A bipolar disturbance is characterised by alternately episodes of exaltation (or mania) and depression, interrupted by free intervals, i.e. a return to a state of balance.  This disorder affects 1 to 2% of the general population.  It gives rise to important suffering for the patient and his family and an important socio-professional handicap.  The mortality rate is twice or three times higher than that of the general population for non treated persons.  This high rate is explained by suicides, risky behaviour (drug abuse, dangerous habits) and a higher level of physical illness and in particular cardio-vascular diseases.  Legal complications often arise (acts of rebellion, refusal to obey, abuse towards representatives of law and order, Highway Code infractions, fraud...).

This disorder is subdivided into different sub-categories according to the nature and the intensity of the symptoms.  It has become standard to distinguish the number 1 type bipolar disorder (BPI) from that of type II (BPII).  The BPI disorder is characterised by one or several maniac or mixed episodes (intrication of excitation and depression) and episodes of depression of varying intensity (the diagnosis may be made in the absence of depression). The BPII disorder is defined by the existence of one or several hypomaniac episodes (moderate mood exaltation) and one or several characteristic depressive episodes.

On the borderline of bipolar disorders is to be found the cyclothymic disorder characterised by mood swings with hypomaniac and depressive periods.  It may be just as invalidating given its chronicity and the fact that it has not been addressed (the disorder remains for the main part unrecognised).

At the Clinique du Château de Garches the treatment of a bipolar disorder is undertaken in several stages, with the active participation of the patient and his family circle.

The first step corresponds to several processes made simultaneously:

• identification of the disorder,
• evaluation of its consequences,
•  search for the factors which trigger off and precipitate the disorder,
• analysis of the underlying personality,
• submission to a somatic check-up.

This phase will consequently enable the establishment of a therapeutical project, in collaboration with the patient, which will take the various determining aspects (biological, psychological and environmental) of the illness into account.

The second phase corresponds to the treatment.  This treatment is at the same time psychological and drug treatments.  It may be broken down in two parts, the curative treatment of the episode (depression or excitation) and the preventive treatment which aims to avoid further relapses.  In the majority of cases, preventive treatment is begun alongside the curative treatment.  This is essentially based on thymoregulators, represented by lithium salts (Téralithe*, Neurolithium*), carbamazépine (Tégrétol*), valproate (Dépamide*) or divalproate (Dépakote*), la lamotrigine (Lamictal*), l’olanzapine (Zyprexa*).

In addition to medicinal treatment, our team is convinced that it is indispensable to provide the patient and his family pedagogical and psychological support.  Indeed, we help the patient to learn to deal with his vulnerability.  To this end, the psycho-educative education dispensed by the clinic offers the patient the possibility of acquiring better knowledge about his disorder and helps him to spot early on the symptoms announcing a relapse.  A good therapeutic alliance makes it possible to control most of the mood swings and avoid having to resort to hospital admissions.  Close family will also be made sensitive to spotting these first signs.

The respect of certain hygienic-dietetic rules such as regular sleep, avoiding periods of overwork and control of alcohol intake and psychostimulants, help towards a favourable evolution.

Managing stressful events in life will be dependent on the momentary reinforcement of psychological support.  Finally certain patients will take advantage from more structured and individual psychotherapies.

Bipolar disorders remain to this day too often ill known, which results in late diagnosis of the patients.  It is therefore advisory to pinpoint this disorder before any depressive episode in order to avoid relapse and maintain a good socio-professional integration.  Hopefully information on the risk to the family should help permit a very precocious diagnosis of such disorders in the children or adolescents.  The Clinique du Château de Garches is very committed towards the education and diffusion of information to the patient and his family.  A series of conferences on this theme is proposed every year to the public outside the clinic in order to bring about a better understanding of depressive illnesses.

