Mood Disorders

Objectives Compare and contrast grief to depressive disorders Identify stages of the grieving (mourning)process Relate interventions appropriate to the grieving process Identify symptoms and behaviors associated with mood disorders Analyze predisposing factors and/or precipitating stressors to mood disorders Apply the nursing process in the care of persons with mood disorders Describe the treatment strategies for mood disorders and the implications for the nursing role

Grief Reactions Grief is universal Grief is the subjective state that follows loss A powerful emotional state that affects all aspects of a person’s life Grief can continue for months, 1-2 years

Loss Types of loss Particularly the loss of a loved one Other types of loss Physiologic Safety Security Self-esteem Self-actualization

Types of Grief Uncomplicated bereavement (normal grief) – this is not a disorder Anticipatory grieving-grief associated with anticipation of predicted loss or death Disenfranchised grief involves a loss not typically acknowledged by society (i.e., a pet, a home) Chronic sorrow-grief associated with ongoing loss such as chronic mental or physical illness

Kubler-Ross Stages of Grieving Normal mourning process: Denial Anger Bargaining Depression Acceptance

Considerations for Interventions Individuals grieve in different ways Stage/phase of grief determines intervention Developmental stage effects grief process Nurses have role in helping persons who are grieving

Maladaptive Responses to Loss: Complicated Bereavement Excessive hostility and bitterness Prolonged emptiness and numbness Inability to weep or express emotion Failure to resume activities, work, go on with their lives

Nursing Understanding Promote expression and release of pain Use of the therapeutic relationship/communication Individualization of care, recognizing various beliefs and practices r/t loss such as death Culture, religious practices, and spiritual beliefs

Nursing interventions for grief Identification of loss Expression of feelings Discuss prior losses Empathetic statements about grief Explore fears about loss Elicit coping strategies Promote cultural, religious, social customs Use the term “dead” rather than euphemisms Clarify misconceptions See Stuart 2013, p. 308, Box 18-9

Additional Interventions Grief counseling Traumatic grief psychotherapy

Grief vs. Major Depression Grief can look very much like depression (overwhelming sadness, poor sleep, poor concentration, decreased appetite, somatic complaints) Unlike depressed persons, the grieving person does not have poor self-attitude, worthlessness Grief can progress to Major Depression

Distinguishing Grief & Depression Feelings of emptiness and loss Pangs (or waves) of grief Positive emotions and humor Preoccupation with the deceased (loss) Depressed mood and/or inability to anticipate happiness or pleasure Persistent Pervasive unhappiness Pessimism GRIEF DEPRESSION

Mood Disorders Depressive Disorders Bipolar Disorders I & II Major Depressive Disorder Postpartum Depression Seasonal Affective Disorder Dysthymic Disorder Cyclothymic Disorder Bipolar Disorders I & II

What is mood? Mood - Pervasive and sustained emotion that colors one’s perspective of the world and how one functions in it

Mood Disorders: 20.9 million American adults (9.5% of the population) have a mood disorder in a given year Median age of onset 30 years old Depressive disorders often co-occur with anxiety and substance abuse NIMH (n.d.). The numbers count: Mental disorders in American. Accessed on September 1, 2013 at http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-America/index.shtml#Intro

Major Depressive Disorder (MDD) 20% of people will experience depressive illness in their lifetime Prevalence rates not affected by race Leading cause of disability among ages 15-44 y.o. Effects 14.8 million (6.7 % of the U.S. population) in a given year Median onset is 32 y.o. More prevalent in women than men, 2:1 Incidence higher in young women, increasing in adolescents, increases with age among men

Major Depressive Disorder (MDD) For at least 2 weeks a depressed, sad mood and/OR loss of interest & pleasure (anhedonia) with 4 of the following: Appetite/weight change * Sleep disturbance daily Psychomotor agitation or retardation (observed by others) Fatigue/low energy daily Guilt or feelings of worthlessness daily Poor concentration or indecisiveness daily Recurrent thoughts of death, suicidal ideation In children, failure to make expected weight gain

Affective features Anger/irritability Anxiety Apathy Withdrawal Denial of feelings Despondency Loss of motivation Guilt Helplessness Hopelessness Loneliness Low self-esteem Pessimism Bitterness Self-destructive thoughts/behaviors

Physiological features of Depression Sleep disturbances Menstrual changes Sexual problems Weight change Abdominal pain Backache Chest pain Dizziness Fatigue Headache GI disturbances

