Bipolar Disorder Clinical Guidelines

Bipolar Disorder Clinical Guidelines
Developed in collaboration with the mental health centers associated with NBHP and FBHP
DSM-IV-TR Diagnostic Code: 296..0x; 296.40; 296.4x; 296.6x; 296.5x; 296.7; 296.89; 301.13; 296.80
Diagnostic considerations:
1. Review diagnostic criteria in DSM as bipolar disorder can be expressed in a variety of ways, and cycle
in different manners, rates and frequencies (rapid, seasonal, etc.). Determine bipolar type: bipolar I,
bipolar II, cyclothymic disorder, and other additional features or specifiers to facilitate understanding of
presentation and course of treatment.
2. Differential diagnoses include schizoaffective disorder and other psychotic disorders, ADHD (see
ADHD vs Bipolar disorder differential diagnosis addendum), substance-induced mood disorder, and
mood disorder/personality change due to a general medical condition.
3. For children and adolescents, although core symptoms are the same their expression may be
developmentally influenced, e.g. during manic episodes, children and adolescents are more likely to be
irritable rather than elated, with destructive outbursts, antisocial behavior, and/or substance use and
depressive periods may include somatic complaints, decreased school performance, social isolation,
poor communication and extreme sensitivity to rejection or failure. Often behavior problems precede
manic episodes and rapid cycling and mixed episodes are more common. Over-diagnosis, in youth must
be guarded against; ensure DSM criteria (including careful evaluation of exclusionary criteria) have
been met.
4. Substance abuse/dependence should be evaluated as a possible primary or secondary diagnosis with
this disorder. At a minimum substance use/dependence should be evaluated every 6-months.
5. Complete assessment using a variety of sources, including brief checklists, such as the Mood Disorder
Questionnaire. Obtain a history of symptoms from objective informants, as many persons with bipolar
disorder may deny or not recognize their symptoms. Family and teacher informants are particularly
important in assessing children and adolescents. Assess family history of bipolar disorder, as well as
other psychotic or mood disorders.
6. Review medical history and current health status. Medical conditions that may cause mood lability
and/or behavioral disinhibition and dyscontrol include endocrinologic disorders, hypothyroidism,
hypoglycemia, seizure disorders, structural brain disorders, e.g. neoplasm, stroke, infectious brain
disorders, toxic/metabolic disorders, and traumatic brain injuries. Urinary tract infections and electrolyte
imbalances may also manifest as psychosis. Consider referral to PCP to rule out these medical
conditions, particularly with late onset of symptoms. Individuals with bipolar disorder have an increased
risk and may be in treatment for chronic and severe medical conditions, e.g. heart disease, and diabetes.
7. Response to medication should not be used as a diagnostic tool. A positive response to medication is
not confirmation of the diagnosis, as similar medications are used to treat non-specific target symptoms
such as over-activity, impulsivity, aggression, and lability. Pharmacological treatments for depression
can sometimes precipitate a manic episode.
8. Late life onset, after age 40, of manic episodes is inconsistent with the natural history of bipolar illness.
The average onset for both men and women is around 20 years of age. Consider alternate etiologies for
symptoms beginning after the age of 40, e.g. substance use, medication side-effects or medical
condition.
Rev. 05/16/12
Treatment Guidelines:
1. Psychoeducation, for clients and families, is key to improved recovery from acute episodes, relapse
prevention and maintenance, including information about bipolar disorder and its treatment, skills for
coping with psychosocial stressors, how to engage in treatment, and monitor occurrence and severity of
symptoms. Identify, with the client, past effective strategies and support continued use of these methods.
Help educate about the importance of consistent medication use. (See practical strategies addendum)
2. Integration of multiple treatment approaches is most effective in promoting long term recovery:
medication management, psychotherapy, psychosocial approaches, psychoeducation, case management,
and peer services. If substance abuse is present, consider referral for co-occurring treatment. Recovery is
positively correlated with family support and attitude, employment, social activity and social skills
training. For depression, promote simple social activities, e.g. going for a walk, making eye contact or
saying hello to others.
3. Medication is one of the treatment foundations. The treatment team should have regular contact to
discuss medication effectiveness, monitor side effects, improve medication adherence, and provide
psychoeducation. A focus on client’s attitudes and behaviors related to medications is more effective in
treatment adherence than psychoeducation alone. Medications often require ongoing monitoring, such as
blood tests, as side effects and complications can be serious, in terms of short term toxicity, and long
term medical conditions. Note that going on and off medications can reduce efficacy (See attached
medication algorithms).
