Bipolar Mania and Medication Noncompliance: A Peculiar Treatment Challenge

One of the most significant challenges I face as a pharmatherapist is getting my bipolar clients to continue taking their medications as prescribed. More often than not, the culprit driving inconsistent usage patterns is the thrilling and invigorating manic “high.”

The manic phase of bipolar disorder carries a peculiar treatment challenge that most other mental disorders do not: Because mania is a desirable and enjoyable state for many, if not most patients, medication noncompliance is a particular hazard during these manic episodes. Repeatedly starting and discontinuing mood stabilizers results in erratic blood levels of these medications and a subsequent decrease in their overall effectiveness. This, in turn, can lead to an increased susceptibility for the occurrence of future episodes, a progressive worsening of symptoms and a heightened mortality risk. Clinicians should continually emphasize the serious risks of noncompliance with these patients and focus on coaching them to take these medications as prescribed.

Enlisting the assistance and cooperation of the bipolar client’s family members can prove to be a significant asset toward gaining medication compliance. Family members are our de facto healthcare specialists and are too infrequently utilized by prescribers and therapists as sources of information regarding the client’s progress (or lack thereof). They are often first to recognize the warning signs of symptom reemergence and can serve as our first-line allies in getting their de-compensating, medication noncompliant bipolar loved one back on the road toward progress.

Medicating Pediatric Bipolar Disorder: Challenges and Concerns

There’s little doubt that the diagnosis of childhood-onset bipolar disorder is on the rise. Office visits by children diagnosed with bipolar disorder multiplied 40-fold from 1994-2003. Disagreements abound as to what this means. Some researchers view the trend as a sign of progress: A disorder that has long gone undiagnosed in children is now being better screened and treated. Others, however, are more skeptical; they perceive the trend to be an example of gross over-diagnosis.

In truth, bipolar disorder is quite difficult to diagnose in children, and the presentation of childhood mania differs dramatically from adults. Children in the manic phase of the disorder tend toward extreme agitation and destructive outbursts, as opposed to the euphoria more common among adults.

The most widely used medications in the treatment of pediatric bipolar disorder are lithium and Depakote. Although studies confirm the effectiveness of these medications, their safety is questionable due to the life-long nature of bipolar disorder. Long term lithium use is linked to weight gain, acne, tremors and kidney dysfunction. Prolonged Depakote use is associated with pancreatitis and liver failure. Both medications require stringent blood-level monitoring. The bottom line: The benefit-vs.-risk of medicating childhood-onset bipolar disorder is a considerable concern.

Bipolar Disorder vs. ADHD: The Quick and Dirty

Irritability, frustration intolerance, aggression and inattentiveness are present in both disorders.

Did I miss anything? What are your experiences when it comes to differentiating Bipolar disorder and ADHD?