Medication compliance is often a problem for people with bipolar disorder. Here's how to help.

For patients suffering from bipolar disorder, it's not uncommon that they don't take medications as prescribed. There are many reasons for this. Some medications for bipolar disorder can cause unpleasant side effects in some patients. Treatment may not be effective or may be perceived as not effective by the patient. Patients may miss the "high" feeling that comes with manic episodes. Bipolar patients who have substance abuse problems are much less like to take their medication.

Bipolar patients may not view themselves as ill, especially during an episode. This is, perhaps, the greatest obstacle to medication compliance among some patients. Someone who does not think they are sick can hardly be expected to take medication.

If bipolar medication noncompliance is a problem for your loved one, consider these steps:

• Ask your loved one's health care professional for specific advice.
• Explain that taking medication regularly can help reduce the severity and duration of a manic episode.
• Investigate psychotherapy options. Cognitive-behavioral therapy, for example, has been shown to improve medication compliance in bipolar disorder patients and help them better cope with stress.
• If side effects are a problem for your loved one, ask his or her health care professional about changing medications, reducing dosage, and/or treating side effects.
• Simplify your loved one's medication regimen by using a pill organizer.
• If appropriate, think about giving your loved one incentives/positive reinforcement for taking medications.

It's common for people with bipolar disorder to stop taking medications. Discover how to improve bipolar medications compliance.

Why Many Don't Take Their Bipolar Medications

Welcome to our bipolar treatment adherence area. Here, we'll discuss why people with bipolar disorder stop taking their medications, the effects of that and what can be done to improve medication adherence.

The failure of individuals with bipolar disorder to take prescribed medications (usually antipsychotics and/or mood stabilizers such as lithium) is one of the most serious problems in psychiatric care. It often leads to a relapse of symptoms, rehospitalizations, homelessness, incarceration in jail or prison, victimization, or episodes of violence.

The failure to take medication is referred to as medication noncompliance or medication nonadherence; the latter is a better term. Nonadherence is also a problem for other medical conditions for which medication must be taken for long periods, including hypertension, diabetes, epilepsy, asthma, and tuberculosis. Nonadherence may be total but is more often partial; it has been suggested that partial adherence be defined as a failure to take 30 percent or more of the prescribed medication during the past month.¹

Why People with Bipolar Stop Taking Medications

Did you know that the single most significant reason why individuals with bipolar disorder fail to take their medication is because of their lack of awareness of their illness (anosognosia)? Other important reasons are concurrent alcohol or drug abuse and a poor relationship between psychiatrist and patient.

Medication side effects, widely assumed to be the most important reason for medication nonadherence, is, in fact, a less important reason compared to the other factors cited. The major reasons for nonadherence with bipolar medications are the following:

Lack of awareness of the illness, also called anosognosia.

Lack of awareness of illness is the single most important reason for nonadherence with medications. In a recent review, 10 of 14 studies that examined awareness of illness and nonadherence in schizophrenia reported that the two are strongly associated.² The other four studies were carried out in countries in which there is a very high rate of patient adherence to medications (e.g., Ireland, 80 percent adherence) because most patients still do whatever the doctor tells them to do; this high adherence rate makes it difficult to measure the effects of lack of awareness.³

Other recent studies have also reported a strong association between lack of awareness and medication nonadherence.⁴ For example, a study of 218 outpatients reported that the correlation between awareness of illness and adherence with medication was highly statistically significant (p<0.007).⁵

When impaired awareness of illness is compared with other reasons for medication nonadherence, it is invariably found to be the single most important reason.⁶ This is true for individuals with bipolar disorder as well as for those with schizophrenia.⁷

Concurrent alcohol or drug abuse

The second most important reason for medication nonadherence in individuals with schizophrenia and bipolar disorder is concurrent substance abuse. This association has been reported in at least 10 studies (Lacro et al. op cit.).⁸ In one such study, it was found that "substance-abusing patients with schizophrenia were 13 times more likely than non-substance-abusing patients to be noncompliant with antipsychotic medication."⁹

Among the reasons for this association is the fact that psychiatrists often tell patients to not drink alcohol when on medication (patients, therefore, stop medication so they can drink), and the fact that some medications counteract the effects of the alcohol or drugs (so the patient cannot experience the desired high).

Poor relationship between psychiatrist and patient

Every study that has examined this has found it to be a factor in patients' nonadherence to medications (Lacro et al., op cit.). It is often referred to as a poor therapeutic alliance.

Medication side effects

This is widely assumed to be crucial and is often cited as the most important reason why individuals with bipolar disorder fail to take their medications. Studies, however, suggest that it is a much less important reason than the three reasons discussed above. In one review, only 1 out of 9 studies found a significant association between side effects and medication adherence in individuals with bipolar and schizophrenia (Lacro et al., op cit.).

