Bipolar disorder

Someone is said to suffer from bipolar disorder when their mood changes exceed thresholds considered normal.

Bipolar suffering

Many bipolar individuals are affected by psychological pain taking a toll on their daily lives and the lives of their loved ones and altering their condition and fate. Sadness, depression, anxiety, insomnia, fatigue, alternating with exhilaration, euphoria, irritability take turns, sometimes bringing about confusion. This suffering, in its most typical forms, pushes the individual to see everything negatively and pushes him to hopelessness and loss of confidence.

Despite advances in medicine, bipolar suffering is often misunderstood or misdiagnosed. Certain medication (such as antidepressants, anxiolytics, sleeping pills, etc.) provide some relief, but at the real risk of addiction lasting for years and inefficacy. There are also side effects leading to weight gain or weight loss, killing sexuality or sedating too much.

The entourage and relatives of bipolar patients often suffer in silence, live in despair or resignation because they have already tried everything, without achieving long-lasting mood stability. This psychiatric spiral gradually destroys the capital of health and the hope of getting one’s life back… the life before psychiatry.

But, THE RETURN TO A NORMAL LIFE IS ALWAYS POSSIBLE!!!

This section of the site guides towards:

  • a simplified and clear explanation of the bipolar disorder phenomenon,
  • the search for a DIAGNOSIS,
  • presenting optimal solutions,
  • defining the results to be expected,
  • Presentation of monitoring tools and
  • Psychoeducation of the patient and his entourage.

Essential questions for Bipolar disorder

1. Should you accept living with bipolar disease?

– No, you should not accept living with this disease, but conquer it instead.

2. Are the results obtained by current psychiatry optimistic or pessimistic?

– To answer this question, we must define ….

3. What does the achievement of optimistic/ favorable results depend on?

– It depends on: 

  • the degree of involvement of the three parties concerned (the patient, their relatives and the medical personnel),
  • the intervention technique (therapeutic conduct and treatment), and
  • tools used for diagnosis and parameters measurement.

4. Is it normal for mood issues to persist, despite treatment and therapeutic measures?

– No, it is not normal!

Today, knowledge advancement allows us to state that a correct and lasting stability of mood is possible. If the therapeutic intervention measures are adapted and comprehensive, the patient should progress towards obvious improvement, a normal life and autonomy.

5. Why do mood problems persist despite treatment and therapeutic measures?

Mood problems today are simple to solve, provided that the right steps are taken rigorously. This means that the mood disorder (bipolar and depression) takes advantage of any possible mistakes. Solutions are similar to the links in a chain, one weak link can compromise the whole cohesion, and therefore the outcome.

An adapted daily conduct remains essential in order to maintain long-term stability. This is why a series of measures must be put in place, with the patient’s involvement and that of their entourage, in order to eliminate all pathological fluctuations in mood.

Difficulties in overcoming Bipolar disorder

In Switzerland, problems related to mental suffering cost 11 billion CHF every year. Despite this expenditure and medical advances, a series of difficulties make therapeutic interventions ineffective, prolong suffering and aggravate the patient’s situation while restricting therapeutic solutions.

I have identified three groups of difficulties to be dealt with in order to overcome bipolar disorder and depression:

  • the patient’s lack of understanding (disinterest, indifference or ignorance) about their illness and possible solutions,
  • their resulting passive and detached attitude, or lack of involvement in decisions affecting them,
  • a lack of clinical observation done by the patient (and those around them) and the absence of tools to measure and verify results.

And when the expected results are negative (relapse, depression, anxiety, insomnia, etc.), disappointment and resignation set in. Bipolar disorder and depression thus create a vicious circle that destroys life, takes away all hope and maintains the suffering.

It is precisely this vicious circle that needs to be broken.

It also requires courage to announce goals and individualized solutions.

Solutions to overcome Bipolar disorder

Bipolar disorder must be conquered by an efficient and effective team made up of three players: the patient, their entourage and the caregivers. The involvement of the three parties forms an integrated system of care called: “the bipolar convention”.

It engages the three parties by assigning each of them the following three roles and objectives:

  • gaining and sharing understanding of the disease, specific problems and possible solutions,
  • cultivating an active attitude and participating in therapeutic decisions,
  • maintaining permanent concern about observing and measuring the clinical evolution of the patient (by means of tools).

Our method is called BIPOLAR THERAPY (NEOPsy) which represents a brand-new approach that applies all efforts and effective techniques for: patient empowerment, disease control and the return to normal life.

