In this post, I highlight some of the differences between DSM and ICD and let you know where you can find treatment guidelines for bipolar disorder published in the US and UK, so you can check them out for yourself.

Comparing DSM and ICD

The big difference between DSM and ICD is that ICD does not use the classifications Bipolar I, Bipolar II, Cyclothymic Disorder, or Bipolar Disorder Not Otherwise Specified (NOS), which is called Bipolar Disorder Not Elsewhere Classified (NEC) in DSM-V. Instead, ICD has a single classification called Bipolar Affective Disorder which it breaks down into subgroups based on symptoms of the current episode:

• Bipolar affective disorder, current episode hypomanic
• Bipolar affective disorder, current episode manic without psychotic symptoms
• Bipolar affective disorder, current episode manic with psychotic symptoms
• With mood-congruent psychotic symptoms
• With mood-incongruent psychotic symptoms
• Bipolar affective disorder, current episode mild or moderate depression
• Without somatic syndrome
• With somatic syndrome
• Bipolar affective disorder, current episode severe depression without psychotic symptoms
• Bipolar affective disorder, current episode severe depression with psychotic symptoms
• With mood-congruent psychotic symptoms
• With mood-incongruent psychotic symptoms
• Bipolar affective disorder, current episode mixed
• Bipolar affective disorder, currently in remission
• Other bipolar affective disorders
• Bipolar affective disorder, unspecified

DSM is similar in that in addition to the Bipolar Disorder I, II, NOS, and Cyclothymic categories, it provides diagnostic criteria for subcategories where relevant. For example, the section on Bipolar I Disorder lists separate diagnostic criteria for the following:

• Diagnostic Criteria for Bipolar I Disorder, Single Manic Episode
• Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Hypomanic
• Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Manic
• Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Mixed
• Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Depressed
• Diagnostic Criteria for Bipolar I Disorder, Most Recent Episode Unspecified

According to DSM-IV, the APA and WHO work closely together to ensure consistency between DSM and ICD:

Those preparing ICD-10 and DSM-IV have worked closely to coordinate their efforts, resulting in much mutual influence. ICD-10 consists of an official coding system and other related clinical research documents and instruments. The codes and term provided in DSM-IV are fully compatible with both ICD-9-CM and ICD-10. … The many consultations between the developers of DSM-IV and ICD-10 (which were facilitated by NIMH, NIDA, and NIAAA) were enormously useful in increasing the congruence and reducing meaningless differences in wording between the two systems.

Finding Bipolar Treatment Guidelines in the US and UK

In both the US and UK, you can find treatment guidelines for bipolar disorder, and in both countries, the recommended treatment guidelines vary based on the current episode a person is experiencing. In other words, treatment depends on whether a person is experiencing acute mania or hypomania, depression, psychoses, and so on.

Bipolar Treatment Guidelines in the US

The American Psychiatric Association’s bipolar treatment guidelines available online are relatively old (2002) and do not reflect the latest research in treatment options:

• Practice Guideline for the Treatment of Patients With Bipolar Disorder Second Edition
• Treating Bipolar Disorder: A Quick Reference Guide which presents the basics in a more accessible format

From 2001 to 2007, the National Institute of Mental Health (NIMH) conducted a study entitled “Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD)” — a long-term study of the effectiveness of current treatments for bipolar disorder including medications and psychosocial therapies. Evidence from this and other studies have influenced the way we approach the treatment of bipolar disorder, but have not, as yet, been reflected in any official publication of treatment guidelines.

Bipolar Treatment Guidelines in the UK

In the UK, the National Institute for Health and Clinical Excellence’s (NICE) published its guide to The management of bipolar disorder in adults, children and adolescents, in primary and secondary care (or check out its Quick Reference Guide). These guidelines were published in 2006.

Although the NICE treatment guidelines are similar to the APA’s guidelines, the NICE publications are more detailed and presented in a more accessible format, complete with decision tree flow charts and quick reference tables of important items to monitor in the ongoing treatment with different medications.

Share Your Insights

We would like to know what you think. Check out the guidelines published by the APA or its Quick Reference Guide and compare it to the NICE guidelines or Quick Reference Guide. Which do you find most useful?