4. Evidence-based therapeutic approaches, including psycho-educational, cognitive behavior therapy,
interpersonal and social rhythm therapy, are recommended in combination with pharmacologic
treatment and family involvement, especially with youth. See resources for clinicians for more specific
therapeutic interventions.
5. Attend to the client’s physical health by coordinating with the primary care physician (PCP) to
identify medical risk factors and coordinate efforts to reduce those risks including regular medical
check-ups. Be knowledgeable about medication side effects and lifestyle risk factors, such as smoking,
substance abuse/dependence, physical activity level and nutrition, as these can negatively impact health
status, complicate treatment, and decrease medication effectiveness. Set health goals with the client
around managing or improving these lifestyle factors.
6. Regularly assess suicidal ideation, manic symptoms, especially high-risk behaviors, depression,
hopelessness, presence of command hallucinations, and substance use. Suicide attempts are more likely
to occur during a depressive or mixed state.
7. Plan ahead. Work with the client to develop an individualized relapse prevention plan, identifying
unique warning signs and what to do when they arise and a crisis plan to assist in dealing with signs of
suicide and provide guidance in seeking help immediately. Encourage clients to share these plans with
support systems.
8. Consistency of routine and structure in daily activities, including regular sleep-wake cycles, meal
times, physical activity, and emotional stimulation are important for recovery. Disruption in these social
rhythms, with disrupted sleep-wake cycles may trigger manic episodes and other relapse symptoms.
*Adapted from American Psychiatric Association (2002). Practice Guidelines for the Treatment of Patients
with Bipolar Disorder (Second Edition). Washington D.C.: Author
Rev. 05/16/12
Resources for Clinicians
Psychoeducational manuals for bipolar disorder
Bauer, M. & McBride, L. (1996). Structured Group Psychotherapy for Bipolar Disorder: The Life
Goals Program. New York: Springer.
Colm, F., Vieta, E. & Scott, J. (2006). Psychoeducation Manual for Bipolar Disorder.
Cambridge: Cambridge University Press.
Cognitive behavior therapy manuals for bipolar disorder
Lam, D., Hayward, P., Bright, J. & Jones, S. (1999). Cognitive Therapy for Bipolar Disorder.
Chichester: John Wiley.
Newman, C., Leahy, R., Beck, A., Reilly-Harrington, N. & Gyulai, L. (2002). Bipolar Disorder: A
Cognitive Therapy Approach. Washington, DC: American Psychological Association.
Otto, M., Reilly-Harrington, N., Kogan, J., et al. (1999). Cognitive Behaviour Therapy for Bipolar
Disorder: Treatment Manual. Boston: Massachusetts General Hospital.
Ramirez Basco, M. & Rush, A. (2007). Cognitive Behavioural Therapy for Bipolar Disorder (Second
Edition). New York: Guilford Press.
Interpersonal therapy manual for bipolar disorder
Frank, E. (2005). Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm
Therapy. New York: Guilford Press.
Family therapy manual for bipolar disorder
Miklowitz, D. J. & Goldstein, M. (2008). Bipolar Disorder: A Family-Focused Treatment Approach (2nd
edition). New York: Guilford Press.
Memoirs
Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness
Manning, Martha (1994). Undercurrents: A life beneath the surface
Websites
www.mcmanweb.com
www.psycheducation.org
www.rdsfoundation.org
Rev. 05/16/12
Practical Strategies for Working with Clients with Bipolar Disorder
PSYCHOEDUCATION
Psychoeducation can be done in a structured fashion at the initial 5-8 sessions of
treatment or can be woven in throughout the treatment. Psychoeducation is different from
education in that it’s tailored to the individual. There are several components to
psychoeducation:
a. Symptom Review-Present list of bipolar symptoms to client and family
members to help the client understand his/her manifestation of the illness.
Elicit from client and family what symptoms they have seen in client.
