Fwd: New Approaches to Bipolar Disorder 5/20/01
LyndaNP
Subject: New Approaches to Bipolar Disorder 5/20/01
From: LyndaNP <Lyn...@bigfoot.com>
Newsgroups: alt.support.depression.manic
soc.support.depression.manic
Date: Sun, 20 May 2001 07:58:29 -0400
New Approaches to Bipolar Disorder
Gary Sachs, MD
Medical Writer: Steffany Fredman
http://www.medscape.com/Medscape/psychiatry/TreatmentUpdate/2000/tu05/pu
blic/toc-tu05.html
Table of Contents
Introduction
General Principles of Treatment
Using a Collaborative Care Approach to Address Potential Obstacles
Summary
Introduction
What is Bipolar Disorder?
Bipolar disorder, also referred to as manic-depression, is a common and
treatable psychiatric disorder. This pernicious illness affects
approximately 1% of the US population and is associated with significant
impairment and an increased risk of suicide.[1] Bipolar disorder is
characterized by periods of abnormal mood elevation, often with
intervening episodes of depression. The consequences of such extreme
affective episodes often have a substantial negative impact on both
patients and their relatives, disrupting finances, relationships,
functional ability to work, and quality of life.
Elevated mood may take the form of mania, hypomania, or a mixed state in
which patients experience both mania and depression (Table 1) . A manic
episode is characterized by an elevated mood that lasts for a week or
longer and often occurs in conjunction with other symptoms, such as
increased energy, racing thoughts, inflated self-esteem, decreased need
for sleep, abnormal irritability, extreme elevation, poor judgment, and
increased participation in risky behaviors. Although many individuals
experience the initial symptoms of mania as pleasurable, a manic episode
may be dangerous. The individual's judgment is severely impaired, and
actions are taken without careful consideration of the potential for
negative impact on health, finances, career, or relationships. In the
case of severe mania, which is frequently characterized by psychotic
behavior, individuals may experience auditory hallucinations and
delusions, paranoia, or mood-incongruent thoughts. "Hypomania" refers to
a period of abnormal mood associated with mild to severe associated
symptoms that may last for a few days to many months. Mania and
hypomania are generally differentiated by the impairment in the
individual's daily functioning, such as relationships or work
performance.
Table 1. Modified Summary of DSM-IV Episodes -- Acute Manic Episodes
Acute Episodes With Elevated Mood
Episode Type Predominant Mood State Symptom Threshold Requires
3 associated features in presence of euphoric or expansive mood. If only
irritable, 4 associated features are required.
Mania High, euphoric, expansive, irritable Present to a significant
degree through at least 1 week, or any duration if hospitalized
* Increased self-esteem/grandiosity
* Decreased need for sleep
* More talkative
* Racing thought/flight of ideas
* Distractible
* Increased goal-directed activities/psychomotor agitation
* Risk-taking
Hypomania High, euphoric, expansive, irritable Present to a
significant degree through at least 4 days
* Increased self-esteem/grandiosity
* Decreased need for sleep
* More talkative
* Racing thought/flight of ideas
* Distractible
* Increased goal-directed activities/psychomotor agitation
* Risk-taking
Mixed Both elevated and depressed At least 1 week during which
symptoms satisfying criteria for depression are present most of the
day/nearly every day and symptoms meeting criteria for mania are present
to a significant degree.
Major depression is a medical and psychiatric disorder that lasts at
least 2 weeks and that produces a combination of physical and emotional
symptoms that produces impairments in multiple domains of functioning.
Central to clinical depression is a loss of pleasure in activities that
had previously been fun or enjoyable. Symptoms often include feelings of
sadness, hopelessness, and pessimism. These symptoms are accompanied by
a wide variety of physical symptoms such as difficulties sleeping, poor
concentration and memory, low energy, and changes in appetite (Table 2).
Table 2. Modified Summary of DSM-IV Episodes -- Depression/Depressive
Episodes
Acute Episodes with Depressed Mood
Episode Type Predominant Mood State Symptom Threshold
Associated Features, Requires 5 in absence including either depressed
mood or diminished interest/anhedonia
Depression Low, dysphoric, sad, disinterested Present most of
the day/nearly every day through at least 2 weeks
* Depressed mood
* Sleep disturbance
* Diminished interest/anhedonia
* Inappropriate guilt/low self-esteem
* Decreased energy/fatigue
* Inability to concentrate/make simple decisions
* Appetite disturbance
* Psychomotor retardation/agitation
* Suicidal ideation/morbid preoccupation
Mixed Both elevated and depressed At least 1 week during which
symptoms satisfying criteria for depression are present most of the
day/nearly every day and symptoms meeting criteria for mania are present
to a significant degree.
