PTSD Case Vignette homework help

Schizophrenia

CASE 1: Emmanuel

Anna Yannucci is a 26-year-old single Caucasian female who was referred to the outpatient mental health facility following a two-week stay at a psychiatric unit of a local hospital. A report from the hospital indicated that her father, Thomas Yannucci, took Anna to the hospital from an apartment where she had been staying for two weeks with a 45-year-old man. Her father believed that this man was a drug user and barely knew his daughter. Mr. Yannucci had learned where Anna was staying when she called him one day to ask for money. He came to the apartment immediately and found that his daughter was apparently not eating well, not changing or washing her clothes, not going outside, and not communicating coherently. When her father arrived, Anna was sitting still and remained quiet, watching television absently. When spoken to, she replied in polite but short phrases and did not initiate conversation. She seemed “lost in her own little world.” Mr. Yannucci brought Anna home from the apartment and later that day drove her to the emergency services unit of the hospital. Mr. Yannucci stated that his daughter “behaves like this much of the time” but he thought that she had lately become even more difficult to communicate with. He added that she always “sat around, spaced out” when she was in her own apartment.

S chizophrenia is a mental disorder characterized by a person’s abnormal patterns of thought and perception. It is a psychotic disorder, that is, a mental state in which the person’s thoughts and perceptions are severely impaired. Schizophrenia includes

two types of symptoms (American Psychiatric Association [APA], 2013). Positive symp- toms represent exaggerations of normal behavior and include hallucinations, delusions, disorganized thinking, and tendencies toward agitation. Negative symptoms represent the absence of what would be considered normal behavior and include flat affect (the absence of expression), social withdrawal, noncommunication, passivity, and ambivalence in deci- sion making. In DSM-IV, five subtypes of schizophrenia were listed, based on its particular symptom presentation, but these have been eliminated from DSM-5 because of their low validity and reliability (APA, 2013).

Prevalence and comorbidity

Schizophrenia has a worldwide prevalence of approximately 1% (Murray, Jones, & Susser, 2003). Data from the National Institute of Mental Health–sponsored Epidemiological Catchment Area research project noted the lifetime prevalence of schizophrenia to be 1.3% in the United States (Kessler, Berglund et al., 2005). Schizophrenia tends to be di- agnosed among African-American persons more frequently than among Caucasians. This imbalance may result because practitioners attribute and weigh particular symptoms

c h a p t e r 5

Schizophrenia 53

differently for clients of different races (Luhrmann, 2010). Clinicians of Caucasian origin tend to interpret the suspicious attitudes of African Americans as symptomatic of schizo- phrenia, representing delusions or negative symptoms, when these attitudes may in fact be protective in situations of perceived discrimination.

Persons with schizophrenia have a high rate of comorbidity for other DSM disorders. The national comorbidity study noted earlier found that 79.4% of persons with lifetime nonaffective psychosis (most often schizophrenia) meet the criteria for one or more other disorders (Kessler, Berglund et al., 2005). These include a mood disorder (most often major depression) (52.6%), anxiety and trauma-related disorders (especially the phobias, posttraumatic stress disorder, and panic disorder) (62.9%), and substance-related disor- ders (26.8%). A recent meta-analysis found that persons with schizophrenia who abuse substances experience fewer negative symptoms than those who are abstinent (Potvin, Sepehry, & Strip, 2006). This suggests either that substance abuse relieves negative symp- toms or that persons with fewer negative symptoms are more prone to substance use. Along these same lines, several studies have found that nicotine use helps alleviate psychotic symptoms in some persons with schizophrenia (Punnoose & Belgamwar, 2006). Finally, schizophrenia is often comorbid with the schizotypal, schizoid, and paranoid personality disorders (Newton-Howes, Tyrer, North, & Yang, 2008).

assessment

The assessment of schizophrenia is done through client interviews, interviews with signifi- cant others, and history gathering. There are no tests currently available that conclusively determine when schizophrenia is present. See Box 5.1 for assessment guidelines.

adults

• Criterion A for schizophrenia requires two of the following symptoms, including at least one of the first three: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and negative symptoms for a period of one month.

• Assess for the duration of active symptoms, which may rule out brief psychotic disorder or schizo- phreniform disorder.

• Refer the client for a medical evaluation to rule out any medical conditions that may be contributing to symptom development.

• Assess whether the client abuses substances or is currently under the influence of a drug that may be causing symptoms.

• Assess for psychosocial stressors that may be con- tributing to symptom development.

• Assess for psychotic or mood disorders among relatives.

• Assess the family system for the possibility of stresses that may precipitate an onset of psychotic symptoms.

• Assess for mood swings at present or in the cli- ent’s history that may indicate a schizoaffective, major depressive, or bipolar disorder.

• Assess for premorbid functioning to determine the presence of a possible schizotypal, schizoid, or paranoid personality disorder.

• Rule out the possibility of neurocognitive, perva- sive developmental, obsessive-compulsive, and substance use disorders.

childhood

• In cases of childhood psychosis, rule out the pres- ence or influence of developmental, anxiety, and mood disorders.

• Visual hallucinations and disorganized speech may be more common than delusions and halluci- nations.

Adapted from Volk et al., 2008.

box 5.1 assessment of schizophrenia

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders54

The admission report stated that Anna had been living with her younger sister in a condominium owned by her father for the past six months. Anna met the man with whom she was most recently staying at a fast-food restaurant. He had bought her lunch and then invited her to his apartment, where he lived alone. Mr. Yannucci did not know why Anna would accept the invitation, but he added that “she does crazy things sometimes.” He thought that the man wanted to take advantage of his daughter financially.

Doctors at the hospital ordered a variety of neurological tests to rule out physical causes of Anna’s symptoms. A toxicology screen found no traces of drugs in her sys- tem. While at the hospital Anna was cooperative, except that she refused to consider taking medications. When asked for her reasons, she replied simply, “I just don’t want to.” Staff efforts to help the client elaborate on any of her thoughts and feelings were not successful. In fact, Anna seemed to become mildly irritable when asked questions, always saying, rather politely but in a monotone, “I just don’t have a lot to talk about right now.” She rarely made direct eye contact with staff but tended to stare blankly. Anna did seem to enjoy walking about the unit, and the nursing staff reported that she often appeared to be talking to herself. Her mood was quite consistent, but as one nurse wrote, “the patient doesn’t seem to be feeling anything.”

Anna’s condominium was located one mile from the mental health agency. She walked to her first appointment alone, arriving on time and with the card in her hand. Her father met her there, coming from his job at a baker y. Anna was dressed appropriately but appeared not to have changed her clothes or bathed in the recent past. She exuded such a strong, disagreeable odor that support staff at the agency complained to the director about her presence in the waiting room. Anna seemed oblivious to this condition. Upon questioning, she denied hearing voices but seemed highly distracted at times, as if her attention were focused on somewhere far away. She minimized the issues of her personal hygiene, saying that she eats “something good ever yday” and bathes “when I need to.” Her answers to all ques- tions were brief. She seemed preoccupied but not upset about being at the agency.

Anna stated that she spent most of her time at home but added, “I like to take walks for exercise.” When asked to elaborate, she said that she took walks everyday to nearby fast-food restaurants or the bank to deposit and withdraw money. She did not have a job, did not attend school, and was not involved in any recreational activities. When asked about her goals in these areas, she said, “I’d like to have a job someday when I’m ready.” When asked about any friends, she said, “I’d like to have friends some- day,” but about the present, she said, “People can’t be trusted.” Anna stated that she got along with her sister, but that “we don’t really talk much.” Thirty minutes into the interview Anna said, “It’s nice meeting you, but I should go now.” The social worker asked if she would mind waiting in the room or outside on the porch while he talked with her father. She agreed, and walked outside. Throughout this interview Anna had maintained the same blank look on her face, revealing no affect.

Mr. Yannucci remained for another half hour and provided background information. He is a 50-year-old Italian American who came to the United States when he was 10 years old. He has worked successfully in the restaurant business for the past 30 years, always maintaining strong ties to the Italian community in his city. The welfare of his family is par- amount to him. He clearly does not understand what might be “wrong” with his daughter, and he tends to see her behavior as “willful misbehaving.” Yet he tried hard to understand her as he told the story of her background.

“I have to be responsible for my daughter. It is a father’s responsibility to care for his family. But I do not understand why she does not try harder. Anna’s mother and I never got along. I was the breadwinner and she was the mother, and she became very

Schizophrenia 55

strange not long after we married. She stayed home all the time and sometimes did not come out of her room. She cried often for no good reason and did not do enough to take care of Anna, her sister, and me. She talked about crazy things and never made sense. Sometimes she walked away from home and did not return for days. Sometimes the hospital would call me—or the police would. She was always wandering around looking for Lord knows what, finally getting into trouble when she stole food and ob- jects out of people’s yards. I did my best to help her get more rest and get outside more with good people, but it did not work. Her behavior became worse as the years went on. Finally, she left me for good. I don’t know where she is, but she lives here in town. A few times she comes to get money from me, but that’s all.”

“Anna was a good girl growing up. She wanted to be a nurse, and she got good grades in school. Everyday she came home from school and went to her room and studied. But she was not a sociable girl. She never had a boyfriend. That was good, because I didn’t want her with dangerous boys. She stayed home and studied and helped take care of me and her sister Beth. She never talked much, but she behaved well and was respectful.”

When asked for details about Anna’s functioning as a child and adolescent, Mr. Yannucci stated, “She did not ever seem to be happy, but that’s only because she was serious, which is a good thing. She didn’t have friends, but that was fine, too, because she was busy at home. She never wanted to go out and play in the neighborhood, even as a young girl. Like I said, she kept to herself and studied. She didn’t need much help from her mother or me. She was independent.”

