A full 23 page paper on the history, signs/symptoms, and treatment on bipolar disorder

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Bipolar disorder is a psychological disorder characterized by alternating episodes of severe elation (mania) and depression. Occurring in 1 to 1.6 percent of all adults over their lifetimes and in 1.2 percent of all children and adolescents, this "severe, recurrent psychiatric disorder" is considered a serious public health problem with staggering social costs (Nathan 1999). These costs include a loss of productivity, decreased life expectancy, and major financial expenditures stemming from abnormal mood shifts that have a negative impact on a person's disposition, energy level, and ability to function in daily life. "The greatest cost of manic-depressive illness is the personal toll it takes on affected individuals and their families. It is also incurable," according to E. Fuller Torrey (2002).

For many years referred to as "manic depression," this disorder is now characterized in two categories: bipolar I and bipolar II. The former is characterized by severe, recurring episodes of mania and depression, while the latter experience consists of hypomania, which is less severe than mania, alternating with depression.

Peter Nathan (1999) points out that although millions of people are affected by this disorder, fewer than one-third of them receive treatment--the lowest percentage of any psychiatric disorder (p. 111).

History of Bipolar Disorder

Bipolar disorder has been studied for a long period of time. Within the last 20 years until recently it was assumed that mania and depression were totally separate illnesses rather than representing the same disorder. The complexity of bipolar disorder presents theorists with an opaque understanding of the origin, course, and outcome. Due to recent research and technologies, theorists are moving toward a better understanding the complexities of a disorder that plagues many people. The goal is to develop a firm definition of what is happening in patients and advance treatments to control symptoms.

Early thoughts/findings

Depression is among the oldest recognized mental illnesses. Although the modern syndrome of mania is not actually found in ancient records, the condition now known as depression was described in Mesopotamian tablets attributed to the second millennium B.C. In later years, the symptoms of depression were documented by both Hippocrates and Galen. While some early scientific discussions did involve the relationship of the two conditions, it was not until the seventeenth century that detailed descriptions of "manic-depressive illness" were recorded (Torrey, 1999 P. 10).

Emil Kraepelin

Emil Kraepelin, credited with the discovery of both schizophrenia and bipolar disorder, was a prominent 19th century academic psychiatrist from northern Germany. It was Kraepelin, with support from French physicians Jean Pierre Falret and Jules Ballarger, who first coined the term "manic-depressive illness" in 1899 (Shorter, 1997 p. 105). In the 1850s, Falret and Ballarger had hypothesized that mania and depression are not simply two separate disorders, but the two occasionally co-exist in some patients and alternate over one's life as "la folie circulaire" or "circular insanity" (p. 105).

Kraepelin divided all mental illnesses into 13 categories that included patients with related symptoms. In his fifth edition book on mental disorders, Kraepelin divided the severe mental illnesses into 2 extensive categories: disorders that were deteriorating and those which were periodic. His category on periodic or mania and depression intrigued both common people and medical personnel the most because it was never thought of as a single disorder. Kreplin described the manic-depressive insanity as, "...on the one hand the whole domain of so-called periodic and circular insanity, on the other hand simple mania, [and] the greater part of the morbid states termed melancholia...In the course of the years I have become more and more convinced that all the above-mentioned states only represent manifestations of a single morbid process" (Mondimore 1999 p. 63). By splitting psychotic illnesses into 2 subgroups, illnesses involving some kind of affective component, and those void of an affective component, he could justify why people acted the way they did. Kraepelin said "in the course of the years I have become more and more convinced that all [of the periodic and circular psychoses plus mania] are really just manifestations of a single disease process," which he identified as "manic-depressive psychosis" (Shorter, 1997 P. 107). Kraepelin went on to say that typically those with manic-depressive illness would improve.