Treatment Challenges in Bipolar Disorder
Advances in clinical research have led to improvements in diagnosis and
treatment, offering patients affected with this disease the hope of an
improved prognosis. Because bipolar disorder is a recurrent illness,[2]
treatment that results in the fewest, briefest, or mildest episodes is
best. However, clinicians treating bipolar patients face a substantial
number of challenges:
* The course of bipolar illness is irregular. Therefore, it is
difficult to determine whether a patient's improvement or worsening is a
manifestation of the natural course of the illness or a response to
treatment.
* The nature of mood disorders tends to make patient reports
unreliable at the times clinicians need to make the most difficult
assessments.
* The distinction between episode and recovery is not always
clear, thus rendering it difficult to ascertain how aggressive treatment
should be.
* Over the course of a patient's treatment, no single agent is
likely to be completely effective for all therapeutic objectives.
* Even effective treatment may be associated with burdensome side
effects.
* Patients are frequently noncompliant with medications. Even
those who faithfully adhere to the treatment regimen when they are well
may disregard the treatment plan when they become ill.
* Patients often need treatment for more than 1 diagnosis.
* Treatment for 1 disorder may worsen a comorbid condition.
* Family members may unwittingly undermine the treatment plan by
offering well-intended but sometimes ill-informed advice.
* Time constraints can make it difficult to conduct a thorough
assessment, provide care, and document the encounter.
* It is difficult to keep up with professional literature on
treatments for bipolar illness.
* Treatment is expensive.
Despite the many difficulties in managing bipolar disorder, the
importance of treatment is clear. Medication and adjunctive psychosocial
therapies may not cure bipolar illness, but the frequency and severity
of the episodes may be substantially lessened and the patient's quality
of life considerably improved. In approaching the treatment of a bipolar
patient, several concomitant strategies may be helpful in guiding the
clinician.
General Principles of Treatment
An effective system of comprehensive care, is one that attempts to
address the multiple problems faced both by the clinician and the
patient. This system, which is called the collaborative care system,
promotes a strong therapeutic alliance among the patient, clinician and
the patient's family.
Strategy 1: Collaborative Care
Establishing a strong therapeutic alliance that includes the clinician,
the patient, and the patient's family members helps to promote the
patient's active participation in his or her treatment. It is believed
that actively engaged patients are more likely to adhere to a prescribed
treatment regimen. Similarly, it is thought that family members who are
invested in working with the physician may be more receptive to learning
how to provide the patient with effective support and assistance.
Collaborative care is based on the principle that each member of the
patient's support system, including the patient himself, is in a
position to make valuable contributions to the patient's care, and
therefore, should be treated respectfully. Implicit in the concept of
mutual respect is the physician's making clear what he or she wishes a
patient to do and why it is important for the patient to follow the
recommended treatment regimen. At critical treatment decision points,
the clinician is responsible for offering a range of appropriate
treatment options, each of which is considered to be both safe and
effective. The patient, in turn, is responsible for making an effort to
process the information presented to him by his doctor and for choosing
from the "menu of reasonable choices" presented. Family members, in
turn, are responsible for supporting the patient in a constructive,
positive manner. The goal of such a therapeutic alliance is to promote
the patient's active participation in his or her own treatment process
by facilitating becoming an educated and responsible consumer of mental
health services.
Basic strategies used in a collaborative care approach include:
* Use active listening to encourage communication and convey to
the patient your understanding of them and their condition.
* Maximize the fund of knowledge of clinicians, patients, and key
members of their support system. This approach results in both expert
clinical providers and patients knowledgeable about bipolar illness and
supports.
* Share the dilemmas encountered over treatment decisions in which
uncertainty is always present and risk must be managed.
* Facilitate the development of a collaborative care
plan/treatment contract in which the patient lays out their routine care
plan and pre-agreed strategies for management of anticipated problems.
* Encourage revising the collaborative care plan/treatment
contract as needed to get better results.
Supplemental tools include the use of a patient workbook and
informational videotape. Together, patients and their families watch the
videotape, which concludes with their developing a treatment contract.