“I didn’t want her going to college, but Anna was determined. She lived at home and went to the university, but she did not do well. She stopped going to school and started stay- ing in her room more. She was still helping out around the house, but not as much, and it got worse. After about a year she started to loaf all the time and sat in the television room alone. She started having bad dreams, because I could hear her screaming many nights in her bedroom. Many times I would notice her talking to herself, but when I asked what she was doing she got quiet and said, ‘Nothing.’ ”

“Two years ago I met my current wife, Margaret, and she did not care for Anna’s be- havior at all. Margaret thought that Anna was ‘crazy,’ which is a terrible thing to say about someone. She thought that Anna should be forced to move away or go to school again, and leave us to our new life. But my wife is a good person. She thought that I was babying Anna, and that I should make her live on her own. But I can’t do that. So as a compromise I got a condominium for Anna and her sister. Margaret told me that she would not marry me un- less I did that. I go and see them everyday! I plead with Anna to get a job and to get busy, but she will not do it. She stays home and does nothing. She is a nice girl, so why would she not want to be busy and have friends? I don’t understand her. And lately she has started wandering off, just like her mother.”

At this point, the interview ended. Anna returned to the room for a few minutes and politely declined an offer to see a physician for a medication evaluation. She did agree to come back to the agency in two days to meet with the social worker again. “It wouldn’t hurt anything” was her response to the invitation.

Directions Part I, Diagnosis Given the case information, prepare the following: a diagnosis, the rationale for the diagnosis, and additional information you would have wanted to know in order to make a more accurate diagnosis.

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders56

bioPsychosocial risk and resilience influences

onset

The specific causes of schizophrenia are not known. Its onset and course are likely due to a mix of biological, psychological, and perhaps some social influences (Cardno & Murray, 2003). Many persons who develop schizophrenia display what is called pre- morbid or “early warning” signs. These include social withdrawal, a loss of interest in life activities, deterioration in self-care, and a variety of “odd” behaviors. The signs can exist for many years, but even when present they do not guarantee the eventual onset of schizophrenia. The stress/diathesis theory holds that schizophrenia results from a mix of heritability and biological influences (perhaps 70%) and environmental and stress factors (approximately 30%) (Cardno & Murray, 2003), which may include insults to the brain, threatening physical environments, emotionally intrusive or demanding experiences, and emotional deprivation.

See Box 5.2 for a summary of issues related to the diagnosis of schizophrenia in special populations.

biological influences

Biological theories of schizophrenia implicate the brain’s limbic system (center of emotional activity), frontal cortex (governing personality, emotion, and reasoning), and basal ganglia (regulating muscle and skeletal movement) as primary sites of malfunction (Conklin &

children

• Schizophrenia is rare prior to adolescence, with only 10% of persons experiencing its onset by that time.

Women

• Men have an earlier onset (ages 18 to 26) com- pared with women (26 to 40 years).

• Women tend to have higher levels of premorbid (prepsychotic) functioning and more “positive” symptoms than do men; women also have a better prognosis with regard to their social functioning potential and response to intervention.

minorities

• African Americans are more frequently diagnosed with schizophrenia than are Caucasians, possibly due to clinician interpretation of culturally ap- propriate suspicion within the African-American community as a negative symptom, rather than a learned attitude.

low ses

• The prevalence of schizophrenia is twice as high in lower than in higher socioeconomic classes for the following three reasons: increased stressors due to living in low SES may contribute to the onset of schizophrenia; persons who develop schizophrenia lose occupational and social skills and fall into the lower classes; and others never develop skills to es- tablish themselves in stable social roles.

older adults

• Older adults have not been studied as extensively with regard to antipsychotic medications effects, so at present there is little data to guide decisions about which medications to prescribe for them.

• There is no clear evidence that any particular psychoso- cial interventions are suited to older adult clients.

Drawn from Fonagy, Target, Cottrell, Phillips, & Kurtz, 2002; Marriott, Neil, & Waddingham, 2006; Mulvany, O’Callaghan, Takei, Byrne, & Fearon, 2001; Seeman, 2003; Trierweiler et al., 2000; Van Citters, Pratt, Bartels, & Jeste, 2005.

box 5.2 schizophrenia in vulnerable and oppressed Populations

Schizophrenia 57

Iacono, 2003). People with schizophrenia are believed to have a relatively high concentra- tion of the neurotransmitter dopamine in nerve cell pathways extending into the cortex and limbic system. Dopamine levels are not considered causal for the disorder, however, and other neurotransmitters, including serotonin and norepinephrine, have also been pro- posed as risk influences (van Os, Rutten, Bart, & Poulton, 2008). Whether symptoms result from abnormal development or deterioration of function is not clear.

Some researchers are beginning to study the influences of certain chromosomes on molecular pathways in the brain as causal mechanisms for schizophrenia (Detera- Wadleigh & McMahon, 2006), but this work remains speculative. Still, its genetic transmission is supported by the higher-than-average risk mechanisms among family members of persons with the disorder (Ivleva, Thaker, & Tamminga, 2008). An identical twin of a person with schizophrenia has a 47% chance of developing the disorder. A nonidentical twin has only a 12% likelihood, which is the same probability as for a child with one parent who has schizophrenia. Other risk factors include a maternal history of schizophrenia and affec- tive disorder (Byrne, Agerbo, & Mortensen, 2002). The age of onset for a child tends to be earlier when the mother has schizophrenia. Further, negative symptoms are frequently seen among nonpsychotic first-degree relatives of people with schizophrenia.

It has also been hypothesized that a variety of neurodevelopmental phenomena ac- count for the onset of schizophrenia (Fatjó-Vilas et al., 2008). These include central ner- vous system development, the quality of nerve cell connections, the manner in which nerve cell activity influences the formation of circuits underlying brain functions, and the development of the dopamine system. The brain volumes of persons with schizophre- nia appear to be lesser than those of persons without the disorder. A recent literature review found that the whole-brain and hippocampus volumes of most study participants were reduced, while ventricular volume was increased (Steen, Mull, McClure, Hamer, & Lieberman, 2006). In genetically predisposed subjects, the change from vulnerability to developing psychosis may be marked by a reduced size and impaired function of the tem- poral lobe (Crow, Honea, Passingham, & Mackay, 2005), although some researchers do not agree that a reduction in size of the temporal lobe or amygdala is inevitable (Vita, Silenzi, & Dieci, 2006). Traumatic brain injury, often cited as a contributing cause of the disorder, increases the chances of schizophrenia in families, but only when there is already a genetic loading (Kim, 2008).

Brain trauma from birth complications has been postulated as one of the pathways to the disorder (Prasad, Shirts, Yolken, Keshavan, & Nimgaonkar, 2007), and obstetrical complications are related to earlier age of onset (Mittal, Ellman, & Cannon, 2008). Post- mortem studies show brain abnormalities indicative of developmental problems in the second or third trimester of pregnancy, such as altered cell migration in the hippocampus and prefrontal cortex. Other postulated (but debated) causes of these abnormalities are re- lated to the higher-than-expected frequencies of prenatal exposure to influenza viruses and infections (urinary and respiratory) in persons who later develop schizophrenia (Keshavan, Gilbert, & Diwadkar, 2006). People with schizophrenia tend to be born in winter or early spring, which means that their mothers were pregnant during a time of year when viruses are more prevalent (Reid & Zborowski, 2006). Also, older men are more likely than younger men to father sons with schizophrenia (Torrey et al., 2009). Although the risk influence is not clear, it could be due to a mild biological degeneration in the father’s reproductive system.

Biological characteristics that are protective of a person’s developing schizophrenia in- clude the absence of a family history of the disorder, normal prenatal development, and a normally developed central nervous system. Protective environmental influences include being born during the late spring, summer, or fall and an absence of physically traumatic events during childhood and adolescence (Geanellos, 2005; Jobe & Harrow, 2005).

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders58

Psychosocial Influences There are no known psychological influences of specific stress events, on the development of schizophrenia, although many years ago they were considered the likely dominant causes (Phillips, Francey, Edwards, & McMurray, 2007). There are, however, some possible social risk influences for schizophrenia. These include living in an urban versus a rural environ- ment, being born into a relatively low socioeconomic status (SES), and having migrated into a new culture (Selten, Cantor-Graae, & Kahn, 2007). Conversely, living in a rural environ- ment, being of middle- or upper-class SES, and geographic stability would be protective.

course and recovery

Schizophrenia tends to be a chronic disorder and complete remission is uncommon (Perkins, Miller-Anderson, & Lieberman, 2006). Its course, however, is variable. Suicide is unfortu- nately the leading cause of premature death in schizophrenia, as 20 to 40% of persons at- tempt suicide at some point in their lives and 9 to 13% succeed (Pinikahana, Happell, & Keks, 2003). Persons most at risk for suicidal ideation during the early stages of the disorder are young white males who are depressed, unmarried, unemployed, socially isolated, function- ally impaired, and lacking external support (Pinikahana et al., 2003). The average life span of persons with schizophrenia is approximately 15 years less than the national average in the United States, although this reduced life expectancy is largely due to lifestyle factors such as high rates of smoking, medication use, side effects of medication, substance use, diet, poor access to health care, and other risks related to poverty (Wildgust, Hodgson, & Beary, 2010).

Although the causes of schizophrenia are uncertain, clues are available to differentiate a better or worse prognosis. These are listed in Table 5.1.

