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National Collaborating Centre for Mental Health (UK). Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care. Leicester (UK): British Psychological Society; 2006. (NICE Clinical Guidelines, No. 38.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care.

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11LIVING WITH BIPOLAR DISORDER: INTERVENTIONS AND LIFESTYLE ADVICE

11.1. INTRODUCTION

11.1.1. Environmental effects on the onset and course of bipolar disorder

A prevailing view among some psychiatrists and other healthcare professionals has been that bipolar disorder is a genetically inherited disorder and its course is therefore biologically pre-determined. In this view, environmental factors such as life stress plays little if any role in the development and course of bipolar disorder, which might respond to pharmacological treatment but not psychosocial interventions (Post et al., 1986).

However, the benefits of self-help and self-management interventions involving the environment have been reported by service users on the overall course of bipolar disorder. For example, people who had stayed well with bipolar disorder for 2 years reported that their successful strategies for staying well included making lifestyle changes, managing sleep and stress, and identifying triggers (such as life stress) for illness episodes (Russell & Browne, 2005). Furthermore, the prevailing view in the research community is now that both genetic and environmental factors determine the onset and course of bipolar disorder. For instance, a history of child or adolescent physical or sexual abuse is associated with a range of adverse outcomes in service users with bipolar disorder, such as earlier onset of bipolar disorder, increased number of other comorbid physical and mental health problems, alcohol and drug misuse, more frequent rapid cycling of mood, and more suicide attempts (Leverich et al., 2002).

A historically important theory has been that life stress is important in bringing on the first bipolar episodes but life stress becomes less important in subsequent bipolar episodes as progressive biological processes then determine the course of the bipolar disorder (Post et al., 1986). Childbirth provides the best evidence that an environmental factor is a risk factor for the onset of bipolar disorder (Tsuchiya et al., 2003). A major life event, such as death in the family, unemployment, recent marriage or marital breakdown, may be associated with a first admission with bipolar disorder (Kessing et al., 2004a). However, there is conflicting evidence whether life events are important only to early episodes of bipolar disorder, or are important in at least some service users with bipolar disorder, in relation to both the onset and recovery from episodes throughout the service user’s life (Hammen & Gitlin, 1997; Johnson & Miller, 1997; Hlastala et al., 2000). The importance of life events to the course of illness is difficult to establish because of methodological problems in dating life events and determining their nature, severity and context (Sclare & Creed, 1990). A life stress for one person may not be a life stress to another person who has a different set of beliefs, past experiences and current social situation. Life stress may also have differing effects on the onset or course of bipolar disorder depending on developmental and demographic factors such as gender and age of onset (Hays et al., 1998; Johnson et al., 2000).

A psychological autopsy study suggests that recent life stress is associated with completed suicide in bipolar disorder, especially if the individual is in a depressive episode. (Isometsa et al., 1995).

Another historically important environmental theory is the role of sleep deprivation in both precipitating and maintaining mania (Wehr et al., 1987). The concept has developed so that disrupted social routine (social rhythms) may precipitate mania (Malkoff-Schwartz et al., 1998), while depression may be precipitated by life stress in the form of stressful life events (Malkoff-Schwartz et al., 2000) or criticism and hostility from the family (Yan et al., 2004). Positive life events such as receiving praise at work have also been linked to the onset of mania (Johnson et al., 2000).

Potentially these concepts may have important implications for the work and lifestyle of service users with bipolar disorder, their carers, families and healthcare professionals. For instance if sleep deprivation, disruption of sleep patterns and social routine bring on mania, then people with bipolar disorder may be advised not to carry out shift work, fly across time zones, and to avoid night flights and early morning travel. Time spent in a family, or even on a ward, when the family or ward atmosphere is stressful, hostile or critical, may be detrimental to the patient with mania or depression and the patient may need to spend time in a different environment or the family may need extra support. Therefore, this chapter will review the evidence relating to whether lifestyle has an impact on the onset of mania or depressive episodes, or suicide attempts.

