Bipolar affective disorder treatment

Few papers have looked at the economic implications of bipolar affective disorder. Most of the published studies look at direct medical costs over the course of a year. Industry-sponsored studies focus on the benefits of a new treatment over older treatments. However, factors individual to a particular patient are likely to be more important than the average cost of a particular treatment. These include selection of patients who are likely to respond to a particular treatment, and psychoeducation coupled with encouragement during follow-up and carefial monitoring, to avoid such expensive outcomes as ftill-blown relapse, serious toxicity or suicide. 

Whatever the mechanism of action of Li+ in the treatment of bipolar affective disorder turns out to be, there is no doubt that the functions of one or more of the neurotransmitters and hormones are involved to some extent. Much of the published data on the effects of Li+ on these systems is equivocal or even contradictory, in many cases reflecting differences in the experimental procedures, in particular the levels of Li+ employed. Often, where it has been looked for, there are differences observed between the acute and chronic effects of Li+. Therefore, the therapeutic relevance of many of these Li+-induced effects is difficult to assess. 

Lithium is commonly used for bipolar affective disorders. Lithium however has a narrow therapeutic index and high risk for toxicity (Groleau 1994). The use of loop diuretics or ACE-inhibitors significantly increases the risk of hospitalisation for lithium toxicity in the elderly (Juurlink et al. 2004). Treatment of elderly patients with lithium should be thoroughly monitored. 

Psychiatric medications do not currently play a prominent role in the treatment of cocaine-dependent patients (see Table 6.4). Although researchers have labored to find medications to treat cocaine addiction, there have not been any notable breakthroughs. As with other substance use disorders, the presence of a psychiatric disorder for which medication is indicated (i.e., depression, anxiety disorders, bipolar affective disorder, or schizophrenia) should prompt appropriate treatment. Similar to the presence of alcohol intoxication, deferring a diagnosis for a day or two in a new patient with no past history is often the more prudent course. 

Bass EW, Means A, McMillen B Buspirone impairs performance of a three-choice working memory escape task in rats. Brain Res Bull 28 455-461, 1992 Bastani B, Arora RC, Meltzer HY Serotonin uptake and imipramine binding in the blood platelets of OCD patients. Biol Psychiatry 30 131-139, 1991 Bauer MS, Whybrow PC Rapid cychng bipolar affective disorder, II treatment of refractory rapid cychng with high-dose levothyroxine a prehminary study. Arch Gen Psychiatry 47 435-440, 1990... 

Berk M, Kirchmann NH, Butkow N Dthium blocks 45Ca uptake into platelets in bipolar affective disorder and controls. Clin Neuropharmacol 19 48-51, 1996 Berman RM, Darnel AM, Anand A, et al Effect of pindolol in hastening response to fluoxetine in the treatment of major depression a double-blind placebo-controlled trial. Am J Psychiatry 154 37-43, 1997 Bernard M, Vergoni AV, Sandiini M, et al Influence of ovariectomy, estradiol and progesterone on the behavior of mice in an experimental model of depression. Physiol Behav 45 1067-1068, 1989... 

D haenen HA, Bossuyt A Dopamine D2 receptors in depression measured with single photon emission computed tomography. Biol Psychiatry 35 128-132, 1994 Di Costanzo E, Schifano E Dthium alone or in combination with carbamazepine for the treatment of rapid-cycling bipolar affective disorder. Acta Psychiatr Scand 83 456-459, 1991... 

Manji HK, Chen G, Shimon H, et al Guanine nucleotide-binding proteins in bipolar affective disorder effects of long-term lithium treatment. Arch Gen Psychiatry 52 135-144, 1995... 

Manji HK, Chen G, Hsiao JK, et al Regulation of signal transduction pathways by mood stabilizing agents implications for the pathophysiology and treatment of bipolar affective disorder, in Bipolar Medications Mechanisms of Action. Edited by Manji HK, Bowden CL, Belmaker RH. Washington, DC, American Psychiatric Press [in press)... 

Manna V [Bipolar affective disorders and role of intraneuronal calcium. Therapeutic effects of the treatment with lithium salts and/or calcium antagonist in patients with rapid polar inversion]. Minerva Med 82 757-763, 1991... 

Lithium salts are used in the treatment of bipolar affective disorder (i.e., manic depression) and occasionally in mania (but its slow onset of action is somewhat of a disadvantage in this case). Its mechanism of action is still open to debate, but lithium has effects on brain monoamines, on neuronal transmembrane sodium flux, and on cellular phosphatidylinositides related to second messenger systems. Lithium is administered in two salt forms, lithium carbonate (8.98) and lithium citrate (8.99). Side effects are common and include diarrhea, kidney failure, and drowsiness with tremor. 

Chouinard G. Clonazepam in the acute and maintenance treatment of bipolar affective disorder. J Clin Psychiatry 1987 48(Suppl 10) 29-36. 

Bauer MS, Whybrow PC. Rapid cycling bipolar affective disorder. II. Treatment of refractory rapid cycling with high-dose levothyroxine a preliminary study. Arch Gen Psychiatry 1990 47 435-440. 