Bipolar I

Just like any other disease or mental illness, there are many levels to the severity at which the patient suffers with bipolar disorder. This concept is what divides the two types of bipolar disorders I and II. By definition from the Diagnostical Statistical Manual IV (DSM-IV), bipolar disorder is any "person who has had a manic episode but not necessarily a depressive episode, although most persons diagnosed as having both." Additional diagnosis is based on whether the individual has reoccurring episodes or has had just one, including the severity--incorporating whether or not the person experiences psychotic features.

Bipolar I serves as the classic form of the disorder. Hallmark characteristics include alternating, uncontrolled manic episodes with extreme moods of depression. Because the degree to which individuals suffer bipolar I symptoms varies broadly, the illness is almost as individual as the person who has it. Typically indications of bipolar I are activated during late teens and into the early twenties. However, it is common for symptoms to show up later in life (Mondimore 1999).

Before the introduction of treatment, the average bipolar I episode would last about 6 months and it was not uncommon for symptoms to last up to a year. However, with modern treatments, episodes of symptoms can be easily suppressed. This keeps patients away from the psychiatrists and typically symptom-free. It is those individuals who choose not to take medication that have relapses or reoccurring episodes. This poses a critical question in understanding bipolar I: "Do these patients have many episodes, or do they have many relapses of a single episode of several years' duration?" (Mondimore 1999 p. 35).

Bipolar II

Some people, however, never completely develop the severe mania symptoms reflective of bipolar I. Instead they face a milder, less debilitating form of mania known as hypomania which alternates with fully developed depression. This classification is known as bipolar II. Typically when an individual is in a state of hypomania they feel good and is believed to be linked with "good functioning and enhanced productivity" (Mondimore 1999 p. 39). Therefore, the person may deny the fact that there is a problem even though family and friends may recognize the persons alternating mood as bipolar disorder. Without proper treatment, however, hypomania can become severe mania or can switch into depression. In 1993 researchers from John Hopkins University studied 266 available 1st-degree relatives of individuals with bipolar disorder. Using the Schedule for Affective Disorders and Schizophrenia--Lifetime Version, they found that bipolar II is more common than bipolar I (Simpson, Folstein, Meyers, McMahon, Brusco, & DePaulo, 1993).

If an individual experiences 4 or more episodes within a twelve-month period, they are said to have rapid-cycling bipolar disorder. Many times these episodes can occur multiple times within a single week or even a single day. Rapid cycling has a tendency to transpire later in the course of the disorder and is ordinarily more prominent in females than males (National Institute of Mental Health Web Site).

Mania aspect

The mania feature of bipolar disorder is typically the most extreme and tense element. Typically the initial onset of this stage starts out slowly and then gradually progresses to more extreme degrees of pathology. It is characterized by beliefs of being on top of the world, substance abuse, outlandish spending sprees, and sexual encounters in which that the person would otherwise not engage. Often the individual suddenly develops a tremendous sense of self-confidence and can even become fearless (Mondimore 1999 p. 12). Given that the person is sifting through many thoughts, he or she often develops what is called pressured speech, or the speeding up of their dialogue. Bipolar has a certain irony to it--it is difficult for the person to realize they are suffering from a disorder because they have a heightened spirit and believe they feel better than usual.

At least 3 of the following symptoms, according to the DSM-IV (2000) symptoms of mania, must be present with "elevated, expansive, or irritable" temperament. If the mood is only irritable, 4 of the 7 symptoms must be present. The first symptom is whether or not the person has an inflated self-esteem or signs of grandiosity. The next condition is if there is a decreased need for sleep and the person only needs a couple hours of sleep to feel rested. The third thing to look for is whether or not the person seems more talkative than usual or shows a pressure to keep talking. Yet another sign is a flight of ideas or subjective experience that thoughts are racing. Fifth is when the individual is easily distracted. Another condition is when one shows signs of increased goal-directed activity. Lastly, excessive involvement in pleasurable activities that have a high potential for painful consequences is another sign. Any of these symptoms must not be due to the use of any drug, whether prescribed or illegal.