Purpose is to help recognize symptoms/episodes, help client differentiate
between self and the illness (if it’s the illness, it comes as part of a cluster
of symptoms), and increase acceptance of the disorder
b. Etiology and Course-explain role of biology and
environmental/behavioral influences. Purpose is to address
blame/guilt/stigma, provide rationale for comprehensive treatment,
identify potential triggering events unique to this person, and help client
understand that even if they do everything right, they may still have some
symptoms although they can influence how often and how severe.
c. Risk and Protective Factors-Review “Risk and Protective Factors”
handout (see attached) for purpose of increasing hope that there are things
in client’s control, engaging family, helping client make informed
decisions about actions they might take, and increasing motivation for
positive health behaviors.
d. Review Treatment Options-Purpose is to increase treatment compliance
e. Wellness/Relapse Prevention Plan-Purpose to help client/family
understand that bipolar is usually a recurring illness, help them identify
early warning signs, promote stabilization and prevent full relapse,
minimize negative consequences of relapse should one occur, and decide
in advance what steps client would like family to take if they enter into an
episode (e.g., While client who is manic may not want family to call
clinician, when client is stable and thinking clearly, they may instruct
family to ignore their protests and call clinician if they become manic.)
Make separate plans for depression, (hypo)mania, and suicide as indicated.
MOOD CHARTING
Mood Charting is a method in which client tracks mood, suicidal ideation, psychotic
symptoms, sleep, alcohol and drug use, exercise, menstrual cycle or anything other factor
that client or therapist thinks may be related to his/her mood fluctuations. Instead of
mood chart, can use Social Rhythm Metric (see E Frank’s manual), in which clients track
the time and other people involved in the 5 items that correlate most highly with changes
in mood. These items are 1) out of bed 2) first contact with another person 3) start
work/school/volunteer/family care 4) dinner 5) to bed.
Improving Completion Rates
a. Make sure client understands rationale behind mood charting. Purpose is
to identify targets for current session, detect prodromal symptoms,
monitor risk and protective factors, measure impact of
medication/behavioral changes, and see patterns that only are apparent
after weeks/months of tracking. (For sample mood charts go to
www.manicdepressive.org/moodchart.html and
www.psychiatry24X7.com or create your own).
b. Provide clear instructions about when to fill it out, where to put it, to bring
to next session.
c. Anticipate difficulties by asking how important they think it is and how
confident they are that they will do it.
d. Start by tracking only a few items.
e. Do one day’s worth of data in session before sending it home with the
client.
f. If it’s overwhelming for client to rate mood, have them start with objective
items like sleep or exercise.
g. Stress that for data to be useful it must be accurate. If there’s info client
doesn’t want to share, no data is better than inaccurate data. Tell client that
if they miss days, not to go back and try to remember as trying to rate past
scores can be affected by current mood. Instead, start with today.
h. If client didn’t do it, explore and problem solve obstacles. For example, if
client didn’t complete it because it’s one more thing that reminds them of
their bipolar disorder, pair it with something else that client is already
doing that reminds them of their disorder, like taking medications.
BEHAVIORAL STRATEGIES
Often initial goal is to prevent them from getting any worse. So if client says homework
didn’t work, ask them to think about how they think they’d feel if they hadn’t done those
things. Also ask them to think about how the homework task fit with their values.
Interpreting and Using Mood/Social Rhythm Metric Data
a. Look for items that have the most variability, not day to day correlation.
b. Look for excessive underactivity or overactivity.
c. Search for triggers that disrupt regular schedule and problem solve around
them.
d. Figure out with client whether to start with easiest thing to change or thing
that will be most impactful.
e. Allow client to experiment with how much change they need to make
without it affecting their mood. For example, a client who likes to sleep in
on the weekend may agree to sleep only an extra hour on the weekend and
track whether that improves mood or whether they need to be more rigid
about wake up times.
f. When client anticipates changes (e.g., relatives coming to visit), help them
plan so they can adapt. For example, plan your activities in the daytime so
you don’t get to bed too late.
Opposite of Emotion Action (OEA)
a. Provide client with the following rationale behind Opposite of Emotion
Action. All emotions have associated with them urges to do certain
actions. While these actions tend to bring short term relief, acting in
accord with emotions tends to perpetuate the emotion in the long run.
Acting opposite of emotion is one of the most powerful ways to shift the
emotion. You can take your mood state out of the equation and allow your
behavior to be guided by your values.
b. OEAs for mania can be
i. scheduling down time
ii. mindful breathing
iii. limiting social stimulation
iv. avoiding stimulants (e.g., coffee, cocaine)
v. sleeping
vi. delaying making decisions for 72 hours and consulting with 2
people who have client’s best interests at heart before making the
decision.
c. OEAs for depression can be
i. Engaging in potentially pleasurable activities
ii. Activity scheduling (see attachment). Schedule in activities that
client intends to do at certain times each day. That way if client
wakes up groggy, they don’t have to figure out what to do.