The psycho-educational programme destined to patients suffering from bipolar disorders

The Clinique du Château de Garches has been proposing for some years now a psycho-educative programme intended for patients suffering from bipolar disorders.  This programme is designed for patients at the end of their hospitalisation as well as those persons seen outside the clinic.  For the patients who are not treated by one of the clinics’ doctors and who would like to take advantage of these measures, a letter from the general practitioner should be supplied.  Permission to participate in the programme will be granted after consulting either Dr GAY or Dr GINDRE.

Enrolment may be made through Mrs Maria BOZZI, administrative assistant at the Clinique du Château de Garches, tel: 00 33 (0)1 47 95 64 02 e-mail  secretariat.mscg@clinique-garches.com.  The programme is made up of 15 weekly 2-hour sessions.  These sessions take place Tuesday evenings between 6 and 8pm.

The number of participants is limited to 15.

Documents are distributed each session and regrouped in a file given out at the first session.

These sessions are animated by Dr Christian GAY, Dr Claire GINDRE, a nurse and a psychologist.

Clinique du Château de Garches Programme

1^st Session: Introduction

Objectives:

• Definition of psycho-education
• Group Presentation
• Principles and rules of functioning of group therapies
• Generalities on bipolar disorders

2^nd & 3^rd Sessions: depression

Objectives:

• Get to know the symptoms of a depressive episode, identify the symptoms that announce a relapse, be aware of the different causes, the consequences and the different ways the depressive disorder may evolve, learn to auto-evaluate oneself (auto-evaluation questionnaire, analogical scale …).
• Simulation (evaluation and valuation of simulated depressive condition)
• Be capable of listing ones own depressive symptoms
• Be able to identify the symptoms announcing a depression
• Get to know the causes of depressive conditions
• Be capable of evaluating ones mood and other symptoms

4^th Session: treatments for depression

Objectives :

• Know how to distinguish an anti-depressor from a tranquilliser, a thymoregulator or a narcoleptic
• Get to know the different therapeutical approaches to depression
• Know the objectives of medicinal treatment
• Know how to distinguish a side effect from an accident related to treatment
• Signification and control of a side effect
• Know the indications for a treatment by ECT
• Be informed about the interest of psychotherapies
• Know the precautions of usage related to anti-depressors

5^th & 6^th sessions: manic excitation and mixed condition

Objectives

• Know the symptoms of a state of excitation
• Identify the symptoms that announce a relapse, be aware of the different causes, the consequences and the different ways the excitation may evolve, learn to auto-evaluate oneself (auto-evaluation questionnaire, analogical scale …).
• Be capable of listing ones own symptoms of excitation
• Be able to identify the symptoms announcing a state of excitation
• Be capable of stipulating the causes of a state of excitation
• Know the differences between a state of excitation and a mixed state
• Simulation
• Be capable of evaluating ones mood and other symptoms
• Presentation of the film « at the summit of the descent°», analysis of the symptoms, comments
• Presentation of the follow-up diagram of bipolar disorders
• First appreciation of this diagram

7^th Session: Treatment of the states of excitation and prevention against relapse

Objectives :

• Know how to distinguish a thymoregulator from a tranquilliser, an anti-depressor from a narcoleptic
• Get to know the different therapeutical approaches to the state of excitation
• Know the objectives of medicinal treatment
• Know how to distinguish a side effect from an accident related to treatment
• Signification and control of a side effect
• Be informed about the interest of psychotherapies
• Know the precautions of usage related to thymoregulators

8^th Session:  Recognition and evaluation of the disorder

Objectives

• Exercises aiming at recognizing the symptons of a relapse and those which announce one from a case presentation and simulation
• Calculation of his bipolarity index
• Evaluation of his mood on the diagram
• Evaluation of his mood based on analogical scales

9^th Session:  Healthy Living Rules

Objectives

• Sleep:  know the consequences of insomnia or hypersomnia and how to facilitate falling asleep
• Know how to respect ones biological clock
• Know the main triggers
• Overwork situations, know how to recognise and control them
• Simulation
• Evaluate ones mood on the diagram

