bipolar

• Bipolar disorder


  A common, lifelong, often severe cyclic mood disorder characterized by recurrent fluctuations in mood, energy, and behavior
• Bipolar disorder


  • Not substance-related or caused by other medical or psychiatric disorders
• Bipolar disorder is influenced by developmental, genetic, neurobiological, and psychological factors
• Multiple gene loci are likely involved in the heredity of mood disorders
• Causes of bipolar disorder

  • Developmental
  • Genetic
  • Neurobiological
  • Psychological
• Manic episode


  Marked impairment in functioning, bizarre behavior, hallucinations, and paranoid or grandiose delusions may occur
• Hypomanic episode

  No marked impairment in social or occupational functioning, no delusions, and no hallucinations
• Rapid cyclers, 20% of patients with bipolar disorder, have four or more episodes per year
• Rapid cycling is associated with frequent and severe episodes of depression and a poorer long-term prognosis
• Women are more likely to have depressive symptoms, older age of onset, better adherence, and thyroid abnormalities
• Men may have more manic episodes and substance use
• Suicide attempts occur in up to 50% of patients with bipolar disorder, and ~10%–19% of individuals with bipolar I disorder commit suicide
• Patients with bipolar II disorder may have a higher rate of suicide attempts than bipolar I patients
• Treatment goals


  • Eliminate mood episode with complete remission of symptoms
  • Prevent recurrences or relapses of mood episodes
  • Return to baseline psychosocial functioning
  • Maximize adherence with therapy
  • Minimize adverse effects
  • Use medications with the best tolerability and fewest drug interactions
  • Minimize polypharmacy when possible
  • Treat comorbid substance use and abuse
  • Eliminate alcohol, marijuana, cocaine, amphetamines, and hallucinogens
  • Minimize nicotine use and stop caffeine intake at least 8 hours prior to bedtime
  • Avoid stressors or substances that precipitate an acute episode
• Nonpharmacologic approaches


  • Adequate nutrition
  • Sleep
  • Exercise
  • Stress reduction
• Psychological interventions


  • Cognitive behavioral therapy (CBT)
  • Interpersonal and social rhythm therapy
  • Group psychoeducation
  • Family focused therapy
  • Enhanced relapse prevention/individual psychoeducation
• The occurrence of Epstein anomaly in infants exposed to lithium during the first trimester is estimated to be between 1 and 10.78:1000, and the risk of neural tube defects is 13.4:1000
• When lithium is used during pregnancy, use the lowest effective dose to prevent relapse, thus lessening the risk of "floppy" infant syndrome, hypothyroidism, and nontoxic goiter in the infant
• When valproate, carbamazepine, and lamotrigine are taken during the first trimester, the risk of neural tube defects is ~4%, ~3%, and ~2%, respectively
• Administration of folic acid can reduce the risk of neural tube defects
• First-generation antipsychotics (FGA) seem to have little teratogenic risk when used during pregnancy
• Data on the SGAs are more limited, risk to benefit ratio must be considered before using antipsychotics during pregnancy
• Lithium, valproic acid, and carbamazepine are used in pediatric bipolar disorder, but data are limited
• Aripiprazole and risperidone are FDA-approved for bipolar mania in adolescents 13–17 years
• Quetiapine is approved as monotherapy or adjunctive therapy to lithium or divalproex in manic patients aged 10–17 years
• Olanzapine is approved for manic or mixed episodes in patients aged 13–17 years
• Lithium is FDA-approved as a mood stabilizer for children older than 12 years
• The elimination half-life of lithium and valproate increases with age
• Older patients can have many comorbidities and take multiple medications, requiring careful monitoring and dosing adjustments
• Teratogenic risk


  Risk of causing abnormal fetal development
• Data on the SGAs (second-generation antipsychotics) are more limited
• Risk to benefit ratio


  Must be considered before using antipsychotics during pregnancy
• Lithium, valproic acid, and carbamazepine


  Used in pediatric bipolar disorder, but data are limited
• Aripiprazole and risperidone


  FDA-approved for bipolar mania in adolescents 13–17 years
• Quetiapine


  Approved as monotherapy or adjunctive therapy to lithium or divalproex in manic patients aged 10–17 years
• Olanzapine


  Approved for manic or mixed episodes in patients aged 13–17 years
• Lithium


  FDA-approved as a mood stabilizer for children older than 12 years
• A guideline for treatment of children and adolescents with bipolar disorder is Practice Parameters for the Assessment and Treatment of Children and Adolescents with Bipolar Disorder
• The elimination half-life of lithium and valproate


  Increases with age
• Older patients


  • Can have many medical comorbidities and increased sensitivity to side effects of mood stabilizers and antipsychotics