The treatment contract contains explicit steps that the patient will
follow to maintain affective stability (ie, taking prescribed
medications, maintaining good mood hygiene) as well as agreed-upon steps
that the clinician and family members will follow on the patient's
behalf if the patient becomes acutely ill. This contract may include the
agreement that if the patient displays certain symptoms (eg, not
sleeping, uncontrolled spending, reckless driving), then family members
will contact the patient's physician. As the patient understands, the
physician may then decide to hospitalize the patient if the patient is
in danger of harming himself or someone else. The premise underlying the
treatment contract is that patients are more likely to comply with a
treatment that they have actively helped to select and develop. This
compliance may be particularly important during periods of affective
instability, when the patient's judgment and functioning may be
impaired. By authorizing his clinician and family members to act on his
behalf while he is not acute symptomatic, the patient exercises
responsibility for his behavior and mental health even during periods of
acute illness.
Strategy 2: Multiphase Treatment Strategy
Bipolar disorder tends to be a recurrent illness in which symptoms wax
and wane. Because patients rarely become "well," it may be difficult to
determine whether and when an episode is over and whether the patient
has recovered from a particular period of affective instability. Given
the high rates of relapse observed among patients who discontinue
treatment before the end of an episode, it is critical that patients
receive treatment of appropriate duration. Therefore, a longer-term
approach to the treatment of bipolar disorder may offer the greatest
hope of keeping the patient as stable as possible for as long as
possible.
Acute phase. The first phase in the management of bipolar disorder is
acute treatment. During this stage of treatment, the goal is to
stabilize the patient's mood and to ensure his safety. In the case of
acute mania, treatment begins by ruling out life-threatening conditions
and eliminating mood-elevating substances. Once these factors have been
properly addressed, the clinician may implement specific therapies to
control acute symptoms. Pharmacologic agents should be added as required
by acuity and treatment response, and each trial should be carried out
to its end point. A trial may be terminated for 1 of the following 3
reasons: the patient discontinues the medication due to intolerance, the
patient fails to respond to the maximal medication dose, or improvement
is sustained through the continuation phase. Divalproex is typically
with the remission of acute symptoms. It is recommended that patients
continue to receive full-dose medication (ie, the dose used during acute
therapy) to maintain effective serum levels. However, the administration
of full-dose continuation medication should be consistent with the
patient's ability to tolerate the medication. During continuation
treatment, it is not uncommon for patients to require modifications in
their medication levels. For instance, many patients require a reduction
in lithium or divalproex whereas carbamazepine may need to be increased.
This need for increase is due to the tendency of carbamazepine to
stimulate the P450 enzymes that metabolize the medication.
In general, clinicians should choose to use continuation treatment for 8
weeks; exceptions to this usual practice may include evidence that the
patient's natural course of the illness is longer or a documented
history of early affective switch (ie, a patient suddenly shifting from
a depressed mood to a manic state).
If the patient has achieved recovery, defined as sustained remission for
more than 8 weeks, the clinician may choose to maintain prophylactic
therapy or to use a gradual taper of acute treatments.
Strategy 3: Menu of Reasonable Choices.
There is considerable heterogeneity in the presentation of bipolar
disorder as well as substantial variability in patients' responses to
treatment. Therefore, the management of bipolar disorder necessitates
consideration of each patient's symptom profile, response history, and
tolerance for particular therapeutic interventions. Engaging the patient
in a manner that fosters active treatment participation may afford the
greatest likelihood of adherence and subsequent optimal outcome. The
physician may facilitate this process by describing the various options
available to the patient, clearly explaining the rationale for
recommending particular medications, and lastly, permitting the patient
to assume some of the responsibility in selecting which medication(s)
are most likely to provide effective relief of symptoms.
The primary therapeutic objectives in treating a patient with bipolar
disorder are to treat the acute depression or mania and to prevent
depressive or manic recurrences. Because no single agent is likely to be
completely effective for all of the therapeutic objectives, clinicians
should draw from a "menu of reasonable choices" at treatment decision
points for each patient. This menu, including the potential benefits and
risks associated with each agent, is then shared with the patient so
that the physician and patient may decide together which agent would be
most appropriate.
