Adherence is an issue that confronts anyone working to manage a difficult medical condition like bipolar disorder. bp Magazine investigates the unique challenges faced by those with mental illness and offers insight for those facing the medication journey.

Peter Newman spent his youth in Birmingham, England and got what he calls "a quite nice telecom job in London." He had his first depressive episode at age 17 and was finally diagnosed with bipolar disorder at age 25. During a particularly acute manic episode, he applied to a Cambridge PhD program and was rather surprised to find himself accepted.

Today, almost 50, Peter Newman, PhD, works as a software engineer in Silicon Valley, enjoying long periods of health, stability, and clarity. These are interrupted unpredictably by episodes of illness, mostly manic ones.

Looking back at the course of his up-and-down existence, Peter says, "I have been taking prophylactic medication for over 20 years. I've had episodes during this time. I had my doubts about the efficacy of the medication, but I kept taking it. Recently, when I changed my medical insurance, there was a period when I could not obtain the medication. I doubt it was just a coincidence that my first episode in eight years occurred while I was not taking the tablets. I should have paid for the medication myself and claimed it back on the insurance later."

Taking drugs doesn't seem natural

For various reasons, "it's the nature of people not to adhere to medical treatment. People with any condition are in general better at not adhering rather than adhering," explains Michael E. Thase, MD, professor of psychiatry at the University of Pittsburgh School of Medicine. However, mental illnesses pose special adherence challenges, explains Dr. Thase, making a point voiced by many experts. "You don't want to be mentally ill and have to take annoying treatments. You want this [problematic behavior and emotional state] to just be your personality what is unique and idiosyncratic about you. This is how bipolar disease differs from heart disease or ulcers. When you have ulcers, you don't have to come to sense who you are as involving having an erosion in your stomach."

And just as an ulcer patient may need to be careful about diet and other lifestyle choices as well as taking medicine, so must a person living with bipolar look at his or her treatment in broad terms. Careful use of medication coupled with a sound diet, regular exercise, and plenty of sleep all contribute greatly to the best health for those affected.

Finding self-awareness

Solid new research has shown that in someone diagnosed, physical changes in the brain hamper that person's ability to fathom the truth of his or her own situation. In other words, the brain dysfunction that is part of bipolar itself often impairs the development of insight or self-awareness concerning the disorder and how best to cope. For relatives of a consumer, this fact can be of critical importance when they offer help. "When you face the frustration of trying to convince a loved one to get or to adhere to treatment, urges Xavier Amador, PhD, remember that the enemy is brain dysfunction, not the person"a point he underscores in his book, I Am Not Sick, I Don't Need Help: Helping the Seriously Mentally Ill Accept Treatment: Practical Guide for Families and Therapists.

Dr. Amador says that ample research has shown that vigilant adherence is key for the best health outcomes. "It's always been clear that consistent treatment is critical in the prevention of suicide, violence, and all sorts of dangerous behaviors," he says. "What had not been clear until quite recently is the huge positive effect that early, ongoing treatment has on the lifetime course of this illness. Whenever someone with serious mental illness has another episode, the long-term outlook for them gets worse. When you can intervene early and limit the number of full-blown psychotic episodes that a person has, he will have much better health and a much higher level of functioning later on in life." Many scientists believe that psychotic episodes are toxic to the brain; Dr. Amador says that there is a great deal of indirect evidence to bolster this notion.

Understanding means doing better

Experts differ on the exact extent of the bipolar medication nonadherence problem, but agree that it is significant. "Most studies find that about half of the people with serious mental illness don't take their medication," says Dr. Amador. Charles Bowden, MD, cites somewhat more encouraging numbers, stating that most studies find "the range of people [living with bipolar] who are in poor compliance to be in the range of 25 percent to 40 percent." He serves as a professor of psychiatry and pharmacology at the University of Texas Health Science Center.

Experts do agree that good understanding about bipolar disorder promotes adherence. Dr. Amador says that a consistent finding among most studies is that the more aware a seriously mentally ill person is of his or her illness and of the benefits they can gain from treatment the better they will do. Research he has done with colleagues has shown that the two crucial aspects of insight that promote good adherence and good outcomes are:

• awareness of certain early warning signs of deterioration, and
• understanding of the benefits of treatment.

Still, learning to deal with bipolar can prove hard and that’s understandable, says Dr. Bowden, when you consider that both the disorder itself and the means to treat it are quite complex. He explains: “This condition is multifaceted. It’s not something you can learn enough about through ten minutes of reading, or looking on the Internet.” Understanding bipolar can prove especially hard both for consumers and their loved ones, because its very nature often involves long stable periods interrupted by spells of illness. The range of treatment options struck Peter Newman as an important hurdle: “Everybody responds differently,” he says. “Some stuff works for some people. Some stuff works for others.”