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Winter 2009/10 | Vol 13 No 2

Issues and trends

Focus on the positive: Treatment for bipolar disorder embraces
self-management

By Astrid Van Den Broek

Stew Ludtke’s diagnosis came in 1999 when he finally dragged himself to his doctor to talk about his nightmare of an experience. He was having delusions, hallucinations and frenetic bursts of energy, compelling him to work 14 hours a day building a five-storey house all by himself. The physician diagnosed Ludke, then 45, with bipolar disorder and prescribed a combination of medications. He also referred Ludtke to a short-term psychotherapy program and later a psychiatrist. But Ludtke felt that something was missing. That’s why he decided to get involved with support groups for people with bipolar disorder through the Mood Disorders Association of British Columbia. “That’s where my recovery started,” says Ludtke. “Medication has come a long way, but you don’t just rely on a pill.”

Today, Ludtke facilitates the Comox Valley mood support group in Courtenay. Along the way, Ludtke has developed his own strategies for managing his mood swings and emotions: “I stopped drinking to try and control my moods, and I quit caffeine because I thought it was keeping me up at night,” he says. “I also exercise regularly, which helps me feel a change in my body and get energized. For my recovery, I’d say medication accounts for about 30 per cent, the support group another 30 per cent, and the rest comes from me.”

The role that self-management plays in Ludtke’s recovery comes as no surprise to Dr. Greg Murray and Dr. Erin Michalak. Murray, director of clinical psychology programs at the Swinburne University of Technology in Australia, and Michalak, an assistant professor in the Department of Psychiatry at the University of British Columbia in Vancouver, recently completed a study that found that wellness factors play a significant role in recovery. The study is one of several being conducted by the international Collaborative RESearch Team to Study Psychosocial Issues in Bipolar Disorder (CREST.BD).

It is a significant finding because bipolar disorder, characterized by high and low mood swings, affects a surprising number of Canadians. The Public Health Agency of Canada estimates that one per cent of Canadians over age 15 have experienced symptoms matching the bipolar disorder diagnosis. It also estimates that about one in 50 adults aged 25 to 44 and 45 to 64 have experienced bipolar-like symptoms at some point in their lives. According to a 2002 Mental Health and Well-Being Survey by Statistics Canada, nearly nine out of 10 Canadians who had experienced bipolar symptoms reported that these symptoms interfered with their lives.

Coping with this disruption has traditionally relied on medication, supplemented with talk-based therapy, but many find that this medical approach fails to recognize the role of self-management, mobilizing the person’s own resources in their recovery. “Bipolar disorder is a serious mental illness that remains poorly understood,” says Murray. “The first line treatments are still medication, which works for the majority of people, but it doesn’t work as well as we would like.” With a complex medication regimen that often includes anti-depressants, antipsychotics and mood stabilizers, finding the right balance for each person can be difficult. “Over the last decade or so there has been a lot of interest from professionals and patients in discovering what else we can add to improve outcomes in bipolar disorder,” says Murray.

For some people, their lives are dominated by bipolar disorder. And for others, it is just a feature of their lives that they manage well and that rarely interferes with their goals. What strategies do these people use as effective tools for managing bipolar disorder?

In the CREST.BD study, researchers consulted with 33 people with bipolar disorder to learn what self-management techniques were and weren’t working for them. “One of the interesting features of bipolar disorder is that two people can have the same level of symptoms but have very different functional outcomes,” says Murray. “For some people, their lives are dominated by bipolar disorder. And for others, it is just a feature of their lives that they manage well and that rarely interferes with their goals. We decided to ask these people [who managed well] about the strategies they use as effective tools for managing bipolar disorder.” The study is currently in press with the Journal of Affective Disorders.

One common wellness point that people in the study identified was sleep. Managing the sleep-wake cycle is one of the key issues a therapist will address with clients. “It’s an important part of psycho-education,” says Murray. “The sleep-wake cycle is a very important point of vulnerability. The study found that high-functioning people identified the critical need to manage sleep as one of the things they had learned about themselves.”

So it was with 54-year-old Sophia van Norden, board chair of the Mood Disorders Association of British Columbia. Part of her self-management strategy included switching to part-time work from her stressful full-time job, which included extensive travel, wreaking havoc on her sleep cycle. “Getting enough sleep prevented me from bouncing around mood-wise and gave me the ability to roll with the punches,” says van Norden. “If unexpected problems happen during the day or your kids or husband are having a meltdown, it gives you tools to think, rather than panicking,” she says, noting that these days she logs a solid – and regular –eight-hour sleep a night.

Along with other strategies, such as keeping active during the daytime and being socially engaged, CREST.BD also found that broader wellness approaches, such as eating well, avoiding alcohol or other addictive substances and monitoring moods, are critical. “That means being proactive and not waiting for the signs of a change in mood, but actually sitting down when you’re feeling OK and writing down a plan, sharing it with important people, so they know the plan as well, and making sure that everyone involved in the plan knows their role and has agreed to it,” says Murray.

What also proved interesting along the way was discovering what didn’t work, and dispelling treatment myths, such as the role of introspection, which is central to cognitive-behavioural therapy. “For our group, the particular strategy of monitoring your thoughts, working out which ones are effective and which ones aren’t, modifying them if necessary, testing hypotheses that come from your thoughts – was not described as paramount,” says Murray. Instead, individuals seemed to focus not on being analytical, but on being more meditative. “They weren’t judging or analyzing or critiquing their thoughts,” says Murray. “It was more that they were interested in simply being mindful of what was going on inside their heads in a more accepting way, in a more Eastern or Buddhist way, if you like.”

These findings resonate with Debbie Radloff-Gabriel, an occupational therapist with the Mood Disorders Research and Treatment Service at Providence Care Mental Health Services in Kingston, Ontario. She sees self-management strategies as part of the mosaic that includes medication and psychotherapy. She is quick to add that ach mosaic is a personalized one. “One of the challenges when someone has bipolar disorder is that the sand is always shifting under their feet,” she says. “Learning how to manage the various ranges of experience and yet still do the things that are important to them is a way forward. Self-management is one of the keys.”

Recognizing the role of self-management strategies on the road to wellness has implications for clinical practice. Murray sees the results of the CREST.BD study as a positive reframing of living with bipolar disorder. “You could see it simply as ‘Bipolar disorder is a serious mental illness with a high risk of suicide,’” says Murray. But the findings offer a more hopeful perspective: “Bipolar disorder is potentially a major burden in people’s lives, but our confidence is growing that we can moderate those outcomes. For each person, we should aim for good quality outcomes, rather than assuming that this is going to be a disastrous feature of their lives.”

It is this positive focus that needs to frame the therapeutic relationship. “Encouraging a focus on wellness has to do with where the clinician starts the story,” says Murray.

For more information about the self-management study and other CREST.BD studies, visit www.crestbd.ca