11.1.2. Lifestyle in relation to overall health and quality of life in bipolar disorder

The effects of lifestyle in people with bipolar disorder are not confined to considerations about the onset of bipolar disorder, the onset and recovery from manic and depressive episodes, and prevention of suicide. While these outcomes tend to be, and probably should remain the most important issues in the mind of many healthcare professionals, there are other important considerations in the minds of people with bipolar disorder and their carers. Issues that are important to people with bipolar disorder include social adjustment and function, quality of life, physical health and appearance, spiritual life, the life of carers and family, issues of personal control over their life, stigma and finances (Osby et al., 2001; Mitchell & Romans, 2003; Morselli et al., 2004). The way a person with bipolar disorder conducts their life can have important implications for these outcomes in addition to their overall mood and recent course of illness. Some of the difficulties in caring for a person with bipolar disorder can be due to a conflict between issues such as personal control of the service user over their treatment and adherence to medication, concern over physical health and appearance and adherence to prophylactic medication associated with weight gain, stigma and receipt of help from mental health services. Persistence from healthcare professionals in an appropriate health setting, coupled with the experience of the service user with bipolar disorder and their carer over time, tends in time to produce a workable and effective management plan.

The quality of life and function of service users with bipolar disorder is comparable to or below the quality of life of other chronic medical illnesses such as multiple sclerosis and diabetes mellitus (Cooke et al., 1996). Symptom-free service users with bipolar disorder may have a better quality of life than clinically stable service users with schizophrenia (Chand et al., 2004) and similar social adjustment to service users with highly recurrent unipolar depressive episodes (Morriss et al., in preparation). Quality of life, function and disability tend to be predicted by the presence of symptoms, especially depressive episodes and depressive symptoms appearing between bipolar episodes, and the number of previous episodes and hospitalisations (Ozer et al., 2002). However, daily stesses, other psychiatric comorbidity, physical health problems, substance misuse, borderline or antisocial personality disorder, over-sedation from medication, social isolation and neurocognitive impairment (Judd et al., 2002; Chand et al., 2004; Thompson et al., 2005; Morriss et al., in preparation) all have an important bearing on the quality of life, function and social adjustment of people with bipolar disorder. Service users with bipolar disorder often have a high degree of educational achievement that is not reflected in their occupational functioning (MDF The BiPolar Organisation, 2001; Morselli et al., 2004). There are particular concerns among a large proportion of service users about stigma and the breakdown of relationships with some family members and friends (Morselli et al., 2004).

Additionally, there is some preliminary evidence that the high intake of omega 3 fatty acids in the diet, typically as fish oil, can have short-term benefits symptomatically in people with bipolar disorder. A small RCT trial involving 30 patients with bipolar disorder found that high doses of omega 3 fatty acids delayed acute bipolar relapse over 4 months (Stoll et al., 1999). An RCT of moderate doses of omega 3 fatty acids in 28 patients with unipolar major depression reduced the severity of depressive symptoms over 8 weeks (Su et al., 2003). However, omega 3 fatty acids can cause gastrointestinal symptoms such as nausea and their effectiveness is unknown over the longer-term, so recommendations about dietary change beyond short-term use cannot be made.

There is a growing concern about the physical health of service users with bipolar disorder. In addition to high mortality (expressed as standardised mortality rates) from suicide and possibly accidents, there is increasing evidence of a doubling of the SMR for cardiovascular mortality and increased mortality from pulmonary embolism in people with bipolar disorder (Osby et al., 2001; Angst et al., 2002; Strudsholm et al., 2005). Compared with United States national population data, the prevalence of diabetes mellitus, chronic obstructive airways disease, lower back pain, HIV infection and hepatitis C seem to be raised (Kilbourne et al., 2004; Beyer et al., 2005). HIV infection and hepatitis C may be explained by comorbid intravenous street drug use, while other health problems, particularly diabetes mellitus and ischaemic heart disease, are likely to be related to increased rates of obesity and metabolic syndrome (McElroy et al., 2002; Mackin et al., 2005). There are many possible reasons for increased obesity, diabetes mellitus and cardiovascular disease in bipolar disorder, including poor diet and lack of activity (Elmslie et al., 2001) and weight gain induced by many of the drugs used to manage bipolar disorder, in addition to growing rates of obesity in the general population. There is evidence that attendance at lithium clinics and longer-term use of medication may be associated with reduced mortality from all causes in people with bipolar disorder (Ahrens et al., 1995; Kallner et al., 2000; Angst et al., 2005). These results may be explained by the choice of patients offered longer-term medication, or attendance at clinics and adherence to medication may be associated with greater interest in lifestyle and reduced exposure to adverse lifestyle factors such as substance misuse, or that people who are adequately treated for their bipolar disorder are better able to look after themselves in relation to their physical health.

There is growing concern over the quality of general medical care that service users with bipolar disorder receive. Service users with bipolar disorder over 50 years of age received less general medical care than people with other mental disorders (Cradock-O’Leary et al., 2002) and obtained fewer investigative or operational procedures after myocardial infarction (Druss et al., 2001).