The comparative lack of importance of side effects in determining medication adherence is also suggested by studies comparing medication adherence in individuals taking first-generation antipsychotics (e.g., haloperidol/Haldol), which often have side effects bothersome to patients, and second-generation antipsychotics (e.g., Seroquel (quetiapine), Zyprexa, Abilify, Geodon), which have far fewer such side effects. Studies comparing adherence rates between first- and second-generation antipsychotics have reported them to be virtually identical.¹⁰

Other factors

Other factors known to contribute to medication nonadherence in individuals with bipolar disorder include cost of medication, no improvement of symptoms, confusion, depression, lack of access to medication because of being homeless or in jail, and (for individuals with bipolar disorder) purposeful stopping of medication because they enjoy being manic.

Effective treatments for cognitive deficits in depression do exist to help the many people with depression suffering from cognitive deficits in areas like memory, concentration, psychomotor skills (relating to muscular activity associated with thought), brain processing speed (slowed thinking) and decision making. Several strategies for treating cognitive deficits in depression have been developed to deal with these challenges.

Remediation Techniques in the Treatment of Cognitive Deficits in Depression

Remediation techniques are drills and exercises designed to reduce the cognitive symptoms associated with depression. These exercises may be done by hand, online or in groups. Computer assisted learning lessons that exercise memory in the form of a game is one example of a remediation technique.

Remediation techniques may also be applied holistically and focus not just on specific cognitive deficits but on psychosocial functioning as a whole. For example, the Neuropsychological Educational Approach to Rehabilitation (NEAR) technique has goals including:

• Improving neurological/psychological functioning
• Gaining an understanding of learning style and providing positive learning experiences
• Promoting awareness of social-emotional context
• Promoting independent learning skills
• Promoting confidence, competence and motivation

The NEAR approach uses computer-assisted learning sessions multiple times per week plus group sessions where sharing is encouraged and specific activities are done to improve cognitive functioning.

Compensatory Strategies in the Treatment of Cognitive Deficits in Depression

Compensatory strategies in the treatment of cognitive deficits in depression focus on trade-offs, positing that there is more than one way to accomplish a given task. These strategies focus on a person's cognitive strengths to make up for their cognitive deficits.

Usage of mnemonic devices is one compensatory strategy. For example, if one needs to get five things from the market but knows he or she is likely to forget all five, they might be able to remember a sentence more easily such as, "Eggs are good for you." This would remind the person to buy eggs, artichokes, gala apples, figs and yogurt.

Understanding one's most effective learning style and creating simple plans that require the least amount of effort are needed to make compensatory strategies work in the treatment of cognitive impairment.

Adaptive Approaches in Dealing with Cognitive Deficits in Depression

Adaptive approaches don't treat the cognitive deficits in depression but, rather, admit that some cognitive deficits are persistent and find ways to work around them.Changes in the environment are used rather than changes in the individual. The usage of human and non-human resources are used in this approach.

A simple example of an adaptive approach is the use of a cell phone to write down grocery lists or record the audio of a task list. Family members may also find they adapt to a person's cognitive deficits by acting on his or her behalf in certain situations.

Medication in the Treatment of Cognitive Deficits in Depression

Medication is not typically used in the treatment of cognitive deficits in depression. However, in a recent systematic review, it was found that some antidepressants do improve cognitive impairment in depression. Data suggests that the following depression medications may improve cognitive deficits:

• Selective serotonin reuptake inhibitors (SSRIs)
• The selective serotonin reuptake inhancer, tianeptine (not approved in the United States)
• The serotonin norepinephrine reuptake inhibitors (SNRIs) duloxetine (Cymbalta) and vortioxetine (Brintellix)
• Other antidepressants bupropion (Welbutrin) and moclobemide (not approved in the United States)

No definitive information on dosages or which medications are best in which circumstances is currently known.

article references

What caregivers need to know about symptoms of mania, medications to treat mania and caring for people with bipolar disorder.

What was once called manic depression or manic-depressive behavior is now called Bipolar I and Bipolar II disorder based on the presenting symptoms. The focus here will be on mania, or Bipolar I illness.

There are three levels of mania, beginning with cyclothymic disorder. This is not considered a major mental illness and there are plenty of people with this condition, who we all think of as very moody, with strong ups and downs. No medication is needed and the individual is able to function in all areas.

The second level of mania is hypomania, which means below mania, and it is more intense, and can be seen by spending sprees, food binging and minor disruption of daily living. There may be some absenteeism from work or school, and the tendency to engage in questionable and impulsive behavior exists. However, it is the degree of disruption of daily life and ability to function that determines the degree of mania.

Full blown mania is a frightening thing to see

While the patient feels confident, attractive and able to perform above and beyond his normal abilities, this false euphoria is the beginning stage of true Bipolar Disorder. Loved ones and family members often mistake this phase for drug use, and manics will describe this as a cocaine-like high.

