In ye olde days, doctors used to call it “compliance.” You were prescribed medication and if you took your meds, you were compliant. If, for whatever reason, you did not take your meds, you were labeled “non-compliant” with all the attendant bad juju that went with it. Non-compliant was fairly well synonymous with “difficult” or “untreatable.”

Treatment options for people who suffer with mental illness are a little more robust than they used to be. Patients objected to the use of the term “compliance” because of the connotation that it involved submission to a doctor’s will regardless of one’s own will. It invalidated very real patient concerns about side effects of medication, as well as treatment resistant disorders. More and more doctors have switched from discussions of compliance to discussions of adherence, which implies a more involved patient role in supporting their own wellness.

Modern treatment for bipolar disorder takes a two-pronged approach by merging the use of stabilizing medication with an appropriate form of psychotherapy. There is no panacea, no cure, and treatment will usually last a lifetime. Back in the late 90’s when I was diagnosed, I belonged to an online bipolar support group. A common disclaimer we used when discussing our personal experiences was “Your Mind May Vary.” No one course of therapy or medication works for all patients; manifestations of the disorder are very personal and individual and no two people will have exactly the same experience. Proof is in the diagnostic criteria itself, in the way that bipolar disorder is no longer considered a singular condition but a spectrum.

People usually seek treatment while they are in the throes of an episode of either depression or mania. In my experience, more people seek treatment for depression than for mania. Manias can be enjoyable and not perceived as a problem, even as a sufferer ruins his or her life and relationships. The delusions allowed by the manias can somehow make the consequences explainable, perpetuating denial, and setting the blame on other people, allowing a sufferer to escape accountability. However a person seeks treatment, treatment is in and of itself crucial to future function and sustainability.

There are several types of treatments available.

Treatment for bipolar disorder can be divided into three general categories. Acute treatment focuses on suppressing current symptoms and continues until remission, which occurs when the symptoms are diminished for a period of time. Continuation treatment prevents a return of symptoms from the same manic or depressive episode. Maintenance treatment prevents a recurrence of symptoms. The risks of long-term medication use must be weighed against the risk of getting sick again (relapse).

First line treatment for the disorder is about stabilization of the sufferer. No other work can be done, nor progress be made, until the acute symptoms can be resolved. For this reason, medication is nearly always the first line of treatment for the disorder. New advances in pharmaceuticals provide patients with several options in addition to the old Lithium standby. Improved options helps increase the chances that a patient will find a tolerable medication. If the side effects of a medication are intolerable, a patient won’t take it, which destroys adherence. I, personally, have had life-threatening adverse reactions to medications, and on two occasions ended up in the ER of my local hospital. Having options improves the chances of finding some success with managing acute symptoms.

For information on the various medications available for treatment of bipolar disorder, you can visit the National Institute of Mental Health Web site. It is worth emphasizing that nearly all of the medications listed have the possibility of serious or debilitating side effects. When a patient decides not to adhere to a treatment plan that includes medication, it may be that they feel they are well (as often happens after medication stabilizes a person or they enter a manic phase), or it may be that the side effects are truly intolerable.

There are some people who cannot tolerate medication at all or for whom no medication is effective. While these sufferers may currently find no relief with medication, there may be something new on the horizon that does help bring some relief. New advances in medicine happen all the time, and new options may improve quality of life in the future. In the meantime, we are still responsible for our actions, and for continuing to use other tools to improve and maintain our level of function and stability.

The second prong of treatment is usually psychotherapy. Psychotherapy also comes in different flavors. (Ribbed for your pleasure? Maybe not quite.) One of the most popular forms of therapy is cognitive behavioral therapy, or CBT. CBT seeks to help change negative thoughts and behaviors and work on developing better coping mechanisms for stress. There is also family therapy, which includes family members and focuses on communication (this therapy is not for everyone; if you have severely dysfunctional family relationships, this is not necessarily the style of therapy for you, in my personal experience with it).

The last therapy I want to discuss is more of a lifestyle management approach, which deals with managing the day to day triggers of unstable moods. These triggers include poor nutrition (blood sugar spikes), poor sleep habits, disorganization, and structure. By establishing a routine that supports mental wellness, many people find that their other efforts at long-term stabilization and maintenance are more effective.

For example, sleep deprivation is a well known and significant trigger for mania. Lifestyle management enforces regulated sleep patterns to reduce issues with sleep deprivation. Following a sleep schedule and routine helps reduce insomnia, sleep avoidance behaviors, and ultimately mania caused by interrupted sleep.

When I am most healthy, I can attribute it to following good lifestyle management habits in conjunction with a good support system of doctors, friends, family, and neighbors. I create structure for myself, under the supervision of my therapist, that includes exercise, time out of the house, appropriate meal plans (no crazy sugar and food binges that cause blood sugar spikes), a schedule and routine to support productivity, a sleep routine and set bedtime and wake times. I find that my mood swings are less severe and that I am generally more even-tempered when I am able to follow this treatment plan.