The rise in obesity and growing evidence of increased morbidity and mortality as a result of obesity require a positive approach by people with bipolar disorder and healthcare professionals. Therefore, the evidence for strategies to prevent weight gain and the benefits of exercise have been examined (Menza et al., 2004), including the effectiveness of exercise in terms of improving mood and preventing recurrence of depressive episodes (Babyak et al., 2000).

11.1.3. Topics covered

This chapter covers the following topics:

  • lifestyle interventions:
    • the prevention and management of weight gain
    • exercise in the management of bipolar depression
    • psychoeducation and information giving
  • managing daily life:
    • sleep patterns
    • social rhythms
    • life events
    • family atmosphere
    • implications for lifestyle and work
  • social support.

11.2. THE PREVENTION AND MANAGEMENT OF WEIGHT GAIN

11.2.1. Introduction

Many drugs used in the routine treatment of bipolar disorder are known to cause weight gain, in particular, olanzapine, quetiapine, valproate and lithium. Many patients find weight gain distressing and it can lead to poor adherence to medication regimes. It is therefore important that healthcare professionals not only take a baseline weight measurement at initiation of treatment, but also monitor weight regularly during treatment. It is also important to advise patients on weight management at the outset of treatment and also if patients gain weight during treatment.

11.2.2. Evidence search

Since there are very few RCTs for the management or prevention of weight gain specifically in people with bipolar disorder, an additional search was undertaken for trials of interventions for, or prevention of, weight gain during treatment with antipsychotics, anticonvulsants and lithium regardless of diagnosis. Databases searched are in Table 86.

Table 86. Databases searched and inclusion/exclusion criteria for the treatment or prevention of medication-induced weight gain.

Table 86

Databases searched and inclusion/exclusion criteria for the treatment or prevention of medication-induced weight gain.

Outcomes

Critical outcomes for this review were those measuring weight change, with body mass index (BMI) being considered the most relevant. When considering the clinical significance of mean changes in weight from baseline following treatment, the GDG acknowledged that the importance of weight loss or gain is a personal issue varying from patient to patient. However, for the purposes of assessing the evidence, a change of 2 kg or more was adopted as an initial indicator of potentially useful benefit.

11.2.3. Weight gain prevention

Studies considered for review

Five trials were identified from searches of electronic databases, three of which met the eligibility criteria set by the GDG. Excluded studies with reasons for exclusion can be seen in Appendix 22. See Table 87 for an overview of included studies. Further characteristics of included studies are available in Appendix 22.

Table 87. Summary of study characteristics for weight gain prevention interventions.

Table 87

Summary of study characteristics for weight gain prevention interventions.

Weight gain prevention review

There is some evidence that nizatidine at 600 mg per day helps prevent weight gain during treatment with olanzapine. However, the weight-gain difference compared with placebo is small. This evidence is from a population with schizophrenia. Although 600 mg is above the dose recommended in the BNF, it is within the licensed dose (summary of product characteristics on www.medicines.org.uk, site visited 3 March 2005).

There is also evidence of the effectiveness of reboxetine (4 mg) in the prevention of weight gain during treatment with olanzapine in people with schizophrenia.

An overview of the results is provided in Table 88, with the full profile in Appendix 23.

Table 88. Summary evidence profile for interventions for weight gain prevention.

Table 88

Summary evidence profile for interventions for weight gain prevention.

Clinical implication

Patients with bipolar disorder who are at high risk of weight gain through starting medication such as olanzapine, and especially those at high risk of adverse consequences of weight gain, for example, several risk factors for metabolic syndrome or existing diabetes or cardiovascular disease, should receive dietary and exercise advice on commencement of medication with the propensity for weight gain.

11.2.4. Weight gain management

Studies considered for review

Eight trials were identified from searches of electronic databases, four of which met the eligibility criteria set by the GDG. Excluded studies with reasons for exclusion can be seen in Appendix 22. See Table 89 for an overview of included studies. Further characteristics of included studies are available in Appendix 22.

Table 89. Summary of study characteristics for weight gain management interventions.

Table 89

Summary of study characteristics for weight gain management interventions.

Summary of evidence profile for interventions for weight gain management

Weight gain management clinical summary

There is some evidence that psychosocial interventions such as giving dietary advice are effective in helping people who have gained weight during treatment with psychotropic drugs. These data include patients with bipolar disorder. However, it is not clear from the available studies whether patients should be referred to a dietician or whether healthcare professionals can give adequate dietary advice without referral.

There is also evidence that adding sibutramine to existing medication helps reduce weight, although this evidence is from people with schizophrenia and related disorders. In a bipolar population there is a risk that such a strategy may induce mania and therefore using an antidepressant would not be considered first-line treatment for preventing or reducing weight gain.

