Physicians should consider bipolar disorder in any patient presenting with depression. Pharmacotherapy with mood stabilizers, such as lithium, anticonvulsants, and antipsychotics, is a first-line treatment that should be continued indefinitely because of the risk of patient relapse.
Full Answer
What is the first-line treatment for bipolar disorder?
First-line treatments for bipolar depressive episodes include lithium or lamotrigine monotherapy. For more severe cases, can add second mood stabilizer (e.g., lamotrigine combined with lithium or divalproex). Atypical antipsychotics can be added for patients with psychotic features (e.g., delusions, hallucinations ).
Which medications are used in the treatment of bipolar disorder?
Lithium and divalproex are first-line mood stabilizers; other options include carbamazepine, oxcarbazepine, and atypical antipsychotics (e.g., aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone). The above medications can be used as monotherapy for patients with less severe illness.
When to add paroxetine to the first-line treatment for bipolar disorder?
When an acute depressive episode of bipolar disorder does not respond to first-line agents at optimal doses, the next steps may include adding lamotrigine, bupropion, or paroxetine. See also, a clinical update on bipolar depression treatments including urgent and first-line therapies.
What is the role of non pharmacological management in the treatment of bipolar?
NON-PHARMACOLOGICAL MANAGEMENT OF BIPOLAR DISORDER Psychosocial management as an adjunct to pharmacotherapy has been shown to be of significant benefit during the management of acute phase of bipolar depression and maintenance phase of illness.
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Which is considered the first line treatment for bipolar disorder?
First-line treatments for bipolar depressive episodes include lithium or lamotrigine monotherapy. For more severe cases, can add second mood stabilizer (e.g., lamotrigine combined with lithium or divalproex).
Which of the following is typically the #1 treatment for bipolar I?
Medication is the key to stabilizing bipolar disorder. Initial treatment of mania consists of lithium or valproic acid (Depakene). If the patient is psychotic, a neuroleptic medication is also given. Long-acting benzodiazepines may be used for treating agitation.
Is lithium first line for bipolar?
Lithium has been the treatment of choice for patients with bipolar disorder (BD) for nearly 70 years. It is recommended by all relevant guidelines as a first-line treatment for maintenance therapy.
Which medication is considered the first line drug to treat mania?
Lithium. Lithium remains a highly effective pharmacological treatment for acute mania. For patients with classic mania, which refers to the presence of euphoria, grandiosity and hyperactivity in a person with a stable episodic course, many experts prefer lithium as a first-line medication.
What is the most effective treatment for bipolar disorder?
The most effective treatment for bipolar disorder is a combination of medication and psychotherapy. Most people take more than one drug, like a mood-stabilizing drug and an antipsychotic or antidepressant.
Which treatment for bipolar disorder is the most common?
The most widely used drugs for the treatment of bipolar disorder include lithium carbonate and valproic acid (also known as Depakote or generically as divalproex).
What is the gold standard treatment for bipolar disorder?
Lithium is considered the gold standard treatment for bipolar disorder (BD). Current clinical guidelines and scientific evidence support its use as a first-line treatment in BD.
Is Lamictal first line for bipolar?
Lamotrigine is indicated for use in numerous clinical guidelines as a first‐line pharmacological agent in the treatment of bipolar depression (Nivoli 2011).
Is lamotrigine first line for bipolar?
Lamotrigine is a mood stabilizer, it also is a first line drug in the acute and maintenance treatment of bipolar disorder, and only one drug called “mood stabilizer for depression”. Lamotrigine is often used in treatment of BD due to more common depressive symptom (9).
Which drug has been used as a treatment for bipolar disorder?
Anticonvulsant medications Three anticonvulsant (anti-seizure) medications — carbamazepine extended-release (Equetro), divalproex (Depakote), and lamotrigine (Lamictal) — are also widely used as mood stabilizers for bipolar disorder. Similar to lithium, they're also first-choice options.
What is the best medication for bipolar depression?
Lithium and quetiapine top the lists for all three phases of the illness: mania, depression, and the maintenance phase. Lurasidone and lamotrigine are either untested (lurasidone) or ineffective (lamotrigine) in mania, but they are essential tools for bipolar depression.
What is the second line treatment for bipolar disorder?
For second-line options, data show that lithium once again is the superior initial monotherapy. Data also support valproate, quetiapine, and lamotrigine as second-line options for monotherapy, especially for patients who fail or have contraindications to lithium therapy.