Risk mechanisms Protective mechanisms

Biological Biological

Gradual symptom onset Prominence of negative symptoms Repeated relapses of active symptoms Medication absence or noncompliance

Later age of onset Brief duration of active phases Good interepisode functioning (with minimal residual symptoms) Absence of brain structure abnormalities Family history of mood disorder

Psychological Psychological

Poor insight into the disorder Delay in intervention

Insight into the disorder Early and ongoing intervention

Social Social

Significant family expressed emotion Poor social adjustment prior to the onset of schizophrenia Noncompliance with, or absence of, psychosocial interventions Absence of a support system Living in an urban area

Development of social skills prior to onset of the disorder Family participation in intervention Interest in independent living Participation in a range of psychosocial interventions Presence of support systems Living in a nonurban area

Sources: Andreasen et al., 2005; Lenoir, Dingemans, Schene, Hart, & Linszen, 2002; Pharoah, Rathbone, Mari, & Streiner, 2003; Zammit, Lewis, Dalman, & Allebeck, 2010.

Risk and Resilience Assessment Table 5.1

Schizophrenia 59

intervention

Although empirical research support for many interventions is limited, there is a consen- sus that the treatment of schizophrenia should be multimodal and include interventions targeted at specific symptoms as well as the social and educational needs of the client and family (Spaulding & Nolting, 2006). In this section we will review medication, individual therapy, group intervention, family intervention, assertive community treatment (ACT), case management, hospitalization, vocational rehabilitation, and early intervention. One literature review established that client satisfaction with interventions for schizophrenia and other psychotic disorders is influenced by multiple factors, including an absence of significant drug side effects, participation in treatment planning and decision making, and involving family members in the intervention plan (Chue, 2006).

medications

Medication is the primary intervention modality for persons with schizophrenia. It cannot “cure” a person of the disorder but can be effective in eliminating or reducing some of the symptoms. The first-generation antipsychotic drugs, most popular from the 1950s through the 1980s, act primarily by binding to dopamine receptors and blocking their transmission (Leonard, 2003). These medications act on all dopamine sites in the brain, although only those in the forebrain contribute to the symptoms of schizophrenia. A reduction in dopa- mine in other areas (extending from the midbrain to basal ganglia) causes adverse effects of akathisia (restlessness and agitation), dystonia (muscle spasms), parkinsonism (muscle stiffness and tremor), and tardive dyskinesia (involuntary muscle movements of the face and limbs). Anticholinergic medications are often prescribed to combat these effects, although they in turn have their own adverse effects of blurred vision, dry mouth, and constipation.

The “second-generation” antipsychotic medications, available in the United States since the late 1980s, act differently from those developed earlier. Clozapine, the first of these, acts selectively on dopamine receptors (Faron-Gorecka et al., 2008). Their sites of action are the limbic forebrain and the frontal cortex, and thus they do not carry the risk of adverse effects for the muscular system. The fact that they block receptors for serotonin suggests that this neurotransmitter also has a role in the production of symptoms. Ris- peridone, introduced in 1994, has fewer adverse effects than the first-generation drugs and is at present the most widely prescribed antipsychotic drug (Yu et al., 2006). Olanzapine, sertindole, ziprasidone, quetiapine, aripiprazole, and amisulpride are other newer medica- tions on the market (Schatzberg & Nemeroff, 2001). Their somewhat greater alleviation of negative symptoms suggests that serotonin antagonist activity is significant in this regard.

Both the first- and second-generation medications continue to be used to treat persons with schizophrenia. Prescribing practices depend on the physician’s preferences and the client’s family history and financial status (the older medications are less expen- sive). The effects of antipsychotic medications on older adults have not been studied as extensively, so at present there is little data to guide decisions about which medications to prescribe for them (Marriott, Neil, & Waddingham, 2006). There is some evidence that the newer atypical antipsychotic medications are more effective for older adults than the first- generation drugs (Van Citters, Pratt, Bartels, & Jeste, 2005).

Directions Part II, Biopsychosocial Risk and Resilience Assessment Formulate a risk and resilience assessment, both for the onset of the disorder and for the course of the disorder, including the strengths that you see for this individual.

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders60

Although almost all physicians recommend antipsychotic medication for persons with schizophrenia, their relative risks and benefits with regard to the patient’s physical and emo- tional well-being are subject to debate (Cohen, 2002). Studies of drug effectiveness for schizo- phrenia symptoms consistently show that many clients discontinue their medication for a variety of reasons, such as perceived ineffectiveness and adverse side effects. One large-scale study found that the first-generation medications were as effective as the newer medications, but discontinuation rates over an 18-month period for all medications were alarmingly high, at 74% (Lieberman et al., 2005). Up until this study, it was assumed that the lesser adverse side effects of the newer medications would be associated with increased compliance.

Nonadherence is best predicted by recent illicit drug or alcohol use and medication- related cognitive impairment (Ascher-Svanum et al., 2006). Fortunately, clinical practices such as counseling, written information, and occasional phone calls can increase medica- tion adherence, at least in the short term (Hanes et al., 2005). Despite the issues of adverse effects and limited effectiveness, medication nonadherence is significantly associated with poorer outcomes in schizophrenia. A multisite study of 1,900 consumers found that client nonadherence was associated with greater risks of hospitalization, use of emergency ser- vices, arrests, violence, victimization, poorer mental functioning, greater substance abuse, and alcohol-related problems (Ascher-Svanum et al., 2006).

Other types of medication are occasionally prescribed for persons who have schizophrenia, usually along with the antipsychotic drugs. These include antidepres- sants, benzodiazepines, and mood stabilizers (Wolff-Menzler, Hasan, Malchow, Falki, & Wobrock, 2010). There is no clear evidence that these medications help alleviate symptoms of depression or control psychotic symptoms, however.

Electroconvulsive therapy (the induction of a seizure by administering an electrical shock to the scalp) is an intervention that has been used for more than 50 years with persons who have schizophrenia. Although controversial, several dozen studies have shown that it can be an effective short-term option for alleviating symptoms, especially when the client has not responded to medication or rapid improvement is sought (Tharyan & Adams, 2005).

Psychosocial interventions

Individual psychotherapy Research on psychodynamic intervention with schizophrenia has limited empirical support. Malmberg and Fenton (2005) concluded that individual psychodynamic treatment is not effective in symptom reduction, reduced hospitalizations, and improved community adjust- ment. One positive aspect of this type of intervention, however, is that it alerts the practi- tioner to the importance of the worker–client relationship. Persons with schizophrenia are often initially distrustful of service providers, so no matter what type of intervention is pro- vided, the practitioner must take care to develop a positive working alliance with the client over time.

Cognitive-behavioral therapy (CBT) is increasingly being used to treat persons with schizophrenia (Kuipers, Garety, & Fowler, 2006). This is based on the premise that current beliefs and attitudes mediate much of the person’s affect and behavior. CBT focuses first on a review of the client’s core beliefs regarding self-worth, the ability to create changes in his or her life, and realistic short- and long-term goals. If the client appears to be thinking “irrationally” in any of these core areas (i.e., drawing conclusions that are insufficiently based on external evidence), the social worker can work toward the client’s acquisition of more “rational” thinking. Clients are helped to (1) modify their assumptions about the self, the world, and the future; (2) improve coping responses to stressful events and life chal- lenges; (3) relabel some psychotic experiences as symptoms rather than external reality; and (4) improve their social skills. It is important to emphasize that although clients with

Schizophrenia 61

schizophrenia engage in psychotic thinking about some or many issues in their lives, some aspects of their thinking are either “rational” or amenable to change.

A meta-analysis of research on the efficacy of CBT for schizophrenia indicates that it is an effective adjunct to medication (Pfammatter, Junghan, & Brenner, 2006). Despite these encouraging findings, it is not yet clear what the specific ingredients of effective psychoso- cial intervention are or which interventions are most effective in particular settings. Fur- ther, CBT does not affect social behavior and overall cognitive functioning (Rathod, Phiri, & Kingdon, 2010). Another group of researchers reviewed clinical trials and concluded that although CBT showed promise, more research was needed to demonstrate its effectiveness relative to “supportive” therapies (Jones, Cormac, da Mota Neto, & Campbell, 2004).

Social skills training (SST) is a type of CBT that addresses deficits in interpersonal relations, which are common among persons with schizophrenia. SST promotes the client’s acquisition of social skills and leads to short-term improvements in cognitive and social functioning (Pfammatter et al., 2006). In a meta-analysis of 22 randomized, control group studies, Kurtz and Mueser (2008) concluded that such training was effective, with certain caveats. Clients perform best on tests of the content of the training interventions but less well on their transfer of that training to activities of daily living. SST also seems to have a mild positive effect on general measures of pathology.

Group interventions Group interventions include insight-oriented, supportive, and behavioral modalities. They are often used in conjunction with other interventions such as medication and CBT. There are few controlled studies of group therapy. In his review of the descriptive literature on both inpatient and outpatient groups, Kanas (2005) concluded that for persons with schizophrenia, groups focused on increased social interaction and managing symptoms were often effective. Group interventions are widely used in inpatient settings, but there is little evidence of their effectiveness in helping stabilize persons who are recently highly symptomatic. A systematic review of five controlled trials of group CBT for schizophrenia indicated, however, that benefits were evident with regard to some symptoms, most promi- nently anxiety and depression (Lawrence, Bradshaw, & Mairs, 2006).

