Spring 2002 Texas Psychologist

American Professional Agency Full 1c pu Winter 2001 p9 IFC

Christopher Blazina, PhD Editor The University of Houston David White, CAE Executive Director

SPRING 2002

VOLUME 53, ISSUE 1

Robert McPherson, PhD Director of Professional Affairs Lynda Keen Bookkeeper Sherry Reisman Director of Conventions and Non-Dues Revenue

Features 10 GUEST EDITOR: Focus on Bipolar Disorder Jodi M. Gonzalez, PhD

Lila Holmes Membership Manager

13 Diagnosis and Treatment in the Broad Clinical Spectrum of Bipolar Disorder TPA BOARD OF TRUSTEES President Walt Cubberly, PhD President-Elect Deanna F. Yates, PhD President-Elect Designate C. Alan Hopewell, PhD

Jodi M. Gonzalez, PhD

19 Medication Management Issues in Psychotherapy of Bipolar Disorder Cheryl Gonzales, MD

24 Bipolar Disorder: Challenges for Pregnancy Barbara Kertz, MS, LPC

Past-President Sam Buser, PhD BOARD MEMBERS Gary Brooks, PhD Ron Cohorn, PhD Patrick J. Ellis, PhD Charlotte Kimmel, PhD Joseph C. Kobos, PhD Suzanne Mouton-Odum, PhD Elizabeth L. Richeson, PhD Ollie Seay, PhD Jose Luis Torres, PhD Jarvis A. Wright, Jr., PhD EX-OFFICIO BOARD MEMBERS Federal Advocacy Coordinator Paul Burney, PhD

Holly Zboyan, BA

28 An Interview with Charles Bowden on Research and Practice in Bipolar Disorder Jodi M. Gonzalez, PhD

Departments 2

4

PUBLISHER

Kim Scheberle Managing Editor Pat Huber Advertising Sales Scott B. Williams Art Director The Texas Psychological Association is located at 1011 Meredith Drive, Suite 4, Austin, Texas 78748. Texas Psychologist (ISSN 0749-3185) is the official publication of TPA and is published quarterly.

www.texaspsyc.org

SPRING 2002

LAW: Duty to Report Child Abuse, Neglect Sam A. Houston Merritt McReynolds Marinelli

6

Student Division Director John Hardie, MS

Rector Duncan & Associates P.O. Box 14667 Austin, Texas 78761 512-454-5262

PRESIDENT’S MESSAGE: Sunrise...Sunset Walt Cubberly, PhD

Federal Advocacy Coordinator Rick McGraw, PhD CAPP Representative Melba J.T. Vasquez, PhD

From the Cover Vincent van Gogh Self-Portrait (1889)

Legislative Taskforce to Review Procedures for Forensic Evaluations Mary Alice Conroy, PhD, ABPP

8

New Members

9

Inside TPA

33 Psychopharmacology on the Move Dee Yates, PhD

34 Texas Psychology Foundation Joseph C Kobos, PhD, President

35 Classified Advertising 36 2001 PSY-PAC Contributors

These last three months do seem so strange to me. Sometimes moods of indescribable mental anguish, sometimes moments when the veil of time and the fatality of circumstances seemed to be torn apart for an instant...

Vincent van Gogh Letter Dated March 29, 1889

Texas Psychologist

1

FROM THE PRESIDENT

Sunrise...Sunset Walt Cubberly, PhD Thank you for the opportunity to serve Texas psychologists and citizens as president of TPA in 2002. I am excited to face the challenge of helping your Board of Trustees create a comprehensive agenda for the legislative session that starts in January of 2003. This year our TPA Board meetings will be largely devoted to defining what our legislative goals will be, not only for 2003, but further out into the future, as well. As your elected representatives, the Board Members want input from you so that we best represent all of psychology. As part of putting together your wishes, I will be traveling to various local area societies (LASs) to collect ideas to put before the board.

M

Part of what makes Rusty Kelly and y first LAS visit was to the Rio Associates so valuable is that Rusty is highGrande Valley Psychological ly regarded for his integrity and has many Association. I was surprised by the large more well developed, trusting friendships turnout. Over half of the psychologists with state legislators than TPA could ever working in the Valley attended and gave me build on its own. The legislaa great deal of valuable input. tive process, fairly or unfairly, I want to thank Dr. Joseph is based on these long-term McCoy, the current president, friendships, and we benefit and all the other psychologists from these friendships by who attended. I shared with association with Rusty. The them that if we could get that less good news is that hiring a percentage of psychologists to lobbying firm that enjoys a show up in our large metrovery good reputation costs politan LASs, we would really more money than hiring a feel pleased.

W a l t C u b b e r l y, P h D lobbyist that does not have so If you would like to have T PA P r e s i d e n t much influence or enjoy such the same opportunity for input a highly regarded reputation. and don’t have a TPA Board Member in your TPA will be working diligently for the LAS (or even if you do), call me (713-528next three years to insure passage of a licens1510) or TPA (512-280-4099 or 888-872ing act that is favorable to psychology.

3435) to arrange a visit.

Many psychologists believe that renewal of For most psychologists, the major legour licensing act involves little more than islative issue before us is Sunset Review. renewing the previous one. This is not the Although Sunset Review doesn’t formally case. The state legislators assigned to our begin until the 2005 legislative session, the Sunset Review Committee are not assigned committee is appointed following the conbecause they are friendly to psychology. clusion of the 2003 session (i.e. June 2003).

They take apart our current licensing law This is closer than most psychologists realline by line and rebuild it line by line. ize. Much will be won or lost before this Meanwhile, every non-psychology special committee is even appointed based on the interest group will try to influence this legquality of the prior relationships that have islation in a way that favors its group and already been built by TPA and our lobbymay be very harmful for the profession of ists. The good news here is that we have psychology. This will certainly include the hired the very best lobbyist to represent us.

2

Texas Psychologist

continuing attempt to lower the standard of practice for psychology to the master’s degree level. For this reason we are asking that each psychologist in Texas contribute $100 per year to our Sunrise Fund until we get our license renewed. If this is too much to ask, we are requesting that you give at least $25 a year to our Mid-Afternoon Fund. (Please forgive our being so corny, but we can’t help ourselves.)

Another major effort of TPA involves pursuing prescription authority for appropriately trained psychologists. PresidentElect Dr. Dee Yates and President-Elect Designate Dr. Alan Hopewell and others are heading up this effort, which will involve a major push in 2003. Many psychologists who have completed the psychopharmacology training are already contributing $2,000 per year into a fund to support passage of this legislation. Updates will be provided throughout the year as an interim study is completed by the state legislature that addresses this issue. The state legislators are trying to educate themselves on the merits of both sides of the issue.

Other projects already under consideration by your TPA Board include working collaboratively with other professional groups on joint projects. I have invited Susan Speight, Legislative Chair for the Texas Association of Marriage and Family Therapy, to dialogue with us at our first Board meeting. We have already had a preliminary discussion regarding issues of mutual concern.

Another group we are planning to work more closely with is the Texas Association of School Psychologists. We are hoping that the current President of TASP, Jan Opella, will also attend one of our Board meetings to discuss ways we can work together. These efforts with TAMFT and TASP will help us be better prepared for the issues likely to challenge us in 2005.

The TPA Board is also trying to build more bridges within our profession. School psychology has been a recent focus. We have encouraged several school psychologists to run for Board membership. If you belong to a group that you believe is underSPRING 2002

represented on your Board, let a current Board Member know and we will try to mentor your group in getting your group represented. As a Board, we are committed to representing all of psychology.

Your Board is also trying to recruit more faculty members to run for Board positions.

If you are in academia, please consider becoming more involved with TPA. We welcome you and consider your presence necessary for our betterment.

As you probably know by now, TPA went to Paris! The Paris workshop, Innovations in Marriage and Family Therapy, had over 70 people signed up. To the best of our knowledge, we are the first state association to host a European workshop. For many reasons, most of which are due to our hard political work and not our travel plans, APA has grown to respect TPA as one of the two or three most outstanding state associations in the country. My hat is off to my colleagues who have put our state association ahead of the curve in so many positive ways. âœŻ

SPRING 2002

TPA has published NEW edition of the Texas Law and the Practice of Psychology!

The new edition, Texas Mental Health Law: A Sourcebook for Mental Health Practitioners, is the most comprehensive book for mental health practitioners ever published. Get the latest information on supervising, ethics, subpoenas, confidentiality, and more.

If you have never purchased a reference book on the laws that pertain to your practice...the time to do so is NOW!

The book costs $35.00. Order your copy today!

Please e-mail orders@bayoupublishing.com or call 800-340-2034 to order your copy!

Texas Psychologist

3

LAW

A person having cause to

Duty to Report Child Abuse, Neglect Sam A. Houston & Merritt McReynolds Marinelli

What are you required to do if an adult client discloses that while a minor he or she sexually abused another minor?

believe that a child’s physical

or

mental health or

welfare has been adversely

W

hile there is no specific legal provision to address this exact situation, Chapter 261 of the Texas Family Code provides in pertinent part: (a) A person having cause to believe that a child’s physical or mental health or welfare has been adversely affected by abuse or neglect by any person shall immediately make a report as provided by this subchapter. …

There is no language in the Code to suggest that a person is excused from this nondelegable affirmative duty just because the suspected abuse or neglect took place in the past, or may have taken place between minors.

On the contrary, the triggering mechanism of the Code, is when the person becoming aware of the past abuse or neglect is made aware of it, regardless of the age of the victim or perpetrator at the time of disclosure.

Thus, the prudent course of action is to report the information to the proper authorities, leaving it up to them to decide whether to investigate or pursue the matter further. That way at least there is a record made regarding the incident, should future reports regarding your client be made unbeknownst to you. Simply put, just because your client confessed to an incident that occurred while a minor, does not mean that he or she is not capable of, or even worse, is continuing to abuse minors.

At the outset of a client relationship you are advised to put in writing and have your clients acknowledge that you are required by law to report all suspected abuse and neglect, whether in the present or past. You should tell him or her you will follow the 4

Texas Psychologist

law and your ethical obligation, and will make such a report regardless of how you are made aware of it. This way it is out in the open and there is no confusion about what you will do with such information should it be disclosed.

As a practical point you should make a note in a separate file stating why you reported despite the remoteness in time between the alleged incident and the time when it was disclosed to you. If you choose not to report, document your reasoning, as well. This way, should the issue arise in the future, you have a written records of the incident. ✯

affected by

abuse or

neglect by any person shall

immediately make a report.

Sam A. Houston offers discounted legal consultation to TPA members. If you need to contact him regarding a legal matter, please do so at (713) 650-6600.

SPRING 2002

LEGISLATIVE NEWS

Legislative Taskforce to Review Procedures for Forensic Evaluations Mary Alice Conroy, PhD, ABPP (forensic) Sam Houston State University

During the 2001 legislative session, SB 553 established a taskforce to “review the methods and procedures used to evaluate a criminal defendant’s competency to stand trial and use of the insanity defense.”

T

he taskforce held its first meeting on Jan. 23 at the state capitol. Chaired

by Sen. Robert Duncan, R-Lubbock, with vice-chair Rep. Patricia Gray, DGalveston, the 16-member group is to submit a final report to the next session of the state legislature.

Sen. Duncan noted that such a taskforce is rarely established, and the members should use the opportunity to make whatever recommendations seem appropriate to improve the quality of forensic evaluations in the criminal justice system and the impact of those evaluations on the continuity of care for those involved. Thus, the work of this taskforce could have far reaching implications for psychologists and psychiatrists who conduct forensic evaluations or who otherwise work within the criminal justice system.

Based upon the initial meeting, questions addressed are likely to include the following: 1) Who is a “disinterested expert?”

2) What training, skills, credentials, or experience should be required of professionals who conduct mental health evaluations for the courts? 3) What specifically should a forensic report include? 4) Where should forensic work be conducted (e.g., hospital, jail, community)? 5) Should the Texas insanity standard be reconsidered? 6) Is the competence for trial standard adequate as currently written? 7) Is the juvenile statute regarding “unfitness to proceed/lack of responsibility” appropriate? 8) Should 6

Texas Psychologist

Texas consider establishing mental health courts? 9) Under what circumstances is there a compelling state interest to mandate continued treatment (including psychotropic medication)? 10) Can statutes regarding diversion and civil commitment be improved to facilitate continuity of care?

11) Can statutory changes improve overall communication between law enforcement and the mental health community? 12) Can

electronic communication be used in evaluations and treatment?

The issues noted above are not all inclusive of what may be considered by the taskforce. They do provide a starting point and hopefully will stimulate thinking among psychologists who practice in this arena.

Do you conduct

forensic evaluations or work in the criminal justice system?

Every indication is that recommendations generated by this group will be taken very seriously by the legislature. As your representative—and the only psychologist appointed to the taskforce—I would be very interested in hearing about ideas, questions and concerns that you may have.

Please feel free to contact me by e-mail at psy_mac@shsu.edu or by phone (936) 294-3806. ✯

SPRING 2002

In a CE Jam? You can receive up to 15 hours continuing education credit through TPA Homestudy materials.

TPA's Homestudy offerings include: • Psychopharmacology I (4 hours) on CD-ROM • Psychopharmacology II (4 hours) on CD-ROM • Issues in Clinical Assessment (4 hours) on CD-ROM • Testing Hispanic Populations (1 hour) printed article

Omega Institute & The Crossings present

theheartof happiness A weekend conference devoted to finding, sustaining, and sharing happiness.

The theme of our 2002 conference series is happiness— happiness of mind, heart, body, and soul. Through keynote talks, workshops, and full-day intensives, some of the nation’s best-selling authors, teachers, and spiritual leaders explore questions of the heart. Come join us as we explore together the heart of happiness.

Austin, Texas Renaissance Austin Hotel May 17-19, 2002 Intensives May 17 & 2 0

• Overview of Multicultural Psychotherapy (1 hour) printed article • Ethical Principles That Need Consideration When Providing Services Electronically (1 hour) printed article.

