Treatment Strategies for Depression and Bipolar

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What are depression and bipolar disorder?

Depression and bipolar disorder (also known as manic depression) are mood disorders, treatable medical conditions involving changes in mood, thought, energy and behavior. They can affect anyone, regardless of age, ethnic background or social status. Mood disorders are not character flaws or signs of personal weakness. A person cannot “snap out of ” or “control” mood changes caused by depression or bipolar disorder.

Major depressive episode: A period of at least two weeks during which at least five of the following symptoms are present.

  • Sadness, crying spells
  • Major changes in appetite and sleep patterns
  • Irritability, anger
  • Worry, anxiety
  • Pessimism, indifference, feeling like nothing will ever go right
  • Loss of energy, constant exhaustion
  • Unexplained aches and pains
  • Feelings of guilt, worthlessness and/or hopelessness
  • Not able to concentrate or make decisions
  • Not able to enjoy things you once liked, not wanting to socialize
  • Excessive alcohol or drug use
  • Recurring thoughts of death or suicide

If you or someone you know has thoughts of death or suicide, contact a medical professional, clergy member, loved one, friend or crisis line such as 1-800-273-TALK immediately.

Manic episode: A distinct period of elevated, enthusiastic or irritable mood that includes at least three of the following symptoms.

  • Increased physical and mental activity and energy
  • Extreme optimism and self-confidence
  • Grandiose thoughts, increased sense of self-importance
  • Irritability, anger
  • Aggressive behavior
  • Decreased need for sleep without feeling tired
  • Racing speech, racing thoughts
  • Impulsiveness, poor judgment
  • Reckless behavior such as spending sprees, major business decisions, careless driving and sexual promiscuity
  • In severe cases, delusions and hallucinations (thinking, seeing or hearing things that aren’t true or don’t exist)

Hypomanic episode: Similar to a manic episode, but less severe and without delusions or hallucinations. It is clearly different from a non-depressed mood with an obvious change in behavior that is unusual or out-of-character. Individuals who have hypomanic episodes and depressive episodes are usually diagnosed with Bipolar II Disorder, while people who have full-blown manic and depressive episodes are usually diagnosed with Bipolar I Disorder. Bipolar disorder that does not follow a pattern is called Bipolar Disorder NOS (Not Otherwise Specified).

Mixed state (also called mixed mania): A period during which symptoms of a manic and a depressive episode are present at the same time.

dysthymia: A long low-grade state of depressed mood, symptoms of which include poor appetite or overeating, insomnia or oversleeping, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions and feelings of hopelessness. The depressed state of dysthymia is not as severe as with major depression, but can be just as disabling.>

cyclothymia: A milder form of bipolar disorder characterized by alternating hypomanic episodes and less severe episodes of depression. The severity of this illness may change over time.

Rapid cycling occurs when a person has four or more manic, hypomanic, mixed or depressive episodes within a 12-month period. For many people, rapid cycling is temporary.

How are mood disorders treated?

A good treatment plan often includes medication to stabilize mood, talk therapy to help with coping skills, and support from a peer-run group like DBSA to help you manage your illness. Seeking treatment does not mean you are weak or a failure, it means you have the strength and courage to look for a way to feel better. Getting treatment for depression or bipolar disorder is no different than getting treatment for diabetes, asthma, high blood pressure or arthritis. Don’t let feelings of shame or embarrassment keep you from getting help.

What is psychotherapy (talk therapy)?

psychotherapy can be an important part of treatment. A good therapist can help you cope with the feelings you are having and change the patterns that contribute to your illness. Behavioral therapy concentrates on your actions; cognitive therapy focuses on your thoughts; and interpersonal therapy looks at your relationships with others. Your loved ones may join you in sessions of family or couples therapy. group therapy involves several, usually unrelated people working with the same therapist and each other. Many therapists use a combination of approaches. One approach is not necessarily better than another – the best choice is the one that works best for you.

How is medication used to treat depression and bipolar disorder?

There are many safe, effective medications that may be prescribed to relieve symptoms of depression or bipolar disorder. You and your doctor will work together to find the right medication or combination of medications for you. This process may take some time, so don’t lose hope.

No two people will respond the same way to a medication, and many people need to try several before they find the best one(s). Different treatments may be needed at different times in a person’s life.

Keep your own records of treatment – how you feel each day, what medications (and dosages) you take and how they affect you – to help your doctor develop a treatment plan for you. DBSA’s Personal Calendar can be very helpful with this.

Your doctor may start your treatment with a medication approved to treat mood disorders. He or she might also add other medications which have been approved by the Food and Drug Administration (FDA) as safe and effective treatments for other illnesses of the brain, but have not yet been specifically approved to treat depression or bipolar disorder. This is called “off-label” use, and can be helpful for people whose symptoms don’t respond to traditional treatments.

Is it safe to take medication if I am pregnant or nursing?