Depression aspect

Everybody faces some sort of depression in his or her life, no matter how happy or content that life may be. Depression can be caused by a stressful event such as a loss of a job, or can be due to a pleasant event such as getting married. The type of depression encountered on a daily basis does not compare, and is different than, depression suffered by a person with bipolar disorder.

Depression affiliated with bipolar disorder is not easily elevated. Just as a manic state fills a person with indescribable pleasure and happiness, depression carries a deep sense of pain and misery. Once the person is in a depressed state it takes a lot to relieve feelings of sadness, remorse, and helplessness. Feelings of guilt are very characteristic to persons with bipolar depression, and are typically absent in "normal" depression. Another key sign of depression is the loss of most and even all pleasurable activities, known as anhedonia. In this state one would find situations such as going to the movies, sporting events, and/or concerts unsatisfying. It is also common for depressed persons to have thoughts of suicide. Suicide is easily justified in the depressed person's mind, and is hard to convince them otherwise because they truly believe they would be better off dead.

At least 5 of the following symptoms, according to the DSM-IV (2000) Symptoms of depression, must be present for 2 weeks and 1 of the symptoms must be the first or second symptoms in the following list in order to classify someone as depressed: Either by subjective report or being observed by others as having a depressed mood most of the day, virtually everyday. Also observed or report of a marked loss of interest or pleasure in almost all/all activities most of the day, virtually everyday. Characterized as having considerable weight loss when not dieting or trying to gain weight or a decrease or increase in appetite. Insomnia or hypersomnia nearly every day. Psychomotor agitation or retardation nearly every day. Fatigue or loss of energy nearly every day. Having feelings of worthlessness or excessive or inappropriate guilt (may be delusional) nearly every day. Diminished ability to think and or concentrate nearly every day. Persistent thoughts of death or a suicide attempt or a specific plan for committing suicide.


Brain structure abnormalities

Because study of the physical aspects of bipolar disorder is in its early testing phase, scientists do not completely understand the causes of onset. Today's technology allows scientists to study the brain structure of people with bipolar disorder more easily than in the past. Studies have used both computerized axial tomography (CAT) and magnetic resonance imaging (MRI) to examine abnormalities of the brains. MRI studies show that the most common abnormality reported is an excess of small, white areas in the brain, also known as "white matter hyperintensities." Many studies have reported that patients with bipolar disorder experience these areas about 3 times more frequently than patients without the "white areas" (Altschuler et al, 1997). Further, studies have been conducted providing evidence that individuals with poor clinical outcome tend to have an increased risk for the enlarged white areas (Moore, P. et al, 2001 p. 356 Torrey for ref. list). These studies are somewhat inconclusive though. Researchers still cannot identify the cause of these lesions, but speculate that either there may be a blockage of a small blood vessel by inflammation, or by abnormalities of glial cells. Scientists also believe the condition may be an outcome of lithium and/or other medication that help treat bipolar disorder (Torrey 1997 p. 110-111).

Decrease glial cells in the frontal lobes of people with bipolar is the most intriguing discovery (Rajkowska et al, 1999). The purpose of glial cells is to support neurons with chemicals such as oxygen and glucose (Kalat 2001). Until recently, bipolar was considered an abnormality of the neurons, thus overlooking the glial cells. One study provided evidence (Moore, G 1999 on bottom of ref. page) that individuals with bipolar disorder have a significant reduction of glial cells in the prefrontal cortex.

Some theories suggest that in the brains of bipolar patients the cortical sulci and the cerebral ventricles that carry cerebrospinal fluid through and around the brain are damaged and inflamed due to improper development. Because it is difficult to interpret studies of this nature, researchers have constructed what is known as meta-analysis. Using this method, results are formed by statistically combining many studies. The most complete meta-analysis available has shown that there is an enlargement of the cortical sulci and lateral ventricles of patients with affective disorders in general (Elkis et al., 1976). Individuals with bipolar disorder have about a 15 percent larger area than compared to a normal human brain. One study in the meta-analysis was established to study patients in their first manic episode. This study showed a statistical correlation between an enlarged lateral ventricle volume and enlarged third ventricle volume in manic-depressive illness. The findings suggest that structural changes in the brain are present at the onset of the illness and most likely do not originate from exposure to medication. (Strakowski et al, 1993).

