BD (MT 2)

• 1. brain (tumors, damage...)
• 2. Infections
• 3. Metabolic disorders ( NB: Hyperthyroid)
• 4. Seizure disorders
• 5. Degenritive DOS in CNS

• 1. Psychostimulants
• 2. Too much Thyroid hormones, such as levothyroxine
• 3. Some antihypertensive medications
• 4. Corticosteroids such as prednisone
• 5. Isoniazid
• 6. Procarbazine
• 7. S-adenosylmethionine (SAMe)

• 1. Manic induction or “Manic push: Tricyclic antidepressants and SSRIs can trigger mania in some
• 2. SRRI abrupt withdrawal
• 3. Manic induction (false mania)

• 1. SSRIs and mood stabilizers
• Some argue SSRIs for short term, some always
• 2. Atypical antipsychotics and SSRIs
• 3. Anticonvulsants and SSRIs

lithium or valproate

• 1. Prevention of relapse
• 2. Reduction of mood symptoms
• 3. Reduction of risk for suicide
• 4. Treatment of bipolar patients does not end with the
• prescription of mood stabilizing medications (stress big issue with depression)

Useful for reducing the frequency and severity of recurrent bipolar episodes

• 1. Biogenic Amine Hypothesis: Lithium may exert its therapeutic effect by modifying membrane excitability via an ionic mechanism. Intriguing, yet inconsistent
• evidence that Li+ competes for Ca2+ binding sites

2. Electrolyte Hypothesis: Biogenic Amine Hypothesis Li act with monomine. Lithium’s actions may be related to its ability to modulate serotonin and/or norepinephrine function

3. 2nd Messenger System Hypothesis: “Lithium alters the transduction of the neurotransmitter-initiated signal by modifying the function of second messengers". Lithium may reduce the post-synaptic actions of 5-HT and NE on second messenger systems.

Processed and cleared by kidneys (not liver): Excreted in its intact form via kidney (95%), sweat, saliva and breast milk (5%)

• 1. Narrow therapeutic-toxic ratio (i.e., low therapeutic index)
• 2. Blood level is more important than the dosage
• Dosage is adjusted according to age, renal function, lithium level and clinical response

• 1. a. Flu-like symptoms
• (Worsened nausea, vomiting, diarrhea, muscular weakness)
• b. Muscle twitching, drowsiness, confusion, arrhythmia, coma, convulsions, death
• c. CNS effects
• (Disorientation, confusion, tinnitus (ringing in the ears),
• worsening of hand tremor, slurred speech, ataxia (gait incoordination), muscle twitching, delirium,
• seizures, coma)
• 2. Inadequate fluid intake increases likelihood of toxicity

lDiuretics will do this as well (have to balance fluid)

lMUST discontinue the drug immediately

• Diuretics will increase lithium levels by retaining lithium
• and eliminating water.
• Sodium trade off with lithium.
• Give up sodium à increase retention of lithium. Diuretics (sodium loss) à more lithium à go toxic:
• 1..Coffee – diuretic effect <NB
• 2. Alcohol – diuretic effect <NB
• Diuretics (sodium loss) à go toxic Combination with tobacco
• Nicotine accelerates the metabolism of caffeine (coffee)
• While still smoking need to drink more coffee to get caffeine effects
• Get increased diuretic effect from fluids alone à go toxic
• If quit smoking, can have dramatic rise in caffeine levels à go toxic

• l. Combination with SSRIs
• -Combination will increase risk of
• serotonin syndrome
• 2. Combination with TCAs (raise the level of TCA increasing effects)
• -Neurotoxic effects
• -Even at normal doses of lithium and TCA
• 3. Muscle relaxants
• -prolongs effects of lithium à go toxic
• 4. Phenothiazines
• -decreases levels of phenothiazines
• 5. Non-steroidal and anti-inflammatory drugs
• -increase lithium retention à go toxic

• FDA has NOT given approval of these drugs
• This type of medication usage is known as "off label"
• Important to recognize "off label" usage is generally
• considered an option only after all traditional treatment methods have failed (can use but more risk/ some used as part of treatment)
• -new drugs work differently for different people and each has its own unique side effects
• These drugs have not been approved by the (FDA) for the treatment of bipolar disorder

• -Fewer side effects than lithium
• 1. Side effects: headaches, rash,
• dizziness
• -Rare but dangerous severe rash: Stevens-Johnson syndrome
• 2. SE: -with ETOH
• -Psychomotor impairment
• -Lower seizure threshold
• -CNS depression
• -. with carbamazepine
• -decrease Lamictal levels
• -increase likelihood of cognitive problems

• (Experimental or off label (no FDA approval for BlRapid cycling BD (4+/yr))
• 1. Side effects like TCAs
• 2. a. Do NOT use with Serzone – dangerous interaction
• -Serzone causes liver toxicity
• b. Negative interactions with Prozac, Luvox, and lithium
• -mandatory regular blood count monitoring
• and periodic liver function tests. several adverse interactions can occur when combined with other drugs due to induction of liver enzymes

• 1. Strong acute efficacy data
• 2. Broad activity spectrum
• 3. Possible antidepressant effects in bipolar disorder
• 4. Long history of use
• 5. No weight gain

• 1.May lose effectiveness over the long-term
• 2. Drug interactions
• 3. Blood disorders
• 4. Narrow therapeutic index
• 5. Acute side-effects

• 1. CNS signs
• 2. Somnolence, seizures, coma
• 3. Gastrointestinal symptoms
• 4. Severe nausea and vomiting
• 5. Cardiac signs
• 6. Arrhythmias

• l. CNS signs
• -Confusion
• 2. Renal signs
• -Urinary retention
• 3. Hematological signs
• Bone marrow suppression
• 4. suicidality

• 1. Classic Antipsychotics: Used for very short term control of excessive psychotic behaviors
• 2. Atypical Antipsychotics: bipolar patients manifest
• psychotic symptoms, either during manic or depressive episodes as monotherapy for episodes of mania or bipolar depression

• 1. Atypical Antipsychotics: either during manic or depressive episodes
• 2. as monotherapy for episodes of mania or bipolar depression
• 3. May also be useful for relapse prevention and maintenance treatment

• compliance is a big issue
• 1. people miss their highs
• 2. life is "boring" without them
• 3. serious side effects
• 4. difficulty with polypharmacy
• 5. often see many changes in meds

• Components for psychoeducational protocols:
• 1. Education about BD
• 2. Relapse prevention
• 3. Medication compliance
• 4. Communication skills training
• 5.Research on family-based interventions (Falloon):
• lower rates of family separations
• greater improvements in level of family functioning
• higher rates of full recovery
• lower rates of rehospitalization for 2 years post-rx
• Over critical hyper involved family more issues

Research on family-based interventions (Falloon): lower rates of family separationsgreater improvements in level of family functioninghigher rates of full recoverylower rates of rehospitalization for 2 years post-rx Over critical hyper involved family more issues

• 1. Somewhere between Bipolar and normal experience:
• -Hypomanic episodes
• -Some depression, but not the full depth of disorder
• -Must have the disorder for at least 2 years before it is
• diagnosed
• -Must be chronic
• 2. Do not have evidence for effectiveness of medications here (NO DATA just
• basic Sx relief)
• Have tried lithium and valproic acid
• Psychotherapy is indicated (characterological problems)

• No research evidence for effectiveness of this approach
• : Based on idea by Akiskal that BPD is subtype of BD (e.g.,
• Bipolar 5)