An overview of the results is provided in Table 90 with the full evidence profile in Appendix 23.

Table 90. Summary evidence profile for interventions for weight gain management.

Table 90

Summary evidence profile for interventions for weight gain management.

11.2.5. Clinical practice recommendations

11.2.5.1.

If a person gains weight during treatment their medication should be reviewed, and the following considered:

  • dietary advice and support from primary care and mental health services
  • advising regular aerobic exercise
  • referral to mental health services for specific programmes to manage weight gain
  • referral to a dietitian if the person has complex comorbidities (for example, coeliac disease).
11.2.5.2.

Drug treatments such as high-dose antidepressants, sibutramine or topiramate* are not recommended to promote weight loss.

11.3. EXERCISE IN THE TREATMENT OF DEPRESSION IN PEOPLE WITH BIPOLAR DISORDER

11.3.1. Introduction

Since depressive symptoms, often below the level of a depressive episode, are present for around one third of the time in people with bipolar disorder (Judd et al., 2002), effective simple treatments for depression can play a useful role in bipolar disorder. There is a growing body of literature primarily from North America examining the effects of exercise in the management of depression. In the past decade ‘exercise on prescription’ schemes have become popular in primary care in the United Kingdom (Biddle et al., 1994), many of which include depression as a referral criterion. Guidelines for exercise referral schemes have been laid down by the Department of Health (2005a).

Several plausible mechanisms for how exercise affects depression have been proposed. In the developed world, taking regular exercise is seen as a virtue; the patient with depression who takes regular exercise may, as a result, get positive feedback from other people and an increased sense of self-worth. Exercise may act as a diversion from negative thoughts, and the mastery of a new skill may be important (Lepore, 1997; Mynors-Wallis et al., 2000). Social contact may be an important mechanism, and physical activity may have physiological effects such as changes in endorphin and monoamine concentrations (Leith, 1994; Thoren et al., 1990).

11.3.2. Definition

For the purposes of the guideline, exercise was defined as a structured, achievable physical activity characterised by frequency, intensity and duration and used as a treatment for depression. It can be undertaken individually or in a group.

Exercise may be divided into aerobic forms (training of cardio-respiratory capacity) and anaerobic forms (training of muscular strength/endurance and flexibility/ co-ordination/relaxation) (American College of Sports Medicine, 1980).

The aerobic forms of exercise, especially jogging or running, have been most frequently investigated. In addition to the type of exercise, the frequency, duration and intensity should be described.

11.3.3. Databases searched and inclusion/exclusion criteria

Since no RCT for the management of bipolar depression was found, the GDG used the review of the use of exercise undertaken for the NICE depression guideline (NCCMH, 2005), updating this with newly published studies. Databases searched are in Table 91.

Table 91. Databases searched and inclusion/exclusion criteria for clinical effectiveness of exercise in depression.

Table 91

Databases searched and inclusion/exclusion criteria for clinical effectiveness of exercise in depression.

11.3.4. Studies considered for review

Twenty-three trials were identified from searches of electronic databases, 11 of which met the eligibility criteria set by the GDG. Excluded studies with reasons for exclusion can be seen in Appendix 22. See summary tables below for an overview of included studies. Further characteristics of included studies are available in Appendix 22. Included studies compared exercise with no treatment, psychotherapy, antidepressants, meditation and relaxation, in addition to comparing different forms of exercise. Some studies included only participants with a diagnosis of depression according to DSM criteria (or equivalent) and some included participants with depression symptoms, most commonly defined as a Beck Depression Inventory (BDI) score of 12 or over.

11.3.5. Exercise versus no exercise

Six studies comparing exercise with no exercise in the treatment of depressive symptoms met inclusion criteria. Two studies included only participants with a diagnosis of depression according to DSM criteria (or equivalent), and four included participants provided they had a BDI score of 12 or over (or equivalent). Summary study characteristics are in Table 92.

Table 92. Summary of study characteristics for exercise interventions versus no treatment/waitlist.

Table 92

Summary of study characteristics for exercise interventions versus no treatment/waitlist.

Summary of evidence profile for exercise versus no exercise

An overview of the results is provided in Table 93, with the full profile available in Appendix 23.

Table 93. Summary evidence profile for exercise versus no exercise.

Table 93

Summary evidence profile for exercise versus no exercise.

