Lifestyle Changes

Classic psychotherapy does not help most patients with bipolar disorder. Nevertheless, many newer approaches are proving to be very useful. Trained mental health professionals can:

• Educate patients about bipolar disorder and its treatments
• Help them comply with drug regimens
• Monitor the patient's on-going status
• Intervene early in manic and depressive episodes to reduce the severity of the attack

In addition, trained professionals can help patients:

• Adjust to the reality of the illness and understand the negative consequences of mania -- particularly important for patients who consider their mania to be positive, creative, and exhilarating
• Cope with feelings of guilt and remorse that occur after manic episodes
• Deal with feelings of imperfection and despair

Cognitive-Behavioral Therapy

Therapists trained in cognitive-behavioral therapy (CBT) may be particularly helpful for many patients. CBT is a structured, conscious method that aims to help a patient recognize negative thoughts and behavioral patterns and to change them. CBT is known to be helpful for other mood disorders, including depression and anxiety, and some studies suggest that it benefits bipolar disorder patients as well. For example, in a 2003 study, patients who were given mood stabilizers and underwent a CBT program that was specifically designed to prevent relapse experienced fewer and shorter episodes and improved social functioning compared to those on mood stabilizers alone.

Using Cognitive-Behavioral Therapy for Bipolar Disorder. Typical goals of CBT for bipolar disorder patients include learning how to:

• Recognize manic episodes before they become full-blown and change behaviors during an episode
• Cope with depression by developing behaviors and thoughts that may help offset the negative mood

Monitoring and Grading Mood. One useful technique is a method that helps the patient predict or recognize an impending episode. This is done using a graph and diary that records and grades the effect of the patient's mental state on energy and physical activity.

There are a number of charts for doing this. With one method, the patient makes a time line across the page and a vertical line on the left side of the time line with a range from -5 to +5:

• -5 to -1 indicate the depressive phase. Minus five is the most severe depressive state and requires hospitalization. At this score, the patient's psychomotor responses are almost entirely negative. The patient is unable to function, has no appetite, and can barely get out of bed. As the scale moves up to zero, the depressive state lessens, so that -1 indicates a subdued mood with slightly less energy than normal.
• Zero is normal.
• +1 to +5 indicate the manic phase. For example, +1 indicates a slightly more active and energetic state than normal. Plus five is the most severe manic state, where the patient is incapable of slowing down, experiences impaired thinking and judgment, and sleeps at least 2 hours less than normal.

To fill out the graph, the patient takes the following steps:

• Using a diary, the patient describes each day, the mood, and its effect on physical activities.
• Using this information, the patient makes a mark on the scale that roughly reflects each day's mood and its effect on function. The patient then connects the mark with that of the previous day's state.
• The patient also describes any significant emotional or physical events, menstruation, medications, and dosages taken, or any factor that may be relevant in influencing mood or activities.
• After several months, the therapist and patient may be able to detect a pattern and possibly identify triggers of bipolar disorder episodes.
• Such information helps the patients to make adjustments that might reduce the severity of mood swings. For example, if a predictor for either manic or depressive episodes is insomnia, the doctor might use sleep-inducing methods or medications that might reduce the severity of the emerging mania.

Family Therapy

It is very important that partners, family members, or both be involved in therapy. CBT can help them learn how to accept the condition, the need for medications, and how to protect themselves and the patient financially during manic episodes. In fact, one study indicated that when a spouse of a patient learned ways of coping with the illness, the partner's chances of sticking to a prescribed treatment improved.

Supporting the Patient. Recommendations for supporting the patient include:

• Create a treatment contract as a first step. In this contract, the patient and family agree to specific steps for maintaining emotional stability. If such measures fail, all parties agree on further actions to be taken during an acute episode, including requests for hospitalization.
• Be supportive. Unlike relatives of patients with alcoholism who may be encouraged to get tough, relatives of patients with bipolar disorder must be strongly supportive because of the high risk for suicide with this disorder. Simply listening attentively and being empathic can help.
• Get the patient to comply with treatment, even if it means threatening a hospitalization if the patient fails to comply.
• Have ready a hotline number or the telephone number of a psychiatrist authorized to commit the patient. The doctor should be willing to facilitate commitment if a patient becomes violent or the family is on the verge of collapse.
• Don't feel guilty and don't make the patient feel guilty. Bipolar disorder results from an imbalance of chemicals in the brain and not from anyone's fault.

Support for the Family. Unfortunately, actions that support a bipolar disorder patient may not be intuitive, and they take their toll. Loved ones must also care for themselves or they may also follow a path to severe depression. They should to boost energy and reduce stress through:

• Exercise
• Meditation
• Relaxation techniques
• Holidays away from the patient
• Involvement in hobbies
• Involvement in support groups, Internet resources with chat rooms, and message boards for bipolar disorder caregivers

Interpersonal and Social Rhythm Therapy

Interpersonal problems (such as family disputes) and disruptions in daily routines or social rhythms (such as loss of sleep or changes in meal times) may make people with bipolar disorder more susceptible to new episodes of their illness. A form of psychosocial treatment called interpersonal and social rhythm therapy (IPSRT) focuses on maintaining a regular schedule of daily activities to reduce these potential triggers and improve emotional stability. Patients also learn how to avoid problems with personal relationships. Preliminary evidence suggests that IPSRT combined with drug therapy works better than medication alone. A 2-year study of patients with bipolar 1 disorder indicated that IPSRT may help prevent new manic episodes.

Lifestyle Factors

Exercise. Exercise is an important part of treatment, particularly in helping manage weight gain. It also helps increase feelings of well-being.

Sleep Management. Good sleep hygiene is particularly important for patients. One study reported that techniques used to enforce healthy sleep helped reduce mood cycling.

Diet. A healthy diet low in saturated foods and rich in whole grains, fresh fruits, and vegetables is important for anyone. People with bipolar disorder should be sure to maintain a regular healthy diet. They may need to restrict calories if they are on medications that increase weight.

Some research indicates that consumption of omega-3 polyunsaturated fatty acids found in oily fish (such as mackerel, sardines, salmon, and bluefish) may help reduce the symptoms of a variety of mental illnesses, including bipolar disorder. Researchers are investigating the effects of eicosapentaneoic acid (EPA) and docosahexaenoic acid (DHA) supplements for patients who have not responded to other treatments. A preliminary 2002 study found that they may benefit patients with depressive symptoms more than those with mania.