What is your opinion on Bipolar Disorder in College students?

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Write a 3 paragraph paper on the article attached. The paper must indicate what you liked and disliked about the article, and was the question answered. The paper must be in APA format if you use direct quotes from the article.

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JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 59, NO. 7 Special Considerations in the Treatment of College Students With Bipolar Disorder Simon M. W. Lejeune, MD Abstract. Bipolar disorder is a relatively common mental disorder that often has its onset during the college years. This means that students simultaneously face both the challenge of late adolescent development and the challenge of adapting to a major mental illness. As a further complication, the college environment is not well suited to the kinds of lifestyle changes that add stability to the lives of people with bipolar disorder. Treatment involves establishing an alliance, education about lifestyle changes, aiding adaptation to the illness, careful medication to minimize side effects, and loosening the affective constriction that can result from fear of relapse. Both the health care provider and student can use the culture of learning and self-discovery in the college setting to the treatment’s benefit. As well, the provider can use the time-limited nature of college to lessen ambivalence about making long-term changes. experience and emotional support during this time can make an important difference in the student’s future.4 Several types of treatment have been shown to be effective in different phases of bipolar disorder.5 These include medication, psychoeducation, cognitive-behavioral therapy, family-focused therapy, and interpersonal and rhythm therapy. A succinct review of these treatments is in the Harvard Mental Health Letter.6 There are certain features of these therapies that appear to be at the core of effective treatment: increased medication adherence, increased knowledge of illness, increased ability to anticipate relapse, and improved interpersonal and family skills.7 In this article, the author describes an approach to an integrated treatment of bipolar patients that is based on his clinical experience and these core principles of effective treatment. Keywords: adolescent development, bipolar disorder, psychoeducation, psychological, psychotherapy, student health services B Psychotherapy and Psychoeducation Students may first present with either mania or depression. Especially with a manic presentation, establishing a working alliance can be particularly difficult: The diagnosis is uncertain, and denial is often prominent. A single manic episode can be caused by several different factors and can result ultimately in several possible diagnoses. The provider and the student do not know if this is a brief psychotic episode, after which there will be no recurrence, or if this is the first of many episodes. Since college is often a time of binge substance use and bipolar disorder is associated with substance abuse, it is also possible the episode was substance induced.8,9 It is important during this stage to be tentative and supportive and not to ask the student to accept any particular diagnosis before it is clear. It is essential to know what students believe about their illness. Commonly, the student believes that a first or second episode was entirely caused by a medication, a substance, or lack of sleep. Such ideas are a useful first step. Students can then think of what happened as the result of something external and controllable, rather than the result of a genetic or constitutional problem over which they have less control. ipolar I disorder is present in 2.6% of the population over 18.1 As well, the college years are a time when the illness may emerge for the first time. In a 10,000-student university, one can expect 1 to 2 cases of first episode mania per year.2 Students with bipolar disorder face many difficult issues at a time when their lives and identities are in flux. To further complicate this, their environment has many of the kinds of stimulation that can exacerbate mania: Students frequently race against deadlines, stay up late for academic or social reasons, and use alcohol and drugs.3 These factors can contribute to making the experience of college, career, and relationships quite difficult. However, since college is traditionally a time of learning and forming identity, it can also be a time when questioning and redefining the self can be supported and normalized. A good treatment Dr Lejeune is the Associate Chief of Mental Health and Counseling at MIT Medical Service in Cambridge, Massachusetts, and with the Department of Psychiatry at Harvard Medical School in Boston, Massachusetts. Copyright © 2011 Taylor & Francis Group, LLC 666 College Students With Bipolar Disorder Since keeping the student in treatment is a critical factor, the provider should ally with this