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Psychosis in Bipolar Disorder – Treatment Decisions
In the last article I talked about the presence of psychosis in bipolar disorder. In this article I will explore the treatment of psychosis in bipolar disorder.
The classic treatment for psychosis is, of course, an antipsychotic. However, there are proponents of other forms for treatment for psychosis. In fact, sometimes even a “wait and see” approach is worth considering.
Options for the treatment of psychosis include:
- antipsychotic medication
- careful monitoring without medication (“wait and see”)
- an alternative approach, where available (such as Mosher’s Soteria House or Open Dialogue in Finland, typically in cases of psychosis related to schizophrenia)
However, even in an alternative approach or a “wait and see” approach, antipsychotic use may be deemed necessary at some point. It varies from person to person.
Delaying Treatment of Psychosis with Antipsychotics
Now, doctors almost always prescribe an antipsychotic immediately for psychosis and rarely do they discuss any delay of that treatment. They may also not fully represent the risks to patients nor take into account a patient’s wishes.
There are some inherent problems with this. Namely, the patient often feels like he/she isn’t being respected, he becomes disenfranchised with psychiatry, he feels coerced, he is more likely to be nonadherent to treatment, and he may be more likely to refuse help in the future.
According to a Psychiatric Times article, these problems come about because doctors may:
- have too much faith in the efficacy of antipsychotics.
- have too strong a belief in the necessity of early treatment with antipsychotics.
- believe that the course of psychosis will naturally get worse over time and possibly harm the brain while doing so.
- believe that it is harder to treat longer-standing psychosis.
- believe that psychotic patients de facto, cannot make treatment decisions.
- believe it is impractical to delay treatment.
And, in point of fact, some of these beliefs are entirely reasonable and may make medicating psychosis a necessity in many cases. But it is important to remember that sometimes the “wait and see” approach is successful and, in some instances, it, too, is reasonable. (Unfortunately, the practicality of this approach is questionable as most people cannot be acutely psychotic in the community and remain safe.)
I do also stress that some people in a psychotic state absolutely are not capable of making good treatment decisions. (This may be due to a clinical lack of insight caused by their illness known as anosognosia.) Some people in psychosis are also at real risk for violent behavior and hurting themselves or someone else. In these cases, treatment without consent is typically necessary.
Taking Part in Bipolar Psychosis Treatment Decisions
The important thing to remember is that the patient’s wishes always need to be heard, even in the cases where they may have to be overridden, and in many cases, his wishes can be realized. Doctors need to be more open to the options suggested by patients and be more forthright about the implications of treatment options.
Doctor need to treat people with psychosis with the same respect that any patient deserves and they should communicate with the patient not like a crazy person, but like a person with a brain who is capable of understanding facts.
I wholeheartedly acknowledge that some people in a psychosis absolutely cannot understand any iota of reality and cannot make treatment decisions, but, on the other hand, some can, and behoves us to at least consider that possibility.