11.3.6. Exercise versus psychotherapy or antidepressants

Four studies comparing exercise with other treatments for depressive symptoms met inclusion criteria. Three studies compared exercise with psychotherapy (two with a full depression diagnosis). Summary study characteristics are in Table 94.

Table 94. Summary of study characteristics for exercise versus psychotherapy and antidepressants.

Table 94

Summary of study characteristics for exercise versus psychotherapy and antidepressants.

Summary of evidence profile for exercise versus psychotherapy or antidepressants

An overview of the results is provided in Table 95, with the full evidence profile available in Appendix 23.

Table 95. Summary evidence profile for exercise versus psychotherapy or antidepressants.

Table 95

Summary evidence profile for exercise versus psychotherapy or antidepressants.

11.3.7. Exercise versus low-intensity exercise and other treatments

Three studies comparing exercise with low-intensity exercise and other treatments in the treatment of depressive symptoms met inclusion criteria. Participants in two had a full depression diagnosis. Summary study characteristics are in Table 96.

Table 96. Summary of study characteristics for exercise versus low-intensity exercise and other treatments.

Table 96

Summary of study characteristics for exercise versus low-intensity exercise and other treatments.

Summary of evidence profile for exercise versus low-intensity exercise and other treatments

An overview of the results is provided in Table 97, with the full evidence profile available in Appendix 23.

Table 97. Summary evidence profile for exercise versus low-intensity exercise and other treatments.

Table 97

Summary evidence profile for exercise versus low-intensity exercise and other treatments.

11.3.8. Clinical summary

There is some evidence that exercise is helpful in reducing depressive symptoms, both in major and minor depression. This evidence could be extrapolated to bipolar patients experiencing a depressed episode, to those beginning to develop a depressed episode, those who have persistent mild depressive symptoms and those trying to prevent depressive symptoms getting worse.

There is the potential for exercise to be both helpful and harmful in mania but there is no research evidence to support either scenario. Exercise may be a healthy way of using up the excess energy in a person with mania and a useful distraction. However, exercise might further arouse the body physiologically, increasing energy, social contact and self-efficacy, exacerbating manic symptoms and potentially increasing further cardiovascular strain.

11.3.9. Clinical practice recommendations

Advice about exercise is included in the general advice recommendation at the end of this chapter.

11.4. PSYCHOEDUCATION AND INFORMATION GIVING

11.4.1. Introduction

Psychoeducation given as a group intervention to people with bipolar disorder or to a family has been demonstrated to reduce bipolar recurrence (Colom et al., 2003a; Colom et al., 2003b; Miklowitz et al., 2003). However, even if psychoeducation were ineffective in reducing bipolar recurrence, people with bipolar disorder and their carers have a need and right to information on the condition. While there are now a variety of websites run by patient and professional organisations, for example MDF The BiPolar Organisation, beyond blue, and the Royal College of Psychiatrists, that will provide general information about the condition, people with bipolar disorder would like to receive information about the condition in relation to their own individual circumstances. The best people to provide this are the healthcare professionals in primary and secondary care who have assessed the patient and their individual circumstances. An important aspect of the therapeutic relationship is the communication between the healthcare professional and patient. Central to this communication is information given about the condition of the patient and the degree to which the healthcare professional meets the patient’s needs for information. There is now a growing evidence base that an important determinant of patient adherence to medication is the quality of the relationship between the patient and the healthcare professional identified as responsible for the medication (Day et al., 2005). A key point is that such information giving should take into consideration the person with bipolar disorder and their carer’s previous experience of the condition and its treatment through health services. Similarly the burden of carers and the psychological well-being of carers may be reduced by accurate information about bipolar disorder applied to the patient in their care (Morselli, 2000).

Like all health interventions where the aim is to support the patient in managing their condition, the healthcare professional should consider a motivational interviewing approach to information giving. The healthcare professional should provide information about bipolar disorder to demonstrate the reality of the problem, explore what is possible with treatment and examine the pros and cons of treatment in both the short-term and longer term as applied to the person’s particular circumstances. Information should be given to the person with bipolar disorder when they are acutely ill but will need to be given again if their symptoms have remitted. The information in the acute phase will be concerned with improving the person’s mental state and returning them as close as possible to normal function. Given the high rates of recurrence (Harrow et al., 1990; Tohen et al., 1990; Keller et al., 1993), the information given on remission will focus on staying well, including preventing further relapse, as well as symptomatic and functional improvement. Thus information giving should be regarded as a continuous process. Carers should be included; carers and the person with bipolar disorder can help each other with their information needs.