Understanding

Understand = the COMPREHENSION chain

Every person needs to understand the meaning of their life, their problems, their efforts. In the case of Bipolar disorder, the patient needs to understand what is happening to him or her, why and especially what to do to get out of it.

Our approach is fighting Bipolar disorder instead of accepting it and living with it. This optimistic approach is essential for good results.

There is a proverb that says that “an enemy visiting a sick person is worse than the disease itself”. Bipolar disorder has three friends:

  • misunderstanding,
  • poor intervention and
  • bad results.

In order to defeat Bipolar disorder, we must annihilate these three friends.

Treating Bipolar disorder is similar to the effort of pulling the patient out of psychiatry with three chains and each one must resist. If a single link in a chain doesn’t hold, in the form of a tiny mistake, the chain can break, causing the whole system to collapse from there and the disease takes the upper hand! This type of error explains the alternance of episodes and relapses as an incessant struggle between imperfect solutions and a much stronger disease.

In reality, the unfavorable results are the consequence of one or more weak links in an ineffective therapeutic intervention. It is therefore necessary to understand that Bipolar disorder benefits from every error in the three therapeutic chains. We must therefore ask ourselves: what are these links? They are multiple.

In order to obtain good results, the therapeutic approach must pay attention to each link. If the right conditions are met, a virtuous spiral will be born, which is necessary for the patient’s improvement.

In the treatment of Bipolar disorder, our objectives are:

  • improvement and lasting mood stability,
  • autonomy,
  • release from psychiatry and
  • returning to a normal life.

This makes it necessary for us to verify the solidity of each link and detect any possible dysfunctions: at the level of the implemented means, the treatment, the entourage, the patient’s involvement, the psychiatrist, the diagnosis, the evaluation of results, etc?

This questioning of each parameter enables the analysis of the cause for the failure. In this section, we are therefore focusing on the chain of UNDERSTANDING of the phenomena of the Bipolar disorder, for an understanding that is accessible to all.

       The patient, but also their relatives, need an enlightened understanding of the disease and possible solutions. In clinical reality, this rarely happens. I have met far too many patients with their loved ones, lost in the ambiguity of information, asking the same questions over and over again: what is Bipolar disorder? Am I bipolar? How do I make the diagnosis? How long does it take to reach the right diagnosis? Why am I sick? What should I do? What are the solutions? Can I get out of this? Is my treatment accurate? Should I still wait for the benefits of my treatment? I feel too many side effects, is that normal? I don’t know my treatment and I don’t know what it’s for? Can I manage without medication? What kind of psychotherapy is best for me? Is my life ruined? What can I do?

Weak links in the understanding chain

Despite the progress in medicine, why are we still unable to explain the phenomena of Bipolar disorder in a simply and clearly?

Far too many patients and their loved ones feel lost and helpless in the face of Bipolar disorder. They don’t know whether this disease is serious or not. They really don’t know what to do other than seek a therapist, confide in them and wait…

Let’s face the reality of psychiatry today:

  • the essential aspects of the disease, treatment and goals to be expected are not sufficiently explained,
  • there is little involvement of the family and friends, and they are often excluded from the consultation sessions,
  • Patients or relatives seek information online, on specialised sites or forums, but this information is often convoluted, incomplete, subjective and inaccurate, often in the form of testimonials or duplication of unclear scientific texts,
  • current (classical) psychiatry is imprecise, struggling to explain the phenomena of bipolar suffering simply and clearly, it actually only lists the symptoms, without any further explanation.

Under these conditions, people simply ask themselves what is bipolar disorder? More often than not, the answers send them to two different lists of symptoms: one for the depressive phase and one for the positive phase, without explaining why these manifestations occur, nor from what intensity, frequency, and/or quantity one declares the disease installed.

Many patients with mild symptoms thus remain undiagnosed, while continuing to feel bad.

      In the case of depression, the explanations given far too often refer to the emotional, social or professional context. This is often not true! As we will see, there are two types of causes that produce depression, which presents itself with the same symptoms. The cause and the mechanisms must be precisely identified in order to engage precise and effective solutions.

Today, the diagnosis of Bipolar disorder is defined by a number of clinical criteria listed in diagnostic manuals (the DSM 5 and the ICD 10). These criteria have been retained following statistical studies, they condense the essential bipolar aspects, without explaining their emergence.