Mood stabilizers are typically used first-line for the treatment of
bipolar disorder. A mood stabilizer is defined as an agent that is
efficacious for the treatment of acute mania, depression, or both, and
offers prophylaxis of subsequent manic or depressive episodes. It may be
administered during the acute, continuation, or maintenance phase, and
it does not worsen an acute episode nor increase the likelihood of
affective switch. When choosing a mood stabilizer, clinicians have
available to them a menu of reasonable choices from which to select
(Tables 3-5). Desirable characteristics of a mood stabilizer are low
risk of intolerable adverse effects (risk < 0.5%) and no specific
contraindications. Examples of primary mood stabilizers include lithium,
divalproex, carbamazepine*, and bilateral ECT -- thyroxine*, clonazepam,
lorazepam, and psychotherapy may be used as adjunctive mood stabilizers.
There is strong empirical support for the acute and prophylactic
efficacy of both divalproex and lithium,[3-5], although data indicate
that lithium is frequently underused.[6] Alternatively,
carbamazepine*[7] or ECT[8] may be used. Tables 3-5 show first-line and
alternative first-line mood stabilizers.
Accumulating evidence also suggests that lamotrigine,[9] olanzapine,[10]
and risperidone[11] possess mood stabilizing properties (Table 6). The
pharmacologic profiles of mood stabilizing agents are shown in Table 7.
A study by Ghaemi and Sachs[12] evaluated the outcome of adjunctive
risperidone treatment in breakthrough episodes of bipolar disorder.
Patients showed improvement in Global Assessment of Functioning scores
and were rated much better on the Clinical Global Impression-Improvement
scale, suggesting that a subgroup of bipolar patients with breakthrough
episodes may benefit from treatment with this novel antipsychotic.
Topiramate and omega-3 fatty acid also have putative mood stabilizing
efficacy.[13,14] According to McElroy and colleagues,[16] preliminary
open observations of adjunctive topiramate treatment suggest that it may
tamoxifen
* Others*: tryptophan, choline, donepezil
Using a Collaborative Care Approach to Address Potential Obstacles
The therapeutic alliance fostered by a collaborative care approach may
ameliorate obstacles facing clinicians in the treatment of bipolar
disorder. Potential obstacles and their proposed solutions are described
below in the context of collaborative care.
Obstacle 1
The course of bipolar illness is irregular. Therefore, it is difficult
to determine whether a patient's improvement or worsening is a
manifestation of the natural course of the illness or a response to
treatment.
Collaborative care solution. Systematic record keeping techniques
provide an objective means of evaluating the fluctuating course of
bipolar illness. Clinicians could use a standardized form to rate the
frequency and intensity of abnormal mood states, which would facilitate
an efficient and rapid assessment of depressed, elevated, irritable, or
anxious moods as well as their duration and severity. Patient-rated
records include a clinical self-report monitoring form and a daily mood
chart.
Obstacle 2
The nature of mood disorders tends to make patient reports unreliable,
often at the times clinicians need to make the most difficult
assessments.
Collaborative care solution. Use of skillful polypharmacy is essential
for treating patient with bipolar disorder who have a comorbid disorder.
Consideration of drug-drug interactions may minimize the risk of
exacerbating the bipolar illness, as will beginning treatment with
options that are least likely to destabilize the patient's mood. For
instance, antidepressants, which are used first-line in the treatment of
panic disorder or social phobia, should be used judiciously in the
treatment of bipolar patients who present with a comorbid anxiety
disorder. Because antidepressants are associated with a greater
likelihood of inducing an affective switch, use of these agents may be
contraindicated in patients with a prior history of affective
instability.
Obstacle 3
The distinction between episode and recovery is not always clear, thus
rendering it difficult to ascertain whether and when treatment should be
modified or discontinued.
Collaborative care solution. Sharing the dilemma with the patient may
ameliorate the risk to the clinician. Although risk cannot be
eliminated, it may be managed in accordance with the patient's
preference for treatment (ie, whether the patient would like to continue
with treatment and if they are able to tolerate possible adverse
treatment effects) and willingness to follow a given treatment regimen.
Accurate assessment of a patient's present level of symptomatology may
also be enhanced by use of an iterative approach. Such a strategy
permits the clinician to view each trial of an intervention as an
attempt to test the most effective strategy for a particular patient,
making modifications as necessary based on information obtained from
prior interventions.
Obstacle 4
During the course of a patient's treatment, no single agent is likely to
be completely effective for all therapeutic objectives.