Psychoeducation programmes may contain sessions on the nature of bipolar disorder, causal and triggering factors, symptoms of mania and depression, course and outcome, using diaries of mood, drug treatments, pregnancy and genetic counselling, risks from treatment withdrawal, alcohol and street drugs, early detection and management of manic and depressive episodes, lifestyle regularity, managing stress and problem solving (Colom et al., 2003a, b). Teaching people with bipolar disorder to recognise the early warning symptoms of mania and depression successfully reduced the number of manic episodes and improved function but did not reduce depressive episodes (Perry et al., 1999). Good coping with mania (Lam & Wong, 1997), such as calming activities, taking time off work and delaying impulsive actions, is encouraged and the person with bipolar disorder advised to seek help from a healthcare professional who may also provide early treatment with medication (Morriss, 2004). Good coping with depression, such as keeping busy to avoid rumination, accomplishing the minimal routine, getting the support of family and friends, and answering unrealistic negative thoughts, have been adopted as part of CBT interventions for early symptoms of relapse (Lam et al., 2003). The recognition and management of early warning symptoms of mania and depression are key features of the self-management training programme of MDF The BiPolar Organisation.

Psychoeducation programmes such as these have been systematically incorporated into care programmes to keep people with bipolar disorder well, along with assessment, care planning and monthly telephone monitoring of symptoms and medication fed back to the treating mental health team (Simon et al., 2005).

However, psychoeducation delivered by healthcare agencies may not provide information on important aspects of social care that can be considerably affected by bipolar disorder, such as work, housing, monetary, legal and insurance matters. Advice on some of these matters can be provided by MDF The BiPolar Organisation, citizen’s advice bureaus, job centres and housing agencies and appropriate members of a CMHT.

11.4.2. Clinical practice recommendation

11.4.2.1.

Healthcare professionals should establish and maintain collaborative relationships with patients and their families and carers (within the normal bounds of confidentiality), be respectful of the patient’s knowledge and experience of the illness, and provide relevant information (including written information) at every stage of assessment, diagnosis and treatment (including the proper use and likely side-effect profile of medication).

11.5. MANAGING DAILY LIFE

11.5.1. Sleep patterns

Concerns over sleep are common among people with bipolar disorder when they are well (Harvey et al., 2005) because sleep disturbance is the most common early symptom of mania and also one of the early symptoms of depression (Jackson et al., 2003). Furthermore, there is some experimental and observational evidence that psychological, interpersonal, environmental and pharmacological factors may precipitate mania though decreased sleep duration (Wehr et al., 1987; Leibenluft et al., 1996). People with bipolar disorder who had no bipolar episodes for two years valued obtaining adequate amounts of sleep and recognising early warning signs of relapse, including sleep disturbance as useful strategies for staying well (Russell & Browne, 2005).

However, sleep disturbance is sometimes a late rather than early symptom of mania and depression (Jackson et al., 2003) and commonly found in people with bipolar disorder who are currently well (Millar et al., 2004; Harvey et al., 2005). Polysomnograph studies show that the sleep disturbance of mania and bipolar depression is very similar to that of unipolar depression, suggesting that the sleep disturbance in bipolar disorder is not unique nor specific to bipolar disorder (Hudson et al., 1992).

Sleep disturbance occurs frequently in everyday life and it is unwise to conclude that sleep disturbance in a person with bipolar disorder will inevitably bring on a manic or depressive episode. Sleep disturbance is too non-specific a symptom to use as an early warning symptom of mania or depression on its own, but it can be useful as one of a number of symptoms and signs that could be used as a relapse signature of impending manic or depressive relapse (Lam & Wong, 1997; Perry et al., 1999). There is enough evidence to suggest that patients with a history of mania precipitated by a period of sleep disturbance should take care over obtaining adequate amounts of sleep (Riemann et al., 2002). Establishing whether sleep disturbance triggers episodes of mania and depression requires meticulous attention to detail concerning the timing and order of symptoms; often sleep disturbance does not trigger an episode of mania or depression but is an early symptom of mania or depression (Sclare & Creed, 1990; Malkoff-Schwartz et al., 1998).

11.5.2. Social rhythms

There is evidence that the daily lifestyle or social rhythm of well people with bipolar disorder is different from people without bipolar disorder (Ashman et al., 1999; Jones et al., 2005). The daily activities do not show as regular a routine pattern from day to day, even when a person with bipolar disorder is well. Often the morning activities of well people with bipolar disorder start later than other people. These activity patterns are unrelated to sleep disturbance. Both a further loss of regularity in the daily pattern of social activities and starting daily activities early in the morning may be associated with the later development of mania (Malkoff-Schwartz et al., 1998; Malkoff-Schwartz et al., 2000). A recently published RCT suggested that increased regularity in the daily routine of activities of people with bipolar disorder may delay the onset of the next bipolar episode (Frank et al., 2005). Avoidance of starting activities too early in the morning may be a useful clinical strategy if there is a personal history of early morning activity preceding the first symptoms of mania.