Moreover, some criteria are contradictory, for example, for the diagnosis of depression there are two diagnostic criteria:

  • ” significant weight loss or gain … or decrease or increase in appetite,
  • insomnia or hypersomnia (sleeping too much)”.

These two aspects are very real, but the diagnostic usefulness is limited without an accurate understanding. The patient is asked if he or they lost or gained 2-4 kg (5%)? Two answers are possible: yes, I have lost weight, or yes, I have gained weight. To the question of sleep: yes, I get little sleep, or yes, I sleep too much. We all know normal people with weight or sleep problems, who are not bipolar.

To the question: what is Bipolar disorder? Doctors rely on diagnostic manuals and refer patients and their families to the same problematic sources of information. Internet searches get the same answers, based on the same criteria from the diagnostic manuals without further explanation. This limited theoretical basis is a source of diagnostic problems. It therefore affects the nature of therapeutic care interventions and especially their adverse outcomes.

Thus, in 1994, a follow-up study by the National Manicodepressive Diseases Association (NDMDA) found that one third of bipolar patients followed-up for ten years were still not well diagnosed. Of these, more than half were already seeing more than three physicians before reaching the correct diagnosis. Six years later, in 2000, the same study found similar results: 69% of the patients were misdiagnosed and only 20% of them were correctly diagnosed in their first year of illness, while 35% of the patients were diagnosed 10 years later. For 67% of the latter, the diagnostic difficulty was due to a poor understanding of bipolar disorder. The conclusion of this study: in order to receive a correct diagnosis, a bipolar patient must consult an average of 4 doctors, after having been misdiagnosed 3 times before.

The conclusion that emerges from this reality: the definition of bipolar disorder does not benefit from an easy, simple and accessible theoretical basis for understanding. This provides a basis for unsatisfactory diagnoses and results. Unsatisfactory results include the presence or persistence of psychological suffering with psychosocial and family consequences, despite all therapeutic interventions.

What to do in this situation? In order to remedy these aspects and to make the essential information accessible and understandable, bipolar phenomena must be explained in another (new) way.

Mood and mood disorder

What is mood and bipolar disorder?

Mood is defined as a global and lasting emotion that colors the perception of the world, being the basis of our vital perceptions, actions and projects. Mood has two extremes: a positive pole, marked by a state of psychological excitement, and a negative (depressed pole), marked by sadness. Bipolar disorder, formerly known as manic-depressive psychosis, manifests itself by a succession of depressive or manic episodes, with normal periods without symptoms. This disorder determines an intermittent and periodic disruption of all neuropsychic functions.

 

This drawing illustrates the dynamics of normal mood, with its upwards (towards the positive pole) and downwards fluctuations (towards the negative pole). These fluctuations are normal, linked to our emotional reactions of daily adaptation. They may last for a few moments, minutes, hours, or days, depending on the impact of the life event on the person.

A drop in mood (towards the negative pole) can be triggered by the appearance of a problem, an uncomfortable situation or indignation. It is a negative feeling of frustration, dissatisfaction or disappointment. The intensity of negative emotional reactions for normal mood should not exceed the negative lower limit.

Conversely, an increase in mood (towards the positive pole) can be triggered by solving a problem, small personal success or a pleasant situation. It manifests itself as a positive feeling of satisfaction, pleasure or happiness. The intensity of normal positive emotional reactions should not exceed the positive upper limit.

 Normal mood fluctuations gravitate towards the neutral polarity level (the zero level) and do not exceed so-called normal limits.

The upper and lower limits represent the extreme negative and positive limits of mood intensity found in the general population. It is assumed that the mood of 95% of people do not exceed these two limits.

Importantly, normal mood has a bipolar nature, because it fluctuates between the two poles, hence its bipolar nature. Being bipolar is simply normal! Everyone has a bipolar mood, which means that everyone’s mood has ups and downs (according to a reactive emotional dynamics of daily adaptation). People who are considered “normal” have a bipolar mood, but not above and below the upper and lower limits.

 

This illustration shows that the mood fluctuations are above the normal upper and lower limit. The person experiences periods of sadness and excitement that are not normal. Their mood (always bipolar) is disturbed and abnormal because the upper or lower limits are exceeded.

  • Bipolar disorder thus refers to individuals who have mood swings that go beyond normal mood limits, whereas
  • Normal individuals have mood swings that do not exceed normal mood limits.

