BIPOLAR DISORDER, DR GIAN LIPPI CONSULTANT PSYCHIATRIST UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL FORENSIC UNIT MANAGEMENT GUIDELINES

CONTENTS PHARMACOTHERAPY PRINCIPLES TREATMENT OF BIPOLAR DEPRESSION TREATMENT OF A MANIC EPISODE MEDICATIONS USED IN THE MAINTENANCE PHASE NEW TREATMENT OPTIONS MOSTLY INEFFECTIVE TREATMENT OPTIONS MANAGEMENT FRAMEWORK TREATMENT TREATMENT OF A HYPOMANIC EPISODE TREATMENT OF A MIXED EPISODE

MANAGEMENT FRAMEWORK HOSPITALIZATION OUTPATIENT TREATMENT 2 TREATMENT APPROACHES BOTH FORMS OF TREATMENT ARE EFFECTIVE BY THEMSELVES BUT ARE MORE EFFECTIVE WHEN USED IN COMBINATION WITH EACH OTHER INPATIENT vs OUTPATIENT CARE REQUIRED (RISK ASSESSMENT) - RISK OF SUICIDE/HOMICIDE - RELAPSE WITH GROSSLY IMPAIRED ABILITY TO GET FOOD & SHELTER IN THE ABSENCE OF A PROPER SUPPORT SYSTEM - RAPIDLY PROGRESSING SYMPTOMS - PSYCHOSIS - VOLUNTARY vs INVOLUNTARY ADMISSION - MOSTLY FOR MANIC, MIXED OR SEVERE DEPRESSIVE EPISODES - HYPOMANIC & MILD TO MODERATELY SEVERE DEPRESSIVE EPISODES - EVALUATE PATIENT FREQUENTLY - PSYCHOTHERAPY - PHARMACOTHERAPY

TREATMENT PSYCHOTHERAPY PHARMACOTHERAPY - DURING MAINTENANCE PHASE / EPISODES OF HYPOMANIA OR MILD DEPRESSION - NOT DURING MANIC, MIXED OR SEVERE DEPRESSIVE EPISODES OR IF PSYCHOSIS IS PRESENT - COGNITIVE BEHAVIOUR THERAPY (CBT) IS TREATMENT OF CHOICE - INTERPERSONAL THERAPY & FAMILY THERAPY ALSO USEFUL - REMEMBER OTHER PSYCHOSOCIAL INTERVENTIONS LIKE PSYCHOEDUCATION & OCCUPATIONAL THERAPY - SPECIFIC ACCORDING TO DIFFERENT PHASES OF THE DISORDER

MOOD STABILIZERS ARE THE MAINSTAY OF TREATMENT PHARMACOTHERAPY PRINCIPLES - COMBINATION MOOD STABILIZERS ARE BECOMING THE RULE RATHER THAN THE TREATMENT OF A MANIC EPISODE (TREAT FROM ABOVE) PREVENTING A MANIC EPISODE (STABILIZE FROM ABOVE) TREATMENT OF A DEPRESSIVE EPISODE (TREAT FROM BELOW) PREVENTING A DEPRESSIVE EPISODE (STABILIZE FROM BELOW) NO MOOD STABILIZER IS EFFECTIVE IN ALL 4 DOMAINS EXCEPTION (DEPENDING ON SYMPTOM PRESENTATION; MONOTHERAPY IS STILL PREFERABLE)

AVOID USE OF ANTIDEPRESSANTS, EXCEPT AS A LAST RESORT TREATMENT OF BIPOLAR DEPRESSION - RISK OF INDUCING HYPOMANIA & RAPID CYCLING USE MOOD STABILIZERS EFFECTIVE IN TREATING DEPRESSION - LAMOTRIGINE - OLANZAPINE / QUETIAPINE / ARIPIPRAZOLE - POSSIBLY LITHIUM ELECTROCONVULSIVE THERAPY (ECT) ANTIDEPRESSANTS - LAST RESORT - ALWAYS IN COMBINATION WITH AT LEAST 1 MOOD STABILIZER - MAY NEED TO BE USED IN COMBINATION WITH 2 MOOD STABILIZERS, 1 EFFECTIVE IN TREATING DEPRESSION, & 1 EFFECTIVE AT PREVENTING MANIC EPISODES PSYCHOTIC DEPRESSION - ADD AN ANTIPSYCHOTIC IF NOT ALREADY ON 1 - PREFERABLY AN ATYPICAL ANTIPSYCHOTIC - PREFERABLY OLANZAPINE / QUETIAPINE / ARIPIPRAZOLE - AVOID HALOPERIDOL, CAUSES DYSPHORIA