How treatable is bipolar 1?
Bipolar disorder is treatable with a combination of medication and therapy. Medications. Mood stabilizers, antipsychotics, and antidepressants can help manage mood swings and other symptoms. It is important to understand the benefits and risks of medications.
What does lithium do for bipolar 1?
Lithium is used to treat mania that is part of bipolar disorder (manic-depressive illness). It is also used on a daily basis to reduce the frequency and severity of manic episodes.
What is the goal of bipolar treatment?
The main goal of treatment of bipolar depression – that is, an individual diagnosed with bipolar 1 disorder or with a history of mania, currently experiencing a major depressive episode – is remission of the major depressive episode in addition to avoiding precipitation of a manic or hypomanic episode.
What is the treatment for bipolar disorder?
anticonvulsants. antipsychotics. antidepressants (see also, a recent perspective that reviews the use of antidepressants in people with bipolar disorder) Electroconvulsive therapy (ECT) is considered for patients with bipolar 1 disorder, experiencing severe or treatment-resistant manic or depressive episodes.
How long does bipolar last after remission?
Following remission of an acute episode, patients may remain at high risk for relapse for up to 6 months. This period of time is considered to be part of the maintenance phase. 1 Maintenance treatment for bipolar 1 should be focused on preventing the relapse of manic or depressive episodes, reducing residual symptoms, reducing suicide risk, and improving the overall quality of life for the patient. Per the American Psychiatric Association guidelines, lithium, valproate, and lamotrigine exhibit significant utility in the maintenance of bipolar disorder. 2,3
How long does bipolar 1 relapse?
Following remission of an acute episode, patients may remain at high risk for relapse for up to 6 months. This period of time is considered to be part of the maintenance phase. 1 Maintenance treatment for bipolar 1 should be focused on preventing the relapse of manic or depressive episodes, reducing residual symptoms, reducing suicide risk, and improving the overall quality of life for the patient. Per the American Psychiatric Association guidelines, lithium, valproate, and lamotrigine exhibit significant utility in the maintenance of bipolar disorder. 2,3
What should be included in a bipolar assessment?
Assessing patients suspected of having have bipolar 1 should include ruling out other psychiatric disorders or causes of symptoms and 3,8. Comprehensive assessment of the patient, patient’s family history, substance use history, home environment, and current caregivers or legal guardians, if applicable.
How old is bipolar 1?
The mean age of onset for bipolar 1 disorder is 18 years, 1 and there is often a significant delay between the onset of symptoms and contact with mental health services. The lifetime prevalence of bipolar 1 disorder is estimated at 1% to 2.4% of the adult population, with occurrence rates similar between males and females.
What is bipolar disorder?
Bipolar disorder is a potentially lifelong, debilitating disorder characterized by episodes of either mania or hypomania, and episodes of depressed mood. Patients with bipolar disorder encounter difficulties with education, jobs, interpersonal struggle, psychosocial dysfunction, marital problems, and multiple suicide attempts and completions.
How effective is carbamazepine?
Carbamazepine has been shown to be efficacious in the management of acute bipolar mania and prevention of relapse. Prior to starting carbamazepine, clinician needs to focus on the history of blood dyscrasias and hepatic dysfunction. When carbamazepine is considered, patients need to be informed about the signs and symptoms of hepatic dysfunction, haematological dysfunction and skin reactions and told to report to the psychiatrist if these symptoms emerge. Baseline investigation prior to starting of carbamazepine may include complete haemogram, liver function tests and renal function test (Table-5). When used in elderly serum electrolytes may also be done, in view of the risk of hyponatremia. Usual starting dose of carbamazepine is 200 mg/day given in divided doses and titrated upward slowly. Once the dose of 800-1000 mg/day is reached the increment of dose may be slower and the usual maintenance dose is about 1000 mg/day, but it can vary from patient to patient and may be 200 to 1600 mg/day. The carbamazepine therapeutic drug levels have not been established in patients with BPAD and the serum levels of 4-12 µg/ml, which is recommended for seizure disorders is commonly used. As with lithium and valproate the serum levels need to be done after 5 days of initiation of treatment or increment of dose.
What is a bipolar disorder?
