Bipolar disorders current

Table 36-4 includes a summary of current drug therapy for bipolar disorder. An algorithm for treatment of bipolar mania is shown in Table 36-2. 

Lithium, divalproex sodium (valproate), aripiprazole, olanzapine, que-tiapine, risperidone, and ziprasidone are currently approved by the FDA for treatment of acute mania in bipolar disorder. Lithium, olanzapine, and lamotrigine are approved for maintenance treatment of bipolar disorder. Quetiapine is the only antipsychotic that is FDA approved for bipolar depression. 

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

The current SSRIs in the United States inclnde fluoxetine, fluvoxamine, sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). All effectively treat major depression. In addition, one or more of the SSRIs has been shown effective in the treatment of dysthymic disorder, the depressive phase of bipolar disorder, premenstrual dysphoric disorder, panic disorder, social phobia, obsessive-compnlsive disorder, bnlimia nervosa, and binge-eating disorder. 

The relative absence of systematic studies of bipolar patients under age 18 forces clinicians to extrapolate data from adult studies. There are four major types of studies that provide information on subjects with bipolar disorder double-blind, placebo-controlled studies of patients with acute mania prospective open-label studies of patients with bipolar disorder (which includes mania, hypomania, manic symptoms, or bipolar NOS, people at risk for mania because of their family history, and those with a history of mania who are not currently manic) case series and anecdotal reports. 

Virtually all anticonvulsants are or have been of interest for the treatment of bipolar disorder. However, the importance of controlled data cannot be understated. For example, gabapentin, an anticonvulsant that initially received much attention as a potential mood stabilizer, was compared with placebo and did not appear to stabilize mood (Frye et al. 2000 Pande et al. 2000). Similar negative results were seen with topiramate in placebo-controlled trials for the treatment of mania. Although these medications might be useful adjuncts in some patients, given the currently expanded pharmacopoeia of medications with positive controlled trial data in bipolar disorder, we do not recommend the primary use of agents that have only case reports as an evidence base or controlled studies with predominantly negative results. 

The olanzapine-fluoxetine combination is currently the only medication approved by the FDA specifically for the treatment of depression in patients with bipolar disorder. This indication was based on data from a double-bhnd, randomized study in which the combination was superior to both olanzapine monotherapy and placebo (Tohen et al. 2003). Treatment-emergent mania or hypomania did not occur more frequently in the olanzapine-fluoxetine combination group than in the placebo group during the acute trial. 

Some patients with bipolar disorder will need antidepressants. Although the switch rate into mania or induction of rapid cychng by antidepressants is controversial, these agents do appear to present a risk for some patients, often with devastating consequences. Therefore, when a patient with bipolar disorder is prescribed an antidepressant, it should only be in combination with a medication that has established antimanic properties. Controlled comparative data on the use of specific antidepressant drugs in the treatment of bipolar depression are sparse. Current treatment guidelines extrapolate from these few studies and rely heavily on anecdotal chnical experience. Overah, tricyclic antidepressants should be avoided when other viable treatment options exist. Electroconvulsive therapy should be considered in severe cases. 

Chapter /, Modem Psychopharmaceuticals, written by Dr Hossein Fatemi, and Chapter 5, Psychopharmaceuticals and the Treatment of Mental Disorders, provide succinct, up to date, and well-referenced information on how to use the major classes of psychotropic drugs. The latter chapter discusses in a frank and balanced manner the ambivalence towards the use of pharmacologic agents in mental disorders felt by some, and the limitations on the achievements of current drugs as ideal therapies for schizophrenia, bipolar disorder and major depression in particular. Clearly, much has been accomplished, but many needs, especially for prevention of relapse, removal of specific types of symptoms, and restoraton of work and social function, remain to be accomplished by drug and psychosocial therapies. 

Murphy and Wetzel (45) concluded that the current estimate of 11 % to 15% lifetime risk of suicide in alcoholics was not tenable based on a more careful examination of the data, and was probably more in the range of 2% to 3.4%. This percentage is still in contrast with the approximate 1% annual incidence of suicide in the United States. Much of the increase, however, could be related to another Axis I diagnosis (e.g., bipolar disorder). 

