• Bipolar disorder often necessitates long-term management. A collaborative approach to management, based on a sound therapeutic relationship, will facilitate engagement and help optimize treatment outcomes
• Patients should be encouraged to take an active role in the management of their own illness and receive psychoeducation about the illness and available treatments options
• There are many facets to managing bipolar disorder and patients are likely to be involved in a range of services by a variety of professionals. Every effort should be made to work cohesively and maintain good communication across all parties
• Patients should be facilitated to access and utilize available resources including peer-support organisations and online resources.
9.1 Self management, psychoeducation, role, and responsibility for illness, insight
For many, bipolar disorder is a recurring illness that is likely to require long-term management or monitoring. Traditionally, the treating doctor or specialist team overseeing care has been allocated the responsibility to fulfil this role however, it is increasingly recognized that the individual is pivotal in their own management and plays an active role in maintaining their own mental health.
Indeed, there is a strong movement led by consumers that focuses on the unique and individual recovery journey, a process that may include progression through a series of stages ranging from a sense of hopelessness and withdrawal from the illness to achieving empowerment through acceptance, better understanding, hope and personal growth. Many mental health services base their treatment philosophy around promoting a recovery-led approach and aim to foster a sense of active involvement in the patient’s own care.
Clinicians can facilitate the recovery process by acknowledging and seeking to understand the patient’s experience and response to their illness, and also facilitate the development of an understanding of their illness and available treatment options, along with identifying what they can do to maximise their own functioning and minimize the risk of relapse. In this context psychoeducation for the individual and also their family and close supports plays an important role as does promoting healthy lifestyle choices and regular routines to optimize and maintain mental health. Further, clinicians should work with individuals to facilitate an understanding and recognition of their own relapse signals and to practice self awareness by monitoring moods and behaviour patterns.
The goal is to achieve a truly collaborative approach to managing the illness with the flexibility and recognition that there will be times when the consumer can take a lead role in this process and other times when the illness becomes more acute and external care providers will need to adopt a more assertive approach. This can be a difficult balance and one that fluctuates across the illness course.
9.2 Therapeutic relationship, role of professional carers, psychiatrists, psychologists, mental health team, and family
The therapeutic relationship is crucial to effective management of the illness and underpins every facet of treatment. The therapeutic relationship begins at the first point of contact and continues to evolve thereafter. The very nature of bipolar illness means it can involve periods of marked instability and a chaotic lifestyle. Further, pharmacological treatments are not always well tolerated or well-liked by the individual and insight may be limited. Each of these factors contributes to increase the risk of periods of nonadherence to treatment. A therapeutic relationship that is built upon trust, collaboration and openness can improve the likelihood of maintaining engagement in treatment and therefore reduce risk of relapse during these unsettled periods.
The treating team providing care for the person with bipolar disorder can vary depending on the individual, severity of the illness and availability and structure of local services. Care may be based in primary care delivered by a GP or as part of a specialist mental health team, delivered privately or publicly. Typically, public mental health care is provided by a team, led by a psychiatrist but with each patient allocated to a primary care coordinator or case manager who oversees the delivery of care and who has an active role in the day-to-day involvement. This is often a nurse or allied health worker. Privately, a psychiatrist may be more directly involved in routine monitoring and may then engage various other disciplines such as nursing, psychology or social work to undertake specific tasks. Care is primarily provided in the community setting but at times of acute illness an inpatient admission, sometimes involuntary, may be required to stabilize mental state or to manage any associated short-term risks.
Bipolar disorder affects not only mood, but impacts on all aspects of the individual’s life. Therefore effective management should consider a broad range of goals and to achieve this, there are a number of health disciplines that possess expertise across different domains. Although a considerable degree of overlap across professions exists, it is likely that a number of disciplines will need to be involved at different stages to deliver tailored aspects of care. In addition to the role of the medical practitioner, nurses have an active role in the delivery and monitoring of medical and physical care and promoting well-being. Psychological treatments are increasingly recognised as beneficial in bipolar disorder, particularly to help prevent relapses and to improve symptoms during acute depressive phases. In bipolar disorder psychologists employ therapies that target interpersonal relationships, family involvement or maintaining structured routines. Social workers have expertise in working with how the individual relates within their own community and particularly work to optimise social inclusion. Occupational therapists are interested in how people engage in meaningful activities, including work and social functioning, both of which can be significantly impacted upon by bipolar disorder.
Bipolar disorder does not affect the individual in isolation and often the family is closely involved and need to be integrated into treatment. The term ‘carer’ is often used to refer to those family members or friends who are responsible for providing direct support or care to a person with a mental illness. ‘Carers’, and indeed other close family members, will likely require emotional support, education about the illness and treatment options, practical strategies to manage difficult behaviours or in times of crisis and can provide an active role in helping to monitor mental health.
9.3 Self help groups, consumer associations, and the role of government organizations
Peer-led organizations can provide an important source of emotional and social support as well as educational resources. Some people find particular benefit in obtaining support from others with shared experiences and such groups often promote a consumer-driven recovery-led approach. Availability varies on locality but usually involves a mixture of smaller community-based groups as well as larger national organizations often with accompanying online resources.
Where required, external agencies or organizations may also be involved by providing disability support or assisting with other non-clinical aspects of care, such as vocational support programmes.
9.4 Web-based interventions and resources
The advent of the internet has provided an abundance of resources that are freely available to access about bipolar disorder and related topics. Accessing the internet can be encouraged as part of promoting self-management and patients should be directed to particularly reputable and well-resourced websites. This can be an opportunity for further psychoeducation and patients should be encouraged to discuss with their clinician any questions they have about the information they are reading. There is also an emerging interest in web-based psychological interventions that are likely to play a role in the management of bipolar disorder. These are particularly focused on providing online programmes for structured interventions such as cognitive behavioural therapy.
References and further reading
Berk M, Berk L, and Castle D (2004). A collaborative approach to the treatment alliance in bipolar disorder. Bipolar Disorders, 6(6), 504–18.Find this resource:
Oades L, Deane F, Crowe T, Lambert WG, Kavanagh D, and Lloyd C (2005). Collaborative recovery: an integrative model for working with individuals who experience chronic and recurring mental illness. Australasian Psychiatry, 13(3), 279–84.Find this resource:
Useful online resources
www.bipolarconnect.com Lists web-based resources for bipolar disorder
www.dbsalliance.org Depression and bipolar support alliance
www.bphope.com Online newsletter for people with bipolar disorder