Lecture Outline:

• Current options and future thinking
• Research studies on new bipolar treatments
• The role of psychotherapy

Editor's Note: the following is a summary of a lecture given by Dr. Po Wong, Assoc. Professor of Psychiatry and senior research scientist at the Stanford University School of Medicine. Direct quotes will be indicated with quotation marks; any other text is paraphrase based on Dr. Wong's words.

We think of bipolar disorder in terms of episodes - manic episodes and depressive episodes. Therefore, much of the treatment available for bipolar disorder has been targeted at treating these acute episodes. Unfortunately, this approach has left a lack of available options for treating bipolar depression. There are many more options (for example, all the second-generation antipsychotics) for treating acute mania than there are for bipolar depression or bipolar maintenance therapy.

However, what Dr. Wong described as the standard course for bipolar disorder makes it clear that we need to alter our treatment priorities. Bipolar disorder tends to worsen with age in individuals without maintenance treatment, meaning shorter wellness periods, and longer, more severe episodes. Moreover, bipolar symptoms are predominantly depressive; however, we still don't have very many options to help people in a bipolar depression.

There are three ways to potentially think about treating bipolar disorder:

1. separate treatments for manic episodes and depressive episodes as they occur
2. stabilize mood first, and then treat lingering depression
3. overall stabilization - treat mania and depression together

This last option, according to Dr. Wong, is where current thinking in psychiatry is progressing. The goal is to be able to stabilize mood from both "above" (mania) and "below" (depression), not just one or the other.

Current research for bipolar disorder treatments

Dr. Wong cited several research studies that are moving bipolar treatment in new directions. For example:

• Research is looking at treating "mixed states" - episodes that have symptoms of both depression and mania (for example, depression with some irritability, agitation, and insomnia). One current study is examining the effectiveness of Seroquel (quetiapine) for treating such mixed states, which are not as uncommon in bipolar disorder patients as previously thought. While we still think of bipolar disorder as being separated into episodes interspersed between asymptomatic periods, research is showing that more and more people with bipolar disorder are not actually completely asymptomatic between episodes; instead, they are in some kind of a mixed state (for example, dysphoric hypomania).
• Research is examining medication options for treating bipolar depression. One option being studied is adding divalproex as an adjunct to mood stabilizers. Another study is looking at using bifeprunox, a new antipsychotic not yet available to the public, for treating bipolar depression.
• Research is looking at treatment of "subsyndromal episodes" - that is, treating preliminary symptoms that appear in high-risk populations, in hopes of preventing a full-blown episode. This is early-intervention for bipolar disorder.

The Role of Psychotherapy

Although psychotherapy (or "talk therapy") has long been anecdotally praised for its importance in treating affective disorders, scientific studies are now coming back with the evidence that these sorts of interventions are truly effective. Two specific therapies that Dr. Wong mentioned have been particularly useful for bipolar disorder are family-focused therapy and cognitive-behavioral therapy. Research is also looking at the possibility of dialectical behavioral therapy for bipolar disorder.