Cognitive features of Depression Ambivalence Confusion Inability to concentrate- “can’t think, can’t focus” Indecisiveness and uncertainty Cognitive distortions Impaired (short-term)memory Negative thinking (self-blame, –deprecation, – destructive) May include psychosis

Behaviors Associated with Depression Aggressiveness/agitation Alcohol/drug abuse Altered activity level/psychomotor retardation Over- dependency Poor hygiene Underachievement Withdrawal

Risk Factors for Depression Prior episodes of depression Family history of depression Prior suicide attempts Female gender Postpartum period Medical comorbidity Lack of social support Life stressors Personal history of sexual abuse Current substance abuse

Models of Causation of Severe Mood Disturbances Multifactorial: Genetic/biological Environmental- Life stressors, loss Poor attachment in infancy/early childhood (object relations) Learned helplessness/hopelessness Most likely a combination of factors explain the cause of depression.

Neurobiology of Depression Decrease in monoamine neurotransmitters (Norepinephrine, Serotonin) in the synapse between neurons Over-Activation of the HPA axis Stress hypothalamus secretes CRH  stimulates pituitary to release ACTH  stimulates adrenal cortex to release glucocorticoids  damages neurons  decrease in neurotransmitters  depression and anxiety CRH = Corticotropin releasing factor ACTH = adrenocorticotropic hormone Glucocorticoids include cortisol

Association with mood d/o Area of evidence for Dysregulation Association with mood d/o Behavior 5HT has a role in aggression, mood, anxiety, psychomotor activity, irritability, appetite, sexual activity, sleep/wake cycle, circadian and seasonal rhythms, neuroendocrine function, body temp., cognition, pain perception Abnormalities found in persons with depression Biochemistry 5HT is found in CSF, blood, brain tissue Low levels found in persons with depression or who have completed suicide Neuroendocrine 5HT has a role in secretion of growth hormone, prolactin, and cortisol Treatment 5HT is enhanced with antidepressants and ECT Clinically effective in the treatment of depression Brain structure MRI In depression shows decreased size of the hippocampus suggesting damage via stress In bipolar disorders shows increased size of brain structures associated with mood Brain function PET In depression, decreased metabolism in the left frontal area, and on the right in mania 5HT = serotonin Stuart (2013, p. 298)

PET scan This PET shows glucose metabolism in depressed brain. The brain on the left is demonstrates hypometabolism in the frontal area (left side of the brain images shown). The brain on the right is a after treatment with antidepressants.

Diagnosis of Depression Psychiatric evaluation Self-report of symptoms Family report of symptoms Signs of depression (decreased sleep, decreased appetite, etc) Medical exam to rule out physical illness Labs – TSH, T3, T4, CBC must rule out medical causes such as hypothyroidism Screening tools

Screening Instruments Hamilton Rating Scale for Depression (HAM-D) (1967) Primary Care-Screener for Affective Disorders (PC- SAD) (Rogers et al, 1998) Primary Care Evaluation of Mental Disorders (PRIME- MD) (Spitzer, et al., 1994) Symptom-Driven Diagnostic System for Primary Care (SDDS-PC) (Broadhead et al., 1995) Beck Depression Inventory (BDI) 1988 Child Depression Inventory Zung Self-Rating Depression Scale (1965)

Impact of Depression Impaired relationships Inability to perform usual activities Loss of productivity Alcohol and other substance abuse Increased use of health care resources Risk of suicide (about 15% of patients with severe depression commit suicide)

Differences by sex: Women More common in women Hormones directly effect the brain Vulnerability to postpartum depression Premenstrual dysphoric disorder Increased risk during transition to menopause Additional stresses at work, home, caring for children and aging parents, abuse, poverty, relationship strains National Institute of Mental Health (n.d.). Depression. Accessed on September 1, 2013 at http://www.nimh.nih.gov/health/publications/depression/index.shtml

Postpartum Depression 13% of all new mothers Associated with drastic hormone changes Higher risk with previous PPD, h/o mood disorder Estradial for treatment

Differences by sex: Men May experience differently Feel tired, irritability, anhedonic, poor sleep, get frustrated, angry More likely to use alcohol/drugs Avoid talking about it Excessive work Behave recklessly More likely to complete a suicide NIMH

Depression in Older adults More medical conditions that are associated with depression (i.e., cardiac, Parkinson’s, stroke, cancer) Medications with SE of depression Older white males age 85 + have the highest suicide rate in the U.S. Psychotherapy and medications are effective treatments NIMH

Depression in Children Children may pretend sick, refuse school, cling to a parent, worry about a parent dying Older children may sulk, get into trouble, be negative and irritable, feel misunderstood Before puberty, no difference in incidence based on sex By age 15 y.o., girls twice as likely as boys NIMH