Genetic theory

For more than 2 centuries, bipolar disorder has been recognized to run in families, and genetic theories continue to be the leading approach to research. The main course in which scientists study the genetic aspect involves twin, adoption, and family history cases (Torrey 1997 p. 116).

Twin studies have been the basis for discovering genetic theories on bipolar disorder. One of the main studies which focuses on twins and bipolar disorder involves research done in Denmark 1977. In this study, Axel Bertelsen and colleagues found that about 74 percent of identical twins were be diagnosed with the disorder as well (Bertelsen et al, 1977). More recent studies (Tabares-Seisdedos et al, 2001) describe similar findings in that the lifetime risk of bipolar disorder in first-degree relatives of a bipolar patient is 40-70% for a monozygotic twin and 5-10% for all other first-degree relatives.

"In sum, twin studies have clearly established that genes are important in the causation of bipolar disorder. In addition, they suggest that depression and other psychiatric disorders may be inherited in families with bipolar disorder. At the same time, however, they have established that non-genetic factors are important as well, since the concordance rate is short of 100 percent" (Torrey 1997 p. 117).

Adoption studies are yet another means of establishing that genetics play an important role in understanding bipolar disorder. According to Torrey (1997) the "biological parents of adopted-away children who do not have bipolar disorder have a 2 percent chance of having this disease. On the other hand, biological parents of adopted-away children who later develop manic-depressive illness, have a 31 percent of having the illness." These numbers have a concordance rate that is very similar to those of children who develop the illness and are not adopted. This shows that genetic make-up does have a contributing role in developing bipolar disorder.

Studies of family lineage also provide evidence that genetics play a role in bipolar disorder. There is about an 8 percent chance of receiving the illness from a first-degree relative, compared to about a 1 percent chance of the general public having the disease. Gerhson (1998) and colleagues have even provided some evidence that there is some sort of linkage between chromosomes 18 and 21 and bipolar disorder.

Neurodevelopmental Theory

This particular theory states that people may have a genetic predisposition to bipolar disorder, but it may never surface or will be latent until triggered by some sort of environmental factor. Researchers do not know for certain whether these environmental factors such as birth complications or viral infections are triggers for predisposed individuals. Inheritance

Of the areas studied, genes seem to be the strongest indicator of bipolar disorder. When focusing on the neurodevelopmental aspect of bipolar disease, winter births and summer onset seem to dominate. Studies show that some people are affected by the seasons and may be more depressed during the winter and have more manic episodes during the summer. Studies in the 1970's in Wales were organized to examine the births of people in the winter months. They found that people born in the winter months were more susceptible to the development of mental illnesses such as bipolar disorder, specifically the depression aspect (Parker & Nielson 1976). Similar findings (Dassa et al, 1993) in France observed that there is a distribution of mental disorders along seasonal lines, but there tended to be more cases during the winter months.

Summer months (not births) are also a period in which persons are more inclined to develop mania. This aspect is totally void of the winter effect and is what is known as seasonality of onset (Torrey 1997). One study, assessing 51,456 admitted patients in England and Wales between 1976 and 1986, showed that he summer peak was most prominent for mania, where it was present in both sexes (Takei et al., 1992). Another more recent study (Cassidy et al., 2002) examined the seasonal variation of mixed states of bipolar disorder as well as the overall seasonality of manic episodes. They concluded that individuals showed a peak manic state in late spring and into the summer.

