Download Bipolar Disorders - Santa Barbara Therapist

Bipolar Disorders
Lithium: works in 40-50% of patients
 Treats mania, hypomania, and prevents
recurrences
 May tx depression in bipolar clients
 Least effective for rapid cyclers and mixed
episodes
 Lots of side effects: gastrointestinal, weight gain,
hair loss, acne, tremor, sedation, decreased
cognition, incoordination
 Long term effects on kidneys, and thyroid
 Narrow therapeutic window-plasma level
monitoring
Anticonvulsants
Like seizures kindle seizures, mania
kindles mania
Treats manic phase
Mechanism of action poorly understood,
but believed to enhance GABA (inhibitory
NT) and reduce glutamate (excitatory NT)
and perform several other functions that
are poorly understood at this time.
Valproic Acid- Depakote
First line tx for bipolar, especially for rapid
cycling or mixed episodes
Plasma levels to ensure therapeutic range
Side effects: hair loss, weight gain,
sedation, effects on developing fetus,
menstrual disturbances, polycystic
ovaries, hyperandrogenism, obesity, and
insulin resistence
Carbamazepine/Tegretol
Less documented effects
Not FDA approved for mania
Side effects include sedation and
hematological abnormalities
Lamotrigine/Lamictal
Not approved for bipolar
Evidence is showing it may be effective
with manic, mixed AND depressive
episodes in bipolar
Topiramate/Topamax
Not yet approved for bipolar
Only anticonvulsant that has side effect of
weight loss instead of weight gain
Other mood stabilizing drugs
 Benzodiazepines: have anticonvulsant actions
and are sedating. Used as adjunct therapies for
agitation and psychotic behavior during mania
 Antipsychotics: for Manic/depressive agitation
and psychosis as adjunctive therapy. Atypical
(newer) antipsychotics are being used for the
management of mania. May become first line tx,
especially for rapid cyclers or mixed episodes-in
clinical trials.
Treatment Resistant patients: Depression
Augmenting agents: lithium, thyroid
hormone, and BuSpar
Thyroid problems are commonly
associated with depression especially in
women. Adding thyroid to cls not
responding to antidepressant (even
without hypothyroidism) can increase
efficacy
Also with bipolar cls resistant to mood
stabilizers and rapid cyclers
Estrogen has few clinical studies as
adjunct, but has important implications
Temazepam, vistiril, benadryl: medications
for sleep/anxiety
Treatment resistant Bipolar
Combination tx with two or more
psychotropics is the rule rather than the
exception for bipolar disorders
First line: lithium or Depakote
Second line: Atypical antipsychotics (sometimes
first line)
Third line: combine the above two
Fourth line: Add benzo or traditional
antipsychotic (restricted to acute phase)
Treating Bipolar with antidepressants
Antidepressants frequently decompensate
a bipolar client, causing hypomania/mania
and rapid/mixed cycling which are much
more difficult to tx
If used, used sparingly and combined with
mood stabilizers or other meds discussed
If the patient is not responding
 Check for A&D, OTC,or other prescription use
 Check hx with meds. Cls often say “I tried that” meaning
they took it for 3 days to a week” Need 4-8 weeks for
effects. If side effects caused discontinuation, consider
augmenting with medication that curbs side effects.
 Check for misdiagnosis: Cl dx is unipolar, but is actually
bipolar. For example, is the cl with unipolar depression
and drug induced agitation actually bipolar with drug
induced rapid or mixed cycling? Another Anti depressant
may worsen the condition even more. Try mood
stabilizer or atypical antipsychotic.
Combining meds
 Combinations should focus on combining the
mechanisms of each drug, not just drugs
 Use principles of synergy: 1+1=3, or 4 or 20
 For depression, think NE and 5HT if not
responding
 For fatigue, apathy and cognitive slowing think
NE (reboxitine not in US, but
desipramine/Norpramine and other TCAs are as
is Welbutrin) Think about side effects and
combinations in making best choices.
Remember
You can treat to Response or
Remission…we want Remission
Prevention is very important due to
Kindling, educate your clients
Reread information on how different
personality types respond to medications
so you can normalize and help cl stay
compliant with meds
 Know the signs of a manic, hypomanic or
depressive episode for your clients. Cls will stop
meds and not tell you because they want to
please you.
 Cls with hypomania and mania will often enjoy
this aspect of their disorder. Educate on
kindling. Have contact numbers for friends,
family, etc. that will need to intervene.
 Hypomania is often left without tx. Controversy
on whether this will increase mania exists.