Ideas about recovery & treatment have greatly changed since our first issue. We asked psychiatrists from our advisory board to reflect on the biggest advances over the past decade—and what the future might hold.
Joseph R. Calabrese, MD, is a professor of psychiatry at Case Western Reserve University in Cleveland and director of the Bipolar Disorders Research Center at University Hospitals Case Medical Center. He is also director of the Mood Disorders Program, which he started in 1989.
Out in the open: There’s been a huge change in awareness. The general population, and consumers that have psychiatric illnesses, are much more informed. Ten to 15 years ago, these diagnoses were a really tough sell to patients. That’s not the case anymore because people know these are real illnesses.
Patients are more educated when we talk about the illness because they’ve usually gone to the Internet and read about bipolar. And their parents and significant others are more accepting. That wasn’t the case as recently as 10 years ago.
Tackling depression: Probably the biggest change in the past 10 to 12 years is that we now have treatments for bipolar depression. That’s important because that’s where our patients spend the majority of their lives. … and depression is where our patients most commonly attempt suicide.
When it comes to mania, we’re pretty well covered. We’ve got lots of [prescribing] options.
There’s greater recognition that many people have a psychiatric disorder and co-occurring substance dependency, but there’s more to be done to improve diagnosis.
Dual diagnosis: There’s greater recognition that many people have a psychiatric disorder and co-occurring substance dependency, but there’s more to be done to improve diagnosis. The field needs to do a better job of having clinicians meet with the family and find out what the person was like prior to the onset of alcohol or drug abuse.
Almost always, if somebody is drug-dependent, there was a pre-existing undiagnosed, untreated psychiatric illness. Too often from a diagnostic perspective, the approach is to dry the patient out and see what’s left, so to speak. With bipolar disorder in particular, you can’t do that. The person will be okay for three to six weeks, then cycle right back to it if the bipolar is not being treated.
Family affair: I would like to see a system where family members routinely come to appointments along with the primary patient. For one thing, family members can help the patient recall symptoms and also make more accurate observations about behaviors like pressured speech, for example. So the likelihood of getting the diagnosis right is improved.
For another thing, the heritability of bipolar disorder is 60 to 80 percent. That is, it’s very likely to run in families. So not only would assessment of the patient be more accurate, but family members would learn more about symptoms and other siblings or relatives might get treatment sooner.
Roger S. McIntyre, MD, FRCPC, a professor of psychiatry and pharmacology at the University of Toronto, heads the University Health Network’s Mood Disorders Psychopharmacology Unit. He is a contributor to the Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines for the management of bipolar disorder.
Better on basics: What I was taught as a medical student is that bipolar disorder is mania and mania is bipolar disorder and they’re one and the same thing. We’ve come to see that there’s much more depression than mania in people with bipolar.
The other advance worth mentioning is that we know a lot more about what pediatric bipolar disorder looks like, what it doesn’t look like, how to differentiate it from other conditions. That’s been a very big change.
Body wise: Ten years ago, we didn’t know how big a problem metabolic conditions like diabetesand cardiac disease are among people with bipolar. Now it would be a routine standard of care to discuss risk factors for general physical health, such as smoking and poor diet, and engage patients about healthy lifestyle habits, sleep hygiene, and exercise.
It’s important for patients to be aware that physical health influences mental health, and vice versa. They do seem to be more aware of physical health problems today, perhaps partly because the medications we prescribe can cause weight gain.
Medications have always been an essential part of treating bipolar illness, but people now also recognize that there is a role for some type of psychotherapy, of education, added to medication.
The field needs to give as much attention to “below the neck” as it does to “above the neck.” This issue has been heavily promoted by experts, but also by patients who want better treatments and treatments that don’t have an adverse effect on their health.
Treatment options: We’ve seen more medications developed and approved by the U.S. Food and Drug Administration (FDA) in the past 10 or 15 years than we have in the past 50 years.
Medications have always been an essential part of treating bipolar illness, but people now also recognize that there is a role for some type of psychotherapy, of education, added to medication. That’s been a big change.
The ideal is to have different disciplines—psychiatrists, medical practitioners, psychotherapists, social workers—come together and work as a team. That seems to provide the greatest chance of success for the patient.
S. Nassir Ghaemi, MD, MPH, is a professor of psychiatry at Tufts University School of Medicine in Boston and director of the Mood Disorders Program at Tufts Medical Center. His books include On Depression and A First-Rate Madness: Uncovering the Links between Leadership and Mental Illness.
New model of recovery: I think there’s been a change all across medicine in terms of patient-centered or holistic recovery models and it has seeped into psychiatry, but change in clinical practice has been slow. Many clinicians still seem to focus on medications and removal of symptoms exclusively
If you take an exclusively symptom-oriented approach, you’ll need to spend a lot of time talking about symptoms and the medications you’re taking to treat them. There’s not enough time and attention left in an appointment for non-symptom discussions, meaning talking about a patient’s life and how they’re doing. This recovery-oriented approach is not necessarily psychotherapy, but it goes beyond the traditional approach to psychopharmacology.
Knowledge is power: People are much better prepared than they used to be. That is a big difference from 10 years ago. The Internet has been a major positive factor here because patients can investigate on their own, to some extent. They can go online and find out what I think and what another practitioner thinks, and make a decision about who to see based on that information.
People are much better prepared than they used to be. … The Internet has been a major positive factor here because patients can investigate on their own, to some extent.
That makes the initial conversation about a treatment plan a lot easier because we can move forward on a shared background of knowledge, as opposed to trying to explain it all in a one-hour session.
A new generation: After two decades of research and discussion, I find that antidepressants are still prescribed far too often despite multiple studies showing that their use in bipolar illness is ineffective at best and harmful at worst. Again, thanks to the Internet, patients can look into this and have a serious discussion with their doctors about treatment choices.
Scientific evidence has to accumulate for a long time before clinicians change their practices. There’s research that shows that when there’s clear scientific evidence that changes a previous medical belief, it takes on average 15 to 20 years for widespread change to occur. That’s equivalent to a generation.
There is hope for the future, because there’s a new generation of psychiatrists trained in the 2000s who are coming into practice, and they’re not beholden to older ideas about drug efficacy. Wider recognition that we should be using antidepressants less frequently is essential for progress in treatment of bipolar illness.