Family interventions Family participation in the client’s intervention is a protective influence (Pharoah, Mari, Rathbone, & Wong, 2010). When a person has schizophrenia, a chronic emotional burden develops, which is shared by all family members. Their common reactions include stress, anxiety, resentment of the impaired member, grief, and depression (McFarlane, 2002). The concept of family (or caregiver) expressed emotion (EE) has been prominent in the schizo- phrenia literature for the past 30 years (Kymalainen & Weisman de Mamani, 2008). EE can be defined as the negative behaviors of close relatives toward a family member with schizo- phrenia, including emotional overinvolvement and expressions of criticism and hostility. The concept is not used to blame family members for the course of a relative’s illness, but to affirm that families need support in coping with it. In a meta-analysis of 27 studies by Butzlaff and Hooley (1998), EE was consistently shown to correlate with symptom relapse, especially for clients with a more chronic disorder. Family environments with low EE are associated with fewer symptom relapses and rehospitalizations than those with high EE environments.

Family interventions in schizophrenia usually focus in part on producing a more posi- tive atmosphere for all members, which in turn contributes to the ill relative’s adjustment. Pilling et al. (2002) conducted a meta-analysis of all randomized clinical studies done on single- and multiple-family intervention (conducted in groups) and found that these inter- ventions were more effective at 12 months than the comparison conditions, which usually included some form of “standard care” (e.g., medication alone). Single-family interventions

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders62

reduced readmission rates in the first year. After two years, all 18 family interventions low- ered the relapse and readmission rates of the ill relative and increased medication compli- ance. Another review of the literature on EE showed that family interventions designed to reduce expressed levels of criticism, hostility, or overinvolvement tend to decrease relapse and increase medication compliance, although families are still left with a significant bur- den (Pharoah, et al., 2010).

Family psychoeducation refers to interventions that are focused on educating participants about the ill relative’s schizophrenia, helping them develop resource supports in managing the disorder, and developing coping skills to deal with related challenges (Griffiths, 2006). A review of 40 randomized controlled studies indicated that (1) education improved members’ knowledge of mental illness, (2) behavioral instruction helped mem- bers ensure that their ill relative take medications as prescribed, (3) relapse prevention skills development reduced the ill relative’s relapses and rehospitalizations, and (4) new coping skills development reduced the distress associated with caregiving (Mueser et al., 2002).

Assertive community treatment and case management interventions Case management is a term used to describe a variety of community-based intervention modalities designed to help clients receive a full range of support and rehabilitation services in a timely, appropriate fashion (Northway, 2005). Case management interventions are usu- ally carried out in the context of large, community-based programs. The most famous of these, ACT, was developed by Stein and Test (1980) in Wisconsin and has since been rep- licated in many other sites around the world. By 1996 there were 397 such programs in the United States (Mueser, Bond, Drake, & Resnick, 1998). The core characteristics of the ACT model of service delivery are assertive engagement, service delivery in the client’s natural environment, a multidisciplinary team approach, staff continuity over time, low staff-to-client ratios, and frequent client contacts. Services are provided in the client’s home or wherever the client feels comfortable and focus on everyday needs. Frequency of contact is variable, depending on assessed client need. Other kinds of case management programs share some, but not all, characteristics of the ACT model.

A number of comprehensive reviews of ACT have been conducted. A recent system- atic literature review of 38 studies by Dieterich, Irving, Park, and Marshall (2010) concluded that clients receiving ACT services were significantly more likely to remain in treatment, experience improved general functioning, find employment, not be homeless, and experi- ence shorter hospital stays. There was also a suggestion that such clients had a lesser risk of death and suicide. In an earlier review of 75 studies, Marshall and Lockwood (2003) found that both ACT and case management were more effective than other forms of intervention in helping clients stay in contact with services, spend fewer days in the hospital, secure employment, and experience life satisfaction. There were no clear differences, however, in measures of mental status and social functioning. ACT was superior to case manage- ment in client use of hospitalization, but differences on the other measures were not clear. Although ACT does promote greater client acceptance of interventions (Tyrer, 1999), an- other comprehensive review indicated that the programs vary considerably with regard to staffing, types of clients, and resources; comparisons are thus difficult to make (Mueser et al., 1998). Further, efforts to make interventions compulsory are not effective in engaging clients (Kisely & Campbell, 2007). That being said, the reviewers found that client gains persist only as long as comprehensive services are continued.

Hospitalization It is widely believed that inpatient hospitalization is an expensive, ineffective, and socially un- desirable treatment setting for persons with schizophrenia. Hospitalization is primarily used now to stabilize persons who are a danger to themselves and others, rather than providing

Schizophrenia 63

active and ongoing interventions. Five randomized controlled trials showed that a planned short-term stay does not encourage a revolving door pattern of admission for people with seri- ous mental illnesses (Johnstone & Zolese, 2005). Still, the use of clubhouses and other partial or day hospitalization programs is effective in reducing inpatient admission and improving outcomes (Marshall et al., 2006). Partial or day hospital programs are staff-run, structured, psychosocial rehabilitation programs for persons with schizophrenia who have the capacity to live in the community. Clubhouses are vocational rehabilitation programs in which members work side by side with staff to complete the work of the facility (e.g., cooking lunch, keeping records, managing a member bank, and answering phones). Members are not paid for their participation, but an employment specialist helps place members in community jobs.

Vocational rehabilitation Vocational rehabilitation is work-related activity that provides clients with pay and the ex- perience of participating in productive social activity. The goals of vocational programs may be full-time competitive employment, any paid or volunteer job, the development of job-related skills, and job satisfaction. Twamley, Jeste, and Lehman (2003) conducted a meta-analysis of randomized controlled trials of vocational rehabilitation that focused on both client placement and support (with training, placement, and occasional contact) or supported employment (more intensive participation by the case manager in the client’s job functions). These programs have a positive influence on promoting work-related activities such as paid employment, job starts, duration of employment, and earnings. Supportive employment programs tend to be more effective than prevocational training (Zito, Greig, Wexler, & Bell, 2007). Unfortunately, a diagnosis of schizophrenia is negatively related to the attainment and maintenance of employment when compared with other diagnoses.

Bond (2004) conducted another meta-analysis of the effectiveness of supported em- ployment for people with severe mental illness. He found that in 13 studies, 40 to 60% of clients obtain competitive employment, versus 20% of those not enrolled. Interestingly, although clients who hold jobs for an extended period of time show benefits such as im- proved self-esteem and symptom control, their employment does not correlate with out- comes such as prevention of hospitalization and quality of life. Another recent systematic review suggests that ACT intervention models produce vocational outcomes that are supe- rior to usual treatment (Kirsh & Cockburn, 2007). The authors emphasize that ACT teams who designated a vocational specialist were most successful in this regard.

Early intervention Early intervention refers to efforts to detect schizophrenia in its early stages (possibly ap- pearing as brief psychotic or schizophreniform disorder) and then provide those persons with phase-specific treatment. Several such programs have been initiated in the United States, Europe, and Australia (Marshall & Rathbone, 2006). Data regarding the risks and benefits of early detection and intervention remain sparse, and the evidence is not suf- ficient to justify preonset treatment as a standard practice (McGlashan, Miller, & Woods, 2001). There are also ethical issues involved in primary prevention efforts, including clini- cal priorities, screening ethics, stigma, confidentiality, and informed consent.

Directions Part III, Goal Setting and Treatment Planning Given your risk and protective factors assessments of the individual, your knowledge of the disorder, and evidence-based practice guidelines, formulate goals and a possible treatment plan for this individual.

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders64

critical PersPective

Schizophrenia remains an enigma. Although it is among the most disabling of all mental disorders, researchers and clinical practitioners are not able to describe exactly what it is, how it is caused, or how it can be effectively prevented or treated. There is a consensus, however, that its primary causes are biological or hereditary (although the extent of those influences is debated), and that family and social environments are more significant to its course than to its onset. There is also a general worldwide agreement on its basic symptom profile. Schizophrenia thus appears to be recognized as a valid mental disorder. Some theo- rists debate, however, whether the symptoms of schizophrenia represent a single or several disorders, and refer to the schizophrenia spectrum disorders as also including schizoaffec- tive disorder and the paranoid, schizoid, and schizotypal personality disorders (Keefe & Fenton, 2007).

A major problem with the diagnosis of schizophrenia is that its causal influences are inferred from the hypothesized actions of antipsychotic medications (Conklin & Iacono, 2003). As more information about the condition’s neurobiology is developed, professionals may become able to articulate its core features. As described earlier, the limited effective- ness of these medications casts some doubt on the validity of the presumed “nature” of schizophrenia. Still, because the pharmaceutical industry and psychiatric profession are so heavily invested in drug marketing (Moncrieff, Hopker, & Thomas, 2005), relatively little research currently focuses on the psychosocial influences on the disorder.

Directions Part IV, Critical Perspective Formulate a critique of the diagnosis as it relates to this case example. Questions to consider include the following: Does this diagnosis represent a valid mental disorder from the social work perspective? Is this diagnosis significantly different from other possible diagnoses? Your critique should be based on the values of the social work profession (which are incongruent in some way with the medical model) and the validity of the specific diagnostic criteria ap- plied to this case.

CASE 2: The Reluctant Day Treatment Member

Donald is a 23-year-old Caucasian male who presents as quiet and polite, with a flat affect. At age 20, he was in church with his family when he started spinning his body around, feeling that something was pushing him. After returning home, he felt restless and randomly moved items and furniture around the house. Over a short period of time, his parents noticed that his speech was becoming disorganized and his behavior more erratic. He would sit outside in cold weather with light clothing, sleep in the backyard, and live in his car. At one point, Donald felt he was possessed by demons and needed to purify his body by not eating. He thought that if he lost weight, the demons would have to leave. From the initial onset of his symptoms until six months ago, Donald was hospitalized 14 times as a result of aggressive behavior toward his family. His aggression was usually characterized by shouting and shoving his parents. Once he punched his father in the face. At times, Donald is bothered by his aggressive thoughts and has sufficient insight to recognize that his illness impacts his life.

