Bipolar disorder

• decrease severity, frequency, and duration of episodes
• promote regular sleep and activity
• decrease negative s/s of episodes
• decrease functional impairment

• 1. bipolar disorder I
• a. M=F
• b. 1+ manic or mixed episodes (usually with major depressive disorder)

• 2. bipolar disorder II
• a. F>M
• b. 1+ MDE and 1+ hypomanic episodes

• 3. cyclothymic disorder
• a. 2 years of repeated hypomanic and depressive s/s

4. bipolar disorder not otherwise specified

• acute mania±psychoses
• bipolar depression (2x compared to mania)

• first line: Li or VPA ± SGA ± BDZ
• second line: CBZ, OXC, Li+VPA
• *(avoid CBZ+OLZ)
• third line: haloperidol, Li+CBZ, CLZ

• for mixed: VPA>Li, OLZ>Li
• refractory: 2MS+SGA, CLZ, ECT

• *d/c antidepressant (taper is possible)

• first line: Li, LTG, QTP, OLZ+SSRI, Li/VPA+SSRI/bupropion
• second line: QTP+SSRI, adjunctive modafinil

• *avoid ARI monotherapy
• *avoid antidepressant monotherapy

• >2 major episodes
• 1 severe episodes
• rapid onset of S/S
• frequent attacks (>1/yr)
• family history

first line: Li, VPA, LTG, OLZ

• growing evidence for:
• 1. QTP as a monotherapy/adjunct for manic/depressive prophylaxis
• 2. RIS, ARI, ZIP for manic prophylaxis

• cognitive dysfunction
• lethargy
• hand tremor (tolerated)
• GI upset (tolerated)
• polydipsia
• polyuria

• cardiac effects (T-wave depression)
• diabetes insipidus
• glomerular dysfunction
• hypothyroidism (not dose-related)
• weight gain
• leukocytosis (benign, reversible)
• acne
• psoriasis

through (after 8-12hours)= 0.8-1.1mmol/L (0.4-0.7mmol/L in elderly)

• mild: cognitive dysfunction, fine tremor, GI s/s, weakness, fatigue
• moderate: confusion, lethargy, ataxia, dysarthria, nystagmus, vomiting, coarse tremor
• severe: seizure, myoclonus, brain damage, coma

• electrolytes (dehydration= increased lithium levels)
• CBC: increased WBC
• SrCr/BUN
• TSH/T4
• weight
• pregnancy test
• urinalysis: lithium inhibits ADH-->SIADH

300-700uM

• sedation
• ataxia
• N/V
• epigastric cramping
• fine hand tremor
• throbocytopenia
• increase LFTs
• pancreatitis
• weight gain
• alopecia
• polycystic ovarian syndrome (amenorrhea, anovulation)

• CBC: increased WBC, decreased platelets
• weight
• pregnancy test
• DI (inhibit metabolism)

17-50uM

*avoid combining with VPA or OLZ

• hepatotoxicity
• hyponatremia
• agranulocytosis (severe leukopenia)
• aplastic anemia
• rash: SJS, toxic epidermal necrolysis

erythromycin, fluoxetine, fluvoxamine, cimetidine, ketoconazole= decrease CBZ Cl

CBZ induction: anticonvulsants, antidepressants, BDZs, warfarin, OCs

LTG 25mg/d-->200mg/d

• *use lower doses with VPA
• *use higher doses with CBZ
• *slow increase dose by 25mg/d q2weeks= decrease risk of rash

rash (10%) within 6-8weeks

• high dose
• fast tiration
• concurrent VPA
• children

• 1. acute mania
• a. effective as adjuncts to lithium/VPA OR as monotherapy
• b. clozapine in refractory/rapid cyclers
• 2. bipolar depression
• a. OLZ and QTP= LTG
• 3. bipolar maintenance
• a. limited data for OLZ or QTP

• adherence
• regular sleep
• education about medications and bipolar disorder
• monitoring efficacy and s/e
• early recognition of s/s
• act as resources