CD-ROM offerings cost $100 for members and $140 for non-members.

Printed article offerings cost $25 for members and $45 for non-members.

If you are in a CE jam and would like more information on these offerings, contact Sherry Reisman at 888-872-3435 or 512-280-4099 or admin@texaspsyc.org.

SPRING 2002

Faculty includes: Ram Dass Debbie Ford Marianne Williamson Oriah Mountain Dreamer Wayne Dyer don Miguel Ruiz Mitch Albom David Whyte and others. . .

Information & Reservations

800.944.1001 www.eomega.org

OMEGA Worldwide Holistic Learning Centers

For 25 years Omega Institute has been a leader in organizing conferences that are equal parts education, relaxation, and celebration.

Omega is pleased to announce its partnership with The Crossings, a progressive learning center and meeting place, opening in Austin in September 2003. The Crossings is co-sponsoring this conference with Omega.

Texas Psychologist

7

PA S S I N G S

NEW MEMBERS The following individuals joined TPA between October 2, 2001 and February 4, 2002. TPA welcomes all of our new members.

Doctoral Art Brownell, PhD Gloria Chriss, PhD Elizabeth Ann Cortez, PhD Barbara Hall, PhD Willam J. Holden, PhD Jennifer Imming, PhD David B. Kelley, PhD George Lazar, PhD William Montgomery, PhD Anthony J. Rogers, PhD Ann I. Roose, PhD Stephen Thorne, PhD Carol Walser, PhD Daniel Yancy, PhD

Associate Katy Adams, MA Jane Carr, MA Martha DuBose, MS Dixie Valdez Student Amy Acosta, MEd Veronica Ahuero Laura Alfonso, MS Chrystina Bacek Kimberly Barton John Beach Helen Beckner, MS Joshua P. Bias, MS Donald Caudle, MA

John O. Charrier, MA Susan Cromwell, PhD James Deegear, MS Katherine DeGeorge, MEd Noel C. Gonzalez Maryann Hetrick Catherine G. King Kate Machemehl, MA Mary Martin Arlene Jean Rivero Lisa Schreindorfer Micheal Shafer, MS Lee Shefferman Katherine Tbaba Deborah Weber, MEd Sharon Young, MA, MEd

Dr. Esme Williams passed away on Dec. 27, 2001 after a battle with cancer. Dr. Williams was born in Guyana and made Austin her home with her husband, Carlyle, for the past four years. Dr. Williams received a PhD from the Counseling Psychology Training Program at the University of Texas at Austin in December, 2001. Her major area of interest was how women cope with the demands of working in non-traditional careers, a passion she developed from her own experiences working in the construction industry in the Houston area prior to beginning her graduate studies at U.T. Dr. Williams presented numerous papers on this topic at state and local professional meetings, and defended her dissertation, “Investigation of gender stereotyping, stress, and coping strategies for women and men in female- and maledominated occupations” in April, 2000. ✯

T PA M E M B E R B E N E F I T S w w w. t e x a s p s y c . o r g • Are you in the market for professional liability insurance?

Psychologist on staff part-time to answer

Call TPA’s preferred vendor, American Professional

member questions and requests for information

Agency, (800) 421-6694.

concerning professional affairs including, but not

• Psychological Tests and Confidential Test Scoring Services Download psychological tests for free. There is a

limited to, ethics, insurance/managed care, and practice management (512) 280-4099.

• Subscription to the Texas Psychologist.

24-hour turnaround on our test scoring services.

Your quarterly journal is designed to provide you

Each test will be scored for $20. For more informa-

with the most current information about professional

tion, please contact the Central Office or visit TPA's

news and practice changes in the state.

“Practice Resources” link on our web page www.texaspsyc.org.

• Discounted Legal Consultation Service: Sam A. Houston (713) 650-6600.

• List serve subscription for timely updates.

8

• Director of Professional Affairs.

Texas Psychologist

• Continuing Education: We offer both live and home study at substantially discounted member rates.

• Fee Collection Service: I.C. System (800) 325-6884.

SPRING 2002

INSIDE TPA

After 26 years at the same location, The Southwest Center for Psychological Development has moved to new quarters in booming southwest Lubbock. The new address of their freestanding building is: 5501 Spur 327, Lubbock, TX 79424.

Psychologists who are part of this expense-sharing association include: James E. Goggin, PhD, Cheryl L. Hall, PhD, Judy W. Halla, EdD, Charles W. Keller, PhD, and J. Scott Robertson, PhD. The Southwest Center, first established in 1969, has been in business longer than any other private practice psychology group in this part of the state.

The National Organization for Victims Assistance called Houston psychologist Pauline Clansy and asked her to activate a team of 13 volunteers to support victims of the World Trade Center disaster. Dr. Clansy immediately gained the appropriate permissions and alerted the All District Crisis Team, which includes 185 members.

During the week of Oct. 20, Dr. Clansy led an interdisciplinary team of 13, which included six psychologists and one post-doctoral resident, to New York and New Jersey to provide services for the New York Children's Assistance Center staff and family members applying for services at the Liberty State Park Family Assistance Center in New Jersey.

It was a very gratifying experience for all involved. All were honored to be called to serve at a trying time in our country's history.

A newly revised edition of James Randall Noblitt’s, PhD, and Pam Perskin’s 1995 book has been published.

SPRING 2002

Cult and Ritual Abuse: Its History, Anthropology and Recent Discovery in Contemporary America is available in both hard and soft bound editions. The full citation is as follows.

Noblitt, J.R., & Perskin, P.S. (2000) Cult and Ritual Abuse: Its History, Anthropology and Recent Discovery in Contemporary America. Westport, CT: Praeger Publisher.

John M. Velasquez, PhD, of the University of the Incarnate Word (UIW; San Antonio) was awarded a two-year Housing and Urban Development grant through the Office of University Partnerships in the amount of $389,374 to fund the expansion of Presa Community Center in San Antonio and the extension of UIW service-learning projects at Presa Community Center.

The HUD grant is an extension and outgrowth of Dr. Velasquez's work with the American Psychological Association's Psychology Partnerships Project (P3) and Campus Compact/ Pew Charitable Trusts. The grant reflects Dr. Velasquez's role of psychologist as community builder while addressing systemic influences on academic achievement, economic development, and urban blight.

Dr. Lynn P. Rehm has been elected President of Division 6: Clinical and Community Psychology of the International Association of Applied Psychology. The IAAP meets every four years as the International Congress of Applied Psychology. In 2002 the meeting will be held July 7-12 in Singapore. Dr. Rehm will become president-elect at that meeting and take over as president at the Athens meeting in 2006.

Dr. Rehm is also the current President of the International Society of Clinical Psychology. This is a relatively new organization that has been holding annual meetings in conjunction with other international meetings. This summer it will be meeting for one day in conjunction with the ICAP in Singapore.

Two long-time members of TPA, Rickie Moore, PhD, and Henry Marshall, PhD, have each released CDs that are aimed at helping many people reduce stress through exciting and innovating methods. Dr. Moore has released an audio CD entitled “Yoga for Inner Peace,” which is meditative and easy to follow. The CD comes with an illustrated instruction booklet.

Dr. Marshall and the Playshop Family's latest CD, “Mantras 4 Inner Peace,” has been touted as inspiring, relaxing, and so beautiful it creates changes in the body/mind and spirit.

Princess Christina of The Netherlands, interestingly enough, has been reported to chant along with this CD. Parachute Associates announces that Sue Cullen, owner of Sue Cullen and Associates, has been selected as the authorized Parachute Associate for Austin. Parachute Associates is the life/work consulting firm authorized by Richard N. Bolles to offer "What Color Is Your Parachute?" workshops for job hunters and career changers in North America. Sue Cullen and Associates provides career development services, as well as training and team building workshops, for a wide variety of individuals and organizations. ✯

Texas Psychologist

9

Guest Editor

Focus Bipolar Disorder Focus ononBipolar Disorder Jodi M. Gonzalez, PhD

Welcome to the spring issue of Texas Psychologist, focus on bipolar disorder. There has been an increased public and professional interest in bipolar disorder, and mental health professionals are treating individuals with bipolar disorder in increasing numbers. These patients seek answers from us about the most beneficial treatments to this complex and chronic disorder.

T

he contributors to this issue are investigators in an unprecedented national study of bipolar disorder, the largest clinical trial ever conducted for bipolar disorder. The Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) began enrolling individuals in 1999 and is both an efficacy and effectiveness study. The principal site of the study is Harvard University, headed by Gary Sachs, MD, and Michael Thase, MD. The STEP-BD is funded by the National Institute of Mental Health and investigates both pharmacological and psychosocial treatments for an estimated 5,000 patients.

The study will continue for up to eight years, possibly longer, in order to follow these individuals long-term.

Any person with a diagnosis of bipolar disorder, cyclothymia or schizoaffective disorder, bipolar type may be enrolled. Minimal exclusion criteria will provide researchers with essential answers on the course and treatment of bipolar disorder. Additional information about STEP-BD, and contact information for interested clinicians or individuals can be found on the web site www.stepbd.org.

This issue will provide an overview of topics relevant to clinicians in the diagnosis 10

Texas Psychologist

and treatment of bipolar disorder. Given the strong biological component of bipolar disorder, you will see contributions by psychiatrists, psychologists, and psychotherapists. We take this approach because a biopsychosocial approach to treatment is particularly relevant in bipolar disorder. In the first article I discuss current issues in diagnosis, and the state of the evidence of psychosocial treatments for bipolar disorder. The seemingly increasing prevalence rate of bipolar disorder is explored, as well as viewpoints about modern classifications

for bipolar disorder. I also summarize psychosocial treatment in bipolar disorder and promising studies. From an integrative perspective, I provide specific recommendations for determining a psychotherapy treatment approach in bipolar disorder.

The second article by Cheryl Gonzales, MD, provides clinicians with an overview of the medication management issues that clinicians observe and may treat in psychotherapy. First, psychological issues that emerge and may impact adherence to medications and successful psychotherapy are outlined. Dr. Gonzales then provides us with up-to-date information on mood stabilizers and other medications used in the treatment of bipolar disorder.

Common side effects and issues related to pharmacological treatments are discussed, as increased awareness and intervention by the psychotherapist can improve the effectiveness and adherence to treatment. This article will be a handy reference in working with the medical complexity of this disorder in psychotherapy.

The third article, by Barbara Kertz, MS, and Holly Zboyan, BA, takes a look at the issue of pregnancy for women who have bipolar disorder. Potential risks to the mother, fetus and the newborn are outSPRING 2002

lined, whether the mother chooses to remain on medication or discontinue.

Psychotherapy can be of primary importance with women and their partners when the choice is to discontinue medication.

Also, a promising new potential mood stabilizing agent of low risk to mother and fetus, omega 3 fatty acids, is described. This article provides information for clinicians to share and discuss with women who are considering pregnancy.

The last contribution to this issue is an interview with Charles Bowden, MD, an internationally recognized expert in bipolar disorder research and practice. Dr. Bowden discusses his viewpoints on the DSM IV descriptions of bipolar disorder and changes we might observe in the DSM in the future.

He informs us about some of studies currently underway in bipolar disorder. Finally, Dr. Bowden provides his opinions on providing psychosocial treatment for bipolar disorder.

Our hope for this issue is to provide the reader with an up-to-date summary of current issues that researchers and clinicians face in the diagnosis and treatment of a complex disorder. Due to limitations of time and space, important areas were not covered. Areas that warrant further discussion include bipolar disorder in children and adolescents, bipolar disorder in the elderly, and psychological assessment for bipolar disorder. The field is witnessing numerous advances in these areas and in bipolar disorder in general, and there will be much beneficial research in future years that is relevant to the individuals that clinicians see in their psychotherapy practices.

An integrative approach to bipolar disorder treatment guided this issue. In closing this introduction, the words of a person who suffers with bipolar disorder best summarize why in bipolar disorder this approach is of utmost importance.

At this point in my life, I cannot imagine leading a normal life without both taking lithium and being in psychotherapy. Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool SPRING 2002

and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. But, ineffably, psychotherapy heals. It makes sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot, do not, ease one back into reality; they only bring one back headlong, careening, and faster than can be endured at times. Psychotherapy is a sanctuary, it is a battleground, it is a place I have been psychotic, neurotic, elated, confused and despairing beyond belief. But, always, it is

where I have believed – or have learned to believe – that I might someday be able to contend with all of this.

No pill can help me deal with the problem of not wanting to take pills; likewise, no amount of analysis alone call prevent my manias and depressions. I need both. It is an odd thing owing life to pills, one’s own quirks and tenacities, and this unique, strange and ultimately profound relationship called psychotherapy. ✯ Jodi M. Gonzalez, PhD University of Texas Health Science Center San Antonio, Texas

Texas Psychologist

11

We can help you get your clients over those inevitable little bumps on the road to recover y .

To a person working toward recovery, every little bump, twist, turn or rough spot in the journey can seem insurmountable. They look to you for support and guidance. That’s where Hazelden can help. Hazelden Foundation offers professionals easy. access to a world of adolescent & adult chemical dependency information, support, services and training. Proven tools. that can help you better ease your clients down the road. Š2002 Hazelden Foundation

Focus on Bipolar Disorder Diagnosis and Treatment in the Broad Clinical Spectrum of Bipolar Disorder Jodi M. Gonzalez, PhD University of Texas Health Science Center San Antonio, Texas

This article summarizes current knowledge in the diagnosis and treatment of bipolar disorder.

Suggestions for new classification systems in bipolar disorder and viewpoints on broadening what is considered the bipolar spectrum are discussed. From these issues, we provide specific recommendations in bipolar disorder diagnosis. The article then shifts focus to treatment, and the history of the psychosocial treatment of bipolar disorder is reviewed. Psychotherapy studies are summarized, as well as recommendations for approaches that may be particularly beneficial in bipolar disorder treatment.

