3 Diagnosis and Treatment Indications (p 28-29)
This chapter provides advice on treatment indications - that is, how to determine the most appropriate treatment. After describing basic issues, we include a decision tree for evaluating the best treatment options/settings, and specific advice for addressing common presentations.
Even though treating BD can be extremely gratifying, not every practitioner will want to take on the responsibility of treating patients with BD in a private practice setting. Patients with BD provide significant clinical challenges, with complex problems and co-occurring disorders. Certain patients cannot be properly treated in a private practice setting, because their symptoms are too serious to be appropriately managed without access to partial hospitalization or inpatient services. How will you decide whether or not you should consider treating a given individual with BD? As summarized in Table 12, your decision-making should consider the stability of the patient, the presence of high-risk symptoms, their willingness to comply with psychiatric and psychological treatment regimens, and the presence of a robust social support system. It is also extremely helpful to have effective communication with psychiatric treatment providers if you are not directly managing medications.
Table 12 Determining if an Outpatient Setting Is Appropriate for the Patient
- Has the patient agreed to take a mood stabilizer, receives current psychiatric care, and is treatment adherent?
- Is there a pattern of recent instability, hospitalizations, or emergency room visits suggesting that standard outpatient treatment will not be sufficient for the patient to remain stable?
- Does the patient have a stable living situation?
- Does the patient have sufficient social support available?
- Does the patient present an acute suicide risk that cannot be managed in outpatient care?
- Will the patient be able to comply with the requirements of outpatient treatment in terms of attending for regularly scheduled appointments?
- Is the patient sufficiently motivated to commit to a course of outpatient treatment?
3.1 Decision Tree for Determining Optimal Treatments
Pharmacological intervention should always be a part of the treatment plan. There are many psychological treatments to consider, and because these have received equivalent levels of research support, treatment planning should be individualized to the patient. In addition to a standard diagnostic assessment discussed in Chapter 1, treatment planning should be guided by the items in Table 13, such as the severity, phase, and course of the illness. Although psychoeducation may be particularly helpful early in the course of the disorder, many patients with highly recurrent illness already have a strong understanding of the nature of the illness and medication treatments. For those patients, considering the extent to which cognitive, behavioral, interpersonal, and family triggers may be relevant should guide your choice of intervention strategies.