References
Basco, R. & Rush, J. (2007) Cognitive-Behavioral Therapy for Bipolar Disorder, 2nd Ed.
Colom, F., Vieta, E. & Scott, J. (2006) Psychoeducation Manual for Bipolar Disorder
Algorithm for Bipolar Depression*
Stage 1
Monotherapy with mood stabilizers or new
generation antipsychotic (NGA)
Response
adequate?
Yes
Continue
No
Stage 2
Combination therapy mood stabilizers plus NGA
Response
adequate?
Yes
No
Stage 3
With non responders always consider other
diagnoses with alternative treatment approaches
such as borderline personality (DBT, EFT etc),
catatonia (benzodiazepine, ECT), and primary
substance abuse
Add a second mood stabilizer
Response
adequate?
Continue
Yes
Continue
No
Stage 4
Continue NGA, two mood stabilizers, cautiously
add antidepressant – not a tricyclic
Response
adequate?
Yes
Continue
No
Stage 5
Switch to a different antidepressant
Response
adequate?
Yes
No
Stage 6
Consider MAOI, stimulant (unless contraindicated)
or ECT
Continue
*References:
Texas Medication Algorithm “Algorithm for Manic/Hypomanic”
2007
Stahl, Stephen M. (2004). Drug combinations for bipolar
spectrum disorders: Evidence-based prescribing or prescribingBased Evidence? J Clin Psychiatry, 65:10.
Medication Algorithm for Mania/Hypomania in Bipolar
Disorder*
Stage 1
Monotherapy with mood stabilizer**
or New Generation Antipsychotic
(NGA)
Response
adequate?
Yes
Continue
No
Stage 2
Monotherapy with a different agent or
combination mood stabilizer and NGA
Response
adequate?
Yes
If non responsive always consider diagnoses
with other primary treatment options such as
borderline personality (DBT etc), catatonia
(benzodiazepine and ECT), substance abuse
Continue
No
Stage 3
Two mood stabilizers plus a NGA
Response
adequate?
Yes
Continue
No
Stage 4
Two mood stabilizers plus two
antipsychotic medications or switch
antipsychotic med to clozapine or ECT
*References:
Texas Medication Algorithm “Algorithm for Manic/Hypomanic” 2007
Stahl, Stephen M. (2004). Drug combinations for bipolar spectrum disorders: Evidence-based
prescribing or prescribing-Based Evidence? J Clin Psychiatry, 65:10.
**Mood stabilizer options: carbamazepine, lithium, valproate, topiramate, or lamotrigine
Tips for Families of People with Bipolar Disorder
Developed in collaboration with the mental health centers of NBHP and FBHP and the Client and Family Advisory Board
1. Participate in treatment and learn about bipolar disorder. Knowledge helps you support your loved
one in managing symptoms, working towards recovery, and handling setbacks. It’s not uncommon to
feel confused or upset by this disorder and the behaviors you are seeing in your loved one. Education
can lead to more understanding and empathy by learning about symptoms and cycles. Check with the
provider about education for families.
2. Support treatment. Seeking help when symptoms first become noticeable can improve recovery.
Empower your family member by working with them and encouraging them to have a voice in treatment
decisions. Ask if they would like you to attend with them for support.
3. Encourage consistent use of medication. Taking medication regularly can reduce relapses. Take side
effects seriously as this causes many people to stop their medications. Be aware that people with bipolar
disorder tend to stop taking their medications because they miss the feeling of mania. Going on and off
medications can decrease the effectiveness. Encourage your loved one to talk to their prescriber about
side effects to increase the chances of finding the right medication. Assist in tracking side effects and
improvements for prescriber visits.
4. Be aware of signs of relapse. The disorder may come and go, with times of improvement and
worsening, regardless of your hopes or actions. You may notice changes in symptoms before your loved
ones and can help them to be more aware. When your loved one is doing well and having fewer
symptoms, it is a good time to agree on a plan for what to do if you notice warning signs of both
depression and mania, so you know how and when to intervene.
5. Don’t be afraid to ask loved ones if they are having thoughts of hurting themselves. Take action if
your loved one’s safety is in question. The act of asking someone about suicide is not dangerous and
will not put the idea in their head.