Bipolar disorder (BPAD) is a serious mental disorder characterized by episodes of depression, hypomania/mania and mixed episodes, with interepisodic recovery. However, many patients with BPAD continue to exhibit residual symptoms in the interepisodic period. The illness usually starts in adolescence or early adulthood and has significant negative impact on the life of the sufferer and their caregivers. Patients with BPAD encounter educational difficulties, job related problems, interpersonal difficulties, psychosocial dysfunction, disability, marital problems, multiple suicidal attempts, completed suicide and medication side effects. Additionally patients with BPAD have high rates of physical and psychiatric comorbidity. The prevalence rates of BPAD vary from country to country. A large multinational study suggests that lifetime prevalence of BPAD-I ranges from 0-1% with a mean of 0.6 (SD-0.4). The prevalence rate of BPAD-II ranges from 0 to 1.1% with a mean of 0.4 (SD-0.3). Additionally a significant proportion of patients have been shown to have subthreshold BPAD with a range of 0.1 to 2.4% with a mean of 1.4 (SD-0.8). There is no nationwide study to evaluate the prevalence rates of BPAD in India. In a country like India, patients have limited resources, poor knowledge about the disorder and treatment; have inadequate access to the health care facilities, which makes treatment of BPAD a challenge. Indian Psychiatric Society (IPS) made first attempt to formulate Clinical Practice Guidelines (CPGs) for management of BPAD in 2005. Since then, over the last one decade there have been several developments, especially in the form of emergence of new evidence for some of the pharmacological agents. Accordingly, these new guidelines attempt to update the previous guidelines published by IPS. These guidelines should be read along with the earlier version of the CPGs, published by IPS in 2005.
What are the mainstays of BPAD management?
The mainstay of management of BPAD is mood stabilizers. The available mood stabilizers include lithium, valproate, lamotrigine, carbamazepine/oxcarbazepine and topiramate.
How much Valproate should I take daily?
Maximum daily dose which is recommended is 60 mg/day but most patients do not require such high doses. The usual therapeutic serum levels which are considered to be efficacious vary from 50 to 100µg/ml. Once the dose of valproate is stabilized, the dosing schedule need to be changed to OD or BD dosing to reduce the side effects and improve compliance. In case OD dosing is given, extended release formulation may be used. However, it is important to remember that the bioavailability of extended release formulations is about 15% less than the immediate release preparations and the dose is to be increased accordingly. Serum valproate levels are to be done after 5 days of starting or increase in the dose of valproate. The sample need to be collected after 12 hours in case patient is receiving immediate release formulation, however, if the patient is receiving extended release formulation, the sample may be collected after 21 to 24 hours (table-5). There is evidence to suggest that patients with BPAD-II, dysphoric or mixed mania, rapid cycling affective disorder, stable episode frequency, later age of onset of illness, shorter duration of illness, long and severe course of illness respond well to valproate. Other indicators for good response to valproate include presence of comorbid alcohol use disorder, mental retardation, anxiety and panic attacks, post-traumatic stress disorders, marked sleep disturbances, explosive dyscontrol and aggression and comorbid migraine.
What are the treatment options for BPAD?
Treatment options for management of BPAD can be broadly classified as mood stabilizers, antidepressants, antipsychotic medications, electroconvulsive therapy (ECT), adjunctive medications and psychosocial interventions [Table-2]. Use of various treatment options is guided by the phase of illness (mania/hypomania/depression/mixed) in which patient presents to the clinician and past treatment history.
What is a comprehensive assessment of a patient?
Assessment of patients is an ongoing process and comprehensive assessment of a patient involves the assessment of patients themselves and their caregivers. The role of taking a proper history from the patient and all the available resources cannot be over-emphasized. In addition to the history taking, proper attention must be paid to the mental status examination. Diagnosis of BPAD is to be made on the basis of current diagnostic criteria, because a diagnosis based on diagnostic criteria can be considered more reliable, facilitates communication among various clinicians and paves the way for management on the basis of evidence based recommendations. It is important to remember that especially during the initial part of the illness, the symptoms may be confusing and at times it may be difficult to distinguish symptoms of mania from other psychiatric syndromes like schizophrenia, acute and transient psychosis and other psychiatric disorders. A possibility of substance induced disorder or disorder secondary to organic causes is to be considered, when the symptoms are atypical or there is evidence of the use of substance or underlying organic causes. Occasionally establishing the definite diagnosis of BPAD may require time.
What is a thorough assessment?
