Mania treatment approach

Few randomized controlled trials have been done to evaluate different approaches for the treatment of acute and recurrent bipolar depression. Nonpharmacologic treatment that may have augmenting effects include phototherapy for seasonal-pattern depression and sleep deprivation for rapid cycling." The use of ECT for severe episodes of mania/mixed episodes, depression, psychotic features (e.g., hallucinations or delusions), or rapid cycling is still considered the best acute treatment approach for those patients who do not respond to first-line mood stabilizers such as lithium and valproate. " ... 

AN APPROACH TO THE TREATMENT OF ACUTE MANIA IN YOUNG PEOPLE... 

Post and Kramlinger (386) have also suggested that lithium added to carbamazepine may be useful in treatment-resistant mood-disordered patients. One possible basis for this approach is that carbamazepine, which has a tricyclic ring structure similar to imipramine, may sensitize postsynaptic serotonin receptors in a similar way to standard drugs such as imipramine. A mood stabilizer (e.g., lithium, valproate, carbamazepine) plus antidepressant may benefit some rapid cycling or mixed bipolar patients, attenuating the propensity to switch from mania to depression. 

Gershon S, Yuwiler A. Lithium ion a specific psychopharmacological approach to the treatment of mania. J Neuropsychiatry 1960 1 229-241. 

The risk of switching into mania, once the patient has emerged from depression, continues to be a factor in treatment considerations. Physicians often choose to discontinue the antidepressant relatively soon after recovery and to continue treatment with the mood stabilizer alone, in order to diminish this risk. This approach is diametrically opposed to the strategies for unipolar depression, where antidepressant treatment must continue at least for 1 year and often longer. 

Psychotherapy is not only possible but can be very productive with the bipolar patient. Miklowitz (1996), in addressing combined psyAotherapy and medication treatment for bipolar disorder, offers a comprehensive and detailed description of two approaches, family psychoeducation and individual therapy. The latter incorporates elements of interpersonal therapy for affective disorders with strategies to stabilize social rhythms. However, the therapist must be skilled at identifying symptoms of hypomania, mania, and depression, and the necessity for medication adjustment referrals. The therapist can be tested especially by the effects of medication noncompliance, when symptoms return and judgment and insight diminish. 

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