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We were just looking for ways I could help, and that was an easy one. The other day, however, I came across an article by Ginnie Graham published on the Tulsa World website entitled “Bill-paying program helps mentally ill avoid becoming homeless,” and it made me realize that missed payments could lead to major problems for those with bipolar who don’t have someone who can take on that task, especially during a major mood episode or during recovery.

It’s great that Volunteers of America has stepped up to the plate to help those with bipolar and other mental illnesses address this challenge in certain communities. If you need help with making bill payments, medication management, or dealing with other activities of daily living, you may want to visit Volunteers of America, find the local office nearest you, and ask about available programs.

Also, we’d like to know who manages your daily finances? Do you manage your finances on your own, does someone else in the household manage the family finances, or do you have outside help? Do any organizations in your community offer help for the “activities of daily living?” If you could get help for one daily activity you have trouble managing on your own, what would it be?

Bill paying photo available from Shutterstock.

I’ve been to several NAMI support group meetings in Lafayette (and Indianapolis when we lived there), and I’ve found them to be very helpful. Even when everything is going well in my family and I don’t really need the support, spending time with others who’ve struggled with mental illness in their families and having an opportunity to help someone by sharing the knowledge I’ve acquired over the years feels great.

The meetings always start and end on time, and the facilitators have been very good about giving everyone a chance to speak and not allowing any attendee to monopolize the meeting.

I always figured it was just good luck that I had attended meetings with outstanding group facilitators, but over the weekend, I discovered that these excellent group facilitators had some help. NAMI provides its support group facilitators an agenda, strategies, and processes to ensure that the meetings are run properly and that everyone leaves feeling better than when they arrived.

Meetings begin with a review of NAMI’s guiding principles and the group rules that everyone agrees to follow. Attendees are then invited (not required) to share their stories, but have a time limit of 1-3 minutes and are encouraged to end by describing their current situation/condition as of today. (The goal is to avoid getting mired in the past and look for positive, practical ways to deal with current situations.)

After story time is group discussion – the facilitator generally prioritizes issues brought up during the sharing of stories and, if someone in the group needs and (more importantly) expresses a desire to hear what the group has to say, group members share their wisdom. Near the end of the meeting, the facilitator closes the meeting with a positive message or asks members to share something positive – maybe a goal they have or something they’re going to do for themselves between now and the next meeting.

If you’ve been to a NAMI support group or other mental-illness support group, please share your experience without breaching confidentiality. Did you find the experience helpful or not? If you found it helpful, what was most helpful about it? If you found the group unhelpful, was there something about it that turned you off?

If you haven’t been to a NAMI support group meeting – NAMI Connection (for consumers), NAMI Family-to-Family (for family and friends), or a mixed group of consumers, family, and friends, please find a NAMI support group near you, attend a meeting, and let us know what you think. To find a support group meeting, first track down your Local NAMI Affiliate, and then call or visit its website. Your comments will help us as we start our support group.

To find a local DBSA (Depression and Bipolar Support Alliance) chapter, use the DBSA Locator.

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Maggie asks…

I’ve messed up my meds by going cold turkey due to difficulties with insurance and lack of funds. Now I have to wait for the mail order prescription and I have not had any lithium for a month. This week I started noticing some of my early signs of my hypomania returning. Tonight, I’m not sleeping.

I don’t have a psychiatrist right now since my insurance wouldn’t cover his $300 office visits. I’ve just started with a new primary MD.

What are my options until I get the meds and get them to a therapeutic level? I really want to sleep! I start struggling with anxiety, agitation, and irritability that can escalate to rage. I’m more than a little nervous at this stage. Can you advise?

Dr. Fink answers…

Your best option at this point may be to contact your primary care physician and explain your situation. Your doctor may be able to provide you with samples or a short-term prescription you can have filled at your local pharmacy to carry you through until your mail-order prescription arrives along with something for the short term to help you sleep.

Mail-order prescriptions often result in delays. The best approach is to plan ahead, if possible, to avoid having to go without your medications. Before requesting a mail-order prescription from your doctor, find out from the mail-order prescription provider how long it typically takes from the time you or your doctor submits the prescription to the time you receive your medication. Plan accordingly. Your doctor may be able to provide you with samples or a short-term prescription to hold you over until your mail-order prescription arrives.