10^th Session:  control relapse

Objectives

• Know the factors that render more vulnerable, trigger off and precipitate relapses
• Know how to control the impact of activating factors
• Case studies for the sake of example
• Simulation
• Evaluation of ones mood on the diagram

11^th Session:  Management of ones personal life (family, social, professional, sport...) Problem solving

Objectives

• Know the dysfunctionnal factors within the family
• Know how to facilitate communication, avoid conflict
• Know how to speak about ones disorder with ones children, spouse, family
• Sex life:  difficulties, risks...
• Know what do tell ones friends, chose ones interlocutors
• Simulation
• Choice of studies, of a profession
• Know how to organise ones working life
• Choice of leisure time activities
• Evaluation of ones mood on the diagram

12^th Session: Control ones emotions

Objectives

• Acquisition of the basic principles of relaxation
• Learn to re-evaluate situations
• Simulation
• Evaluation of ones mood on the diagram

13^th Session:  Cognitive approach

Objectives

• Know how to fight off negative thoughts
• Simulation
• Evaluation of ones mood on the diagram

14^th Session: Management of ones life and acceptation

Objectives

• How to well organise ones days
• How to accept ones disorder and how to get others to accept it
• Simulation
• Evaluation of ones mood on the diagram

15^th Session: Interest of psycho-education

• Evaluation of the 14 sessions, criticisms, comments, appreciation questionnaire
• Presentation of the follow-up notebook.

A 16^th session is planned 6 months afterwards in order to evaluate at a distance the interest of these therapeutic measures.

If you want to know more on the subject

Definition and objectives of psycho-educational measures

In 1998 already, the World Health Organisation made recommendations concerning the education of the patient stipulating: « the therapeutic education of the patient is a recognised process, an integral part of treatment and centred on the patient.  It includes organised activities to enhance awareness, inform, teach and accompany the patient psychologically and socially with regard to the illness, the treatment prescribed and the health establishments, as well as the behaviour of the patient in times of sickness and of health.. This education aims to help the patient and his close family and friends to understand the illness and the treatment, to cooperate with the medical team, live as healthily as possible and maintain or improve the quality of his life.  Education should render the patient capable of acquiring and maintaining the resources necessary to manage his life with the illness in the best possible manner”.

Its application in different chronic medical pathologies such as diabetes, asthma, high blood pressure has proven its efficiency; reducing the frequency and intensity of the crises whilst improving the subject’s quality of life and that of his family.

The term of psycho-education may be defined as the education or theoretical and practical training axed on understanding of the disorder and its various treatment in order to favour the best possible reinsertion of the subject.  Over and above the objectives in common with therapeutical education, psycho-education takes into account the causes and consequences of the illness, control of the factors which trigger it off and the principle psychopathological aspects of the disorder, the quality of the doctor-patient-family relationship.

The psycho-educational approach as it is understood focuses on four main (or final) objectives aims which may only be attained after reaching the intermediary objectives:

Principal (or final) Objectives:

• Optimise medicinal treatment.
• Prevent relapse and reduce the number and length of hospitalisations.
• Improve the subject’s quality of life, in all its dimensions (personal, family, professional, social).
• Favour, maintain and consolidate the therapeutical alliance.

Intermediary Objectives:

• Favour acceptation of the disorder (in the sense of recognition and not resignation) and fight against the stigmatisation of the notion of mental illness attached to it through information and support of the patient and his family. Ignorance perpetuates intolerance, fear, discrimination, rejection, shame, guilt.
• Improve the quality of therapeutical observance and guard against drug abuse.
• Facilitate the identification of symptoms announcing a relapse, help control stressful situations and respect healthy living rules.
• Improve interpersonal relationships and social functioning in inter-critical periods (minor subsyndromic and residual symptoms).

These objectives go far beyond the scope of therapeutical education and constitute a specific approach to bipolar disorders, not only referring to its determinants but also to its consequences and associated pathologies which often constitute factors of resistance to treatment.