6. Create a calm and safe environment. Stress, which can result from positive or negative experiences,
can increase symptoms. You can help by providing, or helping them maintain, a structured and
supportive environment.
7. Take care of yourself. It is common for family members to feel burned out by loved ones with bipolar
disorder. It is easier to support others when you are supported. Join a support group, and make time for
yourself to do things you enjoy. Recognize your limits and don’t be afraid to ask for help. Let others
take the lead in caretaking at times. Avoid self-blame. You can have a positive impact on recovery, but
you aren’t to blame for the illness or responsible for your loved one’s recovery.
8. Acceptance of the disorder and patience will help your loved one, as well as family and friends, deal
with the challenges while still enjoying life. Symptoms change over time, but the underlying disorder
remains. Recognize that recovery is a process; set realistic expectations and help your loved one set
doable goals.
9. Try to be hopeful. With therapy, medication and support, people with bipolar disorder recover and live
full and productive lives. Don’t forget to find ways to have fun and enjoy time together.
Revised 7/1/12
Resources for Clients and Families
Education
National Institute of Mental Health (1.800.421.4211 or www.nimh.nih.gov or
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml)
National Alliance on Mental Illness (http://www.nami.org)
https://www.achievesolutions.net/achievesolutions/en//Home.do
Self help
Jones, S. H., Hayward, P. & Lam, D. H. (2003). Coping with Bipolar Disorder (Second Edition).
Oxford: Oneworld.
Miklowitz, D. J. (2002). The Bipolar Disorder Survival Guide: What You and Your Family Need to
Know. New York: Guilford Press.
Ramirez Basco, M. (2006). The Bipolar Workbook: Tools for Controlling Your Mood Swings, New
York: Guilford Press.
Scott, J. (2001). Overcoming Mood Swings. London: Constable Robinson.
Memoirs
Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness
Manning, Martha (1994). Undercurrents: A life beneath the surface
Revised 7/1/12
Consejos prácticos para familias de personas que padecen del trastorno bipolar
Desarrollado en colaboración con los centros de salud mental de NBHP y FBHP y la Comisión consultiva del consumidor y
asuntos familiares
1. Participe en el tratamiento y aprenda sobre el trastorno bipolar. El conocimiento le ayuda a apoyar a
su ser querido manejar sus síntomas, trabajar para recuperarse, y manejar los reveses. No es raro sentirse
confundido o alterado a causa de este trastorno y los comportamientos que usted observa en su ser
querido. La educación sobre los síntomas y los ciclos le puede brindar más comprensión y empatía.
Hable con el proveedor que le puede informar sobre la educación para familias.
2. Apoye el tratamiento. El buscar ayuda en el momento que se note los síntomas puede mejorar la
recuperación. Hay que fomentar al miembro de su familia trabajando con él o ella y animándole a tener
voz en las decisiones sobre su tratamiento. Pregúntele si quiere que usted asista a reuniones con él o ella
para apoyarlo/la.
3. Anime el uso regular del medicamento. El tomar medicamento de manera regular puede reducir los
reveses. Tome en serio los efectos secundarios, como eso es la razón que muchas personas dejan de
tomar sus medicamentos. Percátese que las personas que padecen del trastorno bipolar suelen dejar de
tomar sus medicamentos porque les hace falta la sensación de manía. El empezar y dejar de tomar
medicinas puede disminuir la eficacia. Anime a su ser querido hablar con la persona que le prepara
recetas sobre los efectos secundarios para aumentar las posibilidades de hallar el medicamento
adecuado. Ayúdele a tomar nota de sus efectos secundarios y las mejorías para sus consultas con la
persona que le prepara recetas médicas.
4. Sea consciente de los signos de revés. El trastorno puede ir y venir, con momentos de mejoría y de
empeoramiento, a pesar de sus esperanzas o sus acciones. Quizás notará cambios en los síntomas antes
que sus seres queridos y les puede ayudar a estar más conscientes. Cuando le está yendo bien a su ser
querido, y cuando sufre de menos síntomas, es buen momento para ponerse de acuerdo y crear un plan
sobre qué es lo que van a hacer si se nota señales de advertencia de depresión y manía, para que sepa
cuándo y cómo intervenir.