If that advice is too late to do you any good, consult your doctor, local pharmacist, or health insurance provider to explore possible short-term solutions.

Mail-order prescriptions are a great way to save a substantial amount of money on medications, but Maggie’s question really reveals the potential downside.

Mailboxes photo available from Shutterstock.

As a husband of a wife with bipolar, I realize that bipolar has taken many things from my wife and our family, but it has also transformed us in some positive ways. After seeing my wife courageously wage her many battles with bipolar, often with little understanding or support from the rest of us, I have gained a deeper respect and appreciation of her. I believe our relationship is stronger as a result of what we’ve experienced. We have seen the best and the worst in and of each other and developed a deeper sense of intimacy. Problems we used to consider significant seem trivial compared to what we have overcome.

My wife has done a fantastic job of adapting to her new reality. She takes her medications, keeps her appointments with her doctor and therapist, and has found less stressful work opportunities that enable her to use her education and expertise. She has even taken on a role of advocacy, speaking to our NAMI class about her struggles with bipolar and her journey to recovery. We had to let go of the past, which hasn’t been easy. Through the process, we’ve all experienced some personal growth – our own personal transformations.

We would like to read some stories of recovery, both from those with bipolar disorder and their loved ones. What did you find most helpful in adapting to your new reality? What did you find least helpful? What have you lost and gained from bipolar disorder? What has changed for you personally, professionally, emotionally, or spiritually? How have your dreams or visions of the future changed? You don’t have to limit your responses to these questions; feel free to share any insights you have about how bipolar disorder has transformed you and your situation.

Reaching hands photo available from Shutterstock.

• Thyroid malfunction
• Hormone imbalances
• Diabetes
• Mononucleosis
• Chronic Fatigue Syndrome (CFS)
• Lupus
• Cancer
• Cushing’s Syndrome
• Hepatitis
• HIV/AIDS
• Rheumatoid arthritis
• Medication or other substances that could have triggered symptoms

Sometimes we wonder whether doctors, including psychiatrists, follow the proper protocol in diagnosing bipolar disorder. Before diagnosing you and prescribing any medication, did your doctor perform a physical exam or refer you to an internist/specialist and/or order various tests to rule out medical issues that may have been causing symptoms of mania or depression?

What was the diagnostic process like for you?

Doctor image available from Shutterstock.

Maggie asks…

My 21-year-old was diagnosed with Bipolar I after an extreme manic episode (he was hospitalized). It was a long and difficult few months (awful treatment, bouncing around to different doctors, etc.) during which his mania tapered down, and then turned into a deep black depression, which he is out of now.

No one can persuade him to take medication. Now that he’s feeling normal again, he seems to think that he doesn’t need medication. So no meds, no therapy, no treatment of any kind. And I am quite sure he’s self-medicating with “other” substances. (He lives with us – me/mom, younger brother, step-father.)

Advice?

Dr. Fink answers…

Based on your description of what your son experienced so far, it’s understandable that he’s reluctant to take medications or seek other forms of therapy. He was hospitalized, which can be dehumanizing; he received inconsistent treatment and bounced around to several doctors, which can be frustrating and discouraging; and then he went from mania to a deep depression, which he may attribute to the treatment he received.

Difficulty with insight into one’s illness is a common component of bipolar disorder in many who suffer with it, but especially in adolescents and younger adults whose brains are still managing numerous developmental tasks and are not particularly skilled at self awareness and self regulation.

Communication is key, but communicating effectively can be very challenging in emotionally charged situations. Confrontation may do more harm than good. You and the rest of the family would probably do well to get some sort of therapy to help you understand what your ill son may be going through and how he’s likely responding internally to what he’s experiencing. Your family may also benefit from learning communications skills that are proven to be effective in situations like this. NAMI Family-to-Family is an excellent resource that has the added benefit of expanding your support network with people who’ve had similar experiences.