Donald is currently receiving treatment from a county mental health agency as an outpatient. He is seen regularly by a social worker and by a psychiatrist who monitors Donald’s medication and coordinates treatment with his primary care physician. Donald is also attempting to become more involved with a day treatment program, but is finding it difficult. Initially,

Schizophrenia 65

he liked the idea of participating in group activities and having the chance to develop social relationships. Over time it became stressful for him, and at one point he said he felt the program was “evil” so he stopped attending. He is trying to attend again, but initially he would go out on the grounds and stay behind the trees. Donald has progressed to being able to come out from behind the trees and sometimes enter the building, but he is still not able to engage in any kind of social interaction. He has been known to wear earplugs during his entire time at the day program to protect himself from perceived ridicule.

When at home, Donald spends the majority of his time in his room. He no longer watches television or listens to music, activities he previously enjoyed doing. His parents encourage Donald to eat dinner with the family several times a week to foster the social interaction he otherwise lacks. He is notably distracted by his internal stimuli and often talks and laughs to himself. He paces, goes in and out of the house, and picks up and examines items that are not there. His speech is often tangential.

Donald is currently obsessed with children and their safety. He mistrusts his father and fathers in general, although abuse by his father has been ruled out. He mistrusts the Catholic church because of reports of child abuse by priests. He often misinterprets parental behavior as child abuse. On a recent visit to a fast-food restaurant, Donald saw a father holding a fussy child. He thought the child was crying because the father was holding the child “in a perverted way,” and he demanded that the father put the child down.

At his intake for the day treatment program, Donald told the doctor that his parents and siblings had murdered his friend. In truth, the friend had died of a heroin overdose. He also reported that he hears a voice that is “nasty” in tone. He stated that the voices “do cruel jokes” on him, and he laughs or talks back to them. He tries to control the voices by praying. Donald also talks about “a presence touching me.” He described it as a sharp jolt of terror, as if someone was in the room with him, touching him. This presence comes and goes, and Donald thinks it may be Satan. He also thinks that people are reading his mind and making fun of him.

Recently, Donald has had problems sleeping and is becoming increasingly agitated over the need to organize protests against abortion. His father contacted Donald’s social worker and requested that both the social worker and the doctor see Donald to reevaluate his medication. When Donald was informed of this appointment, he became extremely annoyed and threatened to cut the doctor’s throat. He left the house on foot, returning several hours later at 2:00 a.m., cold, tired, and wet from the rain. He agreed to be hospitalized the next day.

Over the course of his illness Donald has continued to experience periods of depression. During these periods, which last for several weeks, he will sleep at least 12 to 14 hours a day and has a great deal of difficulty waking. By his parents’ report, he eats less, is more withdrawn, more isolated, and less active than at other times. His depressed moods are noted by his mother, his social worker, and the psychiatrist. He has described other moods in which he feels like “doing a lot of things,” but these episodes were short lived and do not meet the criteria for manic or hypomanic states. According to both Donald and his family members, he does not smoke or use drugs or alcohol.

Despite his psychotic and depressive symptoms, there are times (at most a few days at a time) when he is oriented to reality and does exhibit some insight regarding his illness. Still, he continues to experience “voices” (although understanding that they are not real) and flat affect and withdrawal during these periods.

Donald is the youngest of three children. His mother reported that she had a normal pregnancy and delivery with Donald. He was born in February. Donald’s older brother is 34 and his sister is 26. His mother works as a nurse, and his father is an engineer. There is a family history of mental and mood disorders. Donald’s mother is taking antidepressants, and her brother has bipolar disorder with manic episodes marked by psychosis and a substance use disorder. There is also a history of attempted suicides in Donald’s mother’s family, and a paternal great-uncle had “a breakdown.”

Part Three: Schizophrenia Spectrum and Other Psychotic Disorders66

Donald’s parents describe him as a shy child who did well in school. He was diagnosed with depression at age 13 and took antidepressants until he was 20. At age 15, he had his first suicidal ideation but made no attempt to take his life. He also reported thoughts of suicide when he was 19 and 20, but never made any attempts. Donald graduated from high school with a 3.6 GPA. He attended college for three semesters, earning a 3.1 GPA in his studies. During high school and college Donald held several jobs. He worked in a veterinarian’s office for nine months. He was also employed in retail and as a waiter in several eating establishments, but was unable to stay employed at any of these places more than a few weeks.

The medications Donald currently takes are a cause for concern. His illness has not responded well to medications, even though he is taking many of them. These include Depakote, Zyprexa, Abilify, Geodon, and Risperdal. He experiences several undesirable side effects, most notably tremors of his hands, arms, and feet. The health care providers treating Donald would like to have him try clozapine, described by his social worker as a drug of last resort. This is an unlikely possibility, however, as transitioning medications requires a person to be hospitalized. The patient is then monitored twice weekly during the first six months and weekly for the following six months. Donald has not been particularly compliant with medication and treatment but is especially reluctant to be hospitalized, feeling that hospitals are “evil.”

Please go to the Additional Case Workbook for directions to this case.

CASE 3: Emma’s Private World

Emma is a 59-year-old African-American woman, born in July, who presents with a well-groomed appearance but flat affect. Her medical chart shows that her weight is in the normal range for her height, and she has a medical diagnosis of hypertension. Emma is an inpatient resident at a mental health facility, where she has resided since her admission one year ago.

Emma believes that she still owns a house in another city, in spite of having been shown the deed of sale from 13 years ago. She says her son has been replaced by an impostor who came from a seedpod. Emma also states that she was shot while at work but went home because she didn’t bleed. She denies that she has siblings, saying they were just people who were put in her parents’ house to be raised. She doesn’t want contact with them, and they don’t attempt to contact her. When questioned about some of these beliefs, Emma states that she was instructed by a secret group, of which she is part, not to give out further information. When staff challenge her beliefs, she says it hurts her feelings and responds to them in anger.

Emma has been observed responding to internal stimuli. She also reported that while in her room, she heard her psychiatrist’s voice telling her she was released. Emma does not believe herself to have a mental illness or hypertension and states that she takes her medication only because the nurses give it to her. She is currently being treated with Haldol (a first-generation antipsychotic), the dosage of which was recently increased due to persistent delusions. A previous medication, Zyprexa (a second-generation antipsychotic), was recently discontinued due to lack of efficacy.

This is Emma’s third admission to an inpatient mental health facility. Emma is pleasant when approached. She attends scheduled treatment groups independently. Her records show her to be Protestant, but she does not attend any spiritual services at this time. She participates in occasional outings if prompted.

Prior to admission, Emma was living with her son in a large urban area where she was noncompliant with medication and reportedly caused problems at home. She was originally placed with her son 14 years ago after becoming unable to care for herself in her home, which was located in another city where she had lived for 10 years. At the time she was removed,

Schizophrenia 67

she had no electricity or running water. Her son was appointed legal guardian and payee at that time. At his house, her son stated that Emma would sit in front of the television with no sound and get up only to go outside to smoke. She was reported as being aggressive toward her grandchild and attempted to return to the home she no longer owns. On one occasion she had to be removed from her son’s house by the police for aggressive behavior toward him. On another occasion she had to be removed by the police from a bank, where she erroneously insisted that she had an account. Emma is now estranged from her son. He says he is “worn out from dealing with her.”

Emma has a history of noncompliance with outpatient treatment. She has no history of drug or alcohol abuse but does smoke about half a pack of cigarettes per day. Neither does she have a history of depressive or manic episodes. Her son said there was no family history of schizophrenia that he knew of, and he didn’t think that his mother had suffered from traumatic events as a child. He said that his mother’s parents were strict and would give out “whippings” for misbehavior. Emma came from a poor background, and when she married, the family could have been classified as “working poor.”

When Emma was going through a divorce in her 40s, she told her son that she’d bought him a car and that he should go to the dealer and pick it up. When he spoke with the car dealer, he discovered that his mother had had a number of confused conversations with the dealer, telling him the bank would provide the necessary money. She had not, in fact, bought a car. He soon found out that his mother had also not paid his college tuition bill, which she denied.

Emma was recently evaluated by the occupational therapy department using the Kohlman Evaluation of Living Skills (KELS) and the Allen Cognitive Level Screen (ACLS). She was reported to be friendly and cooperative during this 90-minute evaluation. Emma’s KELS score showed her as able to accomplish some tasks independently but having poor judgment in other areas. She was unable to identify her current source of income but stated that the bank gives money to people who need it. She has not been employed for over 20 years but states that after her release from the mental health facility, her prior employer will find her and send her to France to a government school. Emma’s ACLS results showed weakness in the areas of problem solving, insight, and judgment. Overall, her scores, KELS/fair and ACLS/4.4, demonstrate her need to live in a 24-hour supervised environment.

Please go to the Additional Case Workbook for directions to this case.

references

68

Bipolar and Related Disorders

Catherine is a 38-year-old married Mexican-American female with no children who lives in a rural county. She was court-ordered to attend an outpatient mental health clinic for individual and group anger management services. Two months ago, her husband charged her with assault after she stabbed him in the shoulder with a steak knife during an argument at a local restaurant. Catherine is also awaiting incarceration for an arrest in which she was recklessly driving a vehicle without a license. She has in fact been jailed on five occasions for offenses ranging from disturbing the peace to assault. The social worker met with Catherine on four occasions over five weeks. Catherine is separated from her husband but is open to possibly reuniting with him after she receives professional help.