B

ipolar disorder is a serious mental illness characterized by a chronic course, often requiring lifelong psychiatric and psychological intervention. In a national epidemiological survey conducted in 1990 to 1992, the prevalence rates for bipolar I disorder were reported at 1.6% of the U.S. population (Kessler, 1994). In the last decade, the phenomenology considered to encompass bipolar disorder has evolved and recent studies refer to the disorder more broadly as the “bipolar spectrum” (Akiskal et al., 2000; Cassano et al., 1999). With this evolution, prevalence rates have recently been proposed to be as high as 5%-8% (Akiskal et al.).

Consequently, psychologists are treating more individuals who carry a bipolar diagnosis, and psychological treatments are being formalized and studied for effectiveness. It is essential that psychologists integrate and incorporate this nascent literature on bipolar disorder into the provision of effective psychological treatments. This article will provide an overview of current knowledge in the diagnosis and treatment of disorders in the bipolar spectrum.

SPRING 2002

Diagnosing Bipolar Disorder Discussions about nosology and diagnosis in psychiatry are commonplace. A central issue for classification systems is determining what symptom, cluster of symptoms, or characteristic of a disorder is its sine qua non, or essential element. In recent years, the sine qua non of bipolar disorder has been the existence of one manic or hypomanic episode, in the classic form as DSM IV defines it. In the early 1900s, when Kraepelin developed the first widely used nosological system in psychiatry, the essential element of manic-depression was the cyclical nature of the disorder. Kraepelin included unipolar depression in the manicdepressive spectrum, as depressive episodes were cyclical. This was contrasted with Dementia Praecox (Schizophrenia), which he viewed as having a chronic, non-cyclical course (Kraepelin, 1913/1921).

The essential element of bipolar disorder appears to be evolving yet again. A group of leading clinical researchers who have studied the classification of bipolar disorder advocate a broader definition (Akiskal et al., 2000; Cassano et al., 1999; Maj et al., 1999). Akiskal suggests that up to 50% of

unipolar depressions are in fact in the bipolar spectrum, suggesting the term “soft bipolar” for individuals who may not present with a classic form of mania (Akiskal & Mallya, 1987). These proponents believe that under-diagnosis is plaguing the field and resulting in gross under-treatment, and say that clinicians must be prepared to embrace a broader view of bipolarity. The following categories have been proposed to described the bipolar spectrum observed in clinical practice.

Table 1. Proposed New Categories in a Broad Bipolar Spectrum • Schizobipolar disorder • Depressions with hypomania (irrespective of duration in hypomania) • Pharmacologically induced hypomania • Cyclothymic and hyperthymic (subthreshold hypomanic symptoms) temperaments • Recurrent unipolar depressions with a bipolar family history • Cyclic depressions responsive to mood stabilizers Akiskal et al., 2000

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These categories describe the variety of mood disturbance observed in clinical practice today, and a suggested modern definition of bipolar disorder. What is unclear from these categories is what will constitute the essential element(s) of the disorder.

Not all experts agree that expanding the diagnosis of bipolar disorder is appropriate, and in the most troublesome case may make the diagnostic entity meaningless from both a clinical and research perspective (Soares & Gershon, 2000; Baldessarini, 2000). One example that Baldessarini (2000) cites is the emergent literature showing that lithium is not as effective in the current treatment of bipolar disorder as reported in early studies of lithium. In recent literature describing the bipolar course, individuals are characterized as more chronic and severe than previous studies, suggesting a different population is being studied. The increased heterogeneity may be especially relevant in genetic and pathophysiological research, which for some purposes requires the most pure of phenotypes to most efficiently elucidate the pathophysiology of bipolar disorder. Soares and Gershon (2000) note, “the move towards inclusion of increasing heterogeneous groups of patients under this diagnostic category threatens to jeopardize clinical research, and would be a disservice to the field” (p. 1).

Another argument is the issue of mood variation, which exists in many other disorders of putatively different etiologies. It is noted, “Given the finite limits of how our species can react psychopathologically, it is hardly surprising that affective instability and fluctuations of mood can be found in many, if not most, other disorders” (Baldessarini, 2000, p. 5). Equally concerning is the significant risk of pathologizing normal mood variation if we do not include requirements of duration symptoms and significant impairment.

Recommendations for diagnosis. It may take a considerable length of time to follow the course of an illness before a unipolar, bipolar, or other diagnosis can be applied with confidence. One instrument 14

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now being validated that has potential future benefit is the SCI-MOODS, an adjunct to the Structured Clinical Interview for Diagnosis (SCID). The SCI-MOODS assesses the mood spectrum and related symptoms in greater depth, allowing for a more accurate diagnosis (Cassano et al., 1999). Until the instrument or others are available, the following are recommendations for improving diagnostic accuracy and clarity: • A thorough clinical history is required with presentations of depression, as individuals will rarely present for treatment in a manic state and may have little memory or insight into past manic episodes.

Obtaining past medical records and collateral information directly from loved ones can provide a more comprehensive history. Questions in attempting to elicit a history of mania when interviewing patients are: ° How is your mood right before you become depressed (or directly after)? ° Are there times when others say you aren’t your usual self? ° Have there been times when you were especially productive?

• Asking for specific events such as financial difficulties, relationship problems, drug use, etc. that someone may not have attributed to their mood state.

• In treating someone diagnosed with unipolar depression who is not responding to antidepressants, or responds atypically to anti-depressant treatment, consider a re-evaluation of bipolar disorder. It will be especially important to consider this in individuals with hyperthymic and cyclothymic temperaments.

• A significant family history of bipolar disorder may be suggestive of a bipolar-type depression (i.e., a depression that may respond better to a mood-stabilizer).

Mood stabilizers can reduce the severity of mood episodes significantly. That is, episodes while being treated may be “breakthrough” symptoms rather than full-blown episodes. This is important to consider when diagnosing because the mood states

observed may not be of the same severity of past episodes prior to medication treatments. A diagnosis could be missed when a hypomanic or irritable mood does not meet criteria.

With the recent broadening of criteria, there currently are no agreed upon methods for classifying atypical mood disorders surely being observed in psychologists’ practices. Clinicians can include the above recommendations for diagnosis so that the individual receives the most beneficial pharmacological and psychological treatments available.

Psychosocial Treatment in Bipolar Disorder Prior to the discovery of effective pharmacological interventions, psychoanalysis predominated in the outpatient treatment of bipolar disorder. After the discovery of lithium, lithium clinics were opened to improve management of the disease. In descriptions of treatment provided in these clinics, psychosocial treatment was an important aspect of treatment, in the form of psychoeducation, formal therapy, and supportive self-help therapy (e.g., Fieve, 1975). From these promising psychotherapeutic beginnings, one might expect a proliferation of psychotherapy and then outcome studies for bipolar disorder. However, it is perplexing at times to see the lack of emphasis in the psychotherapy research literature on bipolar disorder. In a recent review of psychotherapy outcome studies (Swartz & Frank, 2001), only 21 conducted studies were identified as methodologically sound for review.

There are various reasons for the insufficient emphasis on psychological treatments.

First, it is a general clinical belief that psychotherapy has little impact on mania, the essential element of bipolar disorder. This belief is supported by research, especially those studies that have looked at more severe manic episodes (Swartz & Frank, 2001). This knowledge likely has led many psychiatrists and psychologists to deemphasize psychological interventions.

Second, although the 1990s saw an exploSPRING 2002

sion of psychotherapy research, the 1990s were also labeled as the decade of the brain, and bipolar disorder is known a “brain disease.” Thus, the productive explosion in bipolar research was seen in genetic, structural, and psychopharmacological studies.

A third contributor to the lack of psychotherapy research for bipolar disorder is found in the amount of research funding for bipolar disorder, as compared to unipolar depression or anxiety. So, in more general ways bipolar disorder has been neglected.

Finally, and probably the most compelling argument, is that almost no clinician or researcher would argue that medication should not be the first line of treatment and a primary focus of study in bipolar disorder.

Even so, most pharmacological treatments do not prevent recurrence and functional impairment in a substantial portion of individuals with bipolar disorder (Goldberg & Harrow, 2001).

Fortunately, what psychotherapy literature does exist suggests that psychological treatments can have a significant impact of the clinical course and outcome for bipolar disorder (Swartz & Frank, 2001). The American Psychiatric Association, Expert Consensus Guidelines, and the Canadian Psychological Association recommend adjunctive psychotherapy for treatment of bipolar depression (APA, 1994; Frances et al., 1998; Kusumakar & Yatham, 1997).

For example, the Consensus Guidelines recommend mood stabilizers as a first line of treatment in depression, followed by the addition of either psychotherapy or antidepressant medication (Frances et al., 1998).

Guidelines also list psychodynamic, cognitive, interpersonal, behavioral, marital/family, and group therapy as potentially beneficial treatment modalities.

The 21 conducted studies reviewed by Swartz and Frank (2001) measured diseasespecific outcomes, functional outcomes (e.g., quality of life, social or occupational functioning), and in some cases cost-analyses (dollars lost or saved by individuals, organizations, or government). Positive outcomes documented were decreases in hospitalization, decreased relapse rates, enhanced SPRING 2002

medication adherence, and a clinical impression of overall improvement. For the depressive phase of bipolar, psychotherapy showed the most promise. Psychotherapies demonstrating significant improvement in bipolar depression were cognitive-behavioral therapy, family-focused therapy, and interpersonal social rhythm therapy. With the exception of one important study (Perry, Tarrier, Morriss, McCarthy & Limb, 1999), the authors found little evidence that the emergence of mania (the more severe type) can be prolonged or prevented with psychotherapy. The Perry et al. (1999) study found that a psychoeducational/ behavioral intervention produced a significantly longer time to relapse into mania.

Finally, the review reported that psychoeducation, group, and psychodynamic therapies demonstrated beneficial outcomes, although it was not clear on what phase of the disorder.

Concerns and limitations in the reviewed psychotherapy research are the ever-present efficacy-effectiveness issue (i.e., will a clinical trial intervention be beneficial in realworld clinical practice?). That is, as bipolar disorder diagnoses are broadening, consensus guidelines for bipolar research studies are asking for a narrowing of eligible study participants. Specifically, the guideline is to exclude “less severe manic symptoms” (Angst et al., 2000). Thus, how likely are these participants to be representative of those seen and treated in clinical practice?

Other studies on psychotherapy treatment take a more qualitative approach, describing key elements in the psychotherapy of individuals with bipolar disorder (Bauer & McBride, 1996). A review of studies on psychosocial treatments for bipolar disorder identified key elements that are listed in Table 2.

The breadth of these key elements should not be too surprising, given that various psychotherapy modalities seem to hold promise in bipolar disorder. This breadth supports the idea of an integrative model of providing psychotherapy, where factors such as disorder quality, stage of change, motivation level, support system and treat-

ment goals all inform the psychotherapy approach (Norcross, 2001). This integration may have various combinations— either phase-specific approaches or integration throughout treatment. For phase-specific, psychoeducation seems to be emerging as an important first phase of treatment.

We name a few examples although there are several. One group psychotherapy under study, the Life Goals Program, has psychoeducation as the first phase and then behavioral and group methods in the later phase of treatment (Bauer & McBride, 1996).

The Family Focused Treatment approach utilizes psychoeducation in initial phases and family and behavioral treatments in later phases (Miklowitz & Goldstein, 1997). Other approaches integrate techniques throughout treatment, such as a group therapy approach that incorporates psychoeducation, group theory and psychodynamic approaches throughout (Kanas, 1999), or Interpersonal Social Rhythm Therapy which utilizes interpersonal and behavioral (circadian-rhythm) techniques (Frank et al., 1994).

Table 2. Key Elements in the Psychotherapy of Bipolar Disorder Identified in Descriptive Reports Predominantly psychoeducation Education regarding illness and treatment Illness management skills Predominantly problem-solving/coping Work Management Family Management Life goals outside of illness Predominantly psychodynamic/interpersonal Dealing with unstable interpersonal relationships Coping with loss Vulnerability Self-concept M. Bauer & L. McBride (1996) Structured Group Psychotherapy for Bipolar disorder: The Life Goals Program.

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Bipolar-Specific Approaches Although an integrative approach is indicated when looking at the clinical and research literature, the literature also acknowledges specific techniques that may be essential to incorporate in the treatment of bipolar disorder. The following approaches can inform treatment and provide important information and feedback during the course of treatment: Psychoeducation. One significant difference with bipolar disorder seems to be the amount of education necessary to inform patients meaningfully about this chronic, episodic, and complex disorder.

For example, there are at least potential five treatment foci, 1) mania, 2) depression, 3) relapse prevention, 4) sequelae of severe episodes, and 5) substantial cognitive and physical effects of medications.

Additionally, assisting the individual in understanding and characterizing which criteria and course modifiers are or are not applicable to them. Education also involves “working through” in an extreme degree, with repetition necessary in the context of the patient’s current experiences, both successes and travails.

At times patients will seek specialists, saying that their therapist has a lack of understanding of bipolar disorder. It behooves clinicians who treat individuals with bipolar disorder to have a good basic knowledge about the disorder and communicate this to patients. (See recommended readings).

Team Approach. Because of the severity of the illness and potential for suicide, mania, and psychosis, a team approach is often necessary, involving both the psychiatrist and family. In some cases, the family is already involved already in the patient’s caretaking. We recommend that if a family member (or loved one) functions as a caretaker, regardless of the patient’s age, they should participate in treatment as needed.

A value of this, unique to bipolar disorder, is that in many instances the family member will recognize and accurately report on important behavior, e.g., irritability, risktaking involvements, and impulsivity that 16

Texas Psychologist

the patient both does not perceive and does not display in the structured environment of the office.

As well as educating the family and summoning their assistance during treatment, family involvement aids in conceptualization of the family system and the beneficial or harmful role to the person’s functioning.