11.5.3. Life events

As described above, there is a view that life events and life stress may be important precipitants of the first or second episodes of bipolar disorder but subsequently the onset of bipolar disorder is largely unrelated to life stress. The phenomenon is called behavioural sensitisation and has been applied also to highly recurrent unipolar depressive disorders (Post et al., 1986). The evidence for this hypothesis is unclear. There is also some evidence that life stress may have a greater impact on the onset of bipolar depressive episodes than manic episodes (Johnson, 2005). In addition there is evidence of an association between stressful life events and the onset of bipolar depressive episodes in the 3 to 6 months following the life event (Malkoff-Schwartz et al., 1998, 2000; Hlastala et al., 2000). Social support that is non-judgemental and available when it is required may prevent episodes of bipolar depression in the face of life stress but not mania (Johnson et al., 1999). Stressful life events may delay the recovery from depressive episodes (Johnson & Miller, 1997) and decrease the effectiveness of lithium prophylaxis for bipolar disorder (Chand et al., 2004). Life events may also be associated with completed suicide in people with bipolar disorder (Isometsa et al., 1995).

There is quite a lot of evidence that the first admission to hospital with mania is precipitated by a stressful life event (Ambelas, 1987; Kessing et al., 2004a). There is also some preliminary evidence that some types of positive life event may precipitate mania. Some people with bipolar disorder are driven to achieve goals and in some attainment, or the possibility of attainment of these goals, may precipitate mania (Johnson et al., 2000).

11.5.4. Family atmosphere

A series of studies have shown that time spent in a family where there is an adverse family atmosphere is associated with a recurrence of depressive episodes rather than manic episodes in people with bipolar disorder (Miklowitz et al., 1988; Yan et al., 2004). The adverse family atmosphere involves emotional, hostile and critical comments directed to the person with bipolar disorder even when they are not in a bipolar episode. Often the comments concern behaviours attributable to bipolar symptoms. For instance, the person with bipolar disorder may lack motivation to look after themselves or the household because they have not fully recovered from a depressive episode but a family member sees them as slovenly rather than ill. When there is an adverse family atmosphere, the family members perceive the symptoms and behaviours of the person with bipolar disorder to be under the person’s direct control and not due to an illness beyond their control (Wendel et al., 2000). The degree to which the person is distressed by the relative’s adverse comments predicts more time spent ill in bipolar episodes over the next year (Miklowitz et al., 2005).

RCTs of interventions targeted at educating the family about bipolar disorder and moderating these negative comments about the person with bipolar disorder show evidence for the reduction of these comments and also a reduction in depressive episodes (Miklowitz et al., 2003; Rea et al., 2003). There is no data to determine whether interventions to reduce the time spent with hostile family members would also reduce depressive episodes in bipolar disorder, but findings on similar approaches in families with schizophrenia (Vaughn & Leff, 1976) suggest that such social interventions may be effective.

11.5.5. Implications for the lifestyle and work of people with bipolar disorder

Overall, there is evidence that in some people with bipolar disorder, their pattern of daily life and exposure to stress can have a clinically important impact on the number of bipolar episodes and the proportion of time they are ill. It is unlikely that all the bipolar episodes can be prevented by interventions that modify lifestyle and reduce life stress, even in people who appear susceptible to such factors. The best guide to the importance of lifestyle factors in any given person with bipolar disorder is a careful review of the person’s past history of illness, especially in relation to bipolar episodes in the previous 5-year period. The clinician should consider with the patient and carer, who can act as a useful informant, the role of sleep disruption, disruption to the person’s daily social routine (especially by activities scheduled for the early morning), seasonal factors, stress from life events and difficulties, positive life situations (especially in relation to goal attainment) and family atmosphere. If any of these factors seem to have preceded a bipolar episode, it is particularly important to establish the timing of this lifestyle factor and the start of any manic or depressive symptoms. There should be evidence that the lifestyle factor definitely preceded the manic or depressive episode.