A thorough assessment includes assessment of comorbid psychiatric and medical conditions. It is important to remember that many a times; comorbidity is not very evident during the acute episode of illness. The comorbid conditions become more evident when the patient has come out of the acute episode of the illness. Evaluation of comorbid substance abuse needs to consider the type and frequency of substance abuse. If the patient does not provide adequate information about the substance use pattern, but there is high index of suspicion, urine or blood screens (with prior consent) can be used to confirm the existence of comorbid substance use/dependence, wherever such facilities are available. Functional impairment in various domains of life including impact of the illness on the family functioning and psychosocial impact of the illness on the caregivers is not to be neglected. A thorough physical examination need to be done to rule out presence of any physical illness and also to rule out episodes secondary to physical illnesses. This may be supplemented by the judicious use of investigations. Depending on the feasibility, unstructured clinical assessments need to be supplemented by documentation of severity and extent of symptoms on appropriate standardized rating scales. Patients with bipolar disorders also have cognitive deficits. Accordingly, depending on the need, detailed cognitive testing may be undertaken. The use of neuroimaging may be indicated in those with atypical features, neurological signs, non-response to treatment and having first episode of illness at a later age and elderly. Caregiver's assessment may involve evaluation of their knowledge about illness, knowledge about treatment, their attitudes and beliefs regarding treatment, the impact of the illness on them and their personal and social resources in the form of burden, distress, stigma, personal and marital life etc.
What is the best medication for manic episodes?
Lithium (Li), valproate (VPA), an atypical antipsychotic (AAP), or another medication should be used as the first line of treatment for manic episodes, according to all of them. During mania, any continued antidepressant medication should be removed, according to all of these professional guidelines.
What is the treatment for manic episodes?
Treatment for an acute manic or mixed episode is to relieve symptoms and facilitate a return to normal psychosocial functioning. To protect the safety of patients and those around them, as well as the creation of a therapeutic partnership, fast control of agitation, hostility, and impulsivity is critical. Compulsory hospitalization is sometimes required to begin effective treatment.
What are the first line mood stabilizers?
The first-line mood stabilizers include lithium and valproate; alternative possibilities include carbamazepine, oxcarbazepine, and atypical antipsychotics (e.g., aripiprazole, olanzapine, risperidone, quetiapine, and ziprasidone).
How many patients with BD get discharged?
Clinical practice differs from recommendations in guidelines. Only one out of every six patients with BD gets discharged on the single medicine that the recommendations recommend.
Is bipolar disorder a chronic illness?
Type I bipolar disorder is a chronic illness marked by recurring bouts of mania and depression that impede functioning and lower health-related quality of life. BD necessitates both acute and long-term treatment. Several guidelines for the management of acute manic states have been published, and all of them agree that monotherapy should be used first.
How long do bipolar patients stay depressed?
Up to a third of patients with bipolar disorder do not respond to treatments in naturalistic studies;4,5,7these figures probably underestimate the proportion of treatment-resistant patients with depression in clinical practice. Even patients who receive adequate pharmacotherapy have lengthy and debilitating periods of subthreshold depressive symptoms after major episodes. Longitudinal studies estimate that patients with bipolar disorder type I spend as many as 3 weeks depressed for every 1 week (hypo)manic; the ratio in bipolar disorder type II is 37:1.5,44Subthreshold depressive symptoms are associated with social and occupational impairment,45and increased psychosocial impairment is prospectively associated with earlier recurrences.46,47
How many people have bipolar disorder?
Bipolar disorders types I and II affect about 2% of the world’s population, with subthreshold forms of the disorder affecting another 2%.1–2Even with treatment, about 37% of patients relapse into depression or mania within 1 year, and 60% within 2 years.3In the STEP-BD cohort (n=1469), 58% of patients with bipolar disorder types I and II achieved recovery, but 49% had recurrences in a 2-year interval; twice as many of these recurrences were of depressive polarity (marked by sad mood, loss of interests, or fatigue) rather than of manic polarity (marked by elevated mood, grandiosity, and decreased need of sleep).4After initial onset, patients with bipolar disorder have residual depressive symptoms for about a third of the weeks of their lives.5In 2009, the direct and indirect costs of bipolar disorder were estimated to be US$151 billion.6Patients also experience psychotic symptoms, impaired functioning, compromised quality of life, and stigma.7,8
How to treat bipolar disorder?