5. No tenga miedo de preguntarles a sus seres queridos si tienen pensamientos de hacerse daño. Tome
acción si tiene dudas en cuanto a la seguridad de su ser querido. El acto de hablar con alguien sobre el
suicidio no es peligroso y no introducirá la idea a su mente.
6. Cree un ambiente tranquilo y seguro. El estrés, que puede ser resultado de experiencias positivas o
negativas, puede aumentar síntomas. Usted puede ayudar proveyendo, o ayudándoles a mantener, un
ambiente estructurado y repleto de apoyo.
7. Cuídese a sí mismo. Es común para los familiares sentirse gastados por sus seres queridos con el
trastorno bipolar. Es más fácil apoyar a otros cuando uno se siente apoyado. Hágase parte de un grupo
de apoyo, y busque tiempo para hacer las actividades que usted disfruta. Reconozca sus límites y no
tenga miedo de pedir ayuda. Deje que los demás tomen control del cuidado en ocasiones. Evite la
autocrítica. Usted puede tener un impacto positivo sobre la recuperación, pero no es culpa de usted que
padece de la enfermedad, ni tampoco es la persona responsable por la recuperación de su ser querido.
8. Aceptar el trastorno y tener paciencia le ayudará a su ser querido, tanto como a familiares y amigos,
manejar los desafíos mientras todavía disfrutándose de la vida. Los síntomas cambian con el tiempo,
Revised 7/1/12
pero el trastorno subyacente permanece. Reconozca que la recuperación es un proceso; establezca
expectativas realistas y ayúdele a su ser querido fijar metas que se pueden lograr.
9. Intente a tener esperanza. Con la terapia, el medicamento y el apoyo, las personas que padecen del
trastorno bipolar se recuperan y viven vidas llenas y fructíferas. Que no se le olvide hallar la manera de
divertirse y de disfrutar del tiempo que pasan juntos.
Recursos para clientes y familias
Educación
National Institute of Mental Health (1.800.421.4211 or www.nimh.nih.gov or
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml)
National Alliance on Mental Illness (http://www.nami.org)
https://www.achievesolutions.net/achievesolutions/en//Home.do
Autoayuda
Jones, S. H., Hayward, P. & Lam, D. H. (2003). Coping with Bipolar Disorder (Second Edition).
Oxford: Oneworld.
Miklowitz, D. J. (2002). The Bipolar Disorder Survival Guide: What You and Your Family Need to
Know. New York: Guilford Press.
Ramirez Basco, M. (2006). The Bipolar Workbook: Tools for Controlling Your Mood Swings, New
York: Guilford Press.
Scott, J. (2001). Overcoming Mood Swings. London: Constable Robinson.
Memorias
Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness
Manning, Martha (1994). Undercurrents: A life beneath the surface
Revised 7/1/12
Tips for Recovery: Bipolar Disorder
Developed in collaboration with the mental health centers of NBHP and FBHP and the Client and Family Advisory Board
1. Be involved in your treatment. Ask Questions. You are the expert on you. Be actively involved in
setting your goals. Ask your mental health providers to explain your diagnosis, treatment choices and
recommendations. Write down questions ahead of time to bring with you or invite a friend or family
member to attend a session. Ask how you can learn more about bipolar disorder (see resource list).
2. Find your way to deal with stress. Stress comes up in times of change. Both positive and negative
events cause stress. Know your triggers so you can handle stress when you know it is coming. Focus,
pace yourself, and take one thing at a time. Work or a hobby can decrease stress and increase your sense
of accomplishment. Do something you like. Remember, you don’t have to deal with stress on your own.
Talk to someone you trust.
3. Taking charge of your physical health improves mental health. Establish a healthy lifestyle. Create a
routine that includes a balanced diet, enough sleep at night, and if needed, only brief naps, physical
activity, and participation in hobbies. Remember, alcohol and illegal drugs can worsen symptoms. Get
natural sunlight for a few minutes every day, especially in the fall and winter. See your Primary Care
Provider (PCP) at least annually. If you don’t have a PCP, ask your therapist for help finding one.
4. Be patient when searching for a medication and take bipolar medications regularly, even if you are
feeling better. It is common for people with bipolar disorder to want to stop their medication because of
side effects or because you are feeling better. Maintain the progress you have made; if you go on and off
of your medications, they will not work as well. It may take several tries to find what works. Tell your
prescriber about side effects and benefits. Ask about medications that may have fewer side effects.