Typical symptoms of full blown mania include rapid and sometimes violent mood swings, with laughter, crying and even rage. Insomnia is common, and often there is a decline in personal attention to grooming and hygiene, eating and concern for one's physical needs.

A manic may run outside in shirt sleeves or nightgown in a downpour, or may dress in a provocative and exposing way. They may refuse meals stating they will eat later or there is no time to eat, and you may have trouble even expressing your concerns before the patient's attention is directed elsewhere.

As the attention span decreases, the mind continues to race, and the manic likes to think of himself as the most clever and humorous individuals. Frequent jokes with an emphasis on punning and rhyming are classic presentation.

Also typical is a train of thought termed tangential

In tangential thinking, the individual in an acute manic phase will "go off on tangents." If you say "it is raining cats and dogs, you better put on a jacket", the patient will say "dog my cats!" or make reference to the movie "Full Metal Jacket and The Dog Days Of War." While initially entertaining, this rapidly becomes both tiring and exasperating for those attempting to co-exist with the manic patient.

Mania is caused by a biochemical imbalance in the brain, and there is a variety of mood stabilizing medications used in its treatment. The classic medication is lithium carbonate, a naturally occurring salt, which has a narrow range of effectiveness and can be toxic at high dosages.

Another medication, used for both mania and seizure control is carbamazepine (Tegretol). It is the drug of second choice but may be used if there are health problems such as heart or thyroid conditions that may preclude the use of lithium.

Bipolar patients have difficulty seeing that their behavior is out of line or that they can endanger themselves in an acute manic episode. The massive high, which seems abnormal to us seems normal to them, and there is an unfortunate tendency to self medicate or avoid medication whatsoever.

A manic who has been up for days without sleep or proper nutrition is at risk for developing manic related psychosis. Symptoms may include increased vigilance, paranoia, hallucinations such as believing others are whispering about them or are devils. In this phase acute, and frequently locked psychiatric observation and treatment is required.

At this extreme level of mania, it is common to find no therapeutic level of Lithium or Tegretol in the bloodstream. Strong medications called anti-psychotics or psychotropic often are given such as Haldol and Thorazine. The goal is to rapidly reduce the mania, using the above medications, anti-manic medications and sometimes tranquilizers in combination with close observation.

At this level patients cannot safely be managed in the home environment, and may suddenly turn on loved ones or friends. Some hostage situations and murder-suicides have been linked to this extreme and disorienting level of manic behavior.

In the home setting, once regulated on a maintenance dose of medication, it is important to follow the Doctor's stated regime exactly.

Medication side effects such as weight gain and edema can be expected but more severe adverse effects such as tremors, lethargy and a metallic taste in the mouth and vomiting should be reported immediately.

Be alert for increasing euphoria or high energy levels as the patient commonly decreases the amount of medication they are taking or flushes it from the body with abnormal amounts of fluid intake. A loved one who tells you everything is fine and brushes off your concerns is liable to be heading for another full-blown episode.

One way to avoid this is to be vigilant for sudden mood swings, noncompliance with regular lab tests and Doctor's visits, (these help to regulate the safe dose of medication in the bloodstream and will pinpoint non-medication compliance), and return of previously risky patterns.

It is said the patients with a Bipolar I diagnosis are often intelligent but not wise. It is then up to the caregivers to educate themselves, attend available support groups and be alert to help loved ones, and themselves, maintain the highest quality of life.

Sources:

• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Text Revision. Washington, DC: American Psychiatric Association; 2000.
• Merck Manuals Online Medical Library, Mania, updated Feb. 2003.

Caring for someone with bipolar disorder can be overwhelming. Read about ways to cope effectively.

Caring for someone with any illness is difficult. Caring for someone with bipolar disorder, a psychiatric illness, is especially hard for many reasons. Health care coverage is far more limited than for other illnesses. Just getting someone who is in a state of mania -- even when psychotic -- hospitalized and accurately diagnosed is a major accomplishment. Bipolar sufferers, particularly when they are in an up (manic) rather than down (depressed) phase, often refuse to see a clinician and stop taking their medication. The medications for bipolar disorder are powerful and have unpleasant side effects. There is no cure for bipolar disorder and so the drugs must be taken for life, a daunting prospect, especially for younger sufferers. Finding the right meds may take as long as several years, and over time they may stop working. For family caregivers, coping with someone who is bipolar, manic or depressed, takes a heavy emotional toll and strains the relationship, often to the breaking point. An added burden is the stigma of mental illness, which leaves families feeling frightened and isolated, unaware that many other families share their experience.