Collaborative care solution. Integration of up-to-date polypharmacy and
psychosocial interventions, such as good mood hygiene, self-help groups,
and psychotherapies, offers the possibility of synergistic therapeutic
effects, which may optimize outcome for the patient. Specialized
psychotherapies for bipolar disorder include the collaborative care
approach, interpersonal/social rhythm therapy, family focused treatment,
and cognitive behavioral therapy.
Obstacle 5
Even effective treatment may be associated with burdensome side effects.
Consideration of treatment-emergent adverse events is imperative because
the presence of side effects is a common reason for patient
noncompliance with the prescribed treatment regimen. Weight gain, the
most common reason patients choose to discontinue effective treatment,
occurs frequently as a result of mood stabilizing medication. Bowden and
colleagues[16] investigated the percentages of patients who experienced
weight gain while on maintenance treatment for bipolar disorder. They
found that 23% of patients gained weight on valproate and 16% gained
weight on lithium, compared with 4% who gained weight while taking
placebo. Weight gain is also commonly associated with the use of
atypical antipsychotic medications, although there may be subtle
differences observed among these agents. For example, Guille and
colleagues[11] observed that patients with bipolar disorder treated with
olanzapine or risperidone exhibited similar patterns of weight gain
after 4 weeks of treatment. However, significant differences were
evident after 8 weeks and at 3 months or longer -- risperidone-treated
patients gained significantly less weight gain than did patients treated
with olanzapine.
Collaborative care solution. As a general principle in the management of
adverse side effects, clinicians should provide patients with profiles
of reasonable treatment choices, beginning with treatment in the form
most attractive to the patient. It is important as well to bear in mind
that perceived and unperceived adverse effects of medications are
potential obstacles to treatment efficacy. Thus, the clinician should be
prepared to offer alternatives and management options for each adverse
effect. For instance, in the case of weight gain, the clinician may
recommend that initial weight management commence with dietary changes
and exercise (eg, walking 200 minutes per week). However, if patients
continue to gain weight despite exercising, the clinician may suggest
extending the exercise to 400 minutes per week, changing the mood
stabilizing medication, or using counteractive treatments, such as
phenylalanine* or topiramate.*
Obstacle 6
Patients are frequently noncompliant with medications. Even those who
faithfully adhere to the treatment regimen when well may disregard the
treatment plan when they become ill.
Collaborative care solution. The use of a treatment contract, in which
the patient, clinician, and family members agree in advance on the
patient's treatment protocol, may facilitate patient compliance and
restabilization during and after an episode of affective illness.
Obstacle 7
Patients often need treatment for more than 1 diagnosis.
Collaborative care solution. Careful diagnostic assessment with
collaboration from the family members gives the clinician a clearer
picture of all of the aspects of a patient's illness. Initial treatment
consideration and interventions may be geared toward the most acute
problems, with the intervention individualized for the most effective
strategy for a particular patient at that point in time. The therapeutic
objectives can be re-evaluated as necessary with the patient and family
to focus on appropriate interventions for other problems.
Obstacle 8
Treatment for 1 disorder may worsen a comorbid condition.
Collaborative care solution. Use of skillful polypharmacy is essential
for treating patients with bipolar disorder who have a comorbid
disorder. Consideration of drug-drug interactions may minimize the risk
of exacerbating the bipolar illness, as will beginning treatment with
options that are least likely to destabilize the patient's mood. For
instance, antidepressants, which are used first-line in the treatment of
panic disorder or social phobia, should be used judiciously in the
treatment of bipolar patients who present with a comorbid anxiety
disorder. Because antidepressants are associated with a greater
likelihood of inducing an affective switch, use of these agents may be
contraindicated in patients with a prior history of affective
instability.
Obstacle 9
Family members may unintentionally undermine the treatment plan by
offering well-intended but sometimes ill-informed advice.
Collaborative care solution. Identify family, friends, and professionals
who are in a position to exert a positive influence on the patient.
Enlist their assistance by explaining to them the clinical presentation
and course of bipolar disorder and by educating them in how family
members may form a psychosocial support system that may buffer patients
from stress or emotional overarousal.
Obstacle 10
Time constraints make it difficult to conduct a thorough assessment,
provide care, and document the encounter.