In the United States, the Research Diagnostic Criteria (RDC) (19) and the DSM-IV (8) both provide clear inclusion and exclusion criteria for a current episode ( Table 9-2). Evaluation of past episodes can be made using the Schedule for Affective Disorders and Schizophrenia—Lifetime Version (SADS-L) ( 20) or the Structured clinical Interview for DSM (21). In other countries, the Present State Exam (PSE) (22) can reliably distinguish mania from other disorders. Table 9-3 reviews the various clinical presentations of primary bipolar disorder and their related DSM-IV diagnoses ( 23) (see also Appendix A, Appendix G, and Appendix H). 

Answers to these questions are just beginning to evolve (Tables 5—5 through 5 — 10). For example, the incidence of depression is about 5% of the population, whereas the incidence of bipolar disorder is about 1%. Thus, up to 15 million individuals are currently suffering from depression and another 2 to 3 million from bipolar disorders in the United States. Unfortunately, only about one-third of individuals with depression are in treatment, not only because of underrecognition by health care providers but also because individuals often conceive of their depression as a type of moral deficiency, which is shameful and should be hidden. Individuals often feel as if they could get better if they just pulled themselves up by the bootstraps ... 

Although the usefulness of the atypical antipsychotics is best documented for the positive symptoms of schizophrenia, numerous studies are documenting the utility of these agents for the treatment of positive symptoms associated with several other disorders (discussed in Chapter 10 see Fig. 10—2). Atypical antipsychotics have become first-line acute and maintenance treatments for positive symptoms of psychosis, not only in schizophrenia but also in the acute manic and mixed manic-depressed phases of bipolar disorder in depressive psychosis and schizoaffective disorder in psychosis associated with behavioral disturbances in cognitive disorders such as Alzheimer s disease, Parkinson s disease, and other organic psychoses and in psychotic disorders in children and adolescents (Fig. 11—52, first-line treatments). In fact, current treatment standards have evolved in many countries so that atypical antipsychotics have largely replaced conventional antipsychotics for the treatment of positive psychotic symptoms except in a few specific clinical situations. 

Pathophysiology of the disorder There is no commonly accepted theory about the biological origins of manic depression or bipolar disorder that would explain the actions of any currently used mood stabiliser in disease-centred terms. 

Goldberg, J., Truman, C. (2003). Antidepressant-induced mama An overview of current controversies. Bipolar Disorder, 5, 407-420. 

Lamotrigine is approved for the treatment of bipolar depression. This anticonvulsant has been shown to have antidepressant properties that are apparently unique among other anticonvulsants currently used for the treatment of bipolar disorder. Although lamotrigine s antimanic properties may be modest, because of its contribution to the often difficult-to-treat bipolar depressive episodes, we are likely to see its use increase. 

Medications are the core feature in the treatment of bipolar disorder. Without their skillful application, there is little hope for a good result. However, the illness and its course, coupled with the current imperfections of medication, make the use of psychotherapy and other psychosocial interventions essential tools. Bipolar patients are faced with myriad issues and obstacles that have a profound impact on how they perceive themselves and their future (Table 3.24). 

Gould, T.D., Quiroz, J.A., Singh, J., Zarate, C.A., and Manji, H.K., 2004a, Emerging experimental therapeutics for bipolar disorder Insights from the molecular and cellular actions of current mood stabilizers. Mol. Psychiatry 9 734-755. 

Developmental disabilities, which again through continued research are often referred to currently as cognitive disabilities, include Tourette s syndrome, dyslexia, and attention deficit hyperactivity disorder. Mental illness includes depression, schizophrenia, bipolar disorder, and borderline personality, to name only a few of the conditions that can destroy the lives of individuals and wreak havoc on family and friends. 

Patients with current or past bipolar disorder or psychosis... 

Goldberg JF, Truman CJ (2003) Antidepressant-induced mania An overview of current controversies. Bipolar Disord 5 407-420. 

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