Given all these challenges, caring for someone with bipolar disorder can be overwhelming and at times an impossible responsibility to maintain. But there are ways to cope effectively. Families for Depression Awareness, the nonprofit organization I founded (after losing my brother and helping my father get diagnosed with depression), has interviewed many families that are doing well. True, it took a while to learn how best to help and support their bipolar family member, and time, too, to learn that caregivers also have needs that must be met. Sometimes the stresses and strains were intense, and these families have had their ups and downs. But by educating themselves about bipolar disorder, improving treatment by finding the best possible medication and therapy solutions possible, and communicating as a tightly knit unit, these families have met the challenges, survived intact, and are emotionally healthy.

Ways of Caring for Someone with Bipolar Disorder

Here are ways that you can help someone with bipolar disorder:

• Become educated. The first step is to become educated about bipolar disorder, so you have realistic expectations and coping options. There are books, brochures, and videos on a variety of topics. We have Family Profiles, (stories of people who cope with bipolar disorder), a brochure, and other resources on our web site, www.familyaware.org.
• Make this is a family matter. Acknowledge that one family member's bipolar disorder affects the entire family. Everyone in your immediate family needs to learn about bipolar disorder, its symptoms and early warning signs, how bipolar is treated, and what the side effects of bipolar medications may be. And to whatever degree possible, each member should participate in the caregiving process. Being a caregiver is stressful, and it is important that family members discuss their feelings and opinions. Sometimes it helps if a skilled family therapist facilitates these discussions in group sessions.
• Be a partner in treatment. Find the right treatment for each individual bipolar sufferer usually means going through a process of trial and error with multiple different medications. Patients also need talk therapy to heal. Finding qualified clinicians (e.g., psychopharmacologist, psychiatrist, psychologist) is essential. As a family caregiver, you can help by finding the best clinicians in your area, scheduling appointments, keeping track of medications and making sure they are taken as prescribed, and being an early warning systems by reporting changes to the clinicians.
• Meet with the patient's clinician. Make sure to meet with the clinician treating your family member from time to time. Try to go with your family member and if needed, set up some appointments on your own. Although clinicians have to maintain patient confidentiality, they can listen to you and you can report issues you are having caring for your family member.
• Be understanding. Let your family member with bipolar disorder continually know that you care. People with bipolar disorder have negative thoughts and are hopeless in a depressive state. They need to be reminded that you and others are concerned about them and that you are working together to help them get well.
• Take care of yourself. Set healthy boundaries on how much you do so you don't burn out. Take a vacation from caregiving from time to time. Many caregivers develop depression, so don't be afraid to seek medical help for yourself. You also may need help processing and dealing with your emotions.
• Find social support. Dealing with bipolar disorder can be lonely and isolating. You've watched the healthy person you once knew deteriorate and suffer. Your friends don't understand bipolar disorder, and it is difficult for you to go out. Make sure you find sources of support such as a bipolar support group in your area.
• Develop a crisis plan. Talk to your family member with bipolar disorder about what you will do if the person becomes manic or suicidal. For example, some people with bipolar disorder and their families decide that it is best for the person with bipolar disorder not to use credit cards. Also, determine what you will do if you need to hospitalize the person. Put your plan in writing.
• Have hope. Remember that in most cases, bipolar disorder is treatable and can be stabilized. The condition is usually cyclical, so be prepared for it to worsen and/or improve at times. Finding the right treatment can be a drawn out process, but in time, a solution will be found.

About the author: Julie Totten is the founder of Families for Depression Awareness, a non-profit organization helping families understand and cope with depression.

Strategies for helping people with bipolar disorder manage their medications and maintain medication compliance.

Many people with bipolar disorder take multiple medications. Managing these medications can be a challenge for caregivers and the person who is taking them. A few simple strategies can make this important task manageable.

Many medical professionals use a concept known as The Five Rights which may also help you as you develop a system to ensure that medications are used correctly.

The Five Rights

• Right drug ~ Always carefully read the labels, many drugs have names which are very similar. Also, if a drug looks different than previously, don't hesitate to call the pharmacist to ensure that the correct drug was dispensed.
• Right person ~ Read the label for your care receiver's name, don't assume that you have the right bottle as another family member could be on the same medication, but a different strength
• Right dose ~ Don't give medication doses "by memory." The dose may have changed. Read the label!
• Right time ~ Although with many medications, there is generally a "two hour window," try to stay as close as possible to the scheduled dosage times. (this means that if a medication is scheduled to be given at 1:00 pm, it may be given at any time from 12:00 PM (noon) to 2:00 PM or an hour before to an hour after the scheduled time. Thus, some medications may be "grouped," and given at the same time. However care must be taken to avoid giving drugs together which are incompatible, would cause adverse side effects, or decrease their effects, if given at the same time or too close together.)
• Right route ~ of administration (oral, injection, etc). Again, read the label. An oral medication administered as an injection can have fatal (not to mention painful) consequences.

Many people have more than one doctor and may take medications that could possibly interact with each other and create a serious health risk (this is known as polypharmacy). It is vital that each health care provider is aware of what the person is taking, including over the counter remedies, vitamins, and herbal preparation.