Antipsychotic drugs are also indicated for schizoaffective disorders, which share characteristics of both schizophrenia and affective disorders. No fundamental difference between these two diagnoses has been reliably demonstrated. They are part of a continuum with bipolar psychotic disorder. The psychotic aspects of the illness require treatment with antipsychotic drugs, which may be used with other drugs such as antidepressants, lithium, or valproic acid. The manic phase in bipolar affective disorder often requires treatment with antipsychotic agents, although lithium or valproic acid supplemented with high-potency benzodiazepines (eg, lorazepam or clonazepam) may suffice in milder cases. Recent controlled trials support the efficacy of monotherapy with atypical antipsychotics in the acute phase (up to 4 weeks) of mania, and olanzapine and quetiapine has been approved for this indication. 

Sofuoglu S, Karaaslan F, Tutus A, Basturk M, Yabanoglu I, Esel E. Effects of short and long-term lithium treatment on serum prolactin levels in patients with bipolar affective disorder. Int J Neuropsychopharmacol 1999 2 S56. 

Goodwin, G. M. 1994, Recurrence of mania after lithium withdrawal. Implications for the use of lithium in the treatment of bipolar affective disorder, Br.J.Psychiatry, vol. 164, no. 2, pp. 149-152. 

Bipolar illness appears to be a changing illness. A comparison of psychiatric services in North-West Wales in the 1890s and the 1990s has shown that the rate of admissions increased from 4.0 every 10 years to 6.3 every 10 years (11). Similarly, the daily hospital occupancy rate for patients with bipolar affective disorder rose from 16 per million to 24 per million. While acknowledging that there have been many social changes that may have contributed to these differences, the authors suggested that current treatments leave much to be desired. Reviews of lithium treatment have reached similar conclusions, particularly regarding the effect of lithium in acute episodes (12). 

Esel E, Ozdemir MA, Turan MT, Basturk M, Kilic H, Kose K, Gonuk AS, Sofuoglu S. Effects of lithium treatment on granulocytes and granulocyte colony-stimulating factor in patients with bipolar affective disorder. Bull Clin Psychopharmacol 2001 11 28-32. 

Of 23 patients with bipolar affective disorder taking neuroleptic drugs, 15 developed akathisia and 18 had parkinsonism during their entire inpatient treatment (217). The patients initially received high-potency neuroleptic drugs (maximum 2000 mg/day of chlorpromazine equivalents) and were assessed weekly. Akathisia developed in 44% of the patients with severe headache or nausea who received prochlorperazine 10 mg intravenously (n = 100) within 1 hour (218). None of the 40... 

Lithium carbonate (Li2C03) treatment is used worldwide for the prophylactic treatment of bipolar affective disorder. Although the molecular mechanism(s) of action remains uncertain, the efficacy is well-demonstrated and can be maintained by continued use of the drug. Lithium succinate is used to treat seborrheic dermatitis, a skin disorder. Other uses currently being explored include treating immunological disorders and cancers. Schrauzer has proposed that lithium may be an essential trace element and has suggested a daily intake of 1.00 mg day . ... 

Dr. J. F. J. Cade, an Australian psychiatrist, first reported on the beneficial use of a lithium compound for a psychiatric disorder, namely, manic behavior in 1949. The early human trials were undertaken after initial experiments on rats, which became quite lethargic after treatment with lithium urate. Fairly large doses were required for treating manic behavior and its use for this disorder has been displaced by organic drugs that carry less risk. His report, however, led to its current nse as a treatment for bipolar affective disorder (also known as manic-depressive disorder). Its use in the United States was curtailed for a decade and a half by the US. Food and Dmg Administration (FDA), which based its decision on incidental poisonings due to overuse of a lithium-based table salt substitute, despite a safe record of controlled psychiatric apphcations in Europe. It has been estimated that by 1985... 

Manic depression currently affects up to 2 percent of the world s population. Clinical studies demonstrate proven effectiveness of lithimn treatment for bipolar affective disorder. Lithium is taken orally and has been used successftdly by some patients for periods exceeding a decade. The action is prophylactic, meaning that it is able to prevent the occurrence of the manic and depressive mood swing phases of the disease once the patient has been... 

Patient education about the role of lithium in the prophylaxis of bipolar affective disorder and discussion of the pros and cons of taking the drug are particularly important to encourage compliance with therapy treatment cards, information leaflets and where appropriate, video material are used. 

Carbamazepine is licenced as an alternative to lithium for prophylaxis of bipolar affective disorder, although clinical trial evidence is actually stronger to support its use in the treatment of acute mania. Carbamazepine appears to be more effective than lithium for rapidly cycling bipolar disorders, i.e. with recurrent swift transitions from mania to depression. It is also effective in combination with lithium. Its mode of action is thought to involve agonism of inhibitory GABA transmission at the GABA-benzodiazepine receptor complex (see also Epilepsy, p. 417). 

Valproic acid is the drug of first choice for prophylaxis of bipolar affective disorder in the United States, despite the lack of robust clinical trial evidence in support of this indication. But treatment with valproic acid is easy to initiate (especially compared to lithium), it is well tolerated and its use appears likely to extend if the evidence-base expands. As the semisodium salt, valproic acid is licenced for use in the treatment of acute mania unresponsive to lithium. (Note sodium valproate, see p. 420, is unlicenced for this indication.)... 

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