1) START A MOOD STABILIZER EFFECTIVE IN TREATING MANIA TREATMENT OF A MANIC EPISODE - VALPROATE (ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY) - LITHIUM (DISADVANTAGE OF SLOW TITRATION DUE TO TOXICITY RISK) - CONSIDER ATYPICAL ANTIPSYCHOTIC 2) ADD ANTIPSYCHOTIC IF NEEDED (ALWAYS IF PSYCHOTIC) - HALOPERIDOL - ATYPICAL ANTIPSYCHOTIC (OLANZAPINE GOOD CHOICE) 3) ADD LONG ACTING BENZODIAZEPINE IF NEEDED - CLONAZEPAM 2mg po tds 4) ECT IF NEEDED APPROPRIATE ADDITIONAL MEASURES - STOP ANTIDEPRESSANT IF PATIENT IS ON 1 - EMERGENCY SEDATION AS NEEDED AS PER USUAL PROTOCOL (IM LORAZEPAM, HALOPERIDOL, OLANZAPINE, ZIPRASIDONE, CLOPIXOL ACUPHASE ETC)

1) START A MOOD STABILIZER EFFECTIVE IN TREATING MANIA TREATMENT OF A - VALPROATE (ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY) - LITHIUM (DISADVANTAGE OF SLOW TITRATION DUE TO TOXICITY RISK) - CONSIDER ATYPICAL ANTIPSYCHOTIC 2) ADD ANTIPSYCHOTIC IF NEEDED (USUALLY NOT NECESSARY) - ATYPICAL ANTIPSYCHOTIC 3) ADD LONG ACTING BENZODIAZEPINE - CLONAZEPAM 2mg po tds APPROPRIATE ADDITIONAL MEASURES - STOP ANTIDEPRESSANT IF PATIENT IS ON 1 (USUALLY NOT NECESSARY) HYPOMANIC EPISODE - HALOPERIDOL

1) START A MOOD STABILIZER EFFECTIVE IN TREATING MIXED TREATMENT OF A MIXED EPISODE - VALPROATE (ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY) - CONSIDER ATYPICAL ANTIPSYCHOTIC 2) ADD ANTIPSYCHOTIC IF NEEDED (ALWAYS IF PSYCHOTIC) - ATYPICAL ANTIPSYCHOTIC EPISODES - MAY NEED TO USE 2 MOOD STABILIZERS, 1 EFFECTIVE IN TREATING DEPRESSION & 1 EFFECTIVE IN TREATING MANIA (EG VALPROATE + LAMOTRIGINE)

LITHIUM MEDICATIONS FOR MAINTENANCE PHASE - MOST EFFECTIVE IN TREATING & PREVENTING MANIC EPISODES - CAN BE CONSIDERED FOR TREATMENT OF MIXED EPISODES & RAPID CYCLING, BUT NOT 1 ST LINE - QUESTIONABLE EFFICACY IN TREATMENT, NOT PREVENTION OF DEPRESSION VALPROATE - MOST EFFECTIVE IN TREATING & PREVENTING MANIC EPISODES - TREATMENT OF CHOICE FOR MIXED EPISODES & RAPID CYCLING - NOT EFFECTIVE IN TREATMENT & PREVENTION OF DEPRESSION CARBAMAZEPINE / OXCARBAZEPINE / ESLICARBAZEPINE - FALLEN OUT OF FAVOUR, NO LONGER ROUTINELY USED, ONLY SPECIFIC CASES - SAME USE PROFILE AS VALPROATE BUT SEEMS TO BE LESS EFFECTIVE LAMOTRIGINE - EFFECTIVE IN TREATING DEPRESSIVE EPISODES - TREATMENT OF CHOICE FOR PREVENTING DEPRESSIVE EPISODES - EFFECTIVE IN PREVENTING MANIC EPISODES - NOT EFFECTIVE IN TREATMENT OF MANIC EPISODES - POSSIBLE / QUESTIONABLE EFFICACY IN TREATMENT OF MIXED EPISODES & RAPID CYCLING

ATYPICAL ANTIPSYCHOTICS NEW OPTIONS & INEFFECTIVE OPTIONS - EFFECTIVE IN TREATMENT OF MANIC EPISODES (RISPERIDONE, QUETIAPINE, ZIPRASIDONE, ARIPIPRAZOLE & ESPECIALLY OLANZAPINE) - EFFECTIVE IN PREVENTING MANIC EPISODES - EFFECTIVE IN TREATING DEPRESSIVE EPISODES (OLANZAPINE, QUETIAPINE & ARIPIPRAZOLE) - NOT EFFECTIVE IN PREVENTING DEPRESSIVE EPISODES - CAN BE CONSIDERED FOR TREATMENT OF MIXED EPISODES & RAPID CYCLING, BUT NOT 1 ST LINE MEDICATIONS MOSTLY INEFFECTIVE AS MOOD STABILIZERS - TOPIRAMATE - GABAPENTIN - LEVETIRACETAM - PREGABALIN - ZONISAMIDE - RILUZOLE - MEMANTINE - KETAMINE - AMANTADINE - CALCIUM CHANNEL BLOCKERS

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