This original definition is fundamental, because it acknowledges our normal bipolar condition and allows us to formulate the central therapeutic goal in a simple way:

  • if a person has bipolar disorder, the goal will be to help them normalize their mood, so that their bipolar fluctuations start falling within normal limits. Thus, the person becomes normal again, meaning a normal bipolar person, like the rest of us.

For a correct diagnosis and treatment of bipolar disorder, identifying the cause of the disorder is of paramount importance because it will guide the intervention and influence the outcome.

Causes that disturb the mood

Mood can be disturbed by two types of causes:

  • either by a psychological cause (meaning a life event),
  • or by a biological cause (see explanation below).

Most people have a distorted view of the phenomenon of mood disorder.

In fact, most people imagine that depression is simply an expression of psychological malaise in reaction to an unfavorable situation in the present, the past or a conflict in the unconscious mind. They deem that the solution for the recovery from depression is to fight, mobilize, resist or resolve this unfavorable situation.

Mood is controlled or influenced by certain biological systems in our body (glands, nervous system, biochemical system, etc.). These systems work together in a dynamic equilibrium that ensures good adaptation to the environment. If this balance is affected, mood can fluctuate. For example, a decrease in thyroid hormones concentration (specific to hypothyroidism) leads to a state of depression. The same is true for mood fluctuations related to the menstrual cycle, childbirth or menopause.

Some medication can disrupt the biological systems and can also cause depression. Some toxic products (drugs, cannabis, etc.) are known to have the potential to disrupt mood (excitement or depression), etc. It is therefore important to remember that mood disorders can be triggered by the disruption of biological functioning.

Two major groups of causes therefore polarize mood beyond its normal limits – causes of a psychological nature and causes of a biological nature.

Knowing the nature (psychological or biological) of the causes of bipolar (mood) disorder is of paramount importance in guiding diagnosis, treatment and outcomes.

A misidentification of the nature of the cause of mood polarization has serious consequences on patients’ therapeutic progress.

Acting

There are several links in the “ACTING” chain, which must be strong and robust in order to overcome bipolar disorder. A single weak link is enough to compromise the intervention effort, because the disease takes advantage of any mistake.

We will analyze these links in order to rule out the weaknesses of an ineffective intervention. One should always keep in mind that the goal of any intervention is to achieve favorable outcomes (see definition of outcomes).

Stages of bipolar intervention.

Let’s also remember that ACTING is a team intervention. In this sense a simple principle applies, which reinforces and mutualizes efforts: the bipolar convention.

It is a question of forming a team made up of three parties, who must play their role and fulfil their obligations:

  • the caring part (the medical staff: the psychiatrist, the general practitioner, the psychologist, the nurse, the social worker, the educators, etc.),
  • the patient and
  • the entourage (relatives, friends, spouse, family, etc.).

Who does what?

The most important thing in this therapeutic approach is the active and involved attitude of the patient and their entourage. They must absolutely have a dynamic approach in understanding the phenomena, the diagnosis, and the possible solutions.

What does this proactive approach consist of?

 The patient and their entourage

First of all, they must feel free to ask questions in order to get informed. Indeed, in light of a good understanding, action gains in motivation, mobilization and efficiency. They can thus observe and monitor the patient’s clinical evolution parameters and communicate them to the doctor or other caregivers.

The patient and their family are thus responsible for feedback after the introduction of the treatment, to confirm the therapeutic improvement or not. They participate in the therapeutic decisions, as they are the ones who are directly affected by the treatment. For this reason, they must acquire the correct knowledge about the disease, the treatment and be able to analyze the results. And this is where action starts with a committed and involved attitude.

The doctor and the health care team

The physician is responsible for the diagnosis, identification of the causes of the disorder and effective treatment. He or she is also responsible for communicating and educating the patient and their entourage, i.e. informing them honestly, transparently and without taboos. He must make his decisions according to the patient and their entourage. It is also important to establish a close relationship with the other members of the medical team (psychologist, nurses, etc.). The healthcare team must follow the directions indicated by the doctor with humanity, support and accompany the patient and their family.

 Stages (links) in the bipolar intervention chain

  1. The exploration stage, which is supposed to collect information about the patient, and therefore information specific to the bipolar disorder,
  2. The diagnostic stage simply gives a name to the mood problem, in view of an optimistic resolution,
  3. The treatment (therapeutic intervention) stage, which is supposed to address the mood problem,
  4. The treatment effectiveness analysis stage should look at the quality of the results obtained at each stage,
  5. At the follow-up/monitoring stage, the patient and their family should observe and monitor the clinical course of the patient’s condition, using specific tools.

