Non-use of bipolar medication typically follows careful ‘risk–benefit’ evaluation

By Joanna Lyford, Senior medwireNews Reporter

An investigation into why and how patients with bipolar disorder manage their moods without medication has found that most individuals are initially motivated by concerns about side effects.

In-depth interviews with 10 patients revealed that, having decided to live without medication, they used a wide range of strategies to manage their moods, including nutrition, self-discipline and channelling their energy into something positive.

“Professionals should place more emphasis on non-medication approaches in order to increase engagement with people who do not use medication,” say the study authors, who were led by Reed Cappleman (Fieldhead Hospital, Wakefield, West Yorkshire, UK), writing in the Journal of Affective Disorders.

The researchers undertook qualitative interviews with five women and five men, all of whom had chosen not to use medication for at least 3 months. Half of the cohort had a history of hospitalisation for bipolar disorder and one participant was currently hypomanic while the remainder were euthymic.

When asked about their reasons for stopping medication, all participants cited side effects as a major concern, describing distress resulting from problems including weight gain, tremors, loss of libido and lithium toxicity. Participants also frequently described side effects changing their view of themselves in ways they found undesirable.

Having decided to stop medication, participants searched for experiences and practical strategies that would help them, often developing their ideas at support groups or in therapy. Of note, they tended to seek out experiences and ideas that were congruent with existing ideas about themselves and their moods.

Strategies included trying to keep moods at a desired level and staving off undesired mood changes, such as by using essential oils, medication or cognitive techniques, and channelling their energy into something positive when they felt their mood was high, such as exercise or creative pursuits.

Participants were generally very aware of their moods or relied on close friends and partners to highlight changes in their moods; they also reported regularly evaluating their decision not to use medication against their previous experiences while taking medication, in order to be sure that the balance was favourable.

Cappleman and colleagues say their study is the first systematic evaluation of the processes by which people manage bipolar moods without medication and note that the findings challenge the widely held view that nonadherence to medication in patients with bipolar disorder is driven by a lack of insight.

“[P]eople who have chosen not to use medication may have already very carefully weighed up the costs and benefits, and a professional stance that emphasises the importance of adherence to medication may act as a barrier to such individuals engaging in services”, they write.

“Instead of focussing on medication adherence, services emphasising a broader range of approaches might engage people who have decided not to use medication.”

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