Try to discuss pregnancy ahead of time with your doctor if you are planning it. If you become pregnant, inform your doctor immediately. You and your doctor should discuss your health in detail and make medication decisions based on your need for the medication compared to the risk the medication may pose to your baby’s health. The greatest period of risk for most medications is during the first three months of pregnancy, but some medications may also be harmful to a baby during later stages of pregnancy. Medications may also be present in breast milk, so your doctor may advise you to stop breastfeeding if you take medication.

How do mood disorders and treatments affect children?

children with mood disorders often have a different set of symptoms than adults do. For example, children with bipolar disorder may switch more quickly between mania and depression, or experience more mixed states. Mania often appears as irritability or rage in children, and may be misdiagnosed as attention deficit hyperactivity disorder (ADHD). Mood Disorder medications used for adults are prescribed for children. If your child has a mood disorder, make sure he or she is being treated by a doctor who has experience treating mood disorders in children. A child with bipolar disorder may have a manic episode if treated with antidepressants alone, so talk to your child’s doctor to see if mood stabilizers should be tried first.

Much has been written about the use of certain types of depression medication in children and adolescents and the possibility of increased risk of suicide. Families and physicians must make informed decisions that compare benefits and risks of all treatment options. Treatment involves more than taking a medication. Parents must monitor their children’s moods and behaviors and develop a close working relationship with their child’s health care provider that includes regular follow-up appointments.

How do mood disorders and treatments affect older adults?

With older adults, depression or bipolar disorder can sometimes be mistaken for normal signs of aging. These symptoms are not a normal part of growing older. Treatment can be very helpful for older adults, and they should be given a thorough physical examination if they have symptoms of a mood disorder. It’s also important for older adults to be aware of possible medication interactions or medication side effects if they are taking several medications for different conditions.

What should I do if I experience side effects?

Many of the medications that affect the brain may also affect other systems of the body, and cause side effects such as dry mouth, constipation, sleepiness, blurred vision, weight gain, weight loss, dizziness or sexual problems. Some side effects become less or go away within days or weeks, while others can be long-term.

Don’t be discouraged by side effects; there are ways to reduce or get rid of them. It may help to change the time you take your medication to help with sleepiness or sleeplessness, or take it with food to help with nausea. Sometimes another medication can be prescribed to block an unwanted side effect, or your dosage can be adjusted to reduce the side effect to a tolerable level. Other times your medication must be changed. Tell your doctor about any side effects you are having. The decision to change or add medication must be made by you and your doctor together, you should never stop taking your medication or change your dosage without talking to your doctor first.

Contact your doctor or a hospital emergency room right away if side effects cause you to become very ill with symptoms such as fever, rash, jaundice (yellow skin or eyes) breathing problems, heart problems (skipped beats, racing), or other severe changes that concern you. This includes any changes in your thoughts, such as hearing voices, seeing things or having thoughts of death or suicide.

Be sure your doctor knows about all the medications you are taking – for your mood disorder and any other physical illnesses you have. This includes over-the-counter or “natural/herbal” treatments. Even natural treatments may interact with your medications and change the way they work.

What if I don’t feel better?

If you don’t feel better right away, remember that it isn’t your fault, and you haven’t failed. Never be afraid to get a second opinion if you don’t feel your treatment is working as well as it should. Here are some reasons your treatment may not be giving you the results you need.

Not enough time: Often a medication may not appear to work, when the reality is that it may not have had enough time to take effect. Most medications for mood disorders must be taken for two to four weeks before you begin to see results. Some can take as long as six to eight weeks before you feel their full effect. So, though it may not be easy, give your medication time to start working.

Dosage too low: With most medications used to treat mood disorders, the actual amount reaching the brain can be very different from one person to the next. A medication must reach the brain to be effective, so if your dose is too low and not enough reaches your brain, you might incorrectly assume the medication doesn’t work, when you actually just need your doctor to adjust your dosage.

Different type (class) of medication needed: Your doctor may need to prescribe a different type of medication, or add one or more different types of medication to what you are currently taking.

Not taking medications as prescribed: A medication can have poor results if it is not taken as prescribed. Even if you start to feel better, keep taking your medication so you can keep feeling better. If you often forget to take your medications, consider using an alarm or pager to remind you, or keeping track of what you have taken using a pillbox with one or more compartments for each day. It may also be helpful for you to keep a written checklist of medications and times taken, or to take your medication at the same time as a specific event: a meal, a television show, bedtime or the start or end of a work day.

Side effects: Some people stop taking their medication or skip doses because the side effects bother them. Even if your medication is working, side effects may keep you from feeling better. In some cases, side effects can be similar to symptoms of depression or mania, making it difficult to tell the difference between the illness and the effects of the medication. If you have trouble with side effects, they don’t go away within a few weeks, and the suggestions on page 6 don’t help, talk to your doctor about changing the medication, but don’t stop taking it on your own.

Medication interactions: Medications used to treat other illnesses may interfere with the medication you are taking for your depression or bipolar disorder. For example, some medications may keep others from reaching high enough levels in the blood, or cause your body to get rid of them before they have a chance to work. Ask your doctor or pharmacist about the possible interactions of each newly-prescribed medication with other medications you are taking.