Catherine is in generally good physical health and reports that she is in regular contact with her family physician. She broke her arm two years ago in a saloon fight, however, and has diminished strength in that arm. She also reports having ankle pain due to possible arthritis, which moderately decreases her mobility. Still, Catherine has kept a full-time job at the post office for the last 15 years, working primarily as a mail sorter and occasionally as a deliverer.

Catherine reports that she has had irritable and “up and down” moods for most of her adult life. She describes extended periods of time when she becomes “hyperactive” and easily annoyed by people around her. Catherine says she has “incredible energy” at those times and “gets a lot done.” At those times she likes delivering the mail, working out at the local recreation center, eating out in restaurants, and going to bars. She rests primarily with “short naps” during her energy bursts. Catherine drinks alcohol (only beer) regularly and makes no apologies for it. “It’s fun. Who says girls can’t hold their liquor like the guys?” Upon further questioning, she admits that she drinks only “enough to get drunk” when she is in a “high-energy” phase. Otherwise she limits herself to a few beers on the weekends.

Catherine admits that she “wears herself out” after about a month of this hyperactivity, becoming “shaky” and “disoriented” from the lack of sleep. When in a manic episode, she is apt to lose her temper and argue with “almost anyone” who gets in the way of her activities. She gets into physical fights frequently, often with strangers, but sees this as acceptable behavior. “I was raised to take care of myself. No one is going to push me around.” Despite her erratic behaviors, Catherine is “accepted for who I am” in her small community. The culture of her Mexican-American family of origin features high levels of emotional expressiveness and Catherine is comfortable behaving this way. She is usually released from jail a few days after her arrests to the custody of her husband, with the charges dropped.

Bipolar disorder is a mood disorder in which a person experiences one or more manic episodes that usually alternate with episodes of major depression (American Psychiatric Association [APA], 2013). Depressive episodes are described in chapter 7. A manic episode is a period in which a person’s mood is elevated and expansive to such a degree that he or she experiences serious functional impairment in all areas of life. Manic episodes may be characterized by unrealistically inflated self-esteem, a decreased need for sleep, pressured speech,

C h a p t e r 6

Bipolar and Related Disorders 69

racing thoughts, distractibility, an increase in unrealistic goal-directed activity, and involvement in activities with a high potential for negative consequences. Manic episodes develop rapidly and may persist for a few days or up to several months. The average duration of bipolar I mood episodes is 13 weeks (Solomon et al., 2010).

Another feature associated with bipolar disorder is the hypomanic episode (APA, 2000), a gradual escalation over a period of days or weeks from a stable mood to a manic state. In this mild form of mania, the person experiences higher self-esteem, a decreased need for sleep, a higher energy level, an increase in overall productivity, and more intensive involvement in pleasurable activities. Its related behaviors may be socially acceptable, but the danger is that the bipolar person’s decreased insight may lead him or her to believe that the disorder has permanently remitted and that there is no need for ongoing interventions. In fact, poor insight is a prominent characteristic of the active phases of bipolar disorder (Grant, Stinson, et al., 2005).

There are two types of bipolar disorder (APA, 2013): Bipolar I disorder is characterized by one or more manic episodes, usually accompanied by a major depressive episode. Bipolar II disorder is characterized by one or more major depressive episodes accompanied by at least one hypomanic episode. Although generally “milder” than bipolar I disorder, bipolar II disorder is characterized by a higher incidence of comorbidity, suicidal ideation, and rapid cycling (Vieta & Suppes, 2008). For both types of the disorder, the duration between episodes tends to decrease as further cycles occur (Geller, Tillman, Bolhofner, & Zimmerman, 2008).

PrevalenCe and Comorbidity

Prevalence estimates of bipolar disorder have increased in recent years and range from 0.5 to 5% (Matza, Rajagopalan, Thompson, & Lissovoy, 2005). The estimated prevalence in the most recent National Comorbidity Survey was 2.1% (Merikangas et al., 2007).

The lifetime prevalence of bipolar I disorder is equal in men and women (close to 1%), although bipolar II disorder is more common in women (up to 5%) (Barnes & Mitchell, 2005). In men the number of manic episodes equals or exceeds the number of depressive episodes, whereas in women depressive episodes predominate. Between 1994 and 2003 there was a 40-fold increase in child and adolescent diagnoses of the disorder, which may be due to changing diagnostic criteria (perhaps informally) or greater practitioner sensitiv- ity to its symptoms (Moreno, et al., 2007). This may diminish with the inclusion of a new diagnosis for children and adolescents, disruptive mood dysregulation disorder, which fea- tures some symptoms similar to those of bipolar disorder.

Bipolar I disorder is often comorbid with other disorders. Its highest rates of comorbid- ity are 71% for anxiety and trauma-related disorders, 56% for substance use disorders, 49% for alcohol abuse, 47% for social phobia, and 36% for a personality disorder (Marangell, Kupfer, Sachs, & Swann, 2006). One study of 500 clients in a bipolar disorder treatment program noted an earlier age of onset (15.6 versus 19.4 years) and an increased presence of suicidal ideation in persons with comorbid anxiety and trauma-related disorders (Simon et al., 2004). Another study concluded that bipolar disorder is more often accompanied by the antisocial, borderline, narcissistic, and histrionic personality disorders than by major depressive disorder (Mantere et al., 2006). Further, a one-year prospective study of 539 outpatients revealed that persons with rapid-cycling bipolar disorder have higher rates of lifetime substance abuse (45.4 versus 36.4%) and anxiety disorders (50.2 versus 30.7%) (Kupka, Luckenbaugh, & Post, 2005). Bipolar disorder is also modestly associated with medical illnesses in adulthood, such as cardiovascular, cerebro- vascular, and respiratory diseases (Krishnan, 2005).

Bipolar women are 2.7 times more likely than men to have a comorbid disorder. Women with bipolar disorder have a premature mortality rate, which may be related to metabolic changes that increase their risk of diabetes and vascular disease (Taylor &

Part Four: Bipolar and Related Disorders70

MacQueen, 2006). Women are also at greater risk for anxiety and trauma-related disorders and thyroid problems. Women have an increased risk of developing episodes of bipolar I disorder in the postpartum period. Bipolar men have a greater prevalence of alcoholism than women do (Barnes & Mitchell, 2005).

Given this information about comorbid disorders, it is important to note that sub- stance abuse and the presence of another comorbid disorder are two major risk influences for suicidal ideation and behavior among persons with bipolar disorder (Hawton, Sutton, Haw, Sinclair, & Harris, 2005). Other risk influences identified in this meta-analysis in- clude a family history of suicide, an early onset of bipolar disorder, high levels of depres- sion, severity of the affective episodes, the “mixed features” type of the disorder, and the presence of rapid cycling.

Catherine says that she doesn’t know why her energy bursts come and go. “I don’t know, it’s all about biorhythms, isn’t it?” She admits to getting “dark, really dark” for extended periods of time as well, sometimes for several months. She is barely able to get her work done when depressed and admits that her boss complains about her “laziness.” When she is not in a “hyper” or “down” mood, Catherine’s moods tend to change throughout any given day. She reports the following symptoms at those times: forgetfulness, shifting ideas, distractibility, cycling between not sleeping at all and sleeping too much, bursts of energy, feelings of elation, decreased interest in most of her daily activities, fatigue, feelings of sadness, and impulsivity.

When asked whether it has ever been suggested that she has a mental problem, Catherine sighs. “My doctor thinks I should take medicine for my moods, but I don’t want to do that. I’m not a doper. I like to drink, but I’m not a doper.” When pressed on this point, Catherine adds, “I’m usually pretty calm when I see my doctor. I don’t go to him when I’m hyper.” Surprisingly, Catherine does not recall that many people in her community have suggested professional intervention to her. “I can take care of myself. All of us had to learn to do that where I came from.” Regarding her drinking, Catherine does not exhibit signs of tolerance or withdrawal. She experiences no physical symptoms when she does not drink for weeks at a time, and she has not increased her overall alcohol intake over the years.

Catherine was born and raised in the Midwest and moved to the mid-Atlantic region when she was six years old. Her mother was a homemaker who was considered “odd” by her siblings. “She stayed home most of the time and seemed sad. She never had any fun. She was pretty, though, but I think Dad married her because he got her pregnant.” Catherine says her mother was nice but not very active and that she drank too much. Her father, a military veteran, was a “great man” whom she loved very much. He “worked all the time” but played with Catherine and her younger brother, to whom she has never been close.

When Catherine was 16 years old, her father died. She says her father was the most important person in her life and remembers becoming “out of control” at about that time. Her mother died of breast cancer when she was 29 years old, though she reports that her mother’s passing was more manageable for her.

Catherine has been married for 15 years to a seemingly supportive husband. “We met at community college. He’s a good man, a calm man, and he taught me to get more focused about my life.” Carl, a manager at a local manufacturing plant, reports that he loves his wife and states, “She is my heart and my life.” Catherine and her husband report having frequent financial difficulties, requiring her husband to work long hours and leaving Catherine at home alone many evenings.

Catherine says she has some friends but inconsistent contact with the people in the community. “I’m friendly with everyone, but nobody in particular.” She stated that she is eager for her mandated treatment to end so that she can resume her work routines without interruption. When asked about her possible sentencing to more time in jail, she shrugged. “I’m sorry for acting up like I do. I hope the judge knows that. My husband is OK with me now. I’m a good person.”

