Medication for Bipolar Depression

Carbolith, Cibalith, Duralith, Eskalith, Lithane, Lithizine, Lithobid 

BIPOLAR DISORDER, MORE THAN JUST DEPRESSION 

The symptoms of bipolar disorder are in some ways similar to unipolar depression but in other ways quite different. Symptoms during the depressed phase are quite similar to those seen in a severe depression, where there is low energy, feelings of hopelessness, and little pleasure in daily activities. The manic 

Groupings Population (1995) Deaths per 100M0 Disabled per 100,000 Incidence per 100 MO Prevalence % 

Since bipolar disorder is much more complicated than unipolar, it is also more difficult to treat. The most commonly used antidepressants, Wellbutrin, Effexor, or SSRIs, can actually trigger or worsen a manic state. Since these drugs elevate mood, someone in a manic phase (whose mood is already elevated) may respond to them by becoming even more manic. Thus 

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Contents Introduction, history and brain basics—Older antidepressants tricyclics and monoamine oxidase inhibitors—Selective serotonin reuptake inhibitors—Second generation antidepressants—Lithium, a medication for bipolar depression—Natural depressants—Teens and antidepressants trends and attitudes—Case study one girl s experience with antidepressants. 

Lamotngine (Lamictal). Lamotrigine, another anticonvulsant used to treat BPAD, is currently FDA approved for the prevention of both depressive and manic episodes during BPAD maintenance therapy. This represents a shift in the paradigms for BPAD therapy, as medications used to treat acute episodes have also typically been used for antimanic prophylaxis. Lamotrigine is not effective in the acute treatment of mania but has become for many the drug of choice for bipolar depression as well as for prevention of subsequent mood episodes of either polarity. 

Quetiapine is indicated for the treatment of schizophrenia and acute mania. Results from a recent study also showed that this medication is an effective treatment for bipolar depression (Calabrese et al. 2005). Quetiapine therapy is initiated at a dose of 25 mg twice a day for patients with schizophrenia, with increases to 50 mg twice a day on day 2, 100 mg twice a day on day 3, and 100 mg in the morning and 200 mg in the evening on day 4. The optimal dose for most patients appears to range between 400 and 600 mg/day, although the drug is safe and efficacious for some patients within a dose range of... 

As with mania and unipolar depression, ECT is a very effective treatment for the depressive phase of bipolar disorder, especially in cases with psychotic symptoms. It is at least as effective as antidepressant medications and probably more effective. Curiously, in spite of its proven antimanic properties, when ECT is administered to depressive bipolars, it may precipitate a switch into mania in some cases. Several other treatments have been tried for bipolar depression, especially in... 

There is, however, a unique risk in the bipolar form that antidepressant treatment may trigger a switch into mania. This may occur either as the natural outcome of recovery from depression or as a pharmacological effect of the drug. Particular antidepressants (the selective serotonin reuptake inhibitors) seem less liable to induce the switch into mania than other antidepressants or electroconvulsive therapy. Treatment for mania consists initially of antipsychotic medication, for instance the widely used haloperidol, often combined with other less specific sedative medication such as the benzodiazepines (lorazepam intramuscularly or diazepam orally). The manic state will usually begin to subside within hours and this improvement develops further over the next 2 weeks. If the patient remains disturbed with manic symptoms, additional treatment with a mood stabilizer may help. 

Anticonvulsants. Finally, several antiseizure medications have been tried. These include valproic acid (Depakote, Depakene), carbamazepine (Tegretol), Lamotrig-ine (Lamictal), and gabapentin (Neurontin). The anticonvulsants are effective treatments for bipolar disorder. Their use for major depression needs to be studied further. Please refer to Section 3.4 Bipolar Disorders. 

Although there are continuation and maintenance guidelines for the use of antidepressants for unipolar depression, it is not clear how long a patient with bipolar depression should be treated with these medications. Rates of recurrence of bipolar depression of approximately 60% have been observed in patients taking adequate doses of lithium, alone or in combination with imipramine (APA, 1994b). As the TCAs have not been shown to be efficacious for youth with... 