5. Be alert to early symptoms of mania. Risky behaviors (spending money, risky sexual behavior,
driving fast) might be signs of mania. You may be afraid to seek treatment because you like how mania
feels and you’re afraid of feeling flat, less capable or less creative. These fears must be weighed against
the benefits of getting and staying well. You may feel good while manic but may also make choices that
harm your relationships, finances, health, or work. If you feel the need to seek stimulation and be more
active, it helps to do the opposite. Slow down and do less. Schedule down time. Avoid stimulants. Wait
at least 72 hours to make big decisions and run it by two people who have your best interests at heart.
6. Be alert to early symptoms of depression. You may feel the need to withdraw and isolate. Try doing
the opposite. Reach out to others and energize. Engage in healthy activities that you have enjoyed in the
past. Schedule activities for the following day, so if you wake up groggy you don’t have to figure out
what to do in that moment. Develop a wellness or relapse prevention plan with your therapist if you
haven’t already done so. This will help you identify and deal with symptoms when they first arise.
7. Treat suicidal thoughts seriously and know when to get help. Talk openly about suicidal thoughts
with your therapist. Get treatment as soon as possible and ask about developing a recovery or crisis plan.
Share your plans with your family and friends. If you believe you can’t keep yourself safe, get help right
away: Call 911, go to the nearest hospital emergency room or call emergency services at your mental
health center: [MHC crisis line phone number].
8. Stay in touch with family, friends, and peers who are positive supports for you. You may want to
isolate at times, especially when feeling depressed, but this can make symptoms worse. Learn to accept
support from others. Ask your therapist for information about community peer support groups.
Revised 7/1/12
Resources for Clients and Families
Education
National Institute of Mental Health (1.800.421.4211 or www.nimh.nih.gov or
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml)
National Alliance on Mental Illness (http://www.nami.org)
https://www.achievesolutions.net/achievesolutions/en//Home.do
Self help
Jones, S. H., Hayward, P. & Lam, D. H. (2003). Coping with Bipolar Disorder (Second Edition).
Oxford: Oneworld.
Miklowitz, D. J. (2002). The Bipolar Disorder Survival Guide: What You and Your Family Need to
Know. New York: Guilford Press.
Ramirez Basco, M. (2006). The Bipolar Workbook: Tools for Controlling Your Mood Swings, New
York: Guilford Press.
Scott, J. (2001). Overcoming Mood Swings. London: Constable Robinson.
Memoirs
Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness
Manning, Martha (1994). Undercurrents: A life beneath the surface
Technology
Search applications (Aps) for mood tracking
Revised 7/1/12
Consejos prácticos para la recuperación: Trastorno bipolar
Desarrollado en colaboración con los centros de salud mental de NBHP y FBHP y la Comisión consultiva del consumidor y
asuntos familiares
1. Participe en el tratamiento. Haga preguntas. Usted es el experto sobre sí mismo. Tome parte activa
en el establecimiento de sus metas. Pídales a sus proveedores de salud mental que le expliquen su
diagnóstico, opciones para el tratamiento, y recomendaciones. Apunte sus preguntas de ante mano para
llevarlas consigo o invite a un familiar o amigo a acompañarle a una sesión. Pregunte cómo usted puede
aprender más sobre el trastorno bipolar (vea la lista de recursos).
2. Encuentre su manera de lidiar con el estrés. El estrés aparece en momentos de cambio. Ambos tipos
de evento, positivo y negativo causan el estrés. Conozca lo que le provoca para poder manejar el estrés
cuando usted sabe que está a punto de presenciarse. Concéntrese, contrólese el tiempo, y maneje las
cosas uno por uno. El trabajo o un pasatiempo puede reducir el estrés y aumentar la satisfacción de sus
logros. Haga algo que a usted le gusta hacer. Acuérdese que no tiene que lidiar con el estrés a solas.
Hable con una persona de confianza.
3. Tomar control de su salud física mejora la salud mental. Establezca un estilo de vida saludable.
Cree una rutina que incluye una dieta balanceada, sueño suficiente en la noche, y si se necesita, sólo
siestas breves, actividad física, y la participación en algún pasatiempo. Acuérdese que el consumo de
las bebidas alcohólicas y las drogas ilícitas pueden aumentar la gravedad de los síntomas. Pase tiempo
en la luz natural del sol por varios minutos cada día, particularmente en el otoño e invierno. Consulte
con su médico de atención primaria (PCP por sus siglas en inglés) por lo menos una vez al año. Si no
tiene PCP, pida a su terapeuta ayuda en conseguir uno.
