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.