partial insight. Then, if more symptoms develop, together the provider and student can watch the pattern unfold and react accordingly. As they reach an agreement about the diagnosis, the emphasis of the treatment will shift more to psychoeducation and adaptation. At this point in the treatment, the student may well benefit from one of the several available references and workbooks for people with bipolar disorder.10–12 The style of the therapeutic relationship is very important. The provider should try to keep track of what is going on in the student’s life without being judgmental or intrusive. The provider may point out activities or patterns that increase the risk of relapse, but students ultimately need to learn from their own experiences. To encourage this, the provider should have a sense of humor and be aware of what will ring true in the relationship. As a 6-foot-4-inch, 50-plus male, for example, this writer can say “at the risk of sounding like your mother. . .” and have it appear humorous, highlighting that he is not his mother, even while sounding like her. The provider can also refer to things as an experiment: This puts a frame around the experience and sets up a context for objective observation. The student can be apprehensive about changing working habits, particularly if those habits have led to success. There may be aspects of mania that are hard to give up, such as being the life of the party, or being bursting with ideas and feeling super intelligent and on top of the world. The student may “ride the wave” and use mania to get things done quickly. The provider should help the student understand that being in treatment does not mean accepting a state of chronic depression, but rather developing a state of heightened selfobservation and acceptance of mood variation. It is important for students to know that their success is the result of their intelligence and diligence and can be maintained or even increased when they are euthymic. At times, students can miss the romance of a chaotic life and resent the stability that is being recommended by the providers, seeing it as externally imposed. Since this belief can easily disrupt the therapy, the provider should be quick to acknowledge the loss of the old pattern and help students feel that they are making a choice to change behavior so that they can better accomplish their goals. “Am I having too much fun?” A student who has had several manic episodes can be very apprehensive about having another one and can become emotionally constricted, afraid that any feelings are a sign of going over the edge. They are no longer confident about knowing what is “normal,” and may worry that enjoying themselves or having a big idea will turn into something else. In this situation, the provider must explain that one of the core dilemmas of bipolar disorder is not knowing naturally how much is too much. It is useful for the provider and the student to be explicit about what reaches the level of “relapse,” defining clearly the usual first signs of the student’s particular mania. In order to prevent or reduce the impact of mania, it is important to identify what sorts of social, familial, and academic acVOL 59, AUGUST–OCTOBER 2011 tivities can be overstimulating.3,13(pp92–102) Deadlines deserve special attention: When racing against time, the student can “overshoot,” and the extra push of energy can become a manic episode. This can be compounded by intentionally not taking medications (“because they slow me down”) or by forgetting medications because of a disrupted schedule. The time after a pressured period is especially risky, since the student will be exhausted, stimulated, and abruptly at loose ends. Sleep patterns in general are particularly important, as disruptions can be either a symptom or precipitant of mood changes. Even though it is not possible to avoid situations of academic or social pressure entirely, the student can learn to anticipate vulnerable times, detect the signs of getting “revved up,” and develop ways for slowing down when needed, including the use of extra medication.13(pp119–126) Similarly, students concerned about the recurrence of depression may need help distinguishing the sadness of a disappointment or a loss from the emergence of a depression. Bearing disappointments and loss, and learning to distinguish these feelings from a depression, is part of normal adolescent development as well as part of learning to live with an affective disorder.14 As with mania, the provider and student together should agree on the characteristics of the onset of the student’s particular depression and develop a plan for intervening to prevent it. Learning when to do “nothing” and tolerate feelings and when to act to prevent a relapse is one of the special developmental tasks of a person with bipolar disorder. As students become more confident that they can identify relapse and avoid it, they will be able to tolerate and even enjoy ordinary fluctuations in mood.15 Relationships present another challenge. An