Download Bipolar I Disorder

Bipolar I Disorder
Treatment
Therapeutic Goals
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Relief of immediate symptoms
Improvement of patient’s well-being
Elimination of stressors
Combined pharmacotherapy and psychotherapy
– Improved medication compliance
– Better monitoring of clinical status
– Decreased number and length of hospitalizations
– Decreased risk of relapse
– Improved social and occupational functioning
Pharmacotherapy
• DIVISION
– Acute Phase
– Maintenance Phase
Treatment of Acute Mania
• Lithium Carbonate
– the prototypical “mood stabilizer
– Therapeutic lithium levels are between 0.6 and 1.2
mEq/L
• Valproate
– only indicated for acute mania; has prophylactic
effects
– Typical dose levels of valproic acid are 750 to 2,500
mg per day, achieving blood levels between 50 and
120 µg/mL
• Carbamazepine and Oxcarbazepine
– Typical doses of carbamazepine to treat acute mania
range between 600 and 1,800 mg per day associated
with blood levels of between 4 and 12 µg/mL
Treatment for Acute Mania
• Clonazepam and Lorazepam
– effective and are widely used for adjunctive treatment
of acute manic agitation, insomnia, aggression, and
dysphoria, as well as panic
– Atypical and Typical Antipsychotics
• Lamotrigine
– Prevent recurrences of manic episodes
• ECT
– Effective in acute mania
– Reserved for rare refractory mania or with medical
complications
Treatment of Acute Bipolar Depression
• Combination of Antidepressants and Mood
Stabilizer
– Olanzepine and Fluoxetine
• Electroconvulsive Therapy
• Calcium Channel Blocker
– Verapamil
– Has acute antimanic efficacy
Table 15.1-37 US Food and Drug Administration (FDA)Approved Medications for the Treatment of Bipolar
Disorders
Mania
Maintenance
Aripiprazole (Abilify)
Yes (2004) No
Carbamazepine XR (Equetro) Yes (2004) No
Divalproex (Depakote)
Yes (1996) No
Lamotrigine (Lamictal)
No
Yes (2003)
Lithium (Lithobid)
Yes (1970) Yes (1974)
Olanzapine (Zyprexa)
Yes (2000) Yes (2004)
Risperidone (Risperdal)
Yes (2003) No
Quetiapine (Seroquel)
Yes (2004) No
Ziprasidone (Geodon)
Yes (2004) No
Maintenace Treatment of Bipolar
Disorder
MOOD STABILIZERS
– Lamotrigine
– Lithium
– Olanzapine
• Ameliorate affective and psychotic symptoms
during acute manic episodes
• Improve depression episodes during acute
bipolar depressive episodes
• Prevent future mood episodes with sustained
treatment at therapeutic levels (prophylactic
benefit)
Psychotherapy
• Patients taking lithium or other treatments for
bipolar I disorder are usually medicated for an
indefinite period of time to prevent episodes of
mania or depression
• Most psychotherapists insist that patients with
bipolar I disorder be medicated before starting
any insight-oriented therapy. Without such
premedication, most patients with bipolar I
disorder are unable to make the necessary
therapeutic alliance.
Psychotherapy
• When those patients are depressed, their abulia
seriously disrupts their flow of thoughts, and the
sessions are nonproductive.
• When they are manic, their flow of associations
can be rapid, and their speech can be so
pressured that the therapist may be flooded with
material and may be unable to make appropriate
interpretations or to assimilate the material into
the patient's disrupted cognitive framework.
Psychotherapy
• American Psychiatric Association (APA)
practice guideline for bipolar disorder
– Recommends combined therapy as the best
approach
– It increases compliance, decreases relapse, and
reduces the need for hospitalization