If you accompany an older adult or someone who is unstable to a physician's office and do not believe that the person understands what the medication is and why it is important, encourage them to ask the physician for a complete explanation.

Medication Compliance

Medication compliance means taking medications as prescribed. Although medications have improved the overall quality of life for people with bipolar disorder, many people resist taking a variety of medications several times a day. People find the medication schedules confusing; they forget what they have taken; people start feeling better and stop taking the medication; or they do not feel that they can afford medications.

A common problem with medication is that the person does not clearly understand what the medication will do for them. The person needs to understand what the medication is and why it is important to take it. "Because the doctor says so" is not enough of an explanation.

Taking medications

• Keep medications visible.
• Make sure a readable clock is visible.
• Post reminders, if necessary.
• Draw a large clock and put color codes on it, if necessary.

To encourage medication compliance explain why the medication is necessary (people are more apt to do what is requested of them when they are given the reason for the request).

Managing Medications is a critical aspect of effectively treating chronic illness. A few simple techniques ensure that storing and taking medications are manageable.

Getting Organized

• Maintain and update a list of all medications, including over the counter drugs, vitamins, and herbal remedies.
• Keep the current medications list visible and available such as in the kitchen on the refrigerator, or posted on a bulletin board in an area of the home where family members and others who may come into the home could easily see.*

Create a chart or check-off system to remind the person to take medications. Examples include:

• Calendars marked with stickers or different color dots.
• A pill box with separate areas for each day of week.
• Poster board with columns and boxes drawn on it (days of the week written across the top and medications down the side).

Encourage the care receiver to have all prescriptions with one pharmacy.

Build a partnership with the pharmacist. The often act as 'gatekeepers' and will alert a person of possible side effects and drug interaction.

If you are the person who picks up medication recommend a pharmacy closer to your home than one closer to a family member who does not get out.

Maintaining Medications

Storage

• Store medications in a cool dry place such as a kitchen cabinet or on a kitchen counter. Do not store drugs in a bathroom medicine cabinet where moisture and heat could damage the medication.
• Keep medicine in its original container with the original label and tightly closed until taken or put in a pill divider.
• Use a black large tip marker pen such as a Sharpie or other large tip pen or place larger, more legible labels on bottles.
• Use an inexpensive drug divider (less than $5.00 at pharmacies and retail stores) to portion out medications:
  - For each day or each medication time.
  - No more than one week at a time.
• If the directions call for refrigeration do not freeze.
• Keep all medicine out of children's reach.

Refills

• Do not save leftover medicine to use later.
• Plan ahead for refills.
  - When you notice that you do not have enough medication for the next week, call the pharmacy for a refill.
  - Allow at least 48 hours for a pharmacy to obtain physician approval, if necessary, or for the pharmacy to fill the prescription.
• If you go to a new pharmacy, you must have a prescription; or the new pharmacist must call the doctor or the original pharmacy to see if a refill is authorized.
• When you leave a physician's office, ask the office staff to call in the prescription to the pharmacy so that it might be ready for pick-up on the way home.
• Use one pharmacy for the whole family if possible. The pharmacist then has a record of all your drugs and can communicate effectively with the doctor.

Discarding Medications

• Do not save leftover medicine to use later.
• Periodically go through all medications and discard drugs that are not taken or beyond expiration dates on the container.
• Check with pharmacist for expiration dates, if necessary.
• Dispose of medicine safely to protect children and pets.

Paying for Medications and Medication Discounts

Some people and older adults do not feel that they can afford medications and so go without. Financial assistance is available.

Communicating with Healthcare Providers

Communication and coordination with health care providers is essential to maintaining good health and managing chronic mental health problems. Building relationships with not only the physician but nurses and office staff will enable questions about medications and treatment to be answered quickly and clearly.

Tell the doctor about any unexpected new symptoms experienced while taking medicine. A change of medicine or a dose adjustment may be needed.

Be Proactive

Don't hesitate to ask questions and expect answers and clarification. Remember that health care is a service, and the bipolar patient and you, if you are the caregiver, are both 'consumers' of this 'service.'

When you speak with the healthcare provider, make sure you take written notes so that you and the patient can look back over the information as needed. If the information you wrote down is not clear call the physician's office and ask to speak to the nurse if the doctor is not available.

Finally, Always encourage the physician to talk directly to the patient. Allow the patient time to answer questions and talk directly with the physician and all healthcare providers.

Remember who the patient is. If it appears that the person does not understand then ask for clarification for them while looking directly between the patient and the health care provider.

Source:

• Grissinger, M., The "five rights". Pharmacy and Therapeutics, October 2002. 27(10): p. 481

Detailed description of anosognosia and how it impacts people with bipolar disorder when it comes to medication compliance.

