Bipolar Disorder; Treatment

Bipolar Disorder; Treatment

For an individual with bipolar disorder, lifelong treatment is necessary. Regular monitoring and consultation with a health care professional is necessary to establish which medication or combination of medication works best.

For more than 30 years, lithium has been one of the main treatments for people with bipolar disorder. But with the advent of newer drugs to treat the disorder over the past decade, the American Psychiatric Association (APA) issued revised treatment guidelines for the illness in April 2002.

Lithium evens out moods so that patients don’t feel as high or as low, but it’s unclear to medical experts precisely how the medication works in the brain. Lithium is not used just for manic attacks, but rather as an ongoing treatment to prevent all types of episodes. It can take up to 14 days to start diminishing severe manic symptoms. It might take a few months of medication before the illness is under control.

When taken regularly, lithium can effectively control depression and mania and reduce the chances of recurrence. However, while it is effective treatment for many people, it doesn’t work for everybody.

Regular blood tests are a must for people taking lithium. Too small a dose might not be effective and too large of one might produce unwanted side effects, including weight gain, tremors, excessive thirst and urination, drowsiness, weakness, nausea, vomiting and fatigue.

Sodium intake also affects the amount of lithium in your body. A dramatic reduction in salt intake, excessive exercise and sweating, fever, vomiting or diarrhea may cause a lithium buildup and lead to toxicity. An overdose of lithium can cause confusion, delirium, seizures, coma and may result, although rarely, in death.

In addition to lithium, valproate (Depakote or Divalproex) is another first-line treatment for bipolar disorder. The anticonvulsants carbamazepine (Tegretol) and oxcarbazepine (Trileptal) may also work as mood stabilizers, although they are not yet FDA approved for this indication. Be advised, however, that evidence suggests that valproate may lead to adverse hormone changes in teenage girls and polycystic ovary syndrome in women who began taking the medication before age 20. The data about this possible adverse effect of valproate are controversial. The problem was first noted in young women who took the medication for the treatment of epilepsy. Experts debate whether valproate causes reproductive problems in women with epilepsy and, if so, whether women with bipolar disorder who take the medication are also at risk. In any case, young female patients taking valproate should be monitored carefully by their health care provider for possible hormonal problems and for polycystic ovary syndrome. Anticonvulsant medications may be combined with lithium, or with each other, for maximum effect. Some anticonvulsant medications (particularly carbamazepine and oxcarbazepine) can interact with hormonal contraceptives to decrease their effectiveness. Check with your health care provider to see if you need a higher dose or more frequent administration.

Another anticonvulsant, lamotrigine (Lamictal), has also been shown to be effective in the treatment of bipolar disorder, especially the depressive phase. Thus, for the depressive phase of the illness, American Psychiatric Association treatment guidelines recommend either lithium or lamotrigine. Antidepressant monotherapy is not recommended. As an alternative, especially for more severely ill patients, combination treatment with lithium and an antidepressant is recommended.

Several classes of antidepressant medications are available. These classes include tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs). Side effects and effectiveness for each class of medication, as well as for the individual brand within it, vary.

It’s important to note that antidepressants can trigger mania and possibly precipitate rapid cycling. This may be especially true of TCAs and MAOIs. In some cases, individuals receive treatment with antidepressants for what appears to be depression, but then become manic. Health care professionals should ask about prior symptoms of hypomania (episodes that include increased energy, euphoria, and irritability) before prescribing antidepressants. During a treatment evaluation, information about prior experiences with bipolar and other mental illnesses should be shared with a health care professional.

If a patient is experiencing psychotic or manic symptoms during an episode of bipolar disorder, sometimes physicians will also prescribe antipsychotic medicine, alone or in combination with lithium to control symptoms. Likewise, physicians might also prescribe antidepressants in addition to the lithium to counter the depressive phase.

For example, Zyprexa (olanzapine) is an antipsychotic medicine approved by the U.S. Food and Drug Administration (FDA) that may be prescribed for the treatment of schizophrenia and for treatment of acute mania and maintenance (long-term) treatment in bipolar disorder. In July 2003, the FDA approved its use in combination with lithium or valproate (Depakote or Divalproex), an anticonvulsant medication, for the treatment of acute bipolar mania. In 2004, a combination pill of olanzapine and fluoxetine was approved for the depressed phase of bipolar disorder. Studies have shown that bipolar patients in manic or mixed episodes treated with Zyprexa in combination therapy demonstrated improved manic and depressive symptoms, when compared to patients treated only with lithium or valproate alone. Olanzapine can also be used alone for the treatment of bipolar disorder.

Other helpful new drugs include the anti-psychotics ziprasidone (Geodon), quetiapine (Seroquel), aripiprazole (Abilify), and risperidone (Risperdal), all FDA approved in 2004 for the treatment of acute mania. It may take up to three weeks of regular use of any medication before symptoms improve or subside. However, if no changes are apparent within six weeks, a review of the medication regimen is probably necessary and options should be discussed with a health care professional.

Electroconvulsive therapy (ECT) is another treatment option for bipolar disorder and other types of major depression. Just prior to ECT treatment, a patient is given a muscle relaxant and general anesthesia. Electrodes are then attached to the patient’s scalp. An electric current causes a brief convulsion. Patients do not remember the treatments and usually awake slightly confused. Acute treatments occur three times per week for two to three weeks. “Maintenance” ECT is also used; patients may receive treatment at most once a week for several months.