Having a family member attend a monthly session, or for a specific period of time, will elucidate how bipolar disorder outcomes impact the family and how the family impacts the disorder. Some opponents might suggest that family involvement promotes dependency, which indeed can occur.

In the case of bipolar disorder, however, family involvement more serves to improve effectiveness of relationships than to promote or deal with dependency.

Charting. Bipolar experts advocate life charting, mood charting, and social rhythm charting in bipolar disorder. Life charting can be indispensable in trying to understand the course of the disease, precipitating factors and treatment effects, for both patients and clinicians. Life charting is a macro documentation of the course of the disorder, typically episode duration, frequency and severity, including time of year, medication regimen at the time of episodes, and relevant stressors that may have contributed to episodes. Mood charting documents specific mood episodes or states in detail where weekly or even daily variation in mood are noted. Mood charting is beneficial in ascertaining if there are mood variations related to time of day, menstrual cycle, dosing, medication changes, etc.

Daily mood charting can also remind someone to take medication, and promote active participation in the treatment process.

Mood charting can be taken to doctor visits to serve as a reminder of previous weeks; few of us can accurately recall past symptoms with clarity. Finally, there is emerging evidence that circadian rhythms may influence bipolarity and episode onset. For example, jet lag, loss of sleep, and irregular schedules that upset the regularity of circadian rhythms are suggested to increase the likelihood of episode onset. With individuals

whose daily routines, especially sleep patterns, are disrupted this would be important to address. Other “rhythms” include interpersonal interactions, mealtimes, work and school schedules, and travel.

Comorbity. Lifetime comorbidity rates are high in bipolar disorder, with 71% for substance use and 93% for anxiety disorders (Kessler et al., 1997). In a recent study, 25% of euthymic bipolar individuals were found to meet criteria for personality disorders (Vieta et. al, 2001). Comorbid conditions are often additional if not primary foci of treatment. The iatrogenic effects of medications may also require therapeutic attention, such as side effects of mood stabilizers and other psychiatric medication as well as the possible changes in course of the disease that these medications may cause (e.g., rapid cycling, mixed episodes).

Length of treatment. Length of treatment is an important consideration in bipolar disorder. As is true with the pharmacotherapy for bipolar, we advocate a longterm approach to psychotherapy treatment.

Estimates suggest that only about 15% to 20% of patients have good overall functioning or complete remission after an index episode (Goldberg, Harrow & Grossman, 1995). Thus, the expectation that shortterm psychotherapy will significantly alter the course of bipolar disorder seems overoptimistic. Often, however, clinicians and researchers apply this short-term model in clinical trials and conclude that psychotherapy is not beneficial. We would argue that the dose-response issue should be resolved before concluding a lack of efficacy. For example, suppose that someone is prescribed a daily dose of divalproex 1500 mg for 6 months of treatment (short-term by pharmacotherapy standards), and then titrated off.

Suppose the patient has a recurrence of mania, and we conclude that divalproex has no efficacy with bipolar disorder. It would be spurious to conclude a lack of efficacy for the medication yet that is what we often conclude with psychotherapy. Ellen Frank, a leading researcher in the psychotherapy treatment of bipolar disorder, noted that SPRING 2002

because of the chronicity of the disease, termination is often not indicated even after long-term treatment. Long-term treatment should not necessarily be translated that weekly psychotherapy is indicated indefinitely, but may include monthly or bimonthly visits, for example. These visits maintain the connection with the provider in case emergencies or adherence issues occur, and is a similar model to treatment of chronic disease in psychiatry and general medicine.

Summary and Conclusions Diagnosis and treatment in bipolar disorder are primary concerns of clinicians and researchers, as the course of the disorder can be severe, chronic and very difficult to treat.

New research suggests that what we view as bipolar and amenable to mood stabilizing treatments would benefit from broadening what we view as the bipolar spectrum.

Broadening of the bipolar spectrum may lead to confusion and disagreements in diagnosis and classification, with some clinicians following DSM IV criteria and others taking a broader, spectrum view. Until modern classification issues are resolved, we have included recommendations for improving diagnostic accuracy with both the classic and broader views in mind.

Psychological treatments developed for bipolar disorder are increasing in the literature. This literature suggests good evidence that psychotherapy can have significant positive clinical effects on the course and outcome of the illness. In addition to the review of therapy approaches, we have also outlined key elements and various techniques the clinician can emphasize during treatment.

Given the complexity of this disorder and heterogeneity of the population we advocate an integrative, patient-specific approach to treatment. A decision about what modality and interventions to use, in addition to psychotherapist expertise and preference, should be based on patient characteristics such as clinical presentation and phase, interpersonal issues, level of functioning and comorbid problems. ✯ SPRING 2002

Recommended Reading For a review of studies of the relationship of family functioning to bipolar disorder and a family treatment based on this research: Miklowitz, D.J. & Goldstein, M.J. (1999). Bipolar disorder: A familyfocused treatment approach. New York, The Guilford Press.

For a psychoeducational self-help guide for families and individuals with bipolar disorder: Miklowitz, D.J. (2002). The bipolar disorder survival guide. New York: Guilford Press.

For a comprehensive review of bipolar disorder, with chapter contributions by leading researchers: Goldberg, J. and Harrow, M. (eds.) (1999). Bipolar disorders: Clinical course and outcome. Washington D.C., American Psychiatric Press.

For a review of diagnostic issues in bipolar disorder: Akiskal, H., Bourgeois, M.L., Angst, J., Post, R., Moller, H.J., Hirschfeld, R. (2000). Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders.

Journal of Affective Disorders, 59, S5-S30.

For a review of psychosocial treatments in bipolar disorder: Swartz, H.A., & Frank, E. (2001). Psychotherapy for bipolar depression: A phase specific treatment strategy? Bipolar Disorders, 3, 11-22.

efficacy in bipolar disorder. European Neuropsychopharmacology, 11, 79-88.

American Psychiatric Association (1994).

Practice guideline for the treatment of patients with bipolar disorder. American Journal of Psychiatry, 151(Suppl. 12), 1-36.

Baldessarini, R.J. (2000). A plea for the integrity of the bipolar disorder concept.

Bipolar Disorders, 2, 3-7.

Bauer, M.S., & McBride, L. (1996).

Structured group psychotherapy for bipolar disorder: The life goals program.

New York: Springer Publishing Company, Inc. Cassano, G.B., Dell’Osso, L., Frank, E., Miniati, M., Faglioni, A., Shear, K., Pini, S., & Maser, J. (1999). The bipolar spectrum: A clinical reality in search of diagnostic criteria and assessment methodology.

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of

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Disorders, 54(3), 319-328.

Fieve, R. (1975). The lithium clinic. A new model for the delivery of psychiatric services. American Journal of Psychiatry, 132, 1018-1022.

Frances, A.J., Kahn, D.A., Carpenter, D., Docherty, J.P., & Donovan, S.L. (1998).

The expert consensus guidelines for treating depression in bipolar disorder.

Journal of Clinical Psychiatr y, 59 (Suppl. 4), 73-79.

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Kessler, R. C., McGonagle, K.A., Zhao, S., Nelson, Ch.B., Hughes, M., Eshlemen, S., Wittchen, H.U., Kendler, K.S. (1994). Lifetime and 12-month prevalence of DSM III-R psychiatric disorders

Help is here Outside Medical Billing designed specifically for the Psychological and Licensed Therapy Industry.

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der in a general population survey.

Psychological Medicine, 27, 1079-1089.

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(1997). The treatment of bipolar disorder: Review of the literature, guidelines and options. The Canadian Journal of Psychiatr y, 42 (Suppl. 2), 67S-100S. Maj, M., Pirozzi, R., Formicola, A.R., & Tortorella, A. (1999). Reliability and validity of four alternative definitions of rapid-

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SPRING 2002

Focus on Bipolar Disorder Medication Management Issues in Psychotherapy of Bipolar Disorder Cheryl Gonzales, MD University of Texas Health Science Center San Antonio, Texas

Abstract The treatment of bipolar disorder is a complicated, multifaceted process. This article seeks to define the common challenges faced by the non-physician professional treating the bipolar patient. It will describe the advantages and disadvantages of the traditional and newer medications physicians are prescribing for bipolar disorder, and address how these issues may ultimately affect the therapy of the bipolar patient. Upon the completion of this article, the clinician should have an increased understanding of the common medications utilized in the treatment of bipolar disorder and related issues that ultimately affect adherence to treatment.

B

ipolar disorder is a common condition affecting between 1%-2% of the population (Regier et al., 1988). Persons afflicted with bipolar disorder are a heterogeneous group, and the condition affects persons equally irrespective of nationality, race, or gender. The commonality of bipolar disorder lies in the severe mood disturbance, which, if left untreated, can lead to significant personal, familial, and occupational disruption. Fortunately, with good pharmacological and psychological intervention, significant benefit and good outcomes can be achieved.

It is well accepted by clinicians that medication should be the first line of treatment in bipolar disorder. The past 20 years have brought many changes to the field of psychiatry, including a host of new medication options available with the potential to treat bipolar disorder. These are not necessarily new medications. Some, such as valproic acid (Depakote) are established medications whose potential to treat bipolar disorder was essentially untapped until the early to mid 1990s. The trend in modern SPRING 2002

psychiatry is to combine a variety of medications until the desired effect is achieved and the patient’s mood symptoms go into remission. This approach has allowed many patients to have fewer and less severe mood episodes. However, the increased complexity in medication regimens can lead to other challenges for psychiatrists. Medication issues are also relevant for psychotherapists, who observe psychological and physical effects of pharmacology and then provide answers to patients about the impact of medications. This article will provide a brief overview of issues relevant for psychotherapists treating individuals with bipolar disorder, in order to provide essential feedback both to the patient and the collaborating psychiatrist.

Benefits of Psychotherapy for Bipolar Disorder Given the complexity of the illness and treatment, the person with bipolar disorder often requires a multifaceted approach to his or her care. Medications are of great benefit and can have dramatic improve-

ments on the severity and length of mood episodes, but they are far from the ideal treatment we seek for our patients. The psychotherapy of the bipolar patient, while a challenge, can be a rewarding experience for both patient and clinician alike, and an invaluable contribution to their pursuit of health.

One particularly challenging aspect of treatment is the development of insight regarding the nature of the illness and the need for ongoing treatment. As with any chronic disease, particularly one that strikes at such a young age, the acceptance of bipolar disorder may be a struggle. While some patients express relief that they have a diagnosis and know what is wrong with them, others react with anger and denial. Helping individuals deal with their anger and denial is profoundly important to the establishment of the long-term doctor/ patient relationship needed to maximize recovery.

Another area where bipolar individuals typically need the help of an outside party is in recognition of certain target symptoms.

Many patients with bipolar disorder will Texas Psychologist

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have a pattern of symptoms that herald an impending manic or depressive episode. For example, many patients experience subclinical changes in sleep, appetite, or energy before they develop a clinical syndrome of mania or depression. If recognized early and treated aggressively, the potential exists to sideline the oncoming episode before it begins; patients must be insightful and observant of their mood and related symptoms before this method can be successful.

A major mental illness is never contained solely in the person who suffers it.

The effects on family and friends are significant and sometimes profound. For this reason, psychotherapy with a bipolar individual almost always involves some level of family intervention, whether it be talking to a parent, spouse or child during a time of crisis, educating them after a new diagnosis has been made, or working with the family during a time of calm. Family members can be invaluable to clinicians as observers, cueing into subtle signs the patient may not exhibit while in the therapist’s office, and alerting the patient to symptoms of which he or she may not yet be aware.

The development of a major mental disorder during crucial developmental periods can be devastating to the individual and interfere with the healthy acquisition of goals. The most common age of onset in bipolar disorder occurs in late adolescence and early adulthood, a time when most people are finishing school, establishing relationships, or starting careers. Also, the severity of the mood disturbance can lead to suicidal ideation (particularly in the depressed and mixed manic states), disrupt family relationships (leading to divorce or alienation from family), and cause the individual to engage in risky or dangerous behaviors (with such consequences as life threatening sexually transmitted diseases, unplanned pregnancies, and accidental death or serious injury). Persons suffering from depressive disorders, including bipolar disorder, make up the vast majority of people who commit suicide each year.

Remission of the mood syndrome and maintenance of remission is the goal of 20

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pharmacotherapy as well as psychotherapy.

Prevention of relapse determines the degree to which the mood disorder is disruptive to the patient’s life. While this may seem obvious to clinicians, it is not always so to our clients. The amount of insight into one’s illness is quite variable among individuals with bipolar disorder, and in combination with the iatrogenic effects of medications, may ultimately lead to adherence difficulties.

Adherence to Pharmacological Treatment One of the greatest frustrations a clinician sees is the recurrence of disease due to discontinuation of effective medications.

Most often, the decision is made by our patients without our knowledge and against our medical advice. What factors contribute to our patient’s ultimate decision to discontinue medications? A significant few that deserve further mention are discussed here.

As previously stated, many persons afflicted with bipolar disorder have significantly impaired insight into the nature and course of their disease. They may not accept or understand the seriousness of their illness or, having been stable for some time, may no longer see the necessity of taking medication. Additionally, mild manic episodes occurring during treatment may lead to medication discontinuation, thus precipitating a full manic episode. Patients in depressive episodes may discontinue medications because they feel hopeless that a medication will benefit them, or will discontinue medication hoping that they will become manic, thus ending a painful depressed phase.

Patient concerns are often medication related. The medications used in the treatment of bipolar disorder may have significant, unpleasant side effects or associations.

Lithium and Depakote, the two most widely utilized mood stabilizers today, both require periodic blood monitoring to ensure that the patient’s blood level of medication is within a certain range. Low levels of circulating medication leads to poor medication efficacy, while high levels lead

to a toxic syndrome. With long term use, both medications can begin to affect certain organs (lithium the kidneys and thyroid gland, Depakote the liver and blood platelets). A third medication, Tegretol, also requires blood monitoring for levels and its effects on bone marrow. Blood monitoring can be a deterrent to take these medications, due to time constraints, fear of needles, or financial concerns.