4. Tenga paciencia cuando busca un medicamento y tome sus medicamentos para el trastorno
bipolar de manera regular, aunque se sienta mejor. Es común para las personas que padecen del
trastorno bipolar querer dejar de tomar sus medicamentos por los efectos secundarios o porque se
sienten mejor. Mantenga el progreso que haya logrado; si comienza y deja de tomar sus medicinas, no
van a funcionar tan bien. Es posible que tenga que intentar varias veces para encontrar lo que le
funcione. Cuente a la persona que le prepara recetas médicas sobre los efectos secundarios y los
beneficios. Pregúntele sobre los medicamentos que quizá tengan menos efectos secundarios.
5. Esté alerta a síntomas tempranos de manía. Comportamientos arriesgados (gastar dinero,
comportamientos sexuales arriesgados, manejar rápidamente) pueden ser signos de manía.
Posiblemente teme buscar tratamiento porque tiene miedo de sentirse vacío de emociones, menos capaz
o menos creativo. Se tiene que comparar estos temores con los beneficios de mejorarse y mantener la
mejoría. Puede ser que se sienta bien mientras estás maníaco pero también puede ser que tome
decisiones que hacen daño a sus relaciones, finanzas, salud, o trabajo. Si se siente que sea necesario
buscar avivamiento y ser más activo, le ayuda hacer el opuesto. Baje su ritmo y haga menos. Programe
tiempo para estar tranquilo. Evite los estimulantes. Espere por lo menos 72 horas para tomar una
decisión importante y pida consejos sobre ella de dos personas que les importa su mejor interés.
6. Esté alerta a síntomas tempranos de depresión. Quizá se sienta la necesidad de retirarse y aislarse.
Intente hacer el opuesto. Contacte a otro y energícese. Participe en actividades sanas que anteriormente
usted disfrutaba. Programe actividades para el siguiente día, así que si se levanta aturdido no tiene que
pensar en qué hay que hacer en ese mismo momento. Desarrolle un plan para el bienestar o para la
prevención en el caso de un revés con su terapeuta, si hasta la fecha no lo han hecho. Esto le ayudará a
identificar y lidiar con los síntomas cuando surjan.
Revised 7/1/12
7. Tome en serio los pensamientos suicidas y sépase cuando debe buscar ayuda. Hable abiertamente
sobre los pensamientos suicidas con su terapeuta. Busque tratamiento lo antes posible y pida
información sobre el desarrollo de un plan para la recuperación o la crisis. Comparta sus planes con sus
amigos y familiares. Si cree que no podrá mantenerse seguro, busque ayuda inmediatamente: Llame al
911, váyase a la sala de urgencias en el hospital más cercano o llame a servicios de emergencia en su
centro para la salud mental: [MHC línea telefónica para la crisis].
8. Manténgase en contacto con familiares, amigos e iguales que representan apoyo positivo para usted.
Quizá a veces quiera aislarse, principalmente cuando se siente deprimido, pero esto puede aumentar la
gravedad de los síntomas. Aprenda a aceptar apoyo de los demás. Pida información a su terapeuta
sobre grupos de apoyo de iguales en la comunidad.
Recursos para clientes y familias
Educación
National Institute of Mental Health (1.800.421.4211 or www.nimh.nih.gov or
http://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml)
National Alliance on Mental Illness (http://www.nami.org)
https://www.achievesolutions.net/achievesolutions/en//Home.do
Autoayuda
Jones, S. H., Hayward, P. & Lam, D. H. (2003). Coping with Bipolar Disorder (Second Edition).
Oxford: Oneworld.
Miklowitz, D. J. (2002). The Bipolar Disorder Survival Guide: What You and Your Family Need to
Know. New York: Guilford Press.
Ramirez Basco, M. (2006). The Bipolar Workbook: Tools for Controlling Your Mood Swings, New
York: Guilford Press.
Scott, J. (2001). Overcoming Mood Swings. London: Constable Robinson.
Memorias
Jamison, K.R. (1995). An unquiet mind: A memoir of moods and madness
Manning, Martha (1994). Undercurrents: A life beneath the surface
Tecnología
Busque aplicaciones (Aps) para el rastreo del estado de ánimo
Revised 7/1/12