Other medical conditions: Sometimes a medication may not work for reasons not related to your mood disorder. Medical conditions such as hypothyroidism, chronic fatigue syndrome, and brain injury can limit the effectiveness of your medication. Sometimes normal aging or menopause can change your brain chemistry and make it necessary to change your dosage or your medication. It’s a good idea to have a complete physical examination and discuss your complete medical history with your doctor.

Substance abuse: Alcohol or illegal drug abuse may interfere with the treatment of depression or bipolar disorder. For example, alcohol reduces the effectiveness 8 of some antidepressants. The combination of alcohol or drugs with your medication(s) may lead to serious or dangerous side effects. It can also be difficult to benefit from talk therapy if you are under the influence. If you are having trouble stopping drinking or using, you may want to consider a seeking help from a 12-step recovery program or a treatment center.

Non-response: Response to any medication, especially those for depression and bipolar disorder, can be very different for each individual. A certain percentage of people won’t respond to a particular medication at all. If you are one of these people, don’t give up hope. There are many treatment strategies available for you and your doctor to try.

What are some other treatments for depression and bipolar disorder?

Electroconvulsive therapy (ECT)

In the 1930s, researchers discovered that applying a small amount of electrical current to the brain caused small mild seizures that changed brain chemistry. Over the years, much has been done to make this form of treatment milder and easier for people to tolerate. ECT can be effective in treating severe depression. However, there can be side effects such as confusion and memory loss. The procedure must be performed in a hospital with general anesthesia.

Transcranial Magnetic Stimulation (TMS)

In TMS therapy, a small hand-held device with a special electromagnet is placed against the scalp and delivers short magnetic pulses that affect the brain. This is believed to help correct the chemical imbalance that causes depression. TMS therapy does not require surgery, hospitalization, or anesthesia. The side effects associated with TMS, such as a mild headache or lightheadedness, are relatively infrequent and usually go away soon after the treatment session. The FDA has not yet approved TMS for treatment of depression. Clinical trials are ongoing.

Vagus Nerve Stimulation (VNS)

VNS involves implanting a small battery-powered device, similar to a pacemaker, under the skin on the left side of the chest. The device is programmed to deliver a mild electrical stimulation to the brain, which may work to correct the chemical imbalance. Studies have shown that VNS can benefit individuals who have not found relief with other treatments. The most common side effects of VNS are hoarseness, sore throat and shortness of breath. The FDA has approved VNS as a therapy for preventing epileptic seizures, but VNS is not yet approved for the treatment of depression. Clinical trials are ongoing.

Magnetic Stimulation Therapy (MST)

MST uses powerful magnetic fields to induce a small, mild seizure, similar to one produced through ECT. Clinical trials have recently begun. researchers believe MST will be able to treat specific areas of the brain. It is hoped that this treatment will not affect memory or concentration. If these treatments interest you, discuss them with your doctor. Work with your doctor in a collaborative partnership to find the treatments that work best for you.

What are some things to find out from the doctor?

  • What dosage(s) of medication should be taken, at what time(s) of day, and what to do if you forget to take your medication.
  • How to change your dosage, if this needs to be done before your next visit.
  • The possible side effects of your medication(s) and what you should do if you experience a side effect that bothers you.
  • How you can reach your doctor in an emergency.
  • How long it will take to feel better and what type of improvement you should expect.
  • The risks associated with your treatment and how you can recognize problems when they happen.
  • If your medication needs to be stopped for any reason, how you should go about it. (Never stop taking your medication without first talking to your doctor.)
  • If psychotherapy is recommended as part of your treatment, and what type.
  • If there are things you can do to improve your response to treatment such as changing your diet, physical activity or sleep patterns.
  • What you can do if your current medication isn’t helpful – what your next step will be.
  • The risks involved if you are pregnant, plan to become pregnant or are nursing.
  • The risks involved if you have another illness, such as heart disease, cancer or HIV.

How can DBSA support groups help me?

With a grassroots network of more than 1,000 support groups, no one with a mood disorder needs to feel alone or ashamed. When combined with treatment, DBSA support groups:

  • Can help you stick with your treatment plan and avoid hospitalization.
  • Provide a place for mutual acceptance, understanding and self-discovery.
  • Help you understand that a mood disorder does not define who you are.
  • Give you the opportunity to benefit from the experiences of those who have “been there.”

Each group has a professional advisor and appointed group leader. Participants are people with mood disorders and/or their family members. Contact DBSA to locate the DBSA chapter or support group nearest you. If there is no group in your area, DBSA can help you start one.

Never Give Up Hope

Right now you might be dealing with symptoms that seem unbearable, and it can be difficult to have patience as you search for effective treatment. The most important thing you can do is believe that there is hope. Treatment does work, and most people can return to stable, productive lives. Even if you don’t feel 100% better right away, it’s important to stick with treatment and remember that you are not alone.

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