Diagnostic investigation

“Diagnostic exploration” means the anamnesis (chronological curriculum of problems, manifestations, events, causes and conditions, biography, different antecedents, family profile etc.).

This exploration is supposed to gather information about the patient, and therefore information pertaining to the bipolar disorder.

This step is critical and essential as it guides the therapeutic intervention. It is the main source of diagnostic errors or late diagnosis of bipolar disorder. This error stems from the fact that the diagnosis of bipolar disorder is based on the verification of a limited number of manifestations mentioned in the 2 lists of symptoms (taken from 2 diagnostic manuals ICD 10 and DSM 5): those for the negative phase (depressive) and those for the positive phase (hypo/manic).

Several tools have been developed for this purpose. The most widespread are :

  1. HCL 32 (or hypomania checklist) is a self-questionnaire designed by Angst,
  2. the MDQ (Mood Disorder Questionnaire) test proposed by Hirschfeld et al (2000),
  3. the Goldberg Bipolar Spectrum Screening Questionnaire, a tool I prefer.

A few more useful diagnostic tools:

  1. SAD-P (“screening assessment of depression-polarity” by SOLOMON D., LEON A., MASSER J. et al., 2006),
  2. the Young’s mania scale, or
  3. the Sachs index.

But, in principle, we need more information for a quick and correct diagnosis. Above all, the information sought must be essential and specific to bipolar disorder.

The objective of the exploration phase is to:

  • find specific bipolar information, as arguments to validate the diagnostic hypothesis;
  • reconstruct the chronological curriculum of the problems;
  • jointly validate (the doctor with the patient and the relatives) the elements found, and reconstruct the patient’s history;
  • jointly issue one or more diagnostic hypotheses for the presumed problems.

This exploration must be organized on 5 levels: biological, psycho-affective, cognitive, behavioral and psychosocial.

At this stage, rigor and precision are necessary. The broad involvement of those who can provide information is important, as each person can provide observations, testimonies or arguments.

The diagnosis

With the information gathered during the exploration stage, we can move on to the diagnostic formulation stage, which simply means that each problem is given a name. It’s not a label stuck on the patient’s forehead, it’s just the name of the problem waiting to be solved, in an optimistic way.

Diagnoses organize the intervention, so that problems are tackled and solved, without leaving any behind.

The initial stage of diagnosis involves three hypotheses:

  • the hypothesis of the cause of the problem;
  • the diagnostic hypothesis, which concerns the probable identification of a problem, and
  • the assumption of effective treatment, which must act on the cause to solve the problems and alleviate the symptoms.

Validation or invalidation of the assumptions is carried out at a later stage, during the analysis of the results obtained, after treatment.

If the results are favorable in the sense of a positive evolution or alleviation of symptoms, then we have confirmation that our diagnostic and causal hypotheses are correct, and that the therapeutic intervention is moving in the right direction. We must therefore continue.

If the results are unfavorable in the sense of an unfavorable evolution or if the symptoms persist, our diagnostic and causal hypotheses are not correct, and the intervention is not going in the right direction.

For example, if the patient has difficulties at work, the symptom is called “inability to work”, a diagnostic hypothesis may be burnout, a causal hypothesis may be sleep disturbance due to an irregular work schedule. In this case, action must be taken on the two causes: take the patient off work for physical recovery, with treatment for the sleep disorder, and possibly ask the employer for a suitable work schedule.

If this treatment acting on the causes leads to an improvement of the symptoms, it is possible to validate the two causal hypotheses and the diagnosis. Otherwise, we must look for the real causes that produced the burnout, which may be: a mood disorder at the origin of the sleep disorder, a psychosocial risk (a pathogenic organization or moral harassment), stress, low self-assertion, etc.

If therapeutic interventions treat only and mainly the symptoms, the causes will continue to act and maintain the disorder. In this case, treating the sleep disorder alone will not solve the problem because it does not address the working conditions that can be a source of stress and burnout. The patient will enter a temporary phase of sleep improvement, which will decline even further later on.

Indeed, treating the symptoms is a wrong approach if the causes are not addressed. The collection of symptoms may result in treatment with a collection of medication, with side effects, long psychotherapy, poor results, aggravation and chronicity of the disorders.

The risk of poor intervention lies in imprecise, ineffective interventions that do not address the root causes of the problems and perpetuate the situation.