You may want to start by re-opening the channels of communication:

1. Use “I” statements to express how you feel and what you’re most concerned about.
2. Ask your son open-ended questions and really listen to the answers without judgment. For example, after describing one of your concerns, ask him how he feels about it or if he has any ideas on how to alleviate the concern. Overall talk less and listen more.
3. Try to empathize with your son by asking follow-up questions to clarify how he feels and then tell him that you understand why he might feel that way. Try to see it from his perspective.
4. Set boundaries. If your son is self-medicating, you don’t have to accept that. If you know your son is doing something that’s unacceptable, use an “I” statement to let him know; for example, “I won’t allow you to stay here when you’re drinking alcohol.” Or “I will have to call the police if you continue using illegal substances.”
5. Work toward an acceptance of the reality that you cannot control this situation and strive to regulate your own emotional responses to this. He will have to work through a lot on his own, and you will not be able to make him move faster or in a different direction, no matter what you say or do.

Also, as you approach problems, try to pick one problem at a time. Your question describes at least four problems:

• Poor treatment from doctors/therapists.
• Poor understanding of his illness.
• Medication non-compliance.
• Self-medicating.

Choose one. For example, you can’t do anything about the treatment your son received in the past, but it might help your son to hear that this is, unfortunately, a common experience. Most people with bipolar disorder bounce around the system for several years before receiving an accurate diagnosis and effective treatment. When people eventually do receive effective treatment, they feel much better and are better equipped to regain control of their lives.

Also realize that this is a journey for everyone involved and not everyone proceeds along the same path at the same speed. While you may have accepted the diagnosis, it may take your son additional time to accept it and learn to deal with it, and that process usually involves trial and error.

Continue to seek out good help and support for your son and for yourselves – having a network of partners and support people on this journey is a key component to getting through it as successfully as possible.

Photo by Kevin N. Murphy, available under a Creative Commons attribution license.

I sighed. This was just another in a long line of these kinds of episodes, and I was pretty sure it would resolve on its own with my relative hunkering down in his house for a while until he was sure the police had gone away.

But then I decided to go see him as soon as I could, because he just turned 80 and I began to wonder if I should be worried that in addition to his bipolar disorder he might not be showing some signs of dementia. I wasn’t sure about the overlap between bipolar and dementia. We know from studies that people with bipolar disorder often have cognitive problems – memory, executive function, and other thinking problems. But does this put them at higher risk for memory problems in old age?

My visit with my relative was, thankfully, uneventful. He was physically fit and taking care of himself as well as he usually does. His rants and wild conversations were about the same as always. The police issue had subsided, as I had expected it would. But I was still curious about this connection between bipolar and dementia.

Unfortunately, the research is limited. An article from the journal Psychogeriatrics, by Masouy et al, published in March 2011, suggests that long-term studies are needed to determine the course of cognitive impairments in bipolar disorder – to see if they are stable or more likely to progress with age. But there are few studies to date that look at this at all.

Another study from the British Journal of Psychiatry in May 2011, by Young, mentions studies suggesting that lithium may be protective against dementia. He says that Alzheimer’s rates are relatively reduced in bipolar patients taking lithium. A study looking specifically at lithium showed that lithium seemed to reduce progression of minimal cognitive impairment. (This seems kind of counter-intuitive to me, because lithium often creates a sensation of cognitive clouding in people who take it, but it at least one study has found that lithium increases brain volume in the hippocampus – a brain region that is very important in mood and emotions. See my previous post, “Lithium Increased Brain Volume in Patients with Bipolar Disorder.”)

This seems to be an area with little research and less understanding, but one that will become more important as more and more people with bipolar disorder live into older years.

Gwen writes…

My son was diagnosed with bipolar disorder in the 5th grade. He is now about to turn 21. He cuts and he cannot hold a job or finish a class at the local community college.

His bipolar disorder seems to be more depression-based than manic, or maybe the lithium and Abilify he takes helps the mania but doesn’t treat the depression.

Are there any medications recently developed which can help the depression? I know there is a study underway looking at this problem, but I can’t find out much about it. Sam took the initial test and they said that he qualified, but is no longer interested in participating in the research.

I also know that lithium has long-term effects on the kidneys and this concerns me.

Do you have any suggestions as to resources I can tap to help Sam? His doctor doesn’t really seem to care about looking at alternatives. He hasn’t actually attempted suicide yet, so the doctor seems happy with the status quo. I think we can do better, but don’t know where to turn.

Any suggestions you have would be helpful.