Research has also provided signs that bipolar disorder may stem from pregnancy and some birth complications. Specific prenatal studies provide researchers with a better understanding of whether genetics combined with some sort of trauma have an affect on the development of bipolar disorder. In many cases, prenatal famine has been linked to an increased risk of developing bipolar disorder. Brown, Os, Driessens, and Hoek (2000) compared the risk of major affective disorder requiring hospitalization in birth cohorts who were and were not exposed, in each trimester of gestation, to the Dutch Famine during the winter of 1944-1945. The study provides evidence that there is a relationship between prenatal famine and bipolar disorder. They found that individuals conceived during the second and third trimester, as opposed to unexposed subjects, were at an increased risk developing major affective disorder requiring hospitalization.

Neurochemical theory

The Neurochemical theories of bipolar disorder are just behind genetics in popularity and research support. The exact cause of bipolar disorder has not been discovered, but researchers think it is not completely psychological. The brain is controlled by neurotransmitters, which are certain chemicals that transmit "messages" between the brain and cells. It is thought that malfunctioning of neurotransmitters can cause certain abnormalities such as bipolar disorder. Today there are about 100 known neurotransmitters. Some of these neurotransmitters such as Dopamine, norepinephrine, seratonin, GABA, glutamine, and acetylcholine are thought to somehow be involved in bipolar disorder. Many studies (Post 1978; Petty et al., 1981) have been performed on patients with bipolar disorder, which examine the levels of these chemicals in the body. Post (1978) findings conclude that there were significantly higher levels of norepinephrine in manic than in depressed patients. When levels of this chemical are too high, mania occurs. When levels of norepinephrine drop, a person may experience depression. Results in the Petty et al. (1981) study shared similar findings. Lowest levels of GABA were found in patients with familial pure depressive disease or depression spectrum disease, while bipolar manic patients had GABA levels that were significantly higher than control values. Because not enough studies have been performed, a restricted conclusion can be made that imbalances in certain neurotransmitters will not cause, but may be a strong factor in affecting the onset of bipolar disorder.

Treatment for Bipolar Disorder: Medications

Many treatment methods exist for bipolar disorder. The most significant are: medication, psychotherapy, and mood charts. Among these, medication is considered to be the most important approach in treating bipolar disorder. According to Torrey (1997), medication treatment seems to have two main goals: first, to alleviate or reduce the duration of an acute manic or depressive episode, and second to maintain the improvement obtained in the acute phase and prevent further cycles of mania or depression (p. 137). However, research has been unsuccessful in specifically identifying an area of the brain affected by medication.

MANIC STATE (mood stabilizers)

Lithium is valuable for treatment of many medical conditions. Among these conditions, it has a remarkably positive affect on bipolar disorder. However, researchers still do not know why lithium has such an outstanding affect. About 60 percent of bipolar patients using lithium report favorable outcomes. There is only a small part of lithium that is used for medical purposes. Lithium is always used in a form of salt. It is this salt element, lithium ion (Li+) that is effective in the treatment of bipolar disorder (Schou, 1993). Lithium is considered a wonder drug because of its rapid onset (it doesn't take 2-3 weeks to take affect). Other side effects such as stomach pains, nausea, muscle weakness, shaking of the limbs, etc., are typically considered mild and do not hinder the person's daily life. Two novel targets of lithium's actions have been identified. Chronic lithium (Li) treatment has been demonstrated to markedly increase levels of the major neuroprotective protein bcl-2 in rat frontal cortex (FC), hippocampus, and striatum. Similar Li-induced increases in bcl-2 are also observed in cells of human neuronal origin and are observed in rat FC. Li has also been demonstrated to inhibit glycogen synthase kinase 3beta(GSK-3beta) (Manji, 2000). There are essentially 2 forms of lithium. The most 2 most common are lithium carbonate, which is a pill form, and lithium citrate, which is a liquid. Typically the drug is administered twice per day ranging to a total of 600-1,200 mg.