Impaired awareness of illness (anosognosia) is a major problem because it is the single largest reason why individuals with bipolar disorder and schizophrenia do not take their medications. It is caused by damage to specific parts of the brain, especially the right hemisphere. It affects approximately 50 percent of individuals with schizophrenia and 40 percent of individuals with bipolar disorder. When taking medications, awareness of illness improves in some patients.

What is Impaired Awareness of Illness?

Impaired awareness of illness means that the person does not recognize that he/she is sick. The person believes that their delusions are real (e.g. the woman across the street really is being paid by the CIA to spy on him/her) and that their hallucinations are real (e.g. the voices really are instructions being sent by the President). Impaired awareness of illness is the same thing as lack of insight. The term used by neurologists for impaired awareness of illness is anosognosia, which comes from the Greek word for disease (nosos) and knowledge (gnosis). It literally means "to not know a disease."

How big a problem is it?

Many studies of individuals with schizophrenia report that approximately half of them have moderate or severe impairment in their awareness of illness. Studies of bipolar disorder suggest that approximately 40 percent of individuals with this disease also have impaired awareness of illness. This is especially true if the person with bipolar disorder also has delusions and/or hallucinations.³

Impaired awareness of illness in individuals with psychiatric disorders has been known for hundreds of years. In 1604 in his play "The Honest Whore", playwright Thomas Dekker has a character say: "That proves you mad because you know it not." Among neurologists unawareness of illness is well known since it also occurs in some individuals with strokes, brain tumors, Alzheimer's disease, and Huntington's disease. The term anosognosia was first used by a French neurologist in 1914. However in psychiatry impaired awareness of illness has only become widely discussed since the late 1980s.²

Is Impaired Awareness of Illness the Same Thing as Denial of Illness?

No. Denial is a psychological mechanism which we all use, more or less. Impaired awareness of illness, on the other hand, has a biological basis and is caused by damage to the brain, especially the right brain hemisphere. The specific brain areas which appear to be most involved are the frontal lobe and part of the parietal lobe.³

Can a person be partially aware of their illness?

Yes. Impaired awareness of illness is a relative, not an absolute problem. Some individuals may also fluctuate over time in their awareness, being more aware when they are in remission but losing the awareness when they relapse.

Are there ways to improve a person's awareness of their illness?

Studies suggest that approximately one-third of individuals with schizophrenia improve in awareness of their illness when they take antipsychotic medication. Studies also suggest that a larger percentage of individuals with bipolar disorder improve on medication.³

Why is Impaired Awareness of Illness Important in Bipolar Disorder?

Impaired awareness of illness is the single biggest reason why individuals with bipolar disorder do not take medication. They do not believe they are sick, so why should they? Without medication, the person's symptoms become worse. This often makes them more vulnerable to being victimized and committing suicide. It also often leads to rehospitalization, homelessness, being incarcerated in jail or prison, and violent acts against others because of the untreated bipolar disorder symptoms.⁵

Impaired Awareness of Illness is a Strange Thing

It's difficult to understand why a person who is sick can't understand they are sick. Impaired awareness of illness is very difficult for other people to comprehend. To other people, a person's psychiatric symptoms seem so obvious that it's hard to believe the person is not aware he/she is ill. Oliver Sacks, in his book The Man Who Mistook His Wife for a Hat, noted this problem:

It is not only difficult, it is impossible for patients with certain right-hemisphere syndromes to know their own problems...And it is singularly difficult, for even the most sensitive observer, to picture the inner state, the 'situation' of such patients, for this is almost unimaginably remote from anything he himself has ever known.

It can seem that self-help for depression is out of reach when depression overwhelms and stifles. Depression negatively impacts mental health and physical health, thoughts, feelings, and behaviors, and it can be very life-limiting. What helps depression when it affects our whole being?

Despite the all-encompassing nature of this illness, there is help for it. Self-help for depression can be very effective (Need Help With Depression? Here's What to Do).

Self-Help for Depression Begins with a Starting Point

An important first step in helping yourself out of depression is untangling yourself from the miserable group of symptoms that comprise depression. This doesn’t mean trying to beat the symptoms yet. Helping depression starts with listening to yourself. According to Strosahl (2008),

“Your depression is telling you something that you need to listen to. It’s a signal that you need to spring into action and address the aspects of your life that are out of balance (p. 2)."

Listening to your depression means paying attention to what, specifically, feels wrong. Self-help for depression involves rating your current level of life satisfaction. On a scale from one through 10, with 1 being the lowest you think you can go and 10 being the highest, where is your life satisfaction?

What Helps Depression is Making Lifestyle Choices

Now you have a starting point. You know how satisfied (or, with depression, dissatisfied) you are with your life. You have an idea of where you’d like to make improvements. The next step in depression self-help is making intentional lifestyle choices.