Collaborative care solution. Clinicians may increase their time
efficiency by enabling patients to collect and provide data before the
initial evaluation and in between routine assessments. Prior to the
patient's first evaluation, a packet of questionnaires may be sent out
to gather information regarding history of childhood and adult
psychiatric illness, psychoactive substance use, medical history, family
history, and prior treatment. During the initial visit, the clinician
may use the Affective Disorder Evaluation (ADE), which quickly and
systematically allows the clinician to obtain DSM-IV (Diagnostic and
Statistical Manual, 4th edition)[17] diagnoses using a modified version
of the SCID (Structured Clinical Interview for DSM-III-R).[18]
During follow-up visits, clinicians may use the Clinical Monitoring Form
(CMF) to assesses the patient's condition over the interval between
clinic visits (Figure 1). The use of this form increases efficiency
during the session by obviating the need for clinicians to write usual
clinical notes. The focus of the CMF is to monitor the patient's current
clinical condition, including mood state, response to treatment, and
adverse effects. The CMF includes modified versions of the SCID current
mood modules and uses the same recording conventions as the ADE. The
recording conventions include a system of weighted scoring for the items
in the SCID modules. This scoring system allows the clinical rating to
generate both categorical outcomes and continuous scores. A formula
applied to the CMF/SCID modules provides subscale scores for depression
and mood elevation, which are highly correlated with standard research
rating scales. The treating psychiatrist applies operational criteria to
the symptom ratings to assign a clinical status at each visit (eg, acute
depression, hypomania, recovering, etc). This status is a critical
determinant because it is used to define clinical decision points as
well as treatment outcome. The CMF provides session-by-session
information on the type and intensity of medication treatment response
as well as the use of other services such as emergency room or inpatient
admissions.
Figure 1. Clinical Monitoring Form
The Patient Self-Monitoring Form is a brief self-report version of the
routine clinical monitoring assessment and given to patients upon
arrival at the clinic (Figure 2) Because its organization corresponds to
that of the CMF, patients completing this form in the few minutes before
their scheduled appointment have an opportunity to increase time
efficiency of routine assessments and increase the time available to
convey other meaningful information. Even at the first visit, most
patients can complete this form with minimal directions from the
receptionist. A poster version of the patient self-monitoring form with
explanatory annotations can be posted in the waiting area. Patients are
instructed to present the completed form and their mood chart to the
treating psychiatrist at the start of each visit.
Figure 2. The Patient Self-Monitoring Form
The Daily Mood Chart is a patient-rated instrument that informs and
supplements the CMF assessments but is not itself an outcome measure
(Figure 3). Clinicians instruct patients in a simple daily charting
technique in which patients record 2 mood ratings (highest and lowest),
hours slept, anxiety and irritability, and medication usage. The chart
is brought to each visit for review by the psychiatrist.
Figure 3. The Daily Mood Chart
Obstacle 11
It is difficult to keep up with professional literature on treatments
for bipolar illness. It is estimated that more than 5000 articles on the
treatment of bipolar disorder are published each year. Given the time
constraints facing most clinicians, many are simply unable to keep
abreast of empirical findings regarding each new agent used for
treatment.
Collaborative care solution. Maintaining an up-to-date record of
first-line agents in a menu of reasonable choices will permit the
clinician to make the best-informed decision for a particular patient.
It is also recommended that clinicians have as-needed access to
consultation with experts in the field as well as information needed to
use innovative treatments.
Obstacle 12
Treatment is expensive.
Collaborative care solution. Present the patient with the costs
associated with "reasonable" options and determine individual (adverse
effects plus expense) cost/benefit ratios. Permit the patient and family
to determine the level of financial burden they are willing to bear in
exchange for the hope of optimizing treatment outcome.
Summary
Bipolar disorder is a recurrent psychiatric illness associated with
significant impairment across multiple domains of patient functioning.
The treatment of bipolar disorder poses substantial challenges to the
clinician, who must simultaneously consider individual patient symptom
characteristics, prior history, and compliance in determining which
treatment intervention is most likely to demonstrate effectiveness. A
challenging disorder to treat, bipolar disorder is not curable, but it
is manageable. The use of a collaborative approach, in which the
physician, patient, and the patient's family members work as a team, may
enhance treatment outcome by engaging the patient as a responsible
active member of the treatment team throughout the course of the
illness.
Recommended Links
For more information on the bipolar programs and other clinical tools
visit www.manicdepressive.org or www.edc.gsph.pitt.edu/stepbd.
References
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LyndaNP
Reality isn't the way you wish things to be, nor the way
they appear to be, but the way they actually are.
- Robert J. Ringer