Valproate, also used to treat bipolar disorder, was initially used in the treatment of epilepsy. This drug is typically administered if the patient doesn't respond to lithium treatment. Normally its effect has a shorter onset period than lithium. About 50 to 60 percent of patients who take this drug respond positively to treatment. Growing data (Lennkh, 2000) indicate that valproate is a well-tolerated and effective agent in bipolar disorder. Controlled studies prove its use in acute mania, often with a rapid onset of action. Open studies (McElroy, 1992) suggest that the drug also reduces the frequency and intensity of recurrent manic and depressive episodes over extended periods. Some common side effects of this drug include: nausea, sleepiness, weight gain due to increased appetite, etc. (Torrey, 1997 p. 151). Valproate is available in tablet form or capsules filled with powder, which can be sprinkled onto food. It is recommended that 500-3,000 mg be administered per day.

Similar to valproate, carbamazepine (tegretol) was first used to suppress symptoms of epilepsy. In comparison to the previous medications, carbamazepine has about a 60 percent success rate. Also, like the preceding drugs, researchers are uncertain exactly why carbamazepine has effect on bipolar disorder. One study showed that the combination of carbamazepine and lithium had significant effect on bipolar disorder. About 70 percent of the subjects had a better course outcome than those strictly on lithium (Bocchetta et al., 1997). Carbamazepine is available in 100 mg chewable tablets, and 200 mg tablets, and the average dose is 600-1,200 mg per day so it is recommended to take it 3 to 4 times per day (Torrey 1997).

Topiramate is a relatively new drug used to treat epilepsy as well. One recent study (Vieta et al., 2002) examining the effectiveness of topiramate found that topiramate might be useful in the long-term treatment of bipolar spectrum disorders, even in the most difficult-to-treat patients. The most significant side effects are: sleepiness, fatigue, dizziness, and decreased concentration. Topiramate is called Topamax in the medical form and is available as 25, 100, and 200 mg tablets and as 15 or 25 mg of powder capsules to be sprinkled on food (Torrey 1997).


One thing that has to be considered when prescribing medication for depression is that they may put a person into a manic state. Knowing this, medication is given according to the severity and time of onset of bipolar disorder.


Antidepressants are among the first group of medications used to treat depression. Within this group, selective serotonin reuptake inhibitors (SSRI's) have the greatest effect in treating the depression aspect of bipolar disorder and are considered the first approach to treatment. SSRI's are effective in approximately 60 percent of individuals. There are many SSRI's available. Some trade names are: Prozac, Zoloft, and Paxil, and the dosage ranges from 10 mg to 100 mg. The most common side effect associated with SSRI's is nausea. Other common side effects include sleepiness, tremors, dry mouth etc. (Torrey, 1997).

Monoamine oxidase inhibitors (MAOI's) are another form of antidepressant. Monoamine oxidase is an enzyme that is produced in two different forms within the body. The first is monoamine oxidase A, which mainly breaks down seratonin and norepinephrine. Monoamine oxidase B largely breaks down dopamine. MAOI's inhibit these enzymes, which is why they are effective in treating depression. Typical side effects include: insomnia, sleepiness, nervousness, and weight gain etc. The pills are available in 15 mg. and are tablet form (Torrey, 1997).

Venlafaxine, another antidepressant, has also been a prominent medication in treating bipolar disorder. In one study, Jay Amsterdam (1998) compared treatment with venlafaxine of patients with mild bipolar disorder. He found that the subjects improved and did not relapse into a manic state.


Antipsychotic medication is used for individuals who experience psychotic episodes such as delusions or hallucinations during bipolar states.

First-generation, or typical, Antipsychotic drugs were among the first to be used. These drugs block dopamine receptors and are effective in decreasing depressive symptoms. They are called typical because when high doses are given, they can cause extrapyramidal side effects (EPS). EPS's are movements that aren't typically associated with normal human movement, and can be found in roughly 60 percent of patients on this type of drug. Among these movements, tardive duskinesia is the most feared movement. It is characterized by involuntary twitching usually of the facial muscles. However, EPS's can be eliminated with "anti-Parkinson's" medications. Other side effects include: weight gain, abnormal menstrual periods in women, and seizures, etc. (Torrey, 1997).