Bipolar and Related Disorders 71

assessment of biPolar disorder

Because of its presumed biological influences, social workers need to participate in a multidis- ciplinary assessment of persons with possible bipolar disorder. A meta-analysis of 17 studies revealed that most persons with bipolar disorder were able to identify symptoms in advance of their first episode, the most common of which is sleep disturbance (77% median prevalence) (Jackson, Cavanaugh, & Scott, 2003). Adults with bipolar disorder are sometimes misdiagnosed with borderline personality disorder, and as noted earlier, the two disorders are sometimes co- morbid (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2004). There is much symptom overlap between them, as both types of clients may experience mood swings, alternating periods of depression and elation, and transient psychotic symptoms. With the personality disorder, how- ever, the mood changes are related to environmental influences and chronic feelings of insecu- rity, whereas bipolar disorder features more biologically patterned mood changes (Stone, 2006). Further, the client with bipolar disorder may function very well when stable, whereas the client with a personality disorder tends to be continuously labile. Other general assessment guidelines are summarized in Box 6.1.

Social workers must be extremely cautious in their diagnoses of children, because there is controversy about appropriate criteria with that population (Stone, 2006). Most researchers agree that bipolar disorder can occur in childhood and adolescence, but that it presents differently in those age groups (Birmaher et al., 2006). Symptoms that are most specific to childhood bipolar disorder include elevated mood, pressured speech, racing thoughts, and hypersensitivity (Youngstrom, Findling, Youngstrom, & Calabrese, 2005). The child typically engages in reckless behavior, but this must be distinguished from either normal behavior or that which may also be associated with other disorders. In fact, a recent longitudinal study found that among children aged 6 to 12 who exhibited symptoms of mania only 11% had bipolar disorder (Findling et al., 2010). As noted earlier, it is anticipated that in the new DSM-5 diagnosis, disruptive mood dysregulation disorder may be given to many children previously diagnosed with bipolar disorder. Valid diagnoses of bipolar dis- order in children can be enhanced with the use of a screening instrument such as the Child Behavior Checklist (Youngstrom et al., 2005).

• Assess family history for the presence of bipolar disorder, other mood disorders, or substance use disorders.

• Assess the client’s social history for evidence of significant mood problems.

• Facilitate a medical examination to rule out any medical conditions that may be responsible for the symptoms.

• Make sure the symptoms are not the result of the direct physiological effects of substance abuse.

• Rule out major depression, which would be the diagnosis in the absence of any manic or hypo- manic episodes.

• Rule out cyclothymic disorder, which is character- ized by the presence of hypomanic episodes and episodes of depression that do not meet criteria for bipolar disorder.

• Rule out psychotic disorders, which are character- ized by psychotic symptoms in the absence of a mood disorder.

• Assess for suicidal ideation.

• Assess the quality of the client’s social supports.

• Evaluate the client’s insight into the disorder.

Source: First, Frances & Pincus, 2002.

box 6.1 assessment Guidelines for bipolar disorder

Part Four: Bipolar and Related Disorders72

Directions Part I, Diagnosis Given the case information, prepare the following: a diagnosis, the rationale for the diagnosis, and additional information you would have wanted to know in order to make a more accurate diagnosis.

bioPsyChosoCial risk and resilienCe influenCes

onset

The etiology of bipolar disorder is primarily biological, although certain psychological and social stresses may contribute to the first episode of mania or depression (Leahy, 2007). Table 6.1 summarizes the risk and protective influences for the onset of bipolar disorder.

Risk Influences Protective Influences

Biological Biological

First-degree relative with bipolar disorder Absence of mood disorders among first-degree relatives

Endocrine system imbalances Asian race

Neurotransmitter imbalances

Irregular circadian rhythms

Obstetrical complications

Postpartum hormone changes

Psychological Psychological

Poor sleep hygiene Effective communication and problem-solving skills

Irregular daily living routines Structured daily living routines

Traumatic experiences during childhood Sense of self-direction, internal rewards

Hypersensitivity

Self-criticism, low self-esteem Positive self-esteem

Exaggerated use of denial

Substance abuse disorders Absence of substance abuse

Mood lability

Transient psychotic episodes

Social Social

Ongoing conflict with family members Positive family relationships

Sources: Berk et al., 2007; Ryan, et al., 2006; Newman, 2006; Scott, McNeil, & Cavanaugh, 2006; Swann, 2006; Youngstrom et al., 2005.

Risk and Protective Influences for the Onset of Bipolar Disorder Table 6.1

Bipolar and Related Disorders 73

Genetic and biological influences Family history studies indicate a higher-than-average aggregation of bipolar disorder in families. Children with a bipolar parent are at an increased risk for mental disorders in gen- eral (Birmaher et al., 2009), and their chances of developing bipolar disorder are between 2 and 10% (Youngstrom et al., 2005). Persons who have a first-degree relative with a mood disorder are more likely to have an earlier age of onset than persons without a familial pat- tern. Twin studies further support the heritability of the disorder. A study of identical and fraternal twins in which one member of the pair had bipolar disorder showed a concor- dance rate of 85% (McGuffin et al., 2003).

Researchers once speculated that the potential for bipolar disorder emanated from a single gene, but studies are now focusing on polygenic models of transmission (Ryan, Lockstone, & Huffaker, 2006). Although genetic research remains promising, the “core” of bipolar disorder remains elusive, because no brain-imaging techniques exist that might provide details about its causes. The limbic system and its associated regions in the brain are thought to serve as the primary site of dysfunction for all the mood disorders. Four areas under study include the role of neurotransmitters, the endocrine system, physical biorhythms, and physical complications during the mother’s pregnancy and childbirth (Swann, 2006). The amounts and activity of norepinephrine, serotonin, gamma-aminobu- tyric acid, and perhaps other nerve tract messengers are abnormal in persons with bipolar disorder, although the causes of these imbalances are unknown (Miklowitz, 2007). Some theories focus on the actions of the thyroid and other endocrine glands to account for ner- vous system changes that contribute to manic and depressive episodes. Biorhythms, or the body’s natural sleep and wake cycles, are erratic in some bipolar persons and may account for, or result from, chemical imbalances that trigger manic episodes. Finally, a few stud- ies have associated obstetrical complications with early-onset and severe bipolar disorder (Scott, McNeil, & Cavanaugh, 2006).

Psychosocial influences Stressful life events may play an activating role in early episodes of bipolar disorder, with subsequent episodes arising more in the absence of clear external precipitants (Newman, 2006). Many of these life events are associated with social rhythm disturbances (sleep, wake, and activity cycles) (Berk et al., 2007). Persons with bipolar disorder who have a history of extreme early-life adversity (e.g., as physical or sexual abuse) show an earlier age of onset, faster and more frequent cycling, increased suicidality, and more comorbid conditions, including substance abuse (Post, Leverich, King, & Weiss, 2001). Most clients can recognize that a depressive or manic episode is coming two to three weeks in advance (Marangell et al., 2006). Such symptoms include changes in motivation, sleep cycle distur- bances, impulsive behavior (for mania), and changing interpersonal behavior. Although such insight may be fleeting, the client may avoid a full manic or depressive episode if he or she receives intervention during this time.

Course and recovery

Bipolar I disorder is highly recurrent, with 90% of persons who have a manic episode de- veloping future episodes (Sierra, Livianos, Arques, Castello, & Rojo, 2007). The number of episodes tends to average four in 10 years (APA, 2000). Approximately 50% of persons with bipolar disorder move through alternating manic and depressed cycles (Tyrer, 2006). About 10% experience rapid cycling (APA, 2000), which implies a poorer long-term out- come, because such persons are at a higher risk for both relapse and suicidal ideation (75% have contemplated suicide) (Mackinnon, Potash, McMahon, & Simpson, 2005). The prob- ability of recovery is also decreased for persons with severe onset and greater cumulative

Part Four: Bipolar and Related Disorders74

comorbidity (Solomon et al., 2010). It is estimated that 40% have a “mixed features” type of the disorder, in which a prolonged depressive episode features short bursts of mania. Women are at risk for an episode of bipolar disorder in the postpartum stage, and they experience rapid cycling more than men do, possibly because of hormonal differences and natural changes in thyroid function (Barnes & Mitchell, 2005). A majority of those affected (70 to 90%) return to a stable mood and functioning capacity between episodes. Between 5 and 15% of persons with bipolar II disorder develop a manic episode within five years, which means that their diagnosis must be changed to bipolar I disorder (APA, 2000). Stud- ies of the natural course of the disorder over one decade indicate that persons with bipolar I  disorder experience depression for 30.6% of weeks, compared with 9.8% of weeks for hypomanic or manic symptoms (Michalak, Murray, Young, & Lam, 2008).

A recent meta-analysis of the literature has summarized the predictors of relapse in bipolar disorder (Altman, Haeri, & Cohen, 2006). Major predictors include the number of previous manic or depressive episodes, a history of anxiety, a persistence of affective symp- toms even when the mood is relatively stable, and the occurrence of stressful life events. Other predictors include poor occupational functioning, a lack of social support, high

Risk Influences Protective Influences

Biological Biological

Childhood onset Adolescent or adult onset

Antidepressant drugs (for bipolar I type)

Number of previous episodes

Persistence of affective symptoms Absence of interepisode mood symptoms and medication adherence

Substance use

Psychological Psychological

Irregular social rhythms Regular social rhythms, sleep cycle

Introversion/obsessiveness

History of anxiety Knowledge about the disorder

Exaggerated use of denial Willingness to assume responsibility for the disorder

Social Social

Low levels of social support Identification and use of social and community resources

Participation in support groups

Absence of professional intervention Ongoing positive alliance with family, mental health professionals

Marital conflicts

Work-related difficulties

High family expressed emotion

Sources: Miklowitz, 2007; Schenkel, West, Harral, Patel, & Pavuluri, 2008; Tyrer, 2006.