Cousens & Mayell (2000) have identified important lifestyle components for decreasing depression. Among them:

• Daily Actions: Depression can zap energy and can make it difficult even to get out of bed. Doing something small every day is a powerful way of helping depression because it provides a sense of purpose (Depression Self-Care for When You’re Really Depressed).
• Exercise: Exercise boosts energy and stress-relieving hormones. Even 15 minutes of low-impact activity is proven to provide depression-beating benefits.
• Connection: Building and maintaining relationships with family and/or friends is a positive lifestyle choice that is a powerful self-help technique for depression. A few ideas for fostering connections: increase contact through texting, e-mailing, or calling; plan times to be together, and ask the person to help you stick with the plan; become involved in your community through volunteering, participating in groups or classes, and more (Are Support Groups for Depression Really Helpful?).
• Create. Creativity helps people let go of their problems and stresses and provides a sense of purpose and accomplishment. Journal, write poetry or stories, paint, sketch, draw, color, build something, play an instrument, sing. And don’t judge it. Just create.
• Laugh. Humor heals. Laughing is self-help for depression that works on an emotional and biological level; indeed, laughing increases positive biochemical and neurotransmitters that elevate mood and decrease the symptoms of depression. (Cousens & Mayell, 2000). Depression might have robbed you of laughter, but you can choose to get it back by seeking it out every day. Read humorous books or listen to audiobooks. Watch funny videos and comedy shows. Take a walk and look for little bits of humor in nature.

Self-Help for Depression: Break Life Areas into Groups

Similar to the above lifestyle choices, Copeland (2001) divides important life areas into the following categories:

• Activities, including both actions and exercise.
• Support, also known as connections.
• Attitude: Attitude involves thinking style as well as focus. Depression has a way of creating negative thoughts, and it tends to pull our attention toward what is wrong in life. Becoming aware of our attitude empowers us to shift our thoughts and attention toward the positive.
• Spirituality: Spirituality could refer to religious beliefs and practice, but it doesn’t have to. Connecting to something outside yourself, developing an appreciation for beauty in the world, and discovering a sense of awe all help to pull people out of a state of depression.
• Management: If you have medication, take it as prescribed. Drink plenty of water (dehydration impacts moods and overall well-being), and eat nutritiously. Also, sleep decreases depression symptoms.

When it comes to self-help for depression, knowing where you are and how you want to improve works well to kick-start recovery. Attending to lifestyle, breaking areas of your life into groups in order to manage them piece-by-piece, and making deliberate choices to overcome depression are effective things you can do to lift yourself out of depression.

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Is bipolar disorder a disability? If the condition is impacting your day-to-day life, you may be wondering if bipolar disorder is classified as a disability under the Americans with Disabilities Act (ADA) and whether or not you can claim benefits. Grasping the technicalities of this issue can be tough, and it’s difficult to determine which information is factual. Here are some facts about bipolar disorder and disability, including what kind of support to expect if you are diagnosed with bipolar disorder.

Is Bipolar Disorder a Disability? Here’s What You Need to Know

If you’re wondering whether bipolar disorder is a disability that qualifies you for Supplemental Security Income (SSI), you may be having trouble working and earning money because of your condition. This doesn’t mean that you are disabled – or even that bipolar disorder is classified as a disability. In this context, the term "disability" simply means that you have the right to be protected in the field of work because of your condition.

Bipolar disorder is one of the many conditions covered by the ADA. However, this does not mean you are automatically entitled to benefits. This law is designed to protect people with bipolar disorder and other qualifying disabilities from discrimination in hiring, promotions, work, pay and benefits. Under the ADA, bipolar disorder is a protected disability, which might mean that your employer has to make special allowances for you at work, such as letting you take regular breaks or permitting you to work from home. Your employer also has a right to deny these accommodations if they would cause the company undue hardship.

Many people manage to work with bipolar disorder, but it does depend on the intensity and frequency of their symptoms. If you feel you are unable to work because of your condition, you may be entitled to social security benefits.

Is Bipolar Disorder a Protected Disability, and Can You Claim Benefits?

So, is bipolar disorder a disability when it comes to social security benefits? The answer largely depends on your symptoms. According to the ADA, to receive benefits for a mental health disorder, you must meet the following requirements in sections A and B, or those in section C.

Section A requirements include medically documented evidence of the following symptoms:

Depression

• Appetite changes with weight loss or gain
• Loss of interest in almost all activities
• Decreased energy
• Agitation
• Feelings of guilt or worthlessness
• Difficulty concentrating
• Hallucinations, delusions or paranoia
• Thoughts of suicide

Mania

• Hyperactivity
• Inflated self-esteem
• Decreased need for sleep
• Distractibility
• Involvement in risky behavior or activities
• Racing thoughts, flight of ideas
• Pressure of speech
• Hallucinations, delusions or paranoid thinking

Section B requires that you have bipolar disorder with a history of episodes of mania and depression “manifested by the full symptomatic picture.” In other words, you must have all or most of the symptoms listed above.