intense love affair can at times be an expression of a mania or be so stimulating that it results in one. The provider can help the student learn to assess whether a particular relationship is stabilizing or destabilizing. A new relationship can also affect medication use: A student might discontinue medication at the beginning of a relationship in order to get a fresh start, to hide the need for medication, or to avoid the effects of medication on sexual functioning. This can complicate the assessment of whether the relationship is destabilizing. Hidden in the excitement about a new relationship can also be a hope that the relationship will cure the illness or be a way to cope with the losses caused by the illness. These fantasies will need to be addressed in the treatment, as they can be a source of unrealistic expectations and disappointment. Especially crucial, people with bipolar disorder are at an increased risk for suicide.16 Bipolar depression can be quick in onset and severe in intensity, and it can have a psychotic element that may not be initially apparent. Mixed states in particular can dangerously combine impulsivity, activation, and despair. Secondarily, the relapse itself increases the risk of suicide because it is a reminder that the student does indeed have an illness, leading to more despair and hopelessness. Careful suicide assessment is a necessity with every depressed student, but because of the tendency to increased impulsivity and rapid mood changes, the provider needs an extra level of vigilance when assessing the student 667 Lejeune with bipolar disorder. This may require more frequent visits during difficult periods and contact with other figures in the student’s life, such as family members, roommates, or resident advisors. The usual stresses and discouragements of school are complicated by bipolar disorder. Students may wonder if they can make it through, asking, “have you personally seen students with bipolar disorder get through school?” They may wonder if they should make changes in career plans because of the illness, despair of ever being in a relationship, or hope to be “better” before beginning one. They may wonder when or whether to tell friends or potential employers about their condition. At these times, the provider can help talk through these very real worries and be an important source of hope. Medication Medication choices are complicated in bipolar disorder. A review of current medication practices can be found at the National Institute of Mental Health Web site.17 In addition, there are concerns about side effects, long-term toxicities, induction of mania, and stigma. This article will concentrate on adherence and side effects, as these are closely tied to the therapeutic relationship. When treating anyone with chronic illness, adherence is one of the most difficult challenges. This is especially true in younger bipolar patients.18 Unless students have had significant exposure to bipolar family members or friends, and thus worry about having such experiences themselves, they may not take medication after a first episode. Even after several episodes, a student may be reluctant to take prophylactic medication, and in some instances one uses a compromise such as intermittent medication or a short-term contract. Rather than recommending medication for the rest of the student’s life, the provider can suggest taking it until graduation as a way of coping with the special stresses of college life. The approach may well differ between graduate and undergraduate students. By graduate school, the bipolar student has often taken on the identity of a person with an illness who needs medication to succeed. Undergraduates, however, are frequently ambivalent about taking medications at all and may see them as adversely affecting their abilities. Medication side effects have important quality-of-life consequences and can affect adherence. Even with the simplest regimen of one mood stabilizer there are side effects, and in women there are concerns about eventual pregnancy. If the student requires a second medication, it may be better to use a second mood stabilizer rather than adding an antipsychotic, since antipsychotic medications may adversely affect cognition.19 With both antipsychotics and mood stabilizers, sedation can be a further serious side effect that affects adherence. Students report needing more sleep than usual, making it harder to get all their work done even if they curtail social activities. If they try to limit sleep, they may fall asleep in classes. Some adjustments can be made by using less sedating agents and night-time dosing. At times small doses of stimulants can be useful, particularly when given in the 668 morning at the same time as the sedating agents. Although this runs counter to the traditional practice of avoiding stimulants in bipolar disorder, there is mounting evidence that it can be done safely.20 Even with second-generation antipsychotics, extrapyramidal side effects can be a problem for