Side effects to medications can also lead some patients to discontinue them in frustration. Problematic side effects include sedation, acne, cognitive slowing, increased appetite, hair loss, sexual dysfunction, and, most notably, weight gain. The following section will provide an overview of medications and their most common or significant side effects.

A Brief Overview of Medications Utilized in Treatment Medications used to treat bipolar disorder come from a variety of medication classes. These include mood stabilizers, sedatives, antidepressants, and antipsychotics. Combinations of medications are frequently needed to achieve the best outcome, which results in increasingly complicated regimens.

The established mood stabilizers consist of lithium, valproic acid, and to a lesser degree Tegretol. Lithium is commonly given in the salt form, lithium carbonate, and less frequently, lithium citrate. Lithium is the first discovered mood stabilizer, and was approved by the U.S. FDA in 1970 for the treatment of acute mania. Between 70% and 80% of patients with bipolar disorder have at least a partial response to lithium therapy when utilized in a manic state (Goodwin & Jamison, 1990). Lithium is also used commonly with other mood stabilizers, benzodiazepines, and antipsychotic medications. Daily dose is variable, but generally from 300mg daily to 1500mg daily in adults. To be properly effective, lithium concentrations in the blood must be monitored routinely and kept within a defined therapeutic window. (0.5-1.4 mEq/L). Lithium therapy has also been SPRING 2002

shown to be a potentiating agent in the treatment of refractory unipolar depression (de Montigny et al., 1983; Heninger et al., 1983; Price, 1989) and more research is showing it to be an effective treatment for bipolar depression as well (Goodwin & Jamison, 1990). Lithium does have unpleasant side effects including weight gain, acne, cognitive dulling, increased urination and over time may affect the kidneys and thyroid gland.

Valproic acid (Depakote), has been in use since 1978 in the United States as an antiepileptic, and has been utilized more often in the treatment of bipolar disorder since the late 1980s. Valproic acid is a first line treatment for mania, is at least equally efficacious as lithium, and has benefit in lithium non-responsive patients, particularly those who have elements of dysphoria within their manic syndromes (Bowden et al., 1994). As with lithium, daily dose is variable in adults and depends on the serum level of the drug, but most patients achieve therapeutic blood levels between doses of 500mg and 2000mg daily. Patients taking valproic acid require blood monitoring to follow serum drug concentrations, and monitor any effect the medication is having on the patient’s liver. Serum drug concentrations should be between 50-100 micrograms/mL for the average patient, but may be titrated up into the low 100’s as the patient’s clinical situation warrants. Patients on valproic acid may experience side effects such as weight gain, experience gastrointestinal side effects such as nausea and increased appetite, and neurological symptoms such as tremor. Gastrointestinal side effects are lessened by using the entericcoated form of the medication (Depakote).

One fairly common and distressing side effect of Depakote is hair loss. Serious side effects to valproic acid are rare, but consist of liver toxicity, pancreatitis, and suppression of blood platelets, which can potentially lead to fatal hemorrhage if not diagnosed.

It is the clinician’s responsibility to monitor a patient’s labs frequently (generally every 4-6 weeks during the initial 6 months of treatment). Intervals between lab work can SPRING 2002

then be lengthened as the patient’s clinical condition remains stable.

Carbemazepine (Tegretol) is another anticonvulsant utilized in the treatment of bipolar disorder. Tegretol, like lithium and Depakote, requires blood monitoring to check levels, with a serum level typically between 4-12 micrograms/mL. Between 33%-50% of Tegretol-treated patients experience side effects such as double vision, blurred vision, fatigue, nausea, dizziness, and balance changes. Also limiting use are interactions with other medications and bone marrow suppression, but it remains a fairly common treatment in patients for whom the standard medications are ineffective.

Lithium and valproic acid both carry black box warnings (the warning on a medication that alerts to a potentially life threatening side effect). Psychotherapists and clinicians with patients taking lithium who observe signs of neurotoxicity, such as significant cognitive impairment, lassitude, restlessness, and irritability will want to alert the treating physician. Unrecognized, neurotoxicity can progress to delirium, seizures, coma, and ultimately death.

Although these are rare events, valproic acid is associated with hepatoxicity and pancreatitis, with symptoms including abdominal pain, jaundice, and nausea. Patients taking either of these medications require education about these syndromes, as early intervention is important in recovery from these very serious clinical events.

Several newer anticonvulsants are also under investigation for treatment of bipolar disorder. One of them, lamotrigine (Lamictal), appears to show good potential for treating the depressed phase of bipolar disorder. One drawback to using Lamictal is the need for a slow titration due to the risk of developing a potentially life threatening skin rash, and patients need to be educated about the rash and contact their physician immediately should a rash appear. Because of the slow titration, it may take several weeks to reach the dose that successfully treats the individual patient.

Other potential medications currently

under investigation as mood stabilizers include topiramate (Topamax), tiagabine (Gabitril), and oxcarbazepine (Trileptal).

Currently, these medications are predominantly in use in the psychiatric community as add-on medications to another mood stabilizer such as lithium or Depakote. These newer medications are clinically in use, but we await the study results to assess their benefit in the course and outcome of bipolar disorder.

Antipsychotics Antipsychotics have long been used in the treatment of acute mania and have demonstrated significant benefits.

Antipsychotics historically have had significant drawbacks with long-term use, including the risk of developing a serious and permanent movement disorder (tardive dyskinesia). The development of atypical antipsychotics has resulted in improved toleration and a substantially reduced risk of long-term side effects. In bipolar disorder, the primary use for antipsychotic medications is in combination with a mood stabilizer, especially if psychotic symptoms occur with mood episodes. There are currently four FDA approved atypical antipsychotics available for prescription: olanzapine, risperidone, quetiapine, and ziprasadone.

One particular antipsychotic, olanzapine (Zyprexa), has received FDA approval for monotherapy of an acute manic syndrome.

Olanzapine is a demonstrated antimanic agent with few of the side effects of traditional antipsychotics. However, it has significant side effects. It is associated with sedation, so it is most often taken at bedtime, and is also associated with significant weight gain. Patients who gain large amounts of weight are also prone to develop illnesses related to obesity, such as diabetes, high cholesterol, and joint problems.

For these reasons, weight management can become an issue for patients treated with this medication.

Risperidone (Risperdal) is another commonly used atypical antipsychotic. There tends to be less weight gain than with olanzapine, but it is associated with more motor Texas Psychologist

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side effects such as stiffness, especially at its higher doses. Risperidone also has been shown to elevate prolactin levels comparably to the older, typical antipsychotics (Umbricht & Kane, 1995), which can lead to such side effects as menstrual irregularities, galactorrhea (abnormal lactation), and sexual dysfunction. Despite these potential problems, most patients tolerate risperidone very well, and it is one of the more commonly utilized atypical antipsychotics in the treatment of bipolar disorder.

Quetiapine (Seroquel) and ziprasidone (Geodon) are the most recently arrived atypical antipsychotics. Both are well tolerated in general. Seroquel’s main side effect is sedation, and is also associated with constipation and dry mouth. Geodon is not sedating, but has been shown to mildly slow down the electrical system of the heart. This is seldom clinically significant (currently there is no FDA recommendation to even monitor EKGs in patients taking this medication), but care should be taken when prescribing Geodon to patients with heart problems, and those who are taking certain other types of medications. Some patients on Geodon also experience dizziness. Both Seroquel and Geodon are new medications, but are becoming more widely utilized in the treatment of bipolar disorder.

It is important to note that the atypical antipsychotics, despite being much safer and better tolerated medications than their earlier counterparts, still carry with them a small but not insignificant risk of developing tardive dyskinesia and other movement disorders. All patients treated with them need to be monitored for the emergence of these syndromes.

Benzodiazepines Because of the excitability and anxiety inherent in the manic and mixed manic states, sedating medications are commonly utilized and medications in the benzodiazepine family are frequently prescribed.

The benzodiazepine family is a large one, and commonly prescribed medications include lorazepam (Ativan), oxazepam (Serax), diazepam (Valium), clonazepam 22

Texas Psychologist

(Klonopin), and alprazolam (Xanax). The main differences in these medications lies in their half lives and length of time to onset of action, with xanax, ativan, and serax having relatively shorter time to onset, and valium and klonopin having a longer time to action. Sedation is the most common side effect of the benzodiazepines. Patients who take benzodiazepines chronically can become physiologically dependent on the medication. Withdrawal symptoms include tremulousness, anxiety, irritability, sleeplessness, and, in worst cases, seizures.

Patients need to be monitored for their use pattern, and any drug seeking behaviors noted, such as seeking treatment and receiving prescriptions from multiple physicians, and increased use of the medication.

Antidepressants Bipolar depression can be extremely difficult to treat, and antidepressants are commonly prescribed in the treatment of depressive episodes. Antidepressants must be used with caution in the bipolar patient, as they hold certain risks. Antidepressants can be destabilizing and cause cycle acceleration and manic switch ( Frye et al., 1996; Prien et al., 1984; Wehr & Goodwin 1987).

For this reason, current clinical recommendations consist of short-term use of antidepressants alongside a mood stabilizer, to minimize the occurrence of these serious consequences (Sachs et al., 2000).

Certain types of antidepressants, specifically the selective serotonin reuptake inhibitors (SSRIs) and Wellbutrin, have become the first line treatments for bipolar depression when an antidepressant is deemed necessary. The SSRIs consist of the well-known medications Prozac, Paxil, Zoloft, and now Celexa. The choice of which antidepressant to use is generally decided based on a careful evaluation of the patient’s medical history, the pharmacokinetics of the drug, and the psychiatrist’s preference and experience.

At present, no single antidepressant outperforms any others in the treatment of bipolar depression, but Wellbutrin and SSRIs may have less risk of manic switch.

These medications are commonly used first line treatments. The time course of a bipolar depressed state can last months to years if left to its own devices, and ending a depressive episode is often lifesaving. For this reason antidepressants are used, although there is not a large database supporting their clinical utility.

The newer atypical antidepressants (Remeron, Serzone, Effexor), as well as the older medications such as the tricyclic antidepressants and MAO inhibitors, are also in use. Fewer patients are still on these older medications because the newer ones are much safer medically and well tolerated.

Medication Use and Pregnancy Pregnancy in the patient with bipolar disorder creates issues not seen in the general population. Ideally, the pregnancy should be planned, as the medications used in treatment of bipolar disorder (particularly the anticonvulsant mood stabilizers, lithium, and benzodiazepines) are associated with different types of birth defects. Most patients understandably express the intention to discontinue their medication in order to become pregnant. Women who become pregnant unintentionally will often abruptly stop their medications once they discover they are pregnant. This can lead to an acute manic or depressive syndrome.

Slow discontinuation of medication prepregnancy, and close follow-up with a physician and therapist can lessen the risk of relapse and optimize the potential for a healthy pregnancy and infant. More about pregnancy is discussed later in the article by B. Kertz and H. Zboyan, also in this issue.

Somatic Therapies It is lastly important to keep in mind that, despite all our experience and training as clinicians there are some cases of bipolar disorder that are so tenacious they will not respond well to our intervention, or may not respond at all. Despite all the advances in pharmacology and psychotherapy that have occurred over the years, there are still many chronically disabled or chronically hospitalized patients who suffer from this SPRING 2002

disease, and remain cycling. In these patients it is a good idea to offer the option of electroconvulsive therapy (ECT). ECT in patients with bipolar disorder is useful for the treatment of depression. It can also be used to treat mania, a lesser-known fact.

While medication treatment is certainly first line treatment for bipolar disorder exacerbations, ECT should not be overlooked. This treatment may have great benefit for patients with bipolar disorder, and for refractory patients, this can be a lifeline.

Other investigational treatments for chronic mood disorders include transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS). In TMS, the patient experiences repeated magnetic pulses to the brain, and in VNS, the patient has an implanted device that repeatedly stimulates the vagus nerve (cranial nerve 10).

Both of these procedures are investigational and not yet in clinical practice. TMS does show some promise as a treatment for bipolar disorder.

ication or treatment, and can alert the psychiatrist in the event of decompensation.

This may allow for earlier medication adjustment, and possibly prevent hospitalization or another severe outcome.

The treatment of bipolar disorder can ultimately be described as a rewarding challenge. The future is promising for the development of new medications as well as new somatic therapies. As we learn more about the causes of bipolar disorder, the potential for development of new pharmacotherapies and psychotherapies is bright, and the collaboration of mental health professionals can serve to greatly benefit our patients. âœŻ

SPRING 2002

antidepressant

resistant

depression. In Extein IL (Ed.), Treatment of Tricyclic Antidepressant Resistant Depression. (pp. 49-79). Washington DC: American Psychiatric Press.

Prien, R.F., Kupfer, D.J., Mansky, P.A., Small, J.G., Tuason, V.B., Voss, C.B., & Johnson, W.E. (1984). Drug therapy in the prevention of recurrences in unipolar and bipolar affective disorders: Report of the NIMH collaborative study group comparing lithium carbonate, imipramine, and a lithium carbonateimipramine combination. Archives of General Psychiatry, 41, 1096-1104.

Regier, D.A., Boyd, J.H., Burke, J.D. Jr.,

References

Rae, D.S., Myers, J.K., Kramer, M.,

Bowden C.L., Brugger, A.M., Swann, A.C.,

Robins L.N., George, L.K. Karno, M., &

Calabrese, J.R., Janicak, P.G., Petty, F.,

Locke, B.Z. (1988). One-month preva-

Dilsaver, S.C., Davis, J.M., Rush, A.J., &

lence of mental disorders in the United

Small, J.G: (1994). Efficacy of dival-

States, based on five epidemiologic

proex vs lithium and placebo in the

catchment area sites. Archives of

treatment of mania. Journal of the

General Psychiatry, 45, 68-779.