If lifestyle factors are identified as precipitating one or more manic or depressive episode, then there are implications for the person with bipolar disorder in terms of their lifestyle. There are also a range of interventions that may possibly help the person. The lifestyle factor can be used as an early warning sign that the person may be becoming ill, although over-reliance on just one lifestyle factor should be discouraged. A history of sleep disturbance or disruption of daily routine precipitating a bipolar episode may mean that the person with bipolar disorder should not undertake shift work, should try to avoid night and early morning travelling and lead a more regular life. A history of stressful life events precipitating bipolar episodes suggests strategies to reduce the likelihood of exposure to these life events (such as taking a less stressful job), cognitive therapy strategies to modify pessimism concerning life stress when it happens, family interventions targeted at reducing hostility and criticism, or spending less time with family members who are critical or hostile.

11.5.6. Clinical practice recommendations

11.5.6.1.

Patients with bipolar disorder should be given advice (including written information) on:

  • the importance of good sleep hygiene and a regular lifestyle
  • the risks of shift work, night flying and flying across time zones, and routinely working excessively long hours, particularly for patients with a history of relapse related to poor sleep hygiene or a irregular lifestyle
  • ways to monitor their own physical and mental state.
11.5.6.2.

People with bipolar disorder should be given additional support after significant life events, such as loss of job or a close bereavement. This should include increased monitoring of mood and general well-being, and encouraging the patient to discuss difficulties with family and friends.

11.6. SOCIAL SUPPORT

11.6.1. Provision of social support

Prospective studies show that good quality social support is associated with a better outcome in bipolar disorder in terms of full recovery, improved depressive symptoms and preventing recurrence of depressive episodes (Johnson et al., 1999; Johnson et al., 2000; Johnson et al., 2003; Cohen et al., 2004). Good quality social support may also reduce the chances of emergency compulsory admission (Webber & Huxley, 2004). In people with depressive episodes, poor-quality social support and poorly integrated social networks are associated with suicidal ideas and suicide attempts (Sokero et al., 2003; Dennis et al., 2005). Therefore, paying attention to helping people with bipolar disorder to obtain good-quality social support and networks of social support that are available at a time of crisis can have an important impact on symptomatic recovery, prevention of recurrence and their safety. Such support should be provided if necessary by health services through CRHTTs, CMHTs, outpatient services or primary care services.

Usually, social support requires an emotionally supportive relationship involving confiding personal information and trust. The social support should be available when it is needed by the person with bipolar disorder. Social support may be provided by one person but a person with bipolar disorder may require a network of social support.

11.6.2. Role of service user groups

Like other mental disorder, people with bipolar disorder may experience isolation because friends, family members, employers and the public at large do not seem to understand their condition and experiences (Morselli et al., 2003; Morselli et al., 2004). Under these circumstances, people with bipolar disorder may feel less isolated and receive valuable information and support from local or national service user groups such as MDF The BiPolar Organisation. Most parts of England and Wales are served by local self-help groups of MDF The BiPolar Organisation and nationally the organisation is able to provide a lot of useful practical advice.

11.6.3. Befriending

There is evidence from a series of studies that providing social support in the sense of befriending (women with depression) confers benefits (Brown & Harris, 1978). In this trial befriending was defined as ‘meeting and talking with a depressed woman for a minimum of one hour each week and acting as a friend to her, listening and “being there for her”’. The trained volunteer female befrienders were also encouraged to accompany their ‘befriendee’ on trips, to broaden their range of activities, to offer practical support with ongoing difficulties and to help create ‘freshstart’ experiences often found to precede remission in previous work. ‘Befriendees’ were women with chronic depression in inner London who were interested in being befriended. Women were allowed to be on other treatments such as antidepressants and contact with other healthcare professionals. Befriending was found to have a clinically significant effect upon remission at one year.

11.6.4. Clinical practice recommendations

11.6.4.1.

Healthcare professionals should consider offering befriending to people who would benefit from additional social support, particularly those with chronic depressive symptoms. Befriending should be in addition to drug and psychological treatments, and should be by trained volunteers providing, typically, at least weekly contact for between 2 and 6 months.

11.6.4.2.

Patients, family and carers should be informed of self-help and support groups and be encouraged to take part in them, particularly at initial diagnosis, and regularly after that. Such groups may provide information on early warning signs, treatment and side effects, and support in time of crisis.

11.7. ADDITIONAL CLINICAL PRACTICE RECOMMENDATION

11.7.1.1.

Patients with depressive symptoms should be advised about techniques such as a structured exercise programme, activity scheduling, engaging in both pleasurable and goal-directed activities, ensuring adequate diet and sleep, and seeking appropriate social support, and given increased monitoring and formal support.

Copyright © 2006, The British Psychological Society & The Royal College of Psychiatrists.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

Bookshelf ID: NBK55353

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