Bipolar Disorder: Preventing a Relapse

Most people with bipolar disorder suffer relapses, a return of bipolar symptoms. Learn how to keep bipolar relapses at bay.

Bipolar disorder cannot be prevented, but often the mood swings can be controlled with medications, if you take them regularly as prescribed by your doctor.

About 1 in 3 people will remain completely free of symptoms of bipolar disorder by taking mood stabilizer medications, such as carbamazepine (Tegretol) or lithium, for life. (read more about medication compliance here)

Other ways to help prevent a depressive or manic mood episode include:

• Eating a balanced diet.
• Exercising daily.
• Avoiding extensive travel into other time zones.
• Getting approximately the same number of hours of sleep every night.
• Keeping your daily routines similar.
• Avoiding alcohol or drugs.
• Reducing stress at work and at home.
• Seeking treatment as soon as you notice symptoms of a depressive or manic episode coming on.

Changes in your sleep patterns can sometimes trigger a manic or depressive mood episode. If you plan extensive travel into other time zones, you may want to call your doctor before you leave to discuss whether you should make any changes in your medications, and what to do if you have a manic or depressive episode while you are away.

Home Treatment

Home treatment is important in bipolar disorder. In addition to taking your medications every day as prescribed, you can help control mood swings by:

Family members often feel helpless when a loved one is depressed or manic. Family members and friends can help by:

• Encouraging the person to take his or her medications regularly, even when feeling good.
• Learning the warning signs for suicide, which include:
  • Drinking heavily or taking illegal drugs.
  • Talking, writing, or drawing about death, including writing suicide notes.
  • Talking about harmful things, such as pills, guns, or knives.
  • Spending long periods of time alone.
  • Giving away possessions.
  • Aggressive behavior or suddenly appearing calm.
• Recognizing a lapse into a manic or depressive episode, and helping the person cope and get treatment.
• Allowing your loved one to take enough time to feel better and get back into daily activities.
• Learning the difference between hypomania and when he or she is just having a good day. Hypomania is an elevated or irritable mood that is clearly different from a regular nondepressed mood and can last for a week or more.
• Encouraging your loved one to go to counseling and join a support group, and joining one yourself if needed.

Mood stabilizers, especially lithium and divalproex (Depakote), are the cornerstones of prevention or long-term maintenance treatment. About 1 in 3 people with bipolar disorder will remain completely free of symptoms just by taking mood stabilizing medication for life. Most other people experience a great reduction in the frequency and severity of episodes during maintenance treatment.

It is important not to become overly discouraged when episodes do occur and to recognize that the success of treatment can only be evaluated over the long term, by looking at the frequency and severity of episodes. Be sure to report changes in mood to your doctor immediately, because adjustments in your medicine at the first warning signs can often restore normal mood and head off a full-blown episode. Medication adjustments should be viewed as a routine part of treatment (just as insulin doses are changed from time to time in diabetes). Most patients with bipolar disorder do best on a combination or "cocktail" of medications. Often the best response is achieved with 1 or more mood stabilizers, supplemented from time to time with an antidepressant or possibly an antipsychotic medication.

Continuing to take medication correctly and as prescribed (which is called adherence) on a long-term basis is difficult whether you are being treated for a medical condition (such as high blood pressure or diabetes) or for bipolar disorder. Individuals with bipolar disorder are often tempted to stop taking their medication during maintenance treatment for several reasons. They may feel free of symptoms and think they don't need medication any more. They may find the side effects too hard to deal with. Or they may miss the mild euphoria they experience during hypomanic episodes. However, research clearly indicates that stopping maintenance medication almost always results in relapse, usually in weeks to months after stopping. In the case of lithium discontinuation, the rate of suicide rises precipitously after discontinuation. There is some evidence that stopping lithium in an abrupt fashion (rather than slowly tapering off) carries a much greater risk of relapse. Therefore, if you must discontinue medication, it should be done gradually under the close medical supervision of your doctor.

If someone has had only a single episode of mania, consideration may be given to tapering the medication after about a year. However, if the single episode occurs in someone with a strong family history of bipolar disorder or is particularly severe, longer-term maintenance treatment should be considered. If someone has had two or more manic or depressive episodes, experts strongly recommend taking preventive medication indefinitely. The only times to consider stopping a preventive medication that is working well is if a medical condition or severe side effect prevents its safe use, or when a woman is trying to become pregnant. Even these situations may not be absolute reasons to stop, and substitute medications can often be found. You should discuss each of these situations carefully with your doctor.

Sources:

• Sachs GS, et al. (2000). Expert Consensus Guidelines Series: Medication Treatment of Bipolar Disorder.
• Sachs GS, et al. (2000). The treatment of bipolar depression. Bipolar Disorders, 2(3, Part 2): 256-260.
• Glick ID, et al. (2001). Psychopharmacologic treatment strategies for depression, bipolar disorder, and schizophrenia. Annals of Internal Medicine, 134(1): 47-60.
• American Psychiatric Association (2002). Practice guideline for the treatment of patients with bipolar disorder (revision). American Journal of Psychiatry, 159(4, Suppl):1-50.

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