and to avoid extremes in work, travel across time zones, diet, or exercise often has a salutary effect. Although there are no empirical data showing the effectiveness of these approaches in treatment-refractory bipolar disorder, the low cost and low risk associated with these commonsense strategies justify their recommendation.
Interestingly, most forms of psychotherapy seem to augment the prophylactic benefit of lithium .
Although the active elements of psychotherapy remain unclear, the prophylactic efficacy of verbal therapies, as with lithium treatment, appears to require continued treatment.
Many patients report beneficial experience from self-help groups such as the National Depressive and Manic Depressive Association.
5.Implement a specific treatment algorithm
It is often effective to offer patients choices selected from among the treatment options considered appropriate given the patients’ current diagnosis and history (individualized menu of reasonable choices).
The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) arranges these options in pathways,
and
The algorithm for bipolar depression (Figure 1) commences with the diagnosis of an acute depressive episode.
The other algorithm comprises mood-stabilizing treatments appropriate for rapid-cycling or other bipolar disorders with treatment-resistant cycling.
from
http://www.health.am/psy/more/treatment ... z2PIxt7yhf