American Medical Association, 271, 918-924.

Summary Psychiatrist/psychotherapist collaborations are commonplace today, as professionals and individuals are aware of the benefit of combining treatments such as medication and structured psychotherapy in the long-term treatment plan. Because the therapist generally sees the patient with greater frequency than the psychiatrist, and is often the person the patient will go to with concerns or complaints about their symptoms and medications, they can be an important link to the psychiatrist. Clearly, education about medications is the responsibility of the physician prescribing the medication.

Nevertheless, since the psychotherapist may be the first person to observe an adverse effect or a related concern, increased knowledge and education by the therapist can improve the treatment and treatment adherence. It is therefore important for the therapist to have basic familiarity with the medications, in order to know when to refer the patient back to his psychiatrist for reevaluation. The therapist can also aid the patient as he or she adjusts to a new med-

tricyclic

Sachs, G.S., Printz, D.J., Kahn, D.A., Carpenter, D., Docherty, J.P. (2000).

DeMontigny, C., Cournoyer, G., Morissette,

The

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R., Langlois, R, & Caille, G: (1983).

Series: Medication Treatment of Bipolar

Lithium carbonate addition in tricyclic

Disorder 2000. Postgraduate Medicine,

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depression: Correlations with the neurobiolgical actions of tricyclic antide-

Umbricht, D., & Kane, J.M. (1995).

Risperidone:

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pressant drugs and lithium ion on the

Schizophrenia Bulletin, 21, 593-604.

serotonin system. Archives of General

Wehr, T.A., & Goodwin F.K. (1987). Can

Psychiatry, 40, 1327-1334.

antidepressants cause mania and wors-

Frye, M.A., Altshuler, L.L., Szuba, M.P.,

en the course of affective illness?

Finch, N.N., & Mintz, J. (1996). The rela-

American Journal of Psychiatry, 144,

tionship between antimanic agent for

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treatment of classic or dysphoric mania and length of hospital stay. Journal of Clinical Psychiatry, 57, 17-21.

Goodwin, F.K., & Jamison, K.R. (1990).

Manic Depressive Illness. New York, Oxford University Press.

Heninger,

G.R.,

Charney,

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ARTICLE REPRINTS

Sternberg, D.E. (1983). Lithium carbonate augmentation of antidepressant treatment: An effective prescription for treatment

refractor y

depression.

Archives of General Psychiatr y, 40, 1335-1342.

Call Pat Huber at (512) 310-9795 for rates and information.

Price, L.A.(1989). Lithium augmentation in Texas Psychologist

23

Focus on Bipolar Disorder Bipolar Disorder: Challenges for Pregnancy Barbara Kertz, MS, LPC Holly Zboyan, BA Baylor College of Medicine Houston, Texas

This article offers practical information for clinicians and patients who are faced with the challenge of treating women with bipolar disorder who are pregnant or planning pregnancy. A brief description of bipolar disorder is followed by a review of the potential risks associated with standard treatments for bipolar disorder during pregnancy, as well as the potential risks associated with discontinuing standard treatments. Recommendations and practical tips are provided to assist clinicians in this challenging dilemma.

For women with bipolar disorder, also known as manic-depressive illness, pregnancy presents a unique challenge. Standard treatment for bipolar disorder includes mood stabilizers, including lithium and anticonvulsants such as valproate (Depakote), carbamazepine (Tegretol) and others, which are associated with an increased risk of birth defects, particularly during the first trimester. Yet, women with bipolar disorder who choose to discontinue medications are at high risk of relapse. As such, patients and clinicians are faced with the challenge of balancing the risk of relapse with risk of potential birth defects. Psychotherapy is an important adjunct in treating bipolar disorder, but, alone, is typically not sufficient to prevent relapse.

Bipolar Disorder: What is it?

Bipolar disorder is a mood disorder characterized by recurrent periods of depression and elevated mood, often interspersed with intervals of mood stability. Cross-sectionally, the depressed phase of bipolar disorder is indistinguishable from unipolar major depression. Periods of elevated mood are classified as either mania or hypomania, depending on their severity and duration.

Symptoms of mania include increased selfesteem, grandiose thinking, reduced need for sleep, increased talkativeness, racing thoughts, distractibility, increased activity, psychomotor agitation, and high-risk behavior. Mania usually has severe negative life consequences. Hypomania is similar to mania, but generally has a shorter duration, 24

Texas Psychologist

milder symptoms, and less severe life consequences.

Bipolar disorder is most commonly diagnosed in young adulthood, which coincides with the time that many women become pregnant or plan pregnancy. Importantly, the disruptions in sleep cycles and/or daily routines that are common during pregnancy and the postpartum period may contribute to, or exacerbate, mood episodes associated with bipolar disorder. Thus, it is important to evaluate the risk of changing or discontinuing treatment during this vulnerable time. The challenge for practitioners is to balance the risk of exposing the fetus to psychiatric drugs with the risk of relapse. This article will briefly review some of the potential risks associated with stan-

dard treatments for bipolar disorder, as well as present some practical tips for clinicians and patients who are faced with this challenge. In some instances, continuing psychiatric medication may be the best choice for both mother and baby.

Mood Stabilizers Lithium, valproate (Depakote), and carbamazepine (Tegretol) are effective mood stabilizers commonly used in the treatment of bipolar disorder. Standard treatment guidelines recommend that patients remain on a mood stabilizer in all phases of the illness (depression, mania, hypomania, and periods of mood stability) (American Psychiatric Association, 1994; Sachs, Printz, Kahn, Carpenter & Docherty, 2000).

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During acute episodes, the use of additional psychiatric medications (antidepressants or antipsychotics) may be necessary.

Mood Stabilizers as Teratogens Unfortunately, first trimester exposure to all of the established mood stabilizers (lithium, valproate and carbamazepine) is associated with an increased risk of birth defects. The primary concerns are cardiac abnormalities associated with exposure to lithium and neural tube defects associated with exposure to valproate and carbamazepine.

The Register of Lithium Babies originally tracked infants exposed to lithium during pregnancy (Schou, Goldfield & Weinstein, 1973). An initial report based on the registry estimated that infants exposed to lithium in the first trimester were 400 times more likely than unexposed infants to have Ebstein’s anomaly (Nora, Nora & Toews, 1974). Since then, more data has been gathered and the risk of Ebstein’s anomaly has been reevaluated. Two review articles by Cohen address the risk of Epstein's anomaly in exposed infants. The risk is currently thought to be about 10 to 20 times higher than in the general population or about 1 in 1,000 to 2,000 exposures (Cohen, Freidman, Jefferson, Johnson & Weiner, 1994; Cohen & Rosenbaum, 1998).

Reports on the use of anticonvulsants (valproate, carbamazepine) during pregnancy come mostly from studies of women with epilepsy. Because birth defects are more common in infants born to women with epilepsy than in the general population, it is possible that the risk of birth defects will be lower in women without epilepsy who use these same medications as mood stabilizers for bipolar disorder.

However, first trimester exposure to most anticonvulsants is related to an increased risk for neural tube defects and orofacial malformations such as cleft palate. For comprehensive reviews of the teratogenic risks associated with mood stabilizers, see Cohen et al., 1998 and Altshuler, et al., 1996.

Additional concerns about the use of SPRING 2002

mood stabilizers during pregnancy result from the possibility of long term neurological and developmental problems. However, at least two studies have not reported an increased long-term risk from use of a mood stabilizer. In 1976, Schou reported on a 5-year follow up study that compared 60 children exposed to lithium during the second and third trimesters to 57 siblings who were not exposed to lithium. This study found no significant developmental differences between the two groups of children. Likewise, a study that compared the IQs of a group of children exposed to carbamazepine with a group of unexposed children found no significant differences between groups (Scolnik et al., 1994).

Risk of Recurrence Following Discontinuation of Mood Stabilizers Despite the potential for harm to the fetus, many factors must be weighed before psychiatric drugs are discontinued for any reason, including pregnancy. An increased risk of relapse is the primary concern. It is important to keep in mind that, in general, the risk of relapse appears to be higher when mood stabilizers are discontinued rapidly. A slow taper of lithium over a two to fourweek period lessens the risk of relapse (Faedda, Tondo, Baldessarini, Suppes & Tohen, 1993).

A study by Viquera and colleagues (2000) found that pregnancy did not offer protection from relapse to women with bipolar disorder who discontinued treatment. Of 101 women, both pregnant and non-pregnant, who discontinued lithium treatment, recurrences occurred in 52.4% of the pregnant women and 57.6% of the nonpregnant women in the 40 week period following lithium discontinuation. Women who tapered their lithium gradually over 15 to 30 days had a lower recurrence rate (37.14%). Of the pregnant women who remained stable during the pregnancy, 70% relapsed during the postpartum period.

Use of Antidepressants Without a Mood Stabilizer Because mood stabilizers are teratogenic,

it might seem reasonable to consider using antidepressants by themselves to prevent or treat depression during pregnancy, especially since tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) appear to be safe for prenatal use. However, the use of antidepressants without a mood stabilizer in patients with bipolar disorder may worsen the course of illness. In a recent naturalistic study of patients with bipolar disorder who were treated with antidepressants, but not concurrent mood stabilizers, 24% of patients “switched” from depression to mania or hypomania (Henry, Sorbara, Lacoste, Gindre & Leboyer, 2001). In addition to triggering mania/hypomania, antidepressants can also trigger rapid cycling or mixed states in some patients. As a result, it is generally recommended that antidepressants be used in conjunction with mood stabilizers in patients with bipolar disorder.

For acute episodes of depression or mania, electroconvulsive therapy (ECT) is generally considered safe for use during pregnancy.

Risks of Untreated Depression and Mania Despite the high risk of relapse, many women choose to discontinue their psychiatric medications while they are attempting to conceive and/or during pregnancy.

However, untreated episodes of either depression or mania also present serious risk to the health of the mother and fetus.

The risk of suicide in patients with bipolar disorder is high. Goodwin and Jamison (1990) have estimated that up to 19% of bipolar patients complete suicide. Although there are no figures for suicide attempts during pregnancy in women with bipolar disorder, it is a serious concern, especially following medication discontinuation.

Suicide attempts expose the fetus to various risks depending on the method used.

Completed suicide is, obviously, fatal to the fetus as well as to the mother.

Depression also carries serious risks for the mother and fetus. Depression can exacerbate the normal fatigue commonly experienced in pregnancy and reduce the mother’s ability to care for herself. Reduced Texas Psychologist

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appetite, especially when coupled with morning sickness, can endanger the mother’s food intake and possibly the nutritional status of the fetus. Reduced interest can affect the mother’s adherence to her own prenatal care, and disinterest and inability to attend to her own needs places both the mother and the fetus at risk.

Newborns exposed to maternal depression have exhibited both prolonged crying and irritability, suggesting that maternal depression affects the newborn’s ability to self–regulate (Weinberg & Tronick, 1998).

Six-month old infants exposed to untreated depression in utero have been found to be more reactive to stress (Newport, Wilcox & Stowe, 2001).

Untreated manic episodes can also present risks for the mother and infant, as they are frequently accompanied by high-risk behavior. Lack of sleep, coupled with increased physical activity and disregard for personal safety can create situations that endanger the mother’s and the fetus’s health.

Guidelines for Discontinuing Psychiatric Medications Although psychiatric drugs carry risk to the fetus, many factors must be weighed before treatment is discontinued.

The woman’s psychiatric history, including the severity of her affective episodes, and her current clinical status are important elements (Packer, 1992). If the woman has had prior pregnancies, the history of her illness during the pregnancies and the postpartum periods should also be considered. If a woman has a history of severe affective episodes when off medication, it may not be reasonable to discontinue treatment, as the risk of relapse may outweigh the risk of birth defects. In unplanned pregnancies, the fetus has often experienced the most damaging exposure by the time the pregnancy is recognized. In cases such as these, the woman and her psychiatrist must work together to determine a medication regime that will minimize risk to both the fetus and the mother.

26

Texas Psychologist

Omega-3 Fatty Acids Research continues to identify mood stabilizers that are not teratogenic. Preliminary research indicates that omega-3 fatty acids, naturally occurring compounds found in fish, plant algae, and flaxseed, may have mood stabilizing properties (Stoll et al., 1999). Omega-3 fatty acids are non-toxic and safe during pregnancy and lactation (Hornstra, Al, van Houwelingen & Foreman-van Drongelen, 1995). As part of the STEP-BD research program (described in the introduction to this issue), a study is currently underway to assess the use of omega-3 fatty acids in women who have decided voluntarily to discontinue medication while planning pregnancy.

How Can Psychotherapy Help?

Psychotherapy, combined with medical management, is an important tool in treating bipolar disorder. Psychotherapy can benefit bipolar patients in many ways, including enhancing mood stability, improving functioning, and reducing the number of hospitalizations (Huxley, Parikh & Baldessarini, 2000). Resources for therapists working with bipolar patients include Miklowitz and Goldstein’s book Bipolar Disorder: A Family-Focused Treatment Approach, Newman, Leahy, Beck & ReillyHarrington’s book Bipolar Disorder: A Cognitive Therapy Approach and Frank’s work with Interpersonal and Social Rhythm Therapy (Frank, Swartz & Kupfer, 2000).

Because of the high risk of relapse during pregnancy, psychotherapy should always be considered when a woman with bipolar disorder is planning a pregnancy or is already pregnant. In our practice, psychotherapy with these women includes proactive planning for pregnancy and the postpartum period. Whenever possible, the woman’s partner is included in sessions focusing on the following issues: Building a medical support team that includes the woman’s psychiatrist and obstetrician or midwife, building a social support network, enhancing communication skills, mood charting, managing sleep,

identifying and managing stressors, prioritizing responsibilities, exploring physical and emotional changes associated with pregnancy and the postpartum, and planning for the postpartum period.