Under section B, you should also be able to demonstrate the following:

• Restrictions of daily activities
• Difficulty maintaining social functioning
• Difficulty concentrating
• Repeated episodes of extended decompensation (the failure to generate psychological coping mechanisms in response to stress, resulting in personality disturbances)

Section C requires documented history of a chronic affective disorder lasting at least two years. This illness should have caused “more than a minimal limitation of ability to do basic work activities.” You should also be taking medication or receiving psychosocial support for one or more of the following:

• Repeated episodes of decompensation
• A process of recovery that would be worsened by even a minimal increase in mental demands
• History of one or more years’ inability to function outside of a highly supportive living arrangement.

Bipolar and Disability: Final Thoughts

As you can see, the question of whether bipolar disorder is a disability does not always have a simple answer. Social Security has a whole raft of special rules that apply to those claiming benefits for mental health issues, and they will not always award disability benefits to people with severe mental health conditions. Bipolar disorder is, however, a protected disability under the ADA, so you have the right not to be discriminated against at work and to apply for reasonable accommodations.

If you’re looking to claim benefits for bipolar disorder, you should work closely with your doctors, therapist, psychiatrist and attorney to prepare your application carefully.

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Bipolar disorder myths still exist, even though our collective understanding of mental illness has improved. Whether it's that article you read online or a disparaging remark from someone you know, it's all too easy to spread misinformation about important topics nowadays. However, if you have just been diagnosed with bipolar disorder or you know someone who has, buying into these misconceptions can be damaging, so it's important to separate fact from fiction. With this in mind, here are some myths about bipolar disorder and the truths that dispel them.

Bipolar Disorder Myths and Facts

Bipolar disorder myths can be damaging to people living with this condition. Managing bipolar disorder is an ongoing challenge, and misinformation can contribute to bipolar stigma and a lack of understanding from others. Here are some common bipolar disorder myths that need dismantling.

Bipolar Myth: People with bipolar disorder are crazy

The fact is, bipolar disorder is an illness. It’s not something you choose, and you cannot help it. People develop bipolar disorder for a variety of reasons, including genetic factors, imbalances in brain chemicals, hormones and environmental stressors.

Having bipolar disorder does not make you crazy. This is a derogatory term that is often wielded with no regard for its meaning. Many people who have bipolar disorder live healthy, happy lives when they are not experiencing episodes, and others find that bipolar medication improves their symptoms.

Bipolar Myth: Bipolar medications turn you into a zombie

This is an outdated belief that does not ring true for most people. In fact, the majority of people find that they function better while taking medication and that many of their bipolar symptoms are markedly diminished.

Of course, bipolar medications can, and often do, have side-effects. Mood stabilizers can make some people feel tired and sluggish. These side-effects of mood stabilizers can easily be addressed by your doctor, who can lower or adjust your dose so that you feel better.  

Bipolar Myth: There is just one type of bipolar disorder

Bipolar disorder isn’t the same for everyone. Like many mental disorders, it exists on a spectrum, and treatments vary according to which type of bipolar disorder a person has.

The three most common forms of bipolar disorder are:

• Bipolar I disorder: Characterized by the existence of at least one episode of full mania
• Bipolar II disorder: Defined by frequent periods of major depression and less frequent episodes of hypomania (a less severe form of mania that lasts for around four days at a time)
• Cyclothymic disorder: A mild mood disorder in which the symptoms of depression and mania/hypomania do not fit the criteria for either bipolar I or bipolar II.

Bipolar Myth: Treatment for bipolar disorder doesn’t work

It is a myth that bipolar disorder treatments don’t work, and most people find that a combination of medication, psychological therapy and changes to their lifestyle help them to manage the symptoms of bipolar. Bipolar disorder is not curable, and some people “relapse” into symptoms during times of stress. Others, however, have sustained periods where they experience little to no symptoms at all.

Crucially, it is nobody’s fault if you continue to have symptoms despite treatment, so it’s important not to place blame. There are always ways to improve treatment, but it can take months or even years to find a route to recovery that works for you.

Bipolar Myths and Facts: Why It’s Important to Know the Difference

It’s important to know the difference between bipolar myths and facts so that you have an accurate picture of what living with this disorder is actually like. If you are newly diagnosed, or you know someone with bipolar disorder, there are plenty of scaremongering stories to be found that can make you think the worst. These stories should be read with caution, and you’re best off sticking to factual sources – at least until you feel more at ease with your diagnosis.

This is not to say that someone else's experience of bipolar disorder isn't real, or that it is somehow invalid – it's just not the whole truth, and it's not necessarily your truth. Bipolar disorder takes many forms and presents slightly differently in everyone.

In reality, bipolar disorder is one of the easiest mental illnesses to treat because it has such strict diagnostic criteria. For most people, the challenging part is getting a proper diagnosis, so you may already have jumped the biggest hurdle. 

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