students who are doing laboratory or other fine motor work or writing on the blackboard in seminars. These side effects can often be treated without changing the primary medication. Weight gain is a frequent reason that students give for discontinuing medication. Some of the gain can be prevented by education before starting the medication and exercise while taking it. Medications that are less likely to cause weight gain can also be used preferentially but may not always be the particular ones that work best for the student. There are some medications that can be used to reduce weight gain, although this use may be off-label.21 Sexual side effects are less of a problem than with antidepressants, but when they occur can usually only be addressed by changing agents or reducing dose. Some students will compare their medicated sex drive to their hypomanic sex drive and misattribute a change in libido to medication side effects rather than a change in affective state. Some perspective on the effects of mood on sex drive can improve adherence in this situation. Finally, medication cost can be a problem. A student on a mood stabilizer and a second-generation antipsychotic may well have medication costs in excess of $5,000 per year. Providers should be aware that many student health plans have a maximum annual medication benefit, which the student can easily exceed. They will then need to investigate other options. Conclusion The college years are a complex time developmentally: Students are defining their physical and mental limits and their relationships with authority figures and peers, as well as forming a more coherent identity and making career choices.22 Campus life is complex: It is not unusual to have erratic sleep patterns, drink alcohol, and take drugs, to be in intense relationships, and to do things under pressure at the last minute by staying up all night. All of these factors complicate the treatment of the student with bipolar disorder. Health care providers should make lifestyle recommendations taking into account the culture of college life. They should help students recognize their mood states and develop strategies to promote stability. The importance of relationships with friends and family and the role of open communication in maintaining stability should not be forgotten. Prescribers need to pay close attention to medication side effects, in particular those that affect academic functioning, and make changes in response to both side effects and mood variation. Health care providers can take advantage of the culture of learning, self-exploration, and tolerance to relieve some of the pain of adaptation. As well, the provider can take JOURNAL OF AMERICAN COLLEGE HEALTH College Students With Bipolar Disorder advantage of the temporary nature of school as a bridge to resolving treatment ambivalence, by framing medication and psychotherapy as short-term experiments rather than longterm obligations. NOTE For comments and further information, address correspondence to Simon Lejeune, MD, Massachusetts Institute of Technology Mental Health and Counseling, Service, E23368, 77 Massachusetts Avenue, Cambridge, MA 02139, USA (e-mail: simon-lejeune@hms.harvard.edu). REFERENCES 1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Arch Gen Psychiatry. 2005;62:617–627. 2. Kennedy N, Everitt B, Boydell J, Van Os J, Jones PB, Murray RM. Incidence and Distribution of first-episode mania by age: results from a 35-year study. Psychol Med. 2005;35:855–863. 3. Russell S, Browne J. Staying well with bipolar disorder. Aust N Z J Psychiatry. 2005;39:187–193. 4. Miklowitz D, Otto M, Frank E, et al. Intensive Psychosocial intervention enhances functioning in patients with bipolar depression: results from a 9-month randomized controlled trial. Am J Psychiatry. 2007;164:1340–1347 5. Rizvi S, Zaretsky A. Psychotherapy through the phases of bipolar disorder: evidence for general efficacy and differential effects. J Clin Psychol In Session. 2007;63:491–506. 6. Miller MM, ed. Improving outcomes in bipolar disorder. Harvard Mental Health Lett. 2008;24:1–2. 7. Milkowitz DJ. Adjunctive therapy for bipolar disorder: state of the evidence. Am J Psychiatr. 2008;165:1408–1419. 8. Cassidy F, Ahearn EP, Carroll BJ. Substance abuse in bipolar disorder. Bipolar Disord. 2001;3:181–188. 9. Wechsler H, Lee JE, Kuo M, Siebring M, Nelson TF, Lee H. Trends in college binge drinking during a period of increased prevention efforts: finding from 4 Harvard School of Public Health College Alcohol Surveys: 1993–2001. J Am Coll Health. 2002;50:203–217. VOL 59, AUGUST–OCTOBER 2011 10. Milkowitz DJ. The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. New York: The Guildford Press; 2002. 11. Basco MR. The Bipolar Workbook: Tools for Controlling Your Mood Swings. New York, NY: The Guilford Press; 2006. 12. Jamison KR. An Unquiet Mind: A Memoir of Moods and Madness. New York, NY: Alfred A. Knopf; 1995. 13. Frank E. Treating Bipolar Disorder: A Clinic ...
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