Conclusion There are no perfect answers for the woman with bipolar disorder who is planning a pregnancy. All of the available options carry risks. Remaining on psychiatric medications during pregnancy carries an increased risk of fetal malformations.

Discontinuing psychiatric medications increases the risk of relapse and the potential negative effects of untreated mood episodes on the mother and fetus. While the risk of relapse can be reduced by a slow tapering of medication, it cannot be eliminated.

New treatments are under investigation and may provide a safer alternative to managing bipolar disorder. For the present, a combination of close psychiatric supervision and psychotherapy focused on issues surrounding pregnancy and postpartum in conjunction with a partner or other supportive person will serve to optimize outcomes for women planning pregnancy.

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Cohen, L.S., Freidman, J.M., Jefferson, J.W., Johnson, E.M., & Weiner, M.L. (1994). A reevaluation of risk of in utero exposure to lithium. Journal of the American Medical Association, 271(2), 46-150.

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Huxley, N.A., Parikh, S.V., & Baldessarini, R.J. (2000). Effectiveness of psychosocial treatments in bipolar disorder: state of the evidence. Harvard Review of Psychiatry, 8(3), 126-40.

Miklowitz, D.J., & Goldstein, M.J. (1997): Bipolar disorder: A family focused treatment approach. New York: The Guilford Press.

Newman, C., Leahy, R.L., Beck, A.T., & Reilly-Harrington, N. (2001): Bipolar disorder: A cognitive therapy approach.

Washington DC: American Psychological Association Press.

Newport, D.J., Wilcox, M.M., & Stowe, Z.N. (2001). Antidepressants during pregnancy and lactation: defining exposure and

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Letter:

Lithium,

Ebstein's Texas Psychologist

27

Focus on Bipolar Disorder An Interview with Charles Bowden on Research and Practice in Bipolar Disorder Jodi M. Gonzalez, PhD

Charles Bowden, MD, is an internationally recognized expert on bipolar disorder and has authored over 200 articles, books, and book chapters. His research is principally on the symptomatic and biological characterization of bipolar disorders and the efficacy and pharmacodynamics of mood stabilizing drugs.

Dr. Bowden is the Chairman of the Psychiatry Department at the University of Texas Health Science Center in San Antonio. He is a member of the Scientific Advisory Board of the National Depressive and Manic-Depressive Association and in 2001 received the association’s Gerald L. Klerman Senior Investigator Award. He is named in Best Doctors in the U.S. in the area of mood disorders. Jodi Gonzalez sat down with Dr. Bowden to discuss bipolar disorder research and practice.

JG: Why do you think bipolar disorder has been receiving so much clinical and research attention of late?

CB: It has always received some attention. It has not had anywhere near the financial support in terms of the National Institute of Mental Health funding; not until the early 90s was there much interest from pharmaceutical companies in terms of drug-related research. So, that’s what has changed, I think. And, some of the reasons for that change have to do with the recognition that a substantial number of people who might be diagnosed initially other than bipolar disorder, fundamentally have bipolar disorders. So, the notion of how many people out there have some form of bipolar disorder has a different answer today than it would have 25 years ago. That’s especially true in select populations – children and adolescents where 25 even 10 years ago you’d have a substantial number of child psychiatrists say “I’ve never seen someone with bipolar disorder.” You wouldn’t find that point of view in the year 2002. Then, there have been more treatments added to what was simply a solo treatment, standing alone, lithium, for 25 years and patients 28

Texas Psychologist

who in many instances either didn’t benefit or didn’t tolerate the substantial side effects of lithium, or both, now can benefit from some other alternatives. You put all those together and you have a very different professional and public perception in the level of interest in bipolar disorder.

JG: You are the site principal investigator for the national STEP-BD study. Can you provide an update on that study?

CB: Well, the STEP study – let me first explain what is meant by STEP; the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

This is an NIMH sponsored, long-term, initially 5-year study possibly to continue longer than that. STEP is a prospective follow-up of patients with bipolar disorder; all forms of bipolar disorder and people in all stages of the illness. STEP has an advantage in that it follows these people into the future. So you can start to ask the important questions. You can do this in part because you are pooling not only the San Antonio center and another site in the state of Texas at Baylor under the direction of Dr. Lauren Marangell, but also 15 other acade-

mic medical centers around the United States. So you have different people in different urban settings studying such a large number of patients, instead of basing the answer just on the impression of one investigator with a handful of patients from his or her experience, you have dozens of investigators and you multiply your sample size.

JG: Is the STEP an efficacy or effectiveness study? (i.e., efficacy is evidence of benefit in a clinical trial; effectiveness is evidence of benefit in a real-world clinical setting) CB: The STEP is a little bit of everything. I view the STEP as having more of an impact on effectiveness and not the general definition of efficacy: does a drug work as well as another treatment, does it work as well or better than placebo, which would be the usual, primary efficacy question.

Rather, how does this treatment, and not just the drugs—I emphasize the drugs because they are central but they certainly are not used alone in the STEP—how does this treatment inform the world? How many people is it applicable to? Is it well tolerated by the patients? Are there serious risks, side effects or laboratory abnormaliSPRING 2002

ties that might not be side effects in the sense of someone complaining but still be risk factors that are added to the patient’s health status over time if those laboratory tests are not followed up on. So, it’s much more along the lines of effectiveness.

Having said that, the STEP has pathways for smaller numbers of patients to test specific treatments. Those specific treatments are for persons, for example, with depression that have not responded to standard treatments, what we call a refractory depression. These patients, more like your standard, pharmaceutical study at 50-60 patients in each treatment group, would be in those kinds of studies. So, for a subset of patients, it’s an efficacy study as well as an effectiveness study.

JG: You mentioned earlier that bipolar disorder is recognized more often in cases where it would previously not have been recognized.

CB: The recognition is at least that it’s on the radar screen of physicians and behavioral health specialists in instances where they would have simply treated substance abuse as an addictive disorder, alcoholism, whatever. Those persons are aware that there is a high comorbidity. They may not be able to cite the references or the statistics, but even drug and alcohol counselors with a bachelor’s degree probably have some awareness that there is some linkage of some addictive disorders to bipolar disorder with the stimulus seeking and impulsivity that goes with a mood disorder.

JG: Bipolar disorder has previously been under-recognized in previous settings?

CB: Yes it has been under-recognized but that under-recognition has multiple facets to it. It’s not that the person is not inclined to think bipolar or because they are under-trained. Part of it is the way DSM IV is structured, where it takes criteria, for example major depressive disorder, and says this is what major depression is in the context of bipolar disorder. The evidence is that although there is a lot of overlap that there are also some substantial differences in the depression you see in bipolar and the SPRING 2002

depression you see in unipolar. So, it’s easy to underestimate the true prevalence even if one is aware of the pitfalls.

lithium is that it really doesn’t require near that much to put the person into a fundamentally different category.

JG: What differences in depression does the DSM not account for?

CB: It tends to view depression as a conglomerate of physical, mood and cognition symptoms. A physical example would be complaining of body aches and pains. Mood would be feeling sad.

Cognition would be preoccupation with particular themes such as pessimism, impaired cognition or slowed thinking.

Although all those are true, the physical or somatic symptoms are relatively lacking and when present are mild in most bipolar depressive conditions, where they are prevalent in other depressions.

JG: Why would somebody need to be in a mixed category? How would that inform treatment?

CB: Mixed manic episodes are associated to poor response to lithium treatment. It doesn’t mean that no patients treated with lithium would respond, but one would be reluctant to treat a person with lithium if you view the person in a mixed group.

JG: What about the DSM IV classification of mania?

CB: The DSM classification of mania works well, up to a point. A full-blown manic episode is easy to recognize at least in its classical form, and in fact has the highest inter-rater reliability of any Axis I disorder. So, there is reluctance to change all the DSM IV criteria if it works so well.

There are some problems with the criteria, and I am sympathetic to the problems that they pose even for experts. They tended historically to require that a manic episode be of such severity that it required hospitalization to be called Bipolar Type I. Well, at a point where a psychiatrist chose hospitalization strictly on the basis of clinical grounds that made sense. In the world that we live in now it does not, with heavily managed care restrictions such that impairing manic episodes do not result in hospitalization. So, hospitalization probably needs to be removed from the diagnostic criteria. And, only in the most recent DSM has there been a classification of mixed mania; at least, a subclassification that a professional can make diagnostically.

However, it is over-restrictive, requiring that the person have the full spectrum of manic and depressive episodes. The relationship at least in terms of response to

JG: Do you mean having mostly mixed episodes or only having one mixed episode would put them in the mixed group?

CB: You are asking more than we know.

What the DSM would require is strictly a cross-sectional look at things. So, the DSM is ahistoric. It doesn’t take into account what health professionals know about the treatment course and history, age of onset or if so, DSM considers those in only the softest fashion. There is nothing that says do things differently because the person was in a mixed episode two years ago. The extent of systematic research on mixed mania isn’t that great. So, it’s an open question as to whether patients with mixed episodes at one point will be highly likely, moderately likely or no more likely than an average patient to have another mixed episode. You would think we would have good information on that, but if you think about it, that requires a long-term, prospective type study. If you tried to glean this information solely from the patient’s family and self-report your reliability of information is increasingly poor. Even when we try to get information from patients on how they were six months ago, we’re on shaky ground. It’s not just in this area, but any clinician would have that experience with his or her patients.

Fortunately, the STEP study will help to answer these questions by looking at people with a different set of criteria qualifying them as having some form of mixed state, comparing them to those who have the full DSM criteria.

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JG: There are a couple of new terms being used in bipolar disorder to describe mania, such as ultra-rapid cycling and ultra-radian cycling. Can you talk about those a little bit?

CB: One of the problems is that as you understand more about a condition, the ways you first defined it may seem inadequate. Rapid cycling is not a diagnosis in the DSM, it is what’s called a course modifier. So, you can call me Bipolar I, II, mixed or non-mixed and you could still add rapid cycling to the diagnostic label as a course modifier. And, it has its own specific set of criteria. It’s not that they are incorrect, but they are inadequate for the degrees of cycling. And there are some patients who don’t cycle on a time frame that is measured in weeks and months but on one that’s measured in days - thus the term ultra-rapid - or even within a day, hours or in some instances, within matters of less than an hour; for those the modifier ultradian has generally been used. I think they are helpful terms, I think they deal with, at least to some degree, different groups of persons with bipolar disorder. Having said that, neither of these terms has worked its way into the parlance of the DSM as we speak.

JG: So, you don’t have the duration requirements, do you still like to have the symptom requirements, the number of symptoms in that 30 minutes or an hour?

CB: That’s a good question. The DSM goes overboard on durational requirements.

Actually, I think this is also true for many other disorders than bipolar disorder.

Certainly those patients who meet the duration qualify for whatever the disorder, but there are many patients who have all the symptoms, the illness defining symptoms, but may have them in a time frame that is simply not what DSM spells out. I think that some relaxation of those time frame requirements would be in the interest of practicing psychiatrists. I think that it’s likely we will see that incorporated into DSM to some degree. In rapid cycling, for example, there are a number of people that have been followed mostly naturalistically, but systematically. The Italian psychiatrist for 30

Texas Psychologist

whom I have substantial respect, Mario Maj, has a series of studies on this issue. He has shown that if we look at this in terms of illness response to treatment, different biological subtypes or abnormalities underlying rapid cycling, we would have better predictive ability by relaxing or eliminating those durational requirements.

JG: The other requirement that can lead into a more gray area is not having the grandiosity of mania but being irritable.

CB: Yes, actually I think we know a great deal about that. That’s amenable simply to descriptive study, where you simply count the portion of patients with symptoms in a given period. And I think the irritability and hostility are more universal symptoms than is grandiosity. It’s a little bit at odds with the lay notion of mania of the person wanting to stay up all night, party all night, drink, have loose sexual relationships, plan on making a million dollars on some grandiose scheme. The degree of unadulterated pleasure in this illness is a lot lower than that notion, as you well know.

JG: In other words, you don’t see grandiosity as a necessary component of mania?

CB: Well, I wouldn’t go so far as to say it’s not necessary in the sense of necessary to explain some of the behavior. Even when there is grandiosity it has a perverse or secondary role. We can have a patient sent to us depressed and describe how his depression is so bad that he has gone to all these top people and how none could help him and how he is suffering in such a major way. So, what he tells us in terms of content is of depression but he tells us in a somewhat grandiose way. “My depression is worse than anyone else’s depression. My depression is beyond the scope of the average mortal to intervene”. So, grandiosity can intrude in this illness in a kind of back door fashion.

JG: Why is bipolar disorder so difficult to treat in children and adolescents?

CB: Foremost, we have fewer good studies on which to base treatment. Also, for treatment to be effective, both the child and

the parents must be involved, and many of the parents have bipolar symptomatology.

Also, the treatment has to work around a schedule of school and extracurricular activities, and not have side effects that interfere with those activities.

JG: How important is it to differentiate between classifications of bipolar, such as bipolar I, bipolar II, and cyclothymia?

CB: Very important, at least to distinguish bipolar I and II. The latter is frequent episodes, including rapid cycling, and is more prevalent in women. Antidepressants are at present overused in bipolar II patients, with consequent mood destabilization. Lamictal has a potential large role for bipolar II’s, based on the evidence I see.

JG: In 1994 you conducted one of the efficacy trials for valproate that resulted in its FDA approval. Since then other potential mood stabilizers have entered the market.

How are studies looking for these new agents?

CB: The study that I had the good fortune to lead in a way defined a methodology that worked that allows you to compare a treatment with placebo plus usual care, or lithium. It led to results such that when psychiatrists started using valproate–divalproex, they got essentially the same kind of results we reported in several articles. One of the main consequences was companies that had previously thought there was no point in involving themselves in bipolar disorder research as far as drug development was concerned came to understand that though lithium was, and remains to this day, a very important, and for some patients, effective treatment, that there were clearly fewer than half of patients with bipolar disorder adequately treated by and tolerant of lithium. So here you have a combination of the recognition that those people being treated with lithium were often having poor outcomes and that there are more people with bipolar disorder than had been commonly understood. In addition, you had a methodology that allowed for study of treatments, at least on the manic side, so they went back to the drawing SPRING 2002

boards and looked at what drugs they had that might have some sort of mood stabilizing properties in them. There’s hardly a major research pharmaceutical company in the world now that does not have or is not endeavoring to develop a drug or a series of drugs that could have some role in improving the lives of some of those patients.