The treatment of the cause, allows to control and solve the problem, the drug treatment will be a minimal optimal, with a minimum of side effects, short and effective psychotherapy, favorable results, without aggravation and chronicity of the symptoms, but on the contrary with an improvement of the patient’s condition.

Diagnostic hypotheses must thus contain the hypotheses of the causes at the origin of the problem, which is often ignored in psychiatry.

Another simple example is when a depressive disorder without a cause may lead to an antidepressant type of therapy or/and psychotherapy. However, if the cause of the depression was a thyroid problem (the case of hypothyroidism), neither antidepressants nor psychotherapy will be very effective. If the cause of the depression is cannabis use, neither antidepressants nor psychotherapy will be the solution, but cessation of cannabis use and psychoeducation.

Another example: if the cause of the depression is bereavement in the family, the solution will not be antidepressants, but grief-centered psychotherapy.

The psychiatric diagnosis must contain the name of the problem, associated with one or more causes. Example of diagnoses: depressive (bipolar) mood disorder with a biological (constitutive) cause.

Formulating the diagnosis in this way prepares and organizes the therapeutic intervention logically and effectively, to act on the cause of the problem and not its symptoms.

At this stage, the diagnosis must be based on elements resulting from the exploration stage, which contains the arguments, manifestations, consequences… linked to one another.

The diagnostic report highlights causal links: certain manifestations have been produced by certain factors and the problem has a certain name (a certain diagnosis).

The diagnostic report must also contain a differential diagnosis, that is, differentiating our diagnostic hypothesis among several other possible hypotheses. In this sense, it is necessary to explain why our hypothesis is the most relevant.

The treatment

This step includes:

  1. The declaration of the objectives to be achieved,
  2. The implementation of monitoring tools to measure the essential parameters before, during and after the procedure, and
  3. Goal-oriented treatment and concrete action to achieve them.

1. The declaration of objectives to be achieved

… entails precisely defining each improvement objective with its action protocol…

For it to be achieved, an objective must be:

  • specific, concerning an action in a very specific way, a parameter or a dimension to be improved,
  • measurable, as in measuring the efforts to be made (e.g. filling in the follow-up sheet, or respecting a bedtime) or the results to be obtained,
  • acceptable, being agreed upon by the patient or by those close to them,
  • realistic, in the sense that the objective must be realistic, achievable and
  • time-limited: a time limit must be set.

Objectives without the description of an action protocol remains imprecise, unmeasurable, unrealistic and prolongs the patient’s discomfort.

Let’s look at the example of a poorly defined objective: improving the patient’s painful state through psychotherapy.

The improvement of the patient’s condition is a global, general and not specific objective. The objective is not measurable, the actions to be implemented are not precise. The objective is not realistic if it is not clearly explained and therefore not limited in time

Psychotherapy is long-lasting, with no time limit and no measure of its effectiveness.

Example of a Therapeutic Goal Protocol:

A specific objective: Improving the quantity, quality and regularity of the sleep cycle. The doctor provides the patient with a monitoring tool (in the form of a table), explaining how to fill it in, on a daily basis: bedtime, wakeup time, naps duration, sleep quality. The doctor also explains during each consultation why sleep is important and during each consultation the doctor, the patient and their relatives analyze the data recorded by the patient together.

A measurable objective: the number of hours of sleep, sleep quality and the parameters associated with the sleep cycle are measured every day.

An acceptable objective: the doctor suggests and explains to the patient the importance of sleep in maintaining a stable mood for their health, and if they agree with the objective, they commit to it. Relatives may also participate in the follow-up (with the patient’s agreement).

A realistic objective: Filling in a column in the table each day (which takes only 1-2 minutes) is a realistic and largely achievable task. However, it is important to verify that the patient does this task well.

A temporally limited objective: recording sleep parameters must be done by the next consultation, or even for one week or longer, depending on the basis initially defined together.

The protocol must contain a check-up list identifying the tasks to be performed:

  • who does what?
  • what tools are used?
  • what parameters should be measured?
  • notification of the verbal commitment of the patient or his/her family circle
  • what medication should be taken? At what time? How?
  • the intervention diary, which should trace the evolution of the interventions and its results.

An inventory of the observed problems must be created in the 5 areas (biological, psycho-affective, cognitive, behavioural and psychosocial) and decide which difficulties to address, in the order of priority.

2. The dashboard (tools for monitoring progress)

Monitoring links action to results. Monitoring uses one or more tools to measure essential parameters: at the starting point, during the therapeutic intervention and afterwards.