Various approaches to psycho-educative measures have been proposed these last few years. Nevertheless, if the objectives and modalities of group work are partially superposable and clearly influenced by cognitive-behavioural therapies, the number of sessions, the selection of the patients, participation or not of the family, make up the specificity of these different approaches.

Practicalities

The different protocols are globally declined in comparable fashion.

• General Information about bipolar disorders and their treatment.

This approach is the indispensable prerequisite to all the techniques.  The need for information is not only on a legal level, such as defined by the law of March 2002.  Many medical and psychiatric pathologies justify the need to inform the patients and even their close family.  The diffusion of this information has been made easier by the work undertaken by patients’ associations and the publication of several popular scientific books.

• Early recognition of the symptoms announcing a relapse

The patient (and his family if it is included in the programme) is trained to identify the first symptoms announcing a manic and depressive relapse, adopt certain behaviour and contact the doctor.

• Respect of healthy living rule, social rhythms.

The change in social rhythms, overwork, lack of sleep, abuse of stimulants and alcohol, represent some of the factors of vulnerability. The application of a program on healthy living rules contributes to limiting exposure to activating or precipitating causes.

• Improvement of the psycho-social functioning modes and the quality of life

This fundamental stage consists in helping the patient to live with his disorder and maintain family and social links.

• Training to evaluate oneself

The patient is trained to evaluate his mood (analogical scale going from - 5 + 5) and to follow its evolution on a diagram which takes account of the hours of sleep, special events, treatment posologies and their plasmatic dosage if pertinent.

Some comments

The psycho educational approach constitutes one of the key elements of the way we take care of bipolar disorders. Nevertheless, it can not be a substitute for medicinal treatment.

This approach is mainly inspired by behavioural techniques.  The number of sessions is variable and depends on the number and type of objectives.  It is limited to 5 or 6 when one sole theme, e.g. Identification of symptoms which announce relapse, has been identified beforehand. It can go up to more than 20 sessions in the case of global treatment comprising several objectives.

These measures are designed first and foremost for patients in normothymic phase.  Nevertheless they could be initiated at the end of hospitalisation in the course of a period of excitation or depression.

In theory, all patients should be accessible for this type of measures, as may be all diabetics, asthmatics, hypertension sufferers.  This inexpensive approach, which is perfectly in keeping with the programme’s health objectives for combating mental diseases, could easily be applied and generalised to all patients.  In practice, it would appear to be logical to propose this measure to patients from the very first bout, given the importance and the need to do ones utmost from the first episode to stop the evolutive process:  the later the disorder is tackled, the more there are risks of relapse, resistance and marginalization.  Moreover, it is generally admitted that the benefits of this approach are inversely proportional to the preceding number of episodes.

Individual therapy may be preferred to that of a group according to the patient’s personality and the evolutive characteristics of the disorder.

Prior consultation is necessary in order to define the objectives with the patient and constitute a homogeneous group, excluding over psycho rigid or antisocial personalities who could exert a negative action on the dynamism of the group.  The respect of confidentiality, punctuality, assiduity constitutes the elementary rules of good functioning of the group.

These measures are delivered by personnel trained in group therapies (psychiatrists, psychologists, nurses).  They constitute a therapeutic approach.

Close family is also concerned by this type of approach. This can be spouses, parents, children or friends.  These family members may be included in the group of patients or integrated in specific groups of those accompanying the patients.  The programmes destined to close family are in superposition as regards that of the patients.  The question related to information given to young children must be raised.  It is adapted according to the age, degree of maturity, the nature of his parent’s disorder.

For illustration purposes, we are enclosing the contents of a programme used within our institution.  The content of the psycho education is laid out in the sheets given out at each session and assembled in a file to be kept by each participant.

In conclusion, the psycho educational measures occupy a preponderant place in the treatment of bipolar patients.  They go much further than the scope of the information transmitted about the illness and its treatments.  These measures, initially proposed in the case of schizophrenic disorders, might be indicated in other mood and anxiety disorders.