ECT has been used for more than 60 years and has been refined since its early introduction as a treatment for depression. According to the National Mental Health Association, ECT is administered to an estimated 100,000 people a year, primarily in general hospital psychiatric units and in psychiatric hospitals. Researchers don’t understand exactly how it works to improve symptoms of depression in some individuals.

Many myths and negative perceptions continue to be perpetuated about ECT. This treatment can be effective for many people with severe depression who have not responded to other forms of treatment. Some experts and patients criticize such side effects as permanent memory loss and confusion, which can occur in some people. However, the National Mental Health Association reports that 80 percent of severely depressed patients improve after being treated with ECT. Generally, patients continue to need psychiatric medications after successful ECT. Like all other treatments, you should undergo a complete physical evaluation before undergoing ECT therapy.

As with all mental illnesses and other serious conditions, bipolar disorder can devastate a person’s self esteem and relationships with others, especially with spouses and family. Without treatment, people with the illness may jeopardize their finances, their careers, their families and their lives. In addition to treatment with medications, psychotherapy (“talk therapy”) is also recommended for individuals with bipolar disorder, as well as for their family members. Consultation with and treatment by a health care professional who has experience in treating bipolar illness is recommended.

There are many treatment issues to consider for women who have bipolar disorder who wish to become pregnant. Though manic episodes don’t typically occur more often during pregnancy for women with bipolar disorder, the postpartum period is a particularly high-risk time for recurrence. Lithium and other types of medications, such as benzodiazepines, certain antipsychotics, valproate, and carbamazepine, that are used to treat bipolar disorder can pose health risks for a developing fetus. Nevertheless, rates of problems vary widely based on the medication.

Haloperidol (Haldol), an older antipsychotic, which has antimanic properties and no clear association with physical or cognitive defects, can also be used for mania control during pregnancy. There is emerging data about the safety of some newer antipsychotics in pregnancy, and these medications are increasingly being used. As with other medications, there is particular concern about physical birth defects resulting after exposing a fetus during the first trimester. Later exposure to certain medications may also affect the developing brain. Some of these medications can be used while breastfeeding, but lithium is generally not recommended if a woman is breastfeeding because it can rise to high levels in the baby.

ECT has also safely been used for decades (with appropriate adjustments) in pregnancy to treat severe mania or depression. Women with bipolar disorder are at high risk for postpartum episodes; for those who prefer not to use medication during pregnancy, a trial off medications (following a gradual taper) prior to pregnancy, possibly only stopping medications after conception, should be considered.

As the time to conception can vary widely, stopping medications prior to conception may result in a woman being unnecessarily off medications for a long time. In cases where medications have been stopped, reinstating medications near the end of the pregnancy may prevent the onset of a postpartum episode. Current research suggests that women can be safely maintained on medications for bipolar disorder throughout their pregnancy.

References

National Institute of Mental Health. Last updated July 2003. http://www.nimh.nih.gov. Accessed Aug. 2003.

“Electroconvulsive Therapy (ECT).” National Mental Health Association. 2003. http://www.nmha.org. Accessed Aug. 2003.

“Overview of Bipolar Disorder and Its Symptoms.” National Depressive and Manic Depressive Association. Updated Aug. 2003. http://www.ndmda.org. Accessed Aug. 2003.

Viguera, Adele C., et al. “The Course and Management of Biopolar Disorder During Pregnancy.” Psychopharmacology Bulletin, 34(3): 339-346, 1998.

Viguera, Adele C., et al. “Risk of Recurrence of Bipolar Disorder in Pregnant and Nonpregnant Women After Discontinuing Lithium Maintenance.” American Journal of Psychiatry. 157(2): 179-184, Feb. 2000.

Vainionpaa LK, et al. “Valproate-induced hyperandrogenism during pubertal maturation in girls with epilepsy.” Annals of Neurology. 45(4): 444-450, 1999.

Yonkers, Kimberly, et al. “Management of Bipolar Disorder During Pregnancy and the Postpartum Period” American Journal of Psychiatry. 161 (4), April 2004 p 608-623

Sachs GS, et al. “The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000.” A Postgraduate Medicine Special Report. http://www.psychguides.com. Modified Jan. 2001.

Tohen, M. et al. “Efficacy of Olanzapine in Combination With Valproate or Lithium in the Treatment of Mania in Patients Partially Nonresponsive to Valproate or Lithium Monotherapy.” Arch Gen Psych 2002; 59:62-69

“FDA Approves Zyprexa for Use in Combination with Lithium or Valproate to Treat Acute Manic Episodes of Bipolar I Disorder” Eli Lilly and Co. Released July 15, 2003. http://newsroom.lilly.com. Accessed Aug. 2003.

“Practice Guideline for the Treatment of Patients with Bipolar Disorder (Revision).” American Psychiatric Association. Published 2002. http://www.psych.org. Accessed Aug. 2003.

Chaudron and Pies. The relationship between postpartum psychosis and bipolar disorder. Review. Journal of Clinical Psychiatry 64:11, Nov 2003 p1284-1292

Keywords: bipolar disorder, mania, symptoms, depression, anticonvulsant medication, antipsychotic, ect, pregnancy, electroconvulsive therapy, lithium

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