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Module 3
Indications for Antipsychotics
Bipolar Disorder
Flavio Guzmán, MD
Outline
• Indications of antipsychotics in different
phases of bipolar disorder:
– Mania/mixed states
– Bipolar depression
– Maintenance treatment
• FDA approved agents for each phase
Use of antipsychotics in bipolar disorder
Mania
Mixed states
Maintenance
Bipolar depression
Mania Management
Acute mania pharmacotherapy
• Patients with BD spend much less time in
mania, hypomania, or mixed states than they
do in depression.
• Many effective treatments for mania, fewer
for maintenance treatment or treatment of
bipolar depression.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical
Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.
Acute mania pharmacotherapy
FGAs
SGAs
Anticonvulsants
Lithium
Antipsychotics for mania
• FGAs are effective in the treatment of mania,
but are frequently avoided due to the risk of
EPS.
• Antipsychotics work as well as lithium in
acute mania, even in the absence of
psychotic symptoms.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical
Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.
FGAs treatment
• Patients with mood disorders might more
vulnerable to developing TD than
schizophrenia patients.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical
Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.
Mixed Episodes
FDA approved SGAs for
manic/mixed episodes
Manic/mixed episodes
• Aripiprazole
• Asenapine
• Quetiapine and
quetiapine XR
• Risperidone
• Olanzapine
• Ziprasidone
Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
N Engl J Med. 2011;364(1):51-9.
The role of SGAs in the treatment of manic/mixed episodes
Manic/mixed episodes
Approved as
monotherapy
• Aripiprazole
• Asenapine
• Quetiapine and quetiapine XR
• Risperidone
• Olanzapine
• Ziprasidone
Manic/mixed episodes
Approved as
adjunctive
• Aripiprazole
• Asenapine
• Quetiapine and quetiapine XR
• Risperidone
• Olanzapine
• Ziprasidone
Lithium
Divalproex
sodium
Bipolar Depression
Bipolar depression
• Depression is the predominant mood state in
bipolar disorder.
• Some clinicians argue that this state is the
most difficult to treat.
• There are few proven strategies for bipolar
depression.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical
Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.
FDA approved SGAs for
bipolar depression
Bipolar
depression
• Quetiapine
• Olanzapine/
fluoxetine
Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
N Engl J Med. 2011;364(1):51-9.
Maintenance treatment
FDA approved SGAs for
maintenance
treatment
Maintenance
treatment
• Aripiprazole
• Olanzapine
• Quetiapine and
quetiapine XR
• Risperidone (LAI)
• Ziprasidone
Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
N Engl J Med. 2011;364(1):51-9.
Maintenance treatment: SGAs
Advantages
• Titration is rapid and
easier. (Compared to
lamotrigine and
lithium)
• Safer in overdose
Disadvantages
• Weight gain
• Metabolic side
effects
• Sedation
Take home points
Antipsychotics are effective for mania, mixed
states and bipolar depression.
Manic/mixed episodesc
• Aripiprazole
• Asenapine
• Quetiapine and
quetiapine XR
• Risperidone
• Olanzapine
• Ziprasidone
Maintenance
treatment
• Aripiprazole
• Olanzapine
• Quetiapine and
quetiapine XR
• Risperidone (LAI)
• Ziprasidone
Bipolar depression
• Quetiapine
• Olanzapine /
fluoxetine
References and further reading
• Frye MA. Clinical practice. Bipolar
disorder--a focus on depression. N Engl J
Med. 2011;364(1):51-9.
• Schatzberg, AF., Cole, JO, and DeBattista,
C. Manual of Clinical
Psychopharmacology. 7th ed.American
Psychiatric Publishing, 2010.