Treatment of bipolar disorder conventionally focuses on acute stabilisation, in which the goal is to bring a patient with mania or depression to a symptomatic recovery with euthymic (stable) mood; and on maintenance, in which the goals are relapse prevention, reduction of subthreshold symptoms, and enhanced social and occupational functioning. Treat ment of both phases of the illness can be complex, because the same treatments that alleviate depression can cause mania, hypomania, or rapid cycling (defined as four or more episodes in 12 months), and the treatments that reduce mania might cause rebound depressive episodes.
What is the best treatment for bipolar disorder?
Lithium, introduced by John Cade in 1949, remains the best established long-term treatment for bipolar disorder.49Although the metal has been in clinical use for more than 50 years, the most convincing evidence of long-term efficacy comes from randomised clinical trials in which lithium was included as an active comparator.50A meta-analysis of five placebo-controlled lithium maintenance trials (n=770) showed that lithium reduces the risk of manic relapses by 38% (RR 0·62, 95% CI 0·50–0·84) and depressive relapse by 28% (0·72, 0·40–0·95).50Lithium is the only known anti-suicidal treatment with randomised evidence of a reduction in the risk of suicide of more than 50%.51However, the benefits of lithium are restricted by adverse effects and a low therapeutic index.52Although little evidence exists of a clinically substantial reduction in renal function in most patients, the risk of end-stage renal failure remains unclear. The risk of congenital malformations in the babies of mothers who have taken lithium during pregnancy is uncertain, but probably lower than previously thought. The balance of risks should be considered before lithium is withdrawn during pregnancy. In addition to known effects of lithium on the thyroid, the risk of hyperparathyroidism is increased and calcium concentrations should be checked before and during treatment.52
Why is lithium unique?
However, lithium remains unique because its main therapeutic use is in bipolar disorder, and investigation of its mechanism of action has, and remains, crucially important in the identification of future targets . Table 1. Validation evidence of putative treatment development targets in bipolar disorder.
What is enrichment design?
Enrichment designs are standard in continuation trials sponsored by industry. Enrichment selects patients with known acute response to, or who can tolerate, the investigational agent. Patients are then randomly assigned to either continue the investigational agent during the active trial or switch to placebo or an active comparator. The enrichment design can answer questions about the continued benefits of the investigational medicine, but is not a fair test of the comparator agents that do not have the prerandomisation selection. For example, one trial protocol treated 2438 patients with quetiapine for 4–24 weeks; 1226 (50%) who responded to treatment were randomly allocated to continue quetiapine or to switch to placebo or lithium (0·6–1·2 mEq/L).40Over 104 weeks, time-to-recurrence of any mood event was significantly longer for patients given quetiapine versus placebo and for patients given lithium versus placebo.
What is efficacy shown as?
Efficacy is shown as a continuous outcome against the dropout rate. Treatments toward the red section combine the worst efficacy and tolerability profiles and treatments towards the green section combine the best profiles.
How is bipolar treated?
Treatment of bipolar I disorder occurs in three stages: (1) acute treatment of a manic or depressive episode, (2) the improvement phase, and (3) the maintenance phase. Treatment of an acute manic or depressive episode focuses on diagnosis, safety, initiation of pharmacological treatment, support, and education.
How many episodes of rapid cycling are there in women?
Women are also more likely to have rapid cycling, which is defined as having four or more manic or depressive episodes per year.
How many manic episodes are there in a lifetime?
Nearly all patients who have one manic episode will have another; the number of manic episodes varies from person to person, but the average number of episodes a patient will have in a lifetime is nine . Some patients have rapid cycling - with four or more manic or depressive episodes in a year.
What are the effects of bipolar disorder?
Associated changes include variation in sleep patterns, changes in appetite, reduced libido, diurnal variation in symptoms, recurrent thoughts of death, and suicidality. Patients with bipolar I disorder are at greatest risk for suicide during depressive episodes and mixed episodes. Mixed episodes:
What causes manic episodes?
Sleep deprivation, drug/alcohol use, and antidepressants can also trigger manic episodes.
Why is it important for primary care physicians and psychiatrists to work closely to coordinate care?
Because patients with bipolar I disorder can have relatively poor health outcomes, and medications for bipolar I disorder can have serious side effects , it is important for primary care physicians and psychiatrists to work closely to coordinate care.
What is a depressive episode?
Depressive episodes are characterized by the triad of low mood, self-attitude and vital sense.