Risk and Protective Influences for the Course of Bipolar Disorder Table 6.2

Bipolar and Related Disorders 75

levels of expressed emotion in the family, and the personality characteristics of introversion and obsessive thinking. We will elaborate on many of these predictors later.

Persons with bipolar disorder tend to experience serious occupational and social prob- lems (Marangell et al., 2006). One study indicated a stable working capacity in only 45% of clients, and 28% experienced a steady decline in job status and performance (Hirschfeld, Lewis, & Vornik, 2003). Missed work, poor work quality, and conflicts with coworkers all contribute to the downward trend for clients who cannot maintain mood stability. From 30 to 60% fail to regain full function between episodes with regard to vocational and so- cial performance. A systematic review by Burdick, Braga, Goldberg, and Malhotra (2007) suggests that although general intellectual function is preserved in persons with bipolar disorder who have stabilized, there may be some negative effects related to verbal memory and attention capacity.

An adolescent who develops bipolar disorder may experience an arrest in psycho- logical development, thus developing self-efficacy and dependency problems that endure into adulthood (Floersch, 2003). A study of 263 children and adolescents with the disorder highlighted some issues related to course (Birmaher et al., 2006). Approximately 70% of the subjects recovered from their first episodes and 50% showed at least one recurrence, most often with a depressive episode. Table 6.2 summarizes the risk and protective factors for the course of the disorder, and Box 6.2 lists other risk influences for bipolar disorder among members of vulnerable populations.

Clients who experience high levels of life stress after the onset of bipolar disorder are four times more likely to have a relapse than clients with low levels of life stress (Tyrer, 2006). Events that can cause these episodes include disruptions in social and family sup- ports and changes in daily routines or sleep–wake cycles, such as air travel and changes in work schedules.

females

• Women are at greater risk of developing bipolar II disorder, which is characterized by symptoms of major depression.1

• Women have an increased risk of developing sub- sequent episodes of bipolar I disorder during the postpartum period.2

• Women are more likely to experience a first epi- sode of depression in bipolar I disorder.

• Rapid-cycling bipolar disorder is more common.3

• Women with bipolar disorder are more likely than men to have a comorbid disorder.

• Women with bipolar disorder are more likely to die earlier than women without the disorder.

• Women are more at risk for anxiety disorders and thyroid problems.

youths

• Extreme early-life adversity may place one at more risk of developing bipolar disorder. This experience may also predetermine an earlier age of onset, faster and more frequent cycling, increased sui- cidality, and more comorbid conditions (including substance abuse).4

race

• Prevalence of bipolar disorder is less among persons of Asian background, but similar among Caucasians, Latinos, and African Americans.

Sources: Ingram & Smith, 2008; Michalak, Murray, Young, & Lam, 2008; Muroff, Edelsohn, Joe, & Ford, 2008; Taylor & MacQueen, 2006.

1Hilty, Brady, & Hales, 1999. 2Hilty et al., 1999. 3Hilty et al., 1999. 4Post, Leverich, King, & Weiss, 2001.

box 6.2 bipolar disorder in vulnerable and oppressed Populations

Part Four: Bipolar and Related Disorders76

One study found that relapse risk was related to both the lingering presence of symptoms of mania and harsh comments from relatives (Schenkel, West, Harral, Patel, & Pavuluri, 2008). Clients from families that are high in expressed emotion (critical com- ments) were likely to suffer a relapse during a nine-month follow-up period. Another study of 360 persons with bipolar disorder indicated that family interactions had impact on the one-year course of the disorder (Miklowitz, Wisniewski, Otto, & Sachs, 2005). Clients who were more distressed by their relatives’ criticisms had more severe depressive and manic symptoms than persons who were less distressed.

intervention

The National Comorbidity Study indicates that 80.1% of all persons with bipolar disorder have received some type of intervention (Merikangas et al., 2007). In another study, more than half (53.9%) of those who sought treatment attended a mental health facility, although 38.3% received services from general medical providers and 20.9% received treatment from non–health care providers (percentages are overlapping) (Wang, Berglund, et al., 2005). These statistics are significant, in that medication is always recommended as a primary intervention for bipolar disorder, so clients will likely benefit from seeing psychiatrists. Psychosocial interventions can be helpful for controlling the course of the disorder. A re- cent literature review found that service providers prefer first to stabilize the client’s mental status and then introduce psychosocial interventions (Fava, Ruini, & Rafanelli, 2005).

medications

The Food and Drug Administration (FDA) has approved a number of medications for the treat- ment of bipolar disorder (Ketter & Wang, 2010). These are summarized in Table 6.3. Most phy- sicians recommend that clients take medication even after their moods stabilize to reduce the risk of recurrence of another mood episode. Generally a single mood-stabilizing drug is not effective indefinitely, and a combination of medications is more often used (Hamrin & Pachler, 2007). It must be emphasized that although older adults may benefit from the same medications as younger populations, they are more susceptible to adverse effects (Young, 2005). Lithium,

D i r e c t i o n s P a r t I I , B i o p s y c h o s o c i a l R i s k a n d P r o t e c t i v e F a c t o r s Assessment Using the directions in the appendix, formulate a risk and protective factors assessment, both for the onset of the disorder and for the course of the disor- der, including the strengths that you see for this individual. What techniques could you use to elicit additional strengths in this client?

Symptoms Medication

For acute mania

For maintenance of stable mood following an acute phase For long-term treatment of bipolar disorder For acute bipolar depression

Lithium, carbamazepine, divalproex, risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole Lithium, olanzapine, lamotrigine, and aripiprazole

Lithium, lamotrigine, and olanzapine The combination of olanzapine and fluoxetine

FDA-Approved Medications Used to Treat Bipolar Disorder Table 6.3

Bipolar and Related Disorders 77

carbamazepine, valproate, and lamotrigine are all used with children who have bipolar disorder, although none has been subjected to randomized, controlled trials (Findling, 2009).

Lithium is the best studied of the mood-stabilizing drugs. It is effective for stabilizing both manic and depressive episodes in bipolar disorder, although it takes several weeks to take effect and is more effective for treating manic than mixed or rapid-cycling episodes (Huang, Lei, & El-Malach, 2007). As a maintenance drug, lithium has been shown in a meta-analysis to be effective in preventing all types of relapses, but it is most effective with manic relapses (Geddes, Burgess, Hawton, Jamison, & Goodwin, 2004). Lithium also has a positive effect on clients’ suicidal ideation. A meta-analysis documented an 80% decrease in such episodes for consumers who have used the drug for 18 months (Baldessarini et al., 2006). Another meta-analysis demonstrated that lithium, compared to both placebo and other medications, is effective in the prevention of deliberate self-harm (with 80% fewer episodes) and death from all causes (55% fewer episodes) in persons with mood disorders (Cipriani, Pretty, Hawton, & Geddes, 2005). Still, lithium is less effective at preventing re- lapses after about five years of use (Scott, Colom, & Vieta, 2007).

The difference between therapeutic and toxic levels of lithium is not great, so monitoring blood levels is important. Most of the common side effects of lithium are tran- sient and benign, but diarrhea, dizziness, nausea and fatigue, slurred speech, and spastic muscle movements characterize lithium toxicity. Lithium should not be prescribed for women during pregnancy, as it is associated with fetal heart problems (Bowden, 2000), and breast-feeding women should not use it because it is excreted in breast milk. Lithium seems to have an antiaggression effect on children and adolescents (Carlson, 2002). It is not advised for children under age eight, as its effects on them have not been adequately studied. Adolescents appear to tolerate long-term lithium use well, but there are concerns about its accumulation in bone tissue and effects on thyroid and kidney function. The decreased kidney clearance rates of older adults put them at a higher risk for toxic blood levels (Schatzberg & Nemeroff, 2001).

Another class of medications, the anticonvulsants, is also effective for the treatment of bipolar disorder, although like lithium they are not effective in treating mania in its ear- liest stages. Three of these are FDA-approved: valproate, carbamazepine, and lamotrigine (Melvin et al., 2008). These medications offer an advantage over lithium in that they usu- ally begin to stabilize a person’s mood in two to five days. A recent systematic review, how- ever, concluded that these drugs are not more effective than lithium overall in preventing relapses (Hirschowitz, Kolevzon, & Garakani, 2010).

Valproate is the most thoroughly tested of the anticonvulsants. Carbamazepine is an alternative to lithium and valproate, but its side effects tend to be more discomfiting than those of the other drugs, and only about 50% of clients who use the medication were still taking it one year later (Nemeroff, 2000). A third anticonvulsant drug, lamotrigine, is used less often to treat manic episodes, but according to a large randomized trial, it is the only drug that is effective for bipolar depression (Bowden, 2005).

The anticonvulsant drugs are all used in the treatment of children with bipolar disorder, but few studies have been done to establish long-term safety (McIntosh & Trotter, 2006). The same qualifications that apply to lithium for pregnant women, children, and older adults also apply to the anticonvulsant medications. Carbamazepine is used more cautiously with chil- dren, as it can precipitate aggression (Ginsberg, 2006), and it has also been associated with developmental and cranial defects in newborns (Swann & Ginsberg, 2004).

Antidepressant medications (usually the selective serotonin reuptake inhibitors) are not generally used for the treatment of bipolar I disorder. They have been shown to induce mania in as many as one third of all clients, and one fourth of consumers experience the activation of a rapid-cycling course (Vieta & Suppes, 2008). In bipolar II disorder, however, the antidepres- sants may be used along with an antimania drug for mood stabilization (Cipriani et al., 2006). After a first episode of bipolar depression, antidepressant therapy should be tapered in two to six months to minimize the possibility of the development of a manic episode.