Among the problems associated with lithium includes the fact the long-term lithium treatment has been associated with decreased thyroid functioning in patients with bipolar disorder. Preliminary evidence also suggest that hypothyroidism may actually lead to rapid-cycling (Bauer et al., 1990). Another problem associated with the use of lithium is its use by pregnant women. Its use during pregnancy has been associated with birth defects, particularly Ebstein's anomaly. Based on current data, the risk of a child with Ebstein's anomaly being born to a mother who took lithium during her first trimester of pregnancy is approximately 1 in 8,000, or 2.5 times that of the general population (Jacobson et al., 1992). Anti-convulsants There are other effective treatments for bipolar disorder that are used in cases where the patients cannot tolerate lithium or can become unresponsive to it in the past. The American Psychiatric Association's guidelines suggest the next line of to be anticonvulsant such as valproate and carbamazepine. These drugs are useful as antimanic agents, especially in those patients with mixed states. Both of these medications can be used in combination with lithium or in combination with each other. Valproate is especially helpful for patients who are lithium noncompliant, experience rapid-cycling, or have comorbid alcohol or drug abuse. Neuropletics

Neuroleptics such as haloperidol or chlorpromazine have also been used to help stabilize manic patients who are highly agitated or psychotic. Use of these drugs is often necessary because the response to them are rapid, but there are risks involved in their use. Because of the often severe side effects, benzodiazepines are often used in their place. Benzodiazepines can achieve the same results as Neuroleptics for most patients in terms of rapid control of agitation and excitement, without the severe side effects. Anti-depressants Antidepressants such as the selective serotonin reuptake inhibitors (SSRIs) fluovamine and amitriptyline have also been used by some doctors as treatment for bipolar disorder. A double-blind study by M. Gasperini, F. Gatti, L. Bellini, R.Anniverno, and E. Smeraldi showed that fluvoxamine and amitriptyline are highly effective treatments for bipolar patients experiencing depressive episodes. This study is controversial, however, because conflicting research shows that SSRIs and other antidepressants can actually precipitate manic episodes. Most doctors can see the usefulness of antidepressants when used in conjunction with mood stabilizing medications such as lithium.

In addition to the mentioned medical treatments of bipolar disorder, there are several other options available to bipolar patients, most of which are used in conjunction with medicine. One such treatment is light therapy. One study compared the response to light therapy of bipolar patients with that of unipolar depresses patients. Patients are free of psychotropic and hypnotic medications for at least one month before treatment.

Bipolar patients in this study showed an average of 90.3~ improvement in their depressive symptoms, with no incidence of mania or hypomania. They all continued to use light therapy, and all showed a sustained positive response at a three month follow-up (Hopkins and Gelenberg, 1994). Another study involved a four week treatment of morning bright light treatment of patients with seasonal affective disorder, including bipolar patients. This study found a statistically significant decrement in depressive symptoms, with the maximum antidepressant effect of light not being reached until week four.

Hypomanic symptoms were experienced by 36~ of bipolar patients in this study. Predominant hypomanic symptoms included racing thoughts, deceased sleep and irritability.

Surprisingly, one-third of controls also developed symptoms such as those mentioned above. Regardless of the explanation of the emergence of hypomanic symptoms in undiagnosed controls, it is evident from this study that light treatment may be associated with the observed symptoms. Based on the results, careful professional monitoring during light treatment is necessary, even for those without a history of major mood disorders.

Another popular treatment for bipolar disorder is electro-convulsive shock therapy.

ECT is the preferred treatment for severely manic pregnant patients and patients who are homicidal, psychotic, catatonic, medically compromised, or severely suicidal. In one study, researchers found marked improvement in 78~ of patients treated with ECT, compared to 62~ of patients treated only with lithium and 37~ of patients who received neither, ECT or lithium (Black et al., 1987).

A final type of therapy that I found is outpatient group psychotherapy. According to Dr. John Graves, spokesperson for The National Depressive and Manic Depressive Association have called attention to the value of support groups, challenging mental health professionals to take a more serious look at group therapy for the bipolar population.

Research shows that group participation may help increase lithium compliance, decrease denial regarding the illness, and increase awareness of both external and internal stress factors leading to manic and depressive episodes. Group therapy for patients with bipolar disorders responds to the need for support and reinforcement of medicationmanagement, the need for education and support for the interpersonal difficulties that arise during the course of the disorder.