Pharmacology mood stabilizers

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. 

Pharmacotherapy is very important for treating Bipolar Disorder, and the use of mood stabilizers, such as lithium, is considered the standard of care. However, after you stabilize a person s mood, you may be left with a person who has not learned a great many life skills over the years precisely because of her or his disorder. Fortunately, cognitive behavioral therapy, including skills training, has been used effectively with bipolar clients after they have been stabilized pharmacologically. Obviously the person must be emotionally stable in order to learn new skills. 

Diagnostic boundaries in juvenile-onset BD need to be defined, since children with hypomania or manic-like symptoms may be increasingly treated with mood stabilizers. In parallel, this would require more complex algorithms because very few controlled trials have been reported (Walkup, 1995). In contrast to the studies of adults reported in the literature, the pharmacological treatment of childhood bipolarity with anticonvulsants remains an understudied area. Carbamazepine appears to be less efficacious than valproate in adult rapid cycling, yet no studies have identified predictors of treatment response to CBZ or any other mood stabilizer (besides lithium) in a pediatric population. 

There is strong evidence that bipolar disorder is associated with SUD in adolescents (Wilens et ah, 1999) and that pharmacological interventions are an effective treatment for youth with SUD and bipolar disorder. Two studies, including one randomized controlled study, have reported that mood stabilizers, specifically lithium and valproic acid (Depakote), significantly reduced substance use in bipolar youth (Donovan and Nunes, 1996 Geller et ah, 1998). In addition, these agents are considered effective agents for the treatment... 

Skillful practice of psychopharmacology requires a broad knowledge of psychiatry, pharmacology, and medicine. In this chapter, we present general principles relevant to the safe and effective use of psychotropic medications. In subsequent chapters, we discuss the major classes of psychotropic medications—antidepressants, anxiolytics, antipsychotics, mood stabilizers, stimulants, and cognitive enhancers—and the disorders for which they are prescribed. The reader should be aware that this nomenclature is somewhat artificial for example, many antidepressant medications are also used to treat anxiety disorders. Generic names are used throughout this book. The appendix provides a fist of trade (brand) names. 

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. 

ECT should be considered for more severe forms of depression (e.g., those associated with melancholic and psychotic features, particularly when the patient exhibits an increased risk for self-injurious behavior) or when there is a past, well-documented history of nonresponse or intolerance to pharmacological intervention. Limited data indicate that bipolar depressed patients may be at risk for a switch to mania when given a standard TCA. A mood stabilizer alone (i.e., lithium, valproate, carbamazepine, lamotrigine), or in combination with an antidepressant, may be the strategy of choice in these patients. Some elderly patients and those with acquired immunodeficiency syndrome may also benefit from low doses of a psychostimulant only (e.g., methylphenidate) (see also Chapter 14, The HIV-Infected Patient ). Fig. 7-1 summarizes the strategy for a patient whose depressive episode is insufficiently responsive to standard therapies. 

In this chapter, we have discussed the mechanisms of action of the major antidepressant drugs. The acute pharmacological actions of these agents on receptors and enzymes have been described, as well as the major hypothesis that attempts to explain how all current antidepressants ultimately work. That hypothesis is known as the neurotransmitter receptor hypothesis of antidepressant action. We have also introduced pharmacokinetic concepts relating to the metabolism of antidepressants and mood stabilizers by the cytochrome P450 enzyme system. 

Discussion of antidepressants and mood stabilizers will begin with the antidepressants that act by a dual pharmacological mechanism, including dual reuptake blockade, alpha 2 antagonism and dual serotonin 2A antagonism/serotonin reuptake blockade. We will also explore several antidepressants under development but not... 

In summary, the combination of pharmacologic and nonpharmacologic measures appears to produce the best chance for a positive outcome for patients with BN. Antidepressants are the class of choice in patients with BN, while other medications such as mood stabilizers are reserved for patients with comorbid psychiatric conditions. Only in unusual circumstances should patients be treated with antidepressants alone, as the chances for success are not high. SSRIs are the antidepressant class of choice for managing BN patients. Evidence suggests the greatest benefit in the acute phase of treatment, whereas data are more mixed for their role in the prevention of relapse. 

Bipolar disorder (manic-depressive illness) is one of the most common of the severe chronic psychiatric disorders. The cyclic mood disorder is characterized by recurrent fluctuations in mood, energy, and behavior encompassing the extremes of human experiences.Bipolar disorder differs from recurrent major depression (or unipolar depression) in that a manic, hypomanic, or mixed episode occurs during the course of the illness. Bipolar disorder is a lifelong illness with a variable course and requires both nonpharmacologic and pharmacologic treatments for mood stabilization. ... 

Clinical experience with various pharmacological regimens (mainly mood stabilizers) has suggested that a drug that is efficacious in one manifestation of mania is not necessarily the treatment of choice for the overall spectrum of manic states. Much progress have been made in the treatment of acute manic states, especially since the demonstrated efficacy of the second-generation antipsychotics (e.g. olanzapine, quetiapine, and risperidone) for the treatment of acute mania. However, treatment of acute manic states remains incomplete, and new treatment strategies are in continuous development. ... 

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