‘Regaining My Balance’ is a psychoeducation module for bipolar disorder that Dr Kadir Abu Bakar, president of the Malaysian Psychiatric Association, emphasises can help those with the disorder cope better.
IMAGINE being caught in a situation where you’re precariously perched on a pendulum of extreme mood swings.
As clichéd as it sounds, it is like being blackmailed to be an unwilling voyager on a rollercoaster ride whilst blind-folded – never being able to predict when the carriage, travelling at intense speeds, will whisk you upwards, or take a nose-dive to hit rock bottom.
In between the two emotional extremes, there are the “normal” days – days that bring challenges and rewards, laughter and tears, hope and regret, determination and resignation.
Each night, before you can sleep, you fervently pin all your hopes on some divine intervention: “Please God, make tomorrow a ‘normal’ day.”
Bipolar disorder is a serious and complex brain disease that affects specific areas of the brain that regulate mood. According to president of the Malaysian Psychiatric Association and senior consultant psychiatrist Dr Kadir Abu Bakar, it is estimated to afflict approximately 3% of the Malaysian population. Though this may not be a significant number at first glance, the reality is that bipolar disorder ranks among the top 10 most disabling disorders in working age adults worldwide (The World Health Organization 2002), and the socioeconomic impact is considerable.
Studies have documented that individuals with bipolar disorder spend substantially more time in the depressive state, as compared to being hypomanic or manic. This is a grave concern as the symptoms of depression, which include persistent and frequent sadness or despair, loss of interest in usually enjoyable activities and chronic fatigue, is far more debilitating.
As reported in The Lancet (2013; 381: 1672-82), antipsychotic drugs are effective in the acute and maintenance treatment of bipolar disorder. Although these medications, or pharmacotherapy, are the first-line treatment for bipolar disorder, numerous researchers have indicated that medication alone often fails to bring individuals suffering from bipolar disorder to a sustained remission.
Dr Kadir elaborates that even patients who receive adequate pharmacotherapy and strictly follow their prescribed treatments, continue to suffer from relapses, or experience lengthy and debilitating symptoms.
In a Spanish study, it was estimated that about 37% of patients relapse into depression or mania within a year, and 60% within two years. Each relapse makes it harder for the patient to gain remission, not only because relapses kill precious brain cells, but also because more issues seem to surface during the course of each relapse, states Dr Kadir.
A silver lining
Treatment guidelines increasingly suggest that optimum management of bipolar disorder needs the integration of pharmacotherapy with targeted psychosocial treatments.
Psychological approaches build on evidence that psychosocial stressors, including family discords, negative life events, or events that disrupt the patient’s sleep rhythms, are associated with relapses and worsening of symptoms.
A novel psychological intervention model, psychoeducation, developed as a result of the Spanish trial, has emerged as an effective strategy in preventing new episodes of mania or depression, and improving social functioning for patients with bipolar disorder.
A major difficulty with bipolar disorder is the inability of the patient to recognize his or her own condition, particularly when in the manic state. Patients often deny their symptoms, which may be perceived as positive feelings.
Psychoeducation, Dr Kadir explains, is a form of training for patients and their families to help them cope with their illness, and to avoid relapses by understanding the way treatment works, the need for absolute treatment compliance, and most importantly, to identify early warning signs of relapse, and help them develop well-structured daily habits.
Psychoeducation involves providing patients and their families with accurate and reliable information about their diagnosis to empower them to better manage their illness.
The evidence for the use of psychoeducation and family-focused therapy as prophylactic adjuncts to medication in people with stabilised bipolar disorders is, at present, quite conclusive.
Dr Kadir asserts that psychoeducation can go very far in terms of treating the patient.
“Psychoeducation opens the door. This is the door of knowledge, which will never shut on the person who is seeking it. It is akin to asking how far a university education can go towards broadening your perspectives and making you a better person – the answer is very, very far.”
Citing another chronic illness as an example, if you are ill with diabetes, how far can education and knowing about diabetes help you?
Well, you can say, look, this piece of cake is 550 calories; I’ve already eaten 1,100 calories today. So if I choose to eat that cake, I have to avoid rice for dinner. Then, I also have to remember to administer my insulin jab on time to stabilise my blood glucose levels.
Similarly, psychoeducation can help with bipolar disorder. In a large way, it helps the patient lead a normal life, despite illness.
The key is to give patients a sense of independence, empowerment, and ultimately, to give them skills to manage their own lives effectively.
Modules for living
That is why modules like “Regaining My Balance” are important for such patients. “Credit must be given to AstraZeneca, who is the first private corporation in Malaysia to help to promote and heighten awareness of psychoeducation on bipolar disorder,” says Dr Kadir.
“Regaining My Balance” modules are mainly psychoeducation-focused, although other behavioural factors that may go beyond information (lifestyle regularity, stress management) are included.
“To be economically sustainable, psychoeducation protocols need to be made briefer for settings that serve large number of patients and have few resources for clinician training,” notes Dr Kadir.
Elements of the “Regaining My Balance” psychoeducative programme include:
Module 1: Understanding your illness
Module 2: Understanding your treatment
Module 3: Family education
Module 4: Maintaining wellness
Module 5: Crisis management
Module 6: Recovery strategies
It is true for every patient out there that psychoeducation helps prevent a relapse, asserts Dr Kadir. If they recognise relapse, they know what to do during a relapse; they are not ashamed to have a relapse; they don’t blame themselves; and they seek help from their doctor.
What is crazy, anyway?
At the end of the day, it is the families’ frustrations that has to be overcome. With each relapse episode, the support group for the patient gets less and less. Dr Kadir has witnessed this all too many times.
“The wife gets tired; the sister says ‘I give up’, the parents don’t know what else to do...”
In the end, the patient is left alone with the doctor, and he ends up in the mental hospital for a long, long time.
Psychoeducation can help deal with a family’s frustrations by continuously giving them information on what must be done and what can be done; therefore empowering them to assert hope.
“I usually tell families that the relapse rate is 50:50; this gives them hope that treatment will be effective,” says Dr Kadir.
Hanging on to hope can be a dangerous thing, for it can propel your spirits sky-high, but subsequently, leave you shattered. The sad reality that bipolar patients have to accept is that there are no sure-fire methods or treatments that can fully guarantee the avoidance of a relapse.
But does it mean you should just give up, and succumb to your illness by perpetuating a self-fulfilling prophecy?
By equipping yourself with knowledge, even when life throws you a difficult situation to handle, you can seek solace and comfort in the fact that it is only the surface of the glass that is cracked; the fundamental you within remains intact.
In the words of the famous Greek poet Aeschylus, “I’m not afraid of storms, for I’m learning to sail my ship.”