JG: Any studies you are conducting now involving these agents?

CB: We are nearly always involved in one or two studies. There have been two major directions for the mood stabilizers that work on the manic side. One is to look at every drug that was initially viewed as an anti-epilectic or seizure medication. That is the class that valproate came from and it’s the class that carbamazepine came from, but there are many others, just to mention a couple of examples at present – topiramate and levetiracetam. Both are marketed for epilepsy but there are studies underway to see what kind of benefit they bring mostly for those in mania. The second is less a new story, but still an interesting one. Early on, it was understood that antipsychotic medications helped in mania. In part it was understood because a substantial percentage of manic episodes have psychotic features, but it also appeared to be the case that the antipsychotics helped some of the other manic symptoms as well as the psychotic ones. Now there is a group of drugs mostly referred to as atypical antipsychotics that has better tolerated side effects, albeit substantial side effects. There has been an equally great interest in the earlier antipsychotics, despite their side effects. It’s a more complex task to read this literature because the antipsychotic drugs have such broad, sedating, and motor slowing effects that they give you results that look like they are really working, but some of that work is really a function of sedative, non-specific, physical slowing kinds of activity.

I think that’s one reason that the antipsychotics have not been elevated to center stage for treatment of bipolar disorder, and is unlikely to occur with the present group of antipsychotics.

SPRING 2002

JG: The STEP also has psychosocial treatments being studied.

CB: Yes. JG: How do you view the role of psychosocial treatment for bipolar disorder?

CB: Interestingly, to my way of thinking, bipolar disorder more than any other chronic, recurrent, severe mental disorder must have a psychosocial treatment component. For many patients that’s not going to be standard, insight-oriented psychotherapy, but for some patients it includes that. But at the very least this treatment requires that patients actively and only gradually over time develop an understanding about the role of environment and psychosocial risk factors in their illness. These include the importance of sleep, the importance of avoiding certain drugs of abuse, and certain drugs that to a non-bipolar patient might be innocuous.

They need to understand the fact that there is something about this illness—it’s still not adequately understood—but the illness itself causes the person to start to think he or she is well. He thinks that he doesn’t need the treatment, doesn’t need the medication, doesn’t need counseling, doesn’t need to keep the next visit. So it’s not exactly the same as denial although it has an element of that. The nature of this illness causes people to make bad judgments, to lack insight, to behave impulsively. This occurs to such an extent that it can place them in danger of being put in jail, risking their life, and avoiding the very treatments that could provide at least temporary respite or more lasting benefits. So, the psychosocial aspect is critical for this illness. It may not be so critical for the person in the hospital for a week, but in the long-term management of this illness where 90 percent of the care takes place, there has to be an active psychosocial component.

JG: I agree with that. At times psychiatrists treating bipolar disorder do not consider psychotherapy as an adjunctive treatment. Is this because there is just not sufficient information on psychosocial treatment available?

CB: Although there is some good psychosocial treatment research being done, the truth of the matter is that the research lags behind some of the impressions that I have, based more on epidemiologic illness course evidence than psychotherapy per se.

I think there is some good work being done—David Miklowitz in Colorado is an example of that—but there are other groups, as well. But when one starts looking at prospective, randomized kind of studies, the field of psychotherapy research is generally weak in regard to that. Also, 90 percent of what has been developed in a really systematic way on bipolar disorder has occurred in the past few years, so it’s not surprising that there wouldn’t be a great deal psychotherapeutically or psychosocially, as well.

JG: I have also heard individuals with bipolar disorder express that they want psychotherapists who specialize in or have a great deal of understanding of bipolar disorder.

Why do you think that is?

CB: Well I think that’s true—of course you and I see perhaps a skewed sample.

The patients that we see here tend to have had the illness for some time. Most of them have some fundamentally basic good understanding about the illness. They realize that it’s complex. Often they have seen psychiatrists for pharmacological treatment, psychosocial treatment, other counselors, and they have seen enough in both camps of care that either misunderstood some fundamental aspects of this illness or may have actually been hurtful in relationship to the current problem.

Thus, they want to deal with professionals who have current, in-depth knowledge of the complexities of this illness. There are a myriad number of reasons for this.

Sometimes it’s influenced by their own grandiosity, but sometimes it’s also influenced by their recognizing that they do have these problems with impulsivity and judgment and unless they are working with someone who has seen it all in terms of the spectrum of bipolar symptomatology, they are concerned that the wellTexas Psychologist

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meaning professional might overlook things that would cause that patient harm because they weren’t staying on top of his or her problems.

JG: I think it’s difficult because when patients come in and they talk about their mood lability, as psychotherapists we tend to want to focus on the psychological contributors to that. It can be hard to differentiate if there is a psychological cause or if they woke up that day and were feeling poorly because of the illness.

CB: I think many people who have psychotherapeutic practices, at least for this condition, are excessively inclined to look for some kind of psychological or conflict cause. It’s not that there is not often an element of one of those, but in bipolar disorder what you see behaviorally is in many ways what you get. It’s better to deal with that principally in terms of the consequences to present safety, present function, present well-being and not look into early or learned experiences. There are plenty of exceptions. Many persons with bipolar disorder have had more than their share of early life conflict for a somewhat unique reason. Because of the high hereditary component of at least the most common form of bipolar disorder, many of these people will have had one or both parents with some form of bipolar disorder, sometimes diagnosed, sometimes not diagnosed. Such a parent would have displayed some of the same unpredictability and impulsivity toward the child that goes with this illness.

JG: What are your views on how we can focus on the relationship of stress to episodes during treatment?

CB: First, we all have stress in our lives.

Second, people with bipolar disorder have more in the way of comorbid anxiety symptoms and anxiety disorders. You name the anxiety disorder in terms of DSM labeling and it’s present with an increased prevalence of cases over that of the general population.

There are several reasons to pay attention to stress and stressful events. It’s a good way to 32

Texas Psychologist

organize your major psychotherapeutic or psychosocial effort for patients with bipolar disorder. It’s not the only way, but as far as the entrée to what will be discussed over a 30 or 45 minute appointment, it is probably as good as any other.

JG: What about the collaborative role of psychologists/therapists and psychiatrists in working with the disorder?

CB: Well, I don’t think there is any one size fits all. In some ways, I think the issue is more of the time requirements and of the organization of practices in the year 2002.

On the issue of time requirements, many psychiatrists simply lack the time to devote major portions of their efforts to counseling and psychotherapy. So, for those reasons they set up liaisons with psychologists.

Psychologists, in turn recognizing that many of the clientele with whom they work need medications, and have medically, biologically-based disorders to deal with, want to work with psychiatrists. Also, more practices are organized in a multidisciplinary way rather than as solo practices as a psychiatrist, social worker, or psychologist.

More practice is delivered in some form of a multidisciplinary setting today than was the case 15 years ago. One reason for this is that solo practices often place the professional at somewhat of a disadvantage in the health care payor environment.

JG: If I am seeing someone weekly, and see someone’s mood shift toward a different episode or phase, should I contact the psychiatrist to change medications as soon as possible? How important is that if the person does not see the psychiatrist for another month and the symptoms are subclinical?

CB: It’s a good question. It is important. Having said that—and this isn’t something that is limited to psychiatrists and psychologists—you see it with physicians too, for example. Even if you have your offices next door to one another, it’s not as easy as the lay individual or the patient might think for us to quickly convey to our colleague working with a patient what’s going on. I think if we found a way to do that more patients would be the bet-

ter for it. There are more instances where there is less than optimal care—it’s not limited to behavioral health—rather than too much.

Several themes can be extrapolated from the discussion with Dr. Bowden. A positive trend is that research in bipolar disorder are increasing, especially in quality and applicability to clinical settings. Additionally, Dr. Bowden mentions investigations with a focus on incorporating modern classifications of bipolar disorder into future DSM editions, to better capture what is observed in clinical practice. Psychosocial treatment also seems to be gaining in prominence in comprehensive bipolar disorder treatments, and our patients are seeking our expert opinions and guidance to enhance their quality of life. ✯

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Contact Pat Huber for more information at 512-310.9795 or e-mail rdpat@rector-duncan.com

SPRING 2002

By Dee Yates, PhD Who will be first?

As I sit down to write this article, New Mexico’s RxP Bill has just passed out of its House of Representatives. By the time this journal is delivered, New Mexico may very well have prescription privileges for psychologists. How did New Mexico get to this point so quickly?

In their first try, during the 2001 New Mexico regular legislative session, the New Mexico Psychological Association got their bill passed out of the House and out of two Senate committees. MNA had the votes to pass the bill in the Senate; however, on the last day of the legislative session the leader in the Senate kept the bill from being brought up for a vote. After psychologists and psychiatrists debated the issue before the governor, he requested the bill be brought up again during the short 2002 session. And now New Mexico could be the first state to pass an RxP bill. A few dedicated psychologists already trained in psychopharmacology, with the backing of the American Psychological Association and psychologists all over the country, have gotten a prescribing bill farther in a shorter time in New Mexico than any other state has.

At this time, 11 states have submitted RxP legislation at least once. Texas is one of those eleven. Texas began planning for prescriptive authority for psychologists as early as 1996. A time line was established that would put TPA in position to submit its first bill in 2001. Task Forces were formed, debates were held and a new lobbyist was hired. On schedule, TPA submitted its first prescribing bill in the 2001 legislative session. With an abbreviated session because of redistricting, it was decided not to push for a vote in committee at that time. Our next opportunity will be in 2003. With at least one other state having passed RxP legislation that could be our year. The question was once, should psychologists prescribe?

The question now is when? The momentum is here. The time is now!

SPRING 2002

Texas A&M Psychopharmacology Program Over 100 psychologists in Texas have already completed a psychopharmacology training program and many of those psychologists are now completing a practicum under the supervision of physicians. Recently, Texas A&M University, with the cooperation of the Texas Psychological Association, developed a psychopharmacology training program for practicing psychologists. The program is offered through Continuing Education in the College of Education. The program will be taught through Distance Learning at various sites around the state. The program will begin with sites in Dallas, San Antonio and College Station. The first cohort is scheduled for April 2002. It is not too late to enroll. Applications are available on line at www.coe.tamu.edu/ ~psypharm/ or by calling Kelli Phelan at 979862-6529. ✯

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ARTICLE REPRINTS

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he mission of the Texas Psychology Foundation is to support activities in Texas that promote psychology and services for the citizens of Texas. An example of recent Foundation activity was the Town Hall on School Violence at the TPA Annual Convention in October 2001. The Town Hall brought together a diverse group of professionals, including judges, school leaders, teenagers and parents from the community, to establish a framework to deal with violence in the school setting.

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and one undergraduate student to defray costs of meritorious research projects.

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PSY-PAC

2001 PSY-PAC Contributors January 1 - February 4 Ron Cohorn, PhD, PSY-PAC President The only organizations that represent psychologists in the Texas Legislature are the Texas Psychological Association and the Psychology Political Action Committee (PSY-PAC). Legislative monitoring for bills that are detrimental to psychology and proactively introduce legislation to further the field are essential to the survival of our profession. These activities are not for just a few special interests, but for the profession in general. As a group, psychologists have not understood the importance of contributing to the PSY-PAC fund, but the events of the next few years will make consistent contributing absolutely necessary.

We will soon be facing sunset of our practice act and we must have funds to adequately protect our profession. Dealing with managed care and promoting prescription privileges are also matters of priority. Unfortunately, only 10 percent of TPA. members contribute to the PAC and 2 percent contribute the majority of total funds. Please consider a contribution, consistent with your income, and help your profession. We can do great things if everyone pulls together.

Please make a personal commitment to contribute regularly to PSY-PAC. Again, thank you for your support.

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Under $100

Tim Branaman, PhD Ron L. Cohorn, PhD

Barbara Abrams, EdD Elizabeth Barry, PhD Connie Benfield, PhD Glenn Bricken, PsyD Barry Bullard, PsyD Caren Cooper, PhD Leslie Crossman, PhD C. Munro Cullum, PhD Linda M. Ingraham, PhD Harry F. Klinefelter,III, PhD Karen Krause, PhD Victor E. Loos, PhD Sam Marullo, Jr., PhD Joseph H. McCoy, PhD Muriel Meicler, PhD Shelley Probber, PsyD Ollie J. Seay, PhD Robert M. Setty, PhD Debbi S. Wagner-Johnson, BA B. R. Walker, PhD Colleen A. Walter, PhD Patricia D. Weger, PhD Mark J. Wernick, PhD Connie S. Wilson, PhD Eirene Wong-Liang, PhD

$500-$999 Kevin G. Smith, PhD

$100-$249 * Laurence Abrams, PhD Kyle Babick, PhD Ray H. Brown, PhD Sam J. Buser, PhD Jim L..H. Cox, PhD Richard Fulbright, PhD Ronald Alan Garber, PhD Humberto S. Gonzalez, PhD Jerry R. Grammer, PhD Charles A. Haskovec, PhD Sophia K. Havasy, PhD Sheila Jenkins, PhD Kevin T. Jones, PhD Nancy A. Leslie, PhD Marcia J. Lindsey, PsyD Leon Morris, EdD J. Randall Price, PhD Shannon E. Scott, PhD Jana Swart, PhD Thomas A. Van Hoose, PhD David S. Wachtel, PhD John W. Worsham, Jr., PhD

36

Texas Psychologist

*Individuals who contribute at least $100 may vote in PSY-PAC elections.

SPRING 2002