According to the Expert Consensus Panel for Mental Retardation Rush and Frances, (2000), the mainstays of the pharmacological treatment of acute mania or bipolar disorder in adults are anticonvulsant medications (divalproex, valproic acid, or carbamazepine) or lithium. Both divalproex or valproic acid and lithium were preferred treatments for classic, euphoric manic episodes. Divalproex or valproic acid was preferred over lithium and carbamazepine for mixed or dysphoric manic episodes and rapid-cycling mania. For depressive episodes associated with bipolar disorder, the addition of an antidepressant (SSRI, bupropion, or venlafaxine) was recommended. According to the Expert Consensus Panel, the presence of MR does not affect the choice of medication for these psychiatric disorders in adults. 

In contrast with lithium, valproate has been associated with a good antimanic response in patients with concurrent depressive symptoms or syndromes. Calabrese and colleagues [Calabrese and Delucchi 1990 Calabrese et al. 1992, 1993a, 1993b] have reported favorable responses in patients with rapid-cycling bipolar disorder with index episodes of either mixed or pure mania who received open-label valproate alone or in combination with other psychotropic medication. For those patients who received valproate alone, 18 [95%] of 19 patients with pure mania had a moderate or better response, and 8 [80%] of 10 with mixed mania did similarly. T. W. Freeman et al. [1992] reported on 14 patients treated with valproate in a double-blind trial with lithium carbonate and found that patients responding to valproate had signifi-... 

Because melatonin is sold over the counter and its production is not the subject of strict regulation as is that of prescribed medications, it is in wide use, but insufficient scientifically controlled information is available. Another consequence of the popularity and availability of the hormone is its use in a wide array of situations in which its efficacy has not been proven yet for instance, as treatment for neurodegenerative diseases or as a sleep-inducing medication. It also has been tried as an antidepressant, but that effect is still unclear. The administration of melatonin to patients with bipolar depression, especially to rapid cyclers, is of interest, especially if its use is associated with the presumed decrease in nocturnal hormonal levels and increase in sensitivity to light (Lewy et al. 1985). The possibility that melatonin also serves as a stabilizer of rhythm in these patients is in accord with the homeostatic effect of several other hormones that have been previously discussed here. 

The study of antidepressant maintenance medications for patients with unipolar MDD has been historically neglected. Such neglect is puzzling. Considering that multiple recurrences may well be the sine qua non for unmedicated patients with manic depression [Coryell and Winokur 1982 NIMH/ NIH Consensus Development Panel 1985 Prien et al. 1984 Suppes et al. 1991 Zis and Goodwin 1979 Zis et al. 1980] and that unipolar illness is pathophysiologically similar to bipolar disorder in many important respects, recurrences could have been presumed to be innate. 

A common mistake is to treat bipolar depression in the same manner that one treats unipolar depression, overlooking the need for a mood stabilizer. In bipolar depression, the first pharmacological intervention should be to start or optimize treatment with a mood stabilizer rather than to start administering an antidepressant medication. In addition, thyroid function should be evaluated, particularly if the patient is taking lithium. Subclinical hypothyroidism, manifested as an increased thyroid-stimulating hormone level and normal triiodothyronine and thyroxine levels, may present as depression in affectively predisposed individuals. In such cases, the addition of thyroid hormones may be beneficial, even if there is no other evidence of hypothyroidism. 

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. 

Not clearly effective for the depressed phase of bipolar disorder Can be complicated to dose Can be complicated to use with concomitant medications... 

When bipolar patients present in a depressive episode, initial treatment with a mood stabilizer is recommended (Post, 2000). If a depressed bipolar does not respond to treatment with a mood stabilizer, an antidepressant is prescribed. Most patients with bipolar disorder end up on multiple medications. Elech o-convulsive therapy is an effective treatment for bipolar disorder in both the manic and depressed phases of the illness. 

Lithium has been the treatment of choice for manic-depressive illness for several decades. Lithium is a trace element found in plants, mineral rocks, and in the human body. Today, the major source of medical lithium is mines in North Carolina. Lithium is classified as an antimonic medication because of its ability to reverse mania, a mood disorder characterized by extreme exeitement and activity, hi addition, lithium is also effective in reversing deep depression, the other mood extreme of manic-depressive illness, and in decreasing the frequency of manic and depressive cycles in patients. Manic-depressive illness is now generally referred to as bipolar disorder, a term preferred in the psychiatric community. 

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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