Recording these parameters makes it possible to assess the evolution of the patient’s health state, the obtained results and, above all, whether the therapeutic direction is correct.

It is carried out by means of one or more tools. The recorded parameters are sleep, mood graphs, fatigue, anxiety, irritability, consumption of toxic products, medication, etc.

Two main types of monitoring tools can be used:

  1. the daily log recording parameters such as sleep, mood, fatigue, anxiety, irritability, consumption of toxic products, sex drive, menstrual cycle, medication, etc., (click here to download a sample of the daily log) and
  2. the MDS 9 (Mood Daily Scale) which records 9 bipolar mood parameters providing a mood/day score. This score is not very important, but rather its variation over time which indicates the positive or negative dynamics of mood change. For example, a patient who measures mood using this scale scores -20 (depression). After 2 weeks of treatment, the patient gets a score of -5, which means that their mood has become less depressed and that the evolution is favorable. This indicates that the therapeutic intervention is beneficial, and that further improvement is needed.

3. Treatment: problems and their solutions

The nature of the solutions must respect the nature of the identified problems, according to the “principle of concordance resolution”. The name sounds a bit complicated, but the meaning is simple: treating a problem of a certain nature with a solution of the same nature. Pneumonia will not be treated with psychotherapy, but rather with antibiotics, just as depression will not be treated with antibiotics, but rather and most likely with psychotherapy.

This principle suggests that we identify the nature of the problem and then look for solutions of the same genre.

A problem produced by a biological cause must be treated with a biological solution (drug treatment), just as a problem produced by a psychological cause must be treated with a psychological solution (psychotherapy).

This is important because often bipolar depression is confused with unipolar depression, hence the simple question: how do you treat depression?

If the depression was caused by a psychological factor (a negative event such as bereavement, separation, job loss, etc.) the solution will be psychotherapy and not medication. The use of antidepressants in this type of depression of psychological origin should be questioned!

If the depression has been caused by a biological factor (bipolar disorder, toxic substances intake, certain medication, the occurrence of various illnesses, etc.) the solution will be the administration of medication and not psychotherapy. The use of psychotherapy alone in this type of depression is neither effective nor recommended!

Types of problems and types of treatment

The problems can be organized in 5 groups, in order to simplify the overview and the analysis of the mood problems, and of the possible solutions as well.

A. Problems of a biological nature

Logically, problems of biological origin require biological solutions, aimed at repairing imbalances in biological functioning. Anything linked with biology and biological functioning can cause mood problems. For example, drinking coffee in the evening can disrupt sleep and without good sleep our body’s functioning will be affected. Certain medication, toxic substances, alcohol, etc. can disturb biological functioning and affect mood.

Three biological solutions are possible:

  • eliminating all biological disruptors (toxic substances, mood-altering drugs)
  • encouraging behavior that is favorable to biological equilibrium, and
  • taking medication that can stabilize mood.

Biological solutions are responsible for a significant (80%) improvement in mood, so their importance remains cardinal.

Here are three quick and effective biological solutions, responsible for 70% of a favorable mood improvement:

  1. – eliminating (progressive reduction and cessation of all toxic products, drugs, cannabis, etc.) or medication destabilizing mood,
  2. – repairing sleep in order to obtain 7-8 hours/day, with a regularity of the cycle thanks to a healthy lifestyle (e.g. going to bed every day between 10 and 11 p.m. in the evening) and
  3. – Taking a mood regulator.

B. Problems of a psycho-affective nature

Problems of a psycho-affective nature are situations, events or consequences that bring suffering to a bipolar individual (quarrels, separation, conflict, grief, adjustment problems, etc.). These difficulties add to, maintain or complicate mood problems.

Solutions to problems of a psycho-affective nature involve various types of psychotherapy that must often accompany other forms of therapeutic intervention.

C. Cognitive Problems

Problems of a cognitive nature are: problems with memory, concentration, attention, analysis, synthesis, reasoning, judgement, etc.). In bipolar disorder, these (cognitive) functions are often affected.

When biological problems decrease, cognitive problems also decrease. On the other hand, cognitive difficulties often persist. The solution to this is cognitive therapy, or cognitive restructuring, which is a kind of training of these functions. Beware of the use of benzodiazepines, which are known to cause persistent impairment in memory, concentration and attention.

D. Behavioral Problems

Problems of a behavioral nature are acts of violence, hostility, fights, arguments, aggression, breaking rules, laws, etc.