Depression in Children In the teen years, often co-occurs with anxiety, eating d/o’s, or substance abuse Childhood depression often persists into adulthood, esp. if not treated NIMH

Other Types of Depression Mood disorder due to medical condition Endocrine dysfunction Hypo- or hyperthyroidism Cushing’s disease Degenerative/structural change Parkinson’s Huntington’s Disease MS TBI Stroke Substance-Induced Mood Disorder Seasonal Affective Disorder (SAD) Adjustment Disorder (situational)

Seasonal Affective Disorder (SAD) Less daylight during the fall and winter causes depression in some people. Overproduction of melatonin disrupts our internal body clock leading to depressive symptoms. If you have had episodes of depression that clearly have an onset in fall or winter followed by remission of symptoms in the spring or summer, you may have SAD.

SAD sx’s Depressed mood Irritability Hopelessness Anxiety Loss of energy Social withdrawal Oversleeping (feeling like you want to hibernate) Loss of interest in activities you normally enjoy Appetite changes, especially a craving for foods high in carbohydrates such as pastas, rice, bread and cereal Weight gain Difficulty concentrating and processing information

Dysthymic Disorder Characterized by chronic low-level depression experienced for at least 2 years Not as severe as MDD, but can prevent normal functioning and feeling well 1.5 % of the adult population in the U.S.

Treatment of Depression Safety - Environment free of harmful objects, safety plan Pharmacology – antidepressants, sleep aids, short term anxiolytics Psychotherapy – Cognitive Behavioral, Interpersonal, Solution Oriented, Supportive Education- Coping skills, self esteem, illness, medications, resources Phototherapy - Artificial bright light for SAD* Electroconvulsive therapy (ECT)* *see additional ppt on physical therapies (ECT, phototherapy, etc.)

Treatment of depression in children and adolescents Unlike adults, children may not respond to tricyclics. Children and adolescents do respond well to SSRIs and perhaps to other classes of antidepressants as well. In 2003 a blackbox warning was implemented r/t increased suicide risk. More recent reports (June 2014) indicates an association between decrease rx and rise in child/teen suicide attempts BMJ sited in NIH HealthDay. Healthday (2014). As antidepressant warnings toughened, teen suicide attempts rose: Study. Accessed on September 16, 2014 at http://www.nlm.nih.gov/medlineplus/news/fullstory_146877.html

Monoamine Oxidase Inhibitors (MAOIs) Usual adult daily dosage ranges (not recommended for children): Phenelzine (Nardil): 30-60mg Tranylcypromine (Parnate): 20-60mg Selegiline (Eldepryl, Atapryl) 10mg Indications: may be useful in the treatment of depressed patients with marked anxiety or phobic symptoms. Selegiline is also used for the treatment of parkinsonism. Because of the potential for serious adverse effects, MAOIs are not commonly used in clinical practice.

Monoamine Oxidase Inhibitors (MAOIs) Pharmacokinetics: antidepressant effects may take 3-6 weeks Most frequent adverse effects: orthostatic hypotension, insomnia, weight gain, edema, and sexual dysfunction. Rare side effect: tyramine-induced hypertensive crisis. Avoid foods that are preserved, pickled or aged (e.g., aged cheese, cured meats or fish, alcoholic beverages) Potential for severe drug-drug interactions

Tricyclic Antidepressants Elavil (amitriptyline) Norpramin (desipramine) Pamelor (nortryptyline) Pertofrane (desipramine) Sinequan (doxepin) Tofranil (imipramine) Anafranil (clomipramine) - OCD

Tricyclic Antidepressants (TCAs): Indications Depression Anxiety disorders Obsessive-compulsive disorder Clomipramine (Anafranil) Chronic pain: Neurogenic pain, Trigeminal neuralgia, Diabetic neuropathy, Sciatica, Fibromyalgia Sleep Disorders Insomnia, Cataplexy

Tricyclic Antidepressants Pharmacokinetics: therapeutic effects within 3-4 weeks; improved energy and sleep in 1-4 weeks Adverse effects: Anticholinergic: dry mouth, blurred vision, constipation, memory effects Antiadrenergic: orthostatic hypotension Antihistaminergic: sedation & weight gain Cardiac: use in patients with conduction defects is contraindicated Because of the potential for severe side effects and even death, TCAs are relatively contraindicated in the elderly, children, pregnant women and suicidal individuals.