And it is a treatment plan. I treat it like insulin and follow instructions as though they were prescribed medicine. When I am consistent, the effects are great. When I screw it up, I can tell the difference. However, it takes some getting used to and if you are in the midst of an acute episode, it is not a first line treatment option. Lifestyle management supports other therapies; I do not think it is as effective independent of other strategies and treatment.

I use lifestyle management strategies in conjunction with CBT in a very goal-oriented format. I am past the psychoeducation phase of my treatment, I already have a lot of insight into my own cycles and treatment options, as well as my triggers, and I need targeted help with specific issues to improve my level of function. I do not take medication. I have had severe adverse reactions to many medications, and while I cannot rule out trying medication again in the future, I have learned to accept that for me, medical intervention is limited.

If a patient chooses not to adhere to a particular aspect of a treatment plan, it may help to understand why. For some, talk therapy is ineffective because they aren’t ready to be honest with themselves about some of their history, or because they do not have a good fit with their therapist. Some people expect that the pills will fix everything and that there’s nothing to discuss. Some people stop taking medication or seeing a doctor when they feel well and return when their symptoms recur. Others simply cannot tolerate the side effects of the medication.

There are responses to all of these challenges, if the patient is willing to try new avenues of achieving wellness. In a way, it’s like alcoholism—you have to first accept you have a problem and then you have to make a commitment to doing the work to get better. New therapists can be found, different styles of therapy can be trialed, new medication options can be sampled, lifestyle management support could help make a difference.

But if a patient refuses all help, then the only thing that family members and friends and other loved ones can do is be available if the person changes his mind and seek out therapy for him or herself to learn to cope. You cannot make someone well, you cannot save people or fix them. You can only protect yourself from their fallout (or enable them to continue to get sicker and sicker; I don’t recommend this approach).

However, if your loved one is truly in crisis, you have options. Hospitalization is not something to consider lightly (particularly involuntary hospitalization), but it can be a true life saver. If you or a loved one discusses acts of self-harm or harm to others, or exhibits signs of being suicidal, call 911. If they exhibit the signs of a psychotic break, call 911. Psychiatric wards are far more humane than they used to be, and while I don’t know of any that are like club med, they are usually a lot better than having your stomach pumped at 3am in the local ER.

Unflattering euphemisms such as looney bin, nuthouse, padded cell, rubber room, etc. continue to reinforce negative stereotypes of psychiatric wards and hospitals. These euphemisms aren’t limited to places, they cover people as well. We are nutters, psychos, crazies, batshit, bonkers, looney, etc. What we don’t hear as often is that we are stigmatized. We are traumatized by our own diagnoses, our own illness, because of negative stereotypes and people who impose those images upon us, but also because of people who refuse any treatment and validate those images by continuing to exhibit unstable, erratic behaviors.

The antonym of stigma is pride. For us, being bipolar is no source of pride, it’s a source of shame. As long as that shame is perpetuated, people will continue in the vicious cycle of denial and treatment non-adherence. We would prefer to pretend that everything is alright, sometimes with the help of well-meaning loved ones who feed the delusion of normalcy, because accepting diagnosis and treatment means admitting we’re crazy—even though it shouldn’t. I’d like to strike that word from the lexicon, it does us such a disservice as a society.

If we are going to get around that stigma, we have to start reframing this disorder so that we do not discuss ourselves in terms of crazy or not crazy. Just like illness is a spectrum, so is wellness. Some of us put on a good show of high-function, but it’s the work of the treatment plan to get the inside to match the outside. Mental wellness means high-function in word, thought, and deed. Sometimes we do have to “fake it ’til we make it” but we have to do the work to make it. The more of us who take on the responsibility for our wellness and function, and who show others that this can be the face of mental illness—functional, well people—the more we will chip away at stigma and develop personal pride.

References:
Bressert, S. (2007.) Treatment of Bipolar Disorder (Manic Depression). Retrieved on April 19, 2009 from http://psychcentral.com/lib/2007/treatment-of-bipolar-disorder-manic-depression/

crazy. (n.d.). Roget’s 21st Century Thesaurus, Third Edition. Retrieved April 19, 2009, from Thesaurus.com website: http://dictionary.reference.com/browse/crazy

loony bin. (n.d.). Roget’s 21st Century Thesaurus, Third Edition. Retrieved April 19, 2009, from Thesaurus.com website: http://dictionary.reference.com/browse/loony bin

Warning Signs of Psychosis. (n.d.) Retrieved on April 19, 2009 from http://www.med.unc.edu/psych/step/warning-signs

Brock, T. P. (2000.) Medication Adherence: Theory, Measurement, and Pharmacist Interventions. Retrieved on April 20, 2009 from http://www.unc.edu/~tbrock/PY1%20-%20Adherence%20part%202%20-%20PHCY%2063/sld002.htm