Second-generation, or atypical, antipsychotics such as clozapine (clozaril), risperidone (risperdal), and olanzapine (zyprexa) leave patients with a lower chance of developing an EPS. Studies have proven (Seabourne & Thomas, 1994; Yatham 2002) that combining atypical antidepressants with mood stabilizers will help reduce manic and depressive symptoms of bipolar disorder. Some side effects with these kids of drugs include: seizures, drooling, and urinary problems etc. (Torrey, 1997).

Treatment for Bipolar Disorder: NON-medications

Social Support-

Social support, as simple as it sounds, has a very positive effect on bipolar disorder. By having the support of family and friends, individuals with bipolar disorder can rely on them to give them helpful feedback and to be concerned. It has been demonstrated in many studies that social support alleviates symptoms of bipolar disorder. One such study followed 59 individuals with the illness longitudinally. Social support was measured by the Interpersonal Support Evaluation List and the Interview Schedule for Social Interaction, and life events were assessed using the Life Events and Difficulties Schedule. Individuals with low social support took longer to recover from episodes and were more symptomatic across a six-month follow-up. Results suggest a polarity-specific effect, in that social support influences depression but not mania (Johnson et al., 1999). If individuals lack a strong support network from family or friends, there are groups such as the National Alliance for the Mentally Ill (NAMI) which can fulfill their needs. These sorts of groups provide a caring, listening environment with feedback and advice on how to deal with their illness. Often speakers are invited, professional and nonprofessional, and to discuss the needs of the individuals and their families (Torrey, 1997).


Many individuals do fine by taking medication while having a strong social support group. For those who do not, psychotherapy combined with medication seems to be another successful method of treating bipolar disorder.

Cognitive therapy is a form of psychotherapy stating that conscious thoughts are the most important ones. The main goal of cognitive therapy is to assist the patient in understanding and monitoring what are called "automatic negative thoughts" (ANT's). In doing this, the therapist is aiming to substitute negative thoughts with new positive ways of thinking through behavioral techniques and positive reinforcement. One question that arises in terms of cognitive therapy is: Are the patients' symptoms relieved because of the therapy or do they have a better understanding of the importance of their medication? A recent study done by Colom (2002) assessed a sample consisting of 121 patients with bipolar disorder. His results were based on how "psycho-educated" they were. The more educated, the lower the risk of having a relapse. He concluded that cognitive therapy may play a very significant role in the enhancement of treatment adherence for people with bipolar disorders.

Because bipolar disorder is a debilitating disorder, it is almost inevitable that the family will get involved. Strong family support, as stated earlier, is very important. Therefore, educating the family through therapy can aid in the understanding of the symptoms, the need for medication, and signs of relapse. Although there have been few studies on family therapy, research has started to connect this approach to improved symptoms. According to a study by Miklowitz (2000), people who underwent family-focused psychoeducational treatment (FFT) had fewer relapses, were more compliant with medication, and experienced fewer symptoms.

Electroconvulsive therapy (ECT)-

ECT is a procedure in which electrical charges are sent to the brain, which produces a seizure for approximately 30 seconds. The main reason to use ECT is to treat sever depression. This treatment is now believed to help treat acute mania. Experiments with ECT that apply shocks to either side of the head (bilateral) cause more memory loss than when the current only to the right side of the brain (unilateral). Over the years, ECT has developed a bad reputation, often perceived as cruel. This is because early attempts provoked long, violent seizures. Now, muscle relaxants are given to patients and it is a simple, quick procedure. This is false however. Researchers have proven that ECT is safe and effective in treating bipolar disorder.

Researchers have just begun to scratch the surface of treating this complex illness known as bipolar disorder. Further, there is also a misunderstanding of why certain treatments work to suppress symptoms of bipolar disorder. However, hopefully with the rapid advancement of technology, a cure for this debilitating illness is in the near future.

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