Gwen

Dr. Fink answers…

This email raises a number of questions that are common to many families I have worked with over the years:

• This young man’s diagnosis of bipolar disorder was made over 10 years ago, during a time when there was a lot of over-diagnosis of bipolar disorder in children. As Gwen indicates, her son seems to be showing more depression than mania.Studies are now indicating that many children with mood regulation problems – severe rages and chronically irritable mood – are more likely to be diagnosed with depression and/or anxiety as adults, than bipolar disorder.Since I don’t know the details, I can’t comment on this case in particular, but given the complexities of this diagnosis in children and the debates about it, a family in this situation may want to consider a completely fresh evaluation to carefully review the diagnosis and treatment plan.
• The National Institute of Mental Health (NIMH) could be an extremely valuable resource. Many of the best studies about childhood bipolar disorder are being done there. Dr. Ellen Liebenluft is one of the most respected researchers in the field, and her group may be doing studies that could be appropriate in this situation.But even if there isn’t a study that this young man or other young people would fit into, (or if the young person has no interest in participating in the research as Gwen indicates in her letter) I would encourage families to at least seek out a second opinion from a psychiatrist who is well versed in this area – a child psychiatrist who also works with young adults would be most helpful I think.
• Treating depression in bipolar disorder is often the most difficult and challenging component of the disorder – and choosing medications to try can be very tricky. Some of the choices may change if the diagnosis changes and certainly, even if he truly has bipolar, treatment of the depressive symptoms is going to be an important conversation, since he seems to be having trouble functioning because of these symptoms.There are a variety of options – I cannot comment in particular because I haven’t done an evaluation of this young man – but I encourage patients and families to seek out a different perspective if they feel the current doctor is not attending to important symptoms.
• Gwen doesn’t mention if her son is in therapy – but this is also going to be a crucial part of long term treatment/management of the kinds of difficulties he is living with. In particular, if he is self harming, connecting with a therapist or group who are specialty trained in Dialectical Behavioral Therapy (DBT) may be valuable.This is a skills-based model, a subtype of Cognitive Behavioral Therapy (CBT), and has an excellent track record of helping people with long-term difficulties regulate mood and behavior. Getting a young person to engage in treatment may be difficult, but it is certainly an option to explore.
• Families benefit from support from other families living with these issues. NAMI is a terrific organization that provides information, networking, training, and family-to-family emotional support that is incredibly helpful to those living with or caring for people with mental illness. I strongly encourage families to look into this or other support organizations as part of managing mood disorders for the long term.

Photo by Alexander Konovalenko, available under a Creative Commons attribution license.

Atypical antipsychotics, for example, have a nasty reputation for causing significant weight gain. Many psychotropic medications have negative sexual side effects, including diminished libido and an inability to climax. Some people, especially those who have experienced hypomania feel as though the medications flat line them – as we say in Bipolar Disorder For Dummies, “Normal is boring.”

As we discussed this in Class 6, it struck me that in some ways, anti-manic medications, including lithium, Depakote, and the atypical antipsychotics are like Kryptonite to Superman. If, in hypomania, you feel energized, creative, powerful, and incredibly sexy, of course you’re going to hesitate to take anything that threatens to ruin those positive feelings… at least until you experience your first full blown manic episode.

I’m not encouraging anyone to stop their medications. The point of all of this in the NAMI class is that it’s important to recognize not only the medications and their side effects, but also the emotional responses to medications… which are present whether we’re talking about psychotropic or non-psychotropic medications.

Acknowledging and discussing these issues is an important first step toward adherence:

1. Empathize. Admit that the medication choices our loved ones are presented with are often lousy.
2. Discuss these issues with our loved one – get it out in the open.
3. Work with the doctor to find a treatment package that maximizes symptom reduction and minimizes undesirable side effects.

Class 6 also provides concrete advice on how to help your loved one move from medication rejection to grudging acceptance to medication adherence, but you’ll need to take the Family-to-Family course to find out. NAMI also offers a Peer-to-Peer course for consumers. Go to NAMI.org, find your local affiliate, and contact them to register for an upcoming course.

In Class 6, we discussed the cost-benefit analysis that our loved ones with brain disorders often engage in to determine what, for them, is the lesser of two evils. We would like to hear about your experience. What are some of the treatment options you or your loved one has had to wrestle with, what choices were ultimately made, and why?

Photo by Mark and Allegra Jarosky-Biava, available under a Creative Commons attribution license.