New Treatment Guidelines Developed for Bipolar Disorder

By Belden, Heidi | Drug Topics, May 20, 2002 | Go to article overview

New Treatment Guidelines Developed for Bipolar Disorder


Belden, Heidi, Drug Topics


Rx CARE

An update in practice guidelines by the American Psychiatric Association (APA) now offers more options to psychiatry healthcare professionals caring for bipolar patients. The APA's original guidelines, published in 1994, were updated based on new data regarding the efficacy of newer anticonvulsants, such as Lamictal (lamotrigine, GlaxoSmithKline), and atypical antipsychotics, such as Zyprexa (olanzapine, Novartis) and Risperdal (risperidone, Janssen) in treating bipolar disorders.

Medications previously un-- studied for use in treating the disorder are now known to be effective and are incorporated into the new guidelines. While there is no cure for bipolar disorder, proper treatment can lower the associated morbidity and mortality, including the rate of suicide.

The new publication contains three principal parts: treatment recommendations; background information and review of available (published and unpublished) evidence; and suggestions for future research needs.

For treatment of an acute manic or mixed (manic and depressive) episode, the guidelines suggest lithium plus an antipsychotic agent, or valproate plus an antipsychotic. For patients less ill, monotherapy with lithium, valproate, or an atypical antipsychotic, such as olanzapine or risperidone, may be sufficient. Controlling symptoms, such as agitation, aggression, and impulsivity, and ensuring the safety of patients and those around them is the goal of therapy in treating a manic or mixed episode.

Atypical antipsychotics are preferred to the older, typical antipsychotics because of a favorable sideeffect profile-fewer extrapyramidal effects, lower incidence of tardive dyskinesia, and less sedation. Shortterm adjunctive treatment with a benzodiazepine may also be beneficial during an acute episode.

The previous guidelines suggested lithium alone or in combination with an antidepressant for treating acute episodes of bipolar depression. Lithium and lamotrigine are now considered the first-line agents; antidepressant therapy is not recommended initially, except in some severely ill patients. For those not responding to first-line agents at optimal doses, adding lamotrigine, bupropion, or paroxetine is the next step. Alternatives include the addition of antidepressants, such as a selective serotonin reuptake inhibitor, venlafaxine, or a monoamine oxidase inhibitor.

"I agree with the use of lamotrigine for the treatment of an acute episode of bipolar depression," said Luriko Ajari, pharmacy manager at the Langley Porter Psychiatric Institute at the University of California San Francisco (UCSF) and assistant clinical professor at the UCSF school of pharmacy. "The antidepressant effects of lithium can take up to two months, and since the depressive phase of bipolar disorder is associated with considerable morbidity, newer recommendations were needed." Ajari believes there are many patients who cannot take lithium, due to its side effects. She further noted that lamotrigine had stabilized many of her patients who relapsed when they could no longer tolerate lithium because of reduced kidney function or other adverse events. Lithium and lamotrigine each exhibit antidepressant properties without inducing switches to mania or rapid cycling.

Rapid cycling refers to four or more episodes (major depressive, mixed, manic, or hypomanic) that occur within one year. The episodes must be separated by at least two months or switch to an episode of the opposite polarity (e. …

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