A treatment algorithm is a set of instructions and guidelines developed by a group of physicians, medical practitioners and academicians. The algorithm is derived from clinical trials, medical literature and collective clinical experience. They are used to standardize and improve the quality of care among a large population. Treatment algorithms take into consideration the costs of treatment and evaluate the benefits and risks of particular treatments. Two widely used treatment algorithms for bipolar disorder in the United States are the Texas Implementation of Medication Algorithms--or TIMA--bipolar algorithm and the Expert Consensus Series--or ECS--bipolar guidelines.
Bipolar Disorder
Mania is a state of elevated mood distinguished by racing thoughts, increased intensity, irritability, altered sleep patterns, euphoria and grandiosity. Hallucinations and psychosis may occur in severe manic episodes. The occurrence of mania in a patient is sufficient for the diagnosis of bipolar disorder even without evidence of depression. Bipolar disorder, also referred to as manic-depressive disorder, is characterized by episodes of mania, which may be accompanied by periodic occurrences of depression. Bipolar disorder encompasses a spectrum of disorders and is classified into several sub-categories based upon the type of episode, manic or depressive and the severity and frequency of episodes. This disorder is difficult to diagnose and to treat, because of the multitude of symptoms and no specific blood test. There is no cure for bipolar disorder. The goals of treatment of bipolar disorder are to reduce symptoms, prevent recurrent episodes and restore psychosocial function.
Medications
The Texas algorithm recommends the mood stabilizers lithium or valproate, or one of the atypical antipsychotics--aripiprazole, quetiapine, risperidone, or ziprasidone--for initial treatment of mania. After patient response and tolerability is evaluated, the combination of a mood stabilizer and atypical anti-psychotic may be recommended. The ECS guidelines are similar in this respect. If symptoms persist, selective serotonin reuptake inhibitors, such as citalopram, fluoxetine, or sertraline may be additionally prescribed and the therapeutic benefit of electroconvulsive therapy evaluated. TIMA reports that there is no evidence that treatment with two antipsychotics is more effective in the treatment of mania. The mood stabilizing drugs are effective for maintenance treatment and to prevent relapse.
Psychotherapy
As reported in the ECS guidelines, the aims of psychotherapy treatment for bipolar disorder are to improve cognitive behavioral function, family education and relationships, and social interaction. Psychotherapy can have long-lasting effects but the benefits are not observed quickly.
Electroconvulsive Therapy
The ECS and Texas algorithms recommend electroconvulsive therapy after other drug treatments in combination have been tried and failed, or in cases of severe mania or depression. The ECS guidelines state electroconvulsive therapy can be life-saving. This treatment is performed in a doctor's office in patients that have been anesthetized. A patient will receive six to ten treatments over a few week time period. A review study in the "American Journal of Psychiatry" reported that 80 percent of manic patients showed marked clinical improvements after electroconvulsive therapy, and that it is an effective treatment for those who do not respond well to medications.
Education
The Texas algorithm states that bipolar patients should be involved in psychoeducation programs that not only provide information on the illness, but also healthy lifestyles and the importance of treatment adherence. A study published in "European Psychiatry" reports that psychoeducational sessions that include information on bipolar disorder, stress management, and strategies to recognize early symptoms of manic or depressive episodes reduce the burden of this disease on both the patient and family.
References
- Texas Medication Algorithm Project Procedural Manual: Bipolar Disorder Algorithms
- Expert Knowledge Systems: The Expert Consensus Guideline Series: Treatment of Bipolar Disorder 2004
- Pubmed: "European Psychiatry": Impact of Cognitive-psychoeducational Interventions in Bipolar Patients and their Relatives
- Pubmed: "American Journal of Psychiatry": Electroconvulsive Therapy of Acute Manic Episodes