Selective Serotonin Reuptake Inhibitors (SSRIs) Adolescents often receive adult dose, but doses are slightly less for children. Fluoxetine (Prozac): 20-80mg/day for depression and anxiety disorders; 60-80mg/ day for bulemia. Prozac weekly: 90mg. Fluvoxamine (Luvox): 100-300mg/day for OCD; 100-200 mg/day for depression Paroxetine (Paxil): 20-50 mg/day Sertraline (Zoloft): 50-200 mg/day Citalopram (Celexa): 20-60mg/day Escitalopram (Lexapro): 10-20mg/day

Selective Serotonin Reuptake Inhibitors (SSRIs) Indications: depression, anxiety, traumatic stress, eating d/o, borderline personality d/o Pharmacokinetics: therapeutic effects may take 3-6 weeks for depression and 12-16 weeks for OCD. Observe for activation of known or unknown bipolar disorder and/or suicidal ideation. Inform parents or guardian of this risk so they can help observe child or adolescent patterns.

Adverse Effects Associated with SSRIs Common: anxiety, agitation, akathisia, insomnia, nausea, diarrhea, sexual dysfunction Most side effects will pass. May need to add buproprion for sexual dysfunction or switch to another agent. Serotonin syndrome (excess serotonin): diarrhea, restlessness, extreme agitation, hyperreeflexia and autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, and possible death. Serotonin discontinuation syndrome: agitation, nausea, disequilibrium, and dysphoria. Tapering is advised. A symptom chart for serotonin discontinuation syndrome can be found in: Warner, C.H., et al. (2006). Serotonin discontinuation syndrome. American Family Physician. Accessed October 15, 2012 at http://www.aafp.org/afp/2006/0801/p449.html

Medication Management of Depression: Novel Agents Serotonin-2 antagonist/ reuptake inhibitors Nephazodone (Serzone): 300-600mg/day Risk of hepatotoxicity so not a first-line med. Trazodone (Desyrel): 150-600mg/day Generally used for insomnia due to sedative properties Risk for priapism in males Should not be used in children/adolescents and used cautiously with elderly. Serotonin/norepinephrine reuptake inhibitors (SNRIs) Venlafaxine (Effexor): 75-225 mg/day Higher incidence of activation with children and adolescents. Effective with anxiety control. Can cause hypertension. Duloxatine (Cymbalta): 40-60mg/day Significant potential for liver toxicity so alcohol prohibited. Taper down on both of these medications should be slow due to significant serotonin discontinuation syndrome. A symptom chart for serotonin discontinuation syndrome can be found in: Warner, C.H., et al. (2006). Serotonin discontinuation syndrome. American Family Physician. Accessed October 15, 2012 at http://www.aafp.org/afp/2006/0801/p449.html

Medication Management of Depression: Novel Agents Norepinephrine dopamine reuptake inhibitor (NDRI) Bupropion (Wellbutrin; Zyban): 225-450mg/day Also available in SR and XL forms May increase seizure risk: avoid if hx of seizures or bulemia Commonly used as an augmenting agent with other antidepressants, no sexual side effects, useful for smoking cessation Has been used to treat ADHD in children at 100-250 mg/day Alpha 2 antagonist / noradrenaline and specific serotonergic agent (NaSSA) Mirtazepine (Remeron): 15-45mg at bedtime Antihistamine effects: Highly sedating at lower doses but also causes weight gain.

Comparison of Antidepressant Side Effects Tricyclic SSRI MAOI Anticholinergic ++++ + Sedation Hypotension ++ 0/+ Seizures +++ Cardiac Weight gain Sexual dysfunction Other bleeding Hypertensive Crisis

Safety Patients with depression are at particular risk when they appear to be coming out of their depression because they may then have the energy and opportunity to kill themselves

Bipolar Disorder Bipolar I: 1 or more manic episodes Bipolar II: Recurrent major depressive episodes with hypomanic episodes

Bipolar Disorder Prevalence of BD I & II is 2.6% in the U.S. adult population (based on interview-based survey) Average age of onset is 25 years old Having a parent or sibling who has Bipolar Disorder increases a child’s chance, but most who have family hx, will not get it NIMH (n.d.) Biplolar disorder among adults. Accessed on February 11, 2014 at http://www.nimh.nih.gov/statistics/1BIPOLAR_ADULT.shtml

Predisposing Factors for Bipolar Disorder Male: female = 1:1 No difference based on race/ethnicity Onset = adolescence, middle aged women Etiology = Genetics Prognosis = Variable

Bipolar Disorder Imaging studies Brain development pattern is different Brain’s prefrontal cortex in adults tends to be smaller and function less well than adults without NIMH

Bipolar I