The treatment of these problems is therefore also of a behavioral nature, psychotherapy with lifestyle, discipline, behavioral effort, exposure, desensitization, etc.

E. Problems of a psycho-social nature

Problems of a psycho-social nature include: problems related to social functioning such as work, family, relationship to money, etc. The treatment of these problems consists in taking administrative, medical measures (work cessation), social accompaniment, orientation and social and financial support in order to improve the patient’s social condition.

Analysis of the treatment’s effectiveness

The monitoring tools enable results measurement due to therapeutic measures and the achievement of the set objectives.

Treatment generating AVERAGE RESULTS or unfavorable development should not be accepted!

For bipolar disorder, therapeutic benefits can be obtained quickly.

One should never accept negative results, or negative mood, marked by instability.

As already reiterated, one should not accept to live with bipolar disorder (with ups and downs) but fight it instead.

The meaning of this fight lies in improvement, as evidenced by the monitoring tools. The results analysis must focus on the quality of the obtained results, according to the logic of 3 hypotheses pending verification:

  • that the incriminated cause is correct,
  • that the assigned diagnosis is correct, and
  • that the suggested treatment is correct.

It is the results that verify the three hypotheses and validate or not our chain of action.

Two situations are possible.

1. If the obtained results are favorable (symptoms improvement):

  • the cause of the problem has been well identified and therefore the causal hypothesis is validated,
  • the diagnostic hypothesis is validated (the diagnosis is correct) and
  • the suggested treatment is beneficial because it produced favorable results.

2. If the obtained results are not favorable (no improvement or poor decrease in symptoms) everything must be questioned (because we do not know at what level the error lies)! This means that:

  • either the cause of the problem has not been well identified and therefore the causal hypothesis is not correct,
  • or the problem has not been well identified and therefore the diagnostic hypothesis has not been verified (the diagnosis is incorrect),
  • or the suggested treatment is ineffective because it has not produced favorable results,
  • or all the assumptions are incorrect.

Let us never forget that before we begin our treatment:

  • a diagnosis must be assigned,
  • one or more causes must be identified, and
  • the objectives to be achieved must be clearly stated.

Let us never forget to establish and analyze the results of a treatment. If they are favorable the treatment can continue, if not, we must have the honesty to question everything.

This step must lead to a decision: to continue the current treatment, or to change it.

It is also necessary to ensure the sustainability of the results (the most difficult objective to achieve!), which means maintaining the favorable results in a sustainable way.

There is a big difference between short-term and long-term results. The results must be favorable, long-lasting and solid, because it is easy to plant a rose in the dessert, but very difficult to bring it to life!

This explains the importance of this step, of verifying and validating hypotheses in the medium and long term, through monitoring and follow-up.

The monitoring follow-up

This is the last phase of the treatment, when the doctor found the right treatment formula.

If the treatment is effective, it should provide lasting benefits.

The treatment is maintained for as long as necessary, and optimizations are always possible. Follow-up should continue at home. It will be carried out by the patient themselves or by their entourage, who must observe and monitor the evolution.

For this purpose, the follow-up and monitoring tools are of a valuable aid. Periodic consultations with the doctor are necessary where one analyses the results and recorded parameters with the monitoring and surveillance tools.

If the mood stability is long-lasting, treatment and observation of the parameters should be continued.

If the situation deteriorates, we must analyze it and understand why? If not, we have to call everything into question and start from scratch, because improvement has not been sustainable.

The results

The results chain reflects the quality of our work. Results deserve exceptional attention because they motivate us. The achievement of results must be stimulating, motivating and mobilizing.

Our approach is based on results, conditioned and oriented by their quality.

 What results do we want to achieve?

Objective: Favorable RESULTS = achieving the following objectives in a sustainable way:

  • sleep improvement (sleep 7-8 h/day) with a regular sleep cycle,
  • cessation of toxic products,
  • mood improvement (in the sense that negative/depressed mood and positive mood should normalize),
  • mood stabilization (sustainably stopping mood fluctuations),
  • fatigue elimination,
  • reduction of (and if possible) elimination of anxiety and distress,
  • cessation of relapses (hospitalizations or emergency room visits),
  • finding a mild, effective treatment with minimal side effects,
  • becoming autonomous, able to manage one’s disease on one’s own (by taking medication, through observation, decision-making relative to the disease),
  • keeping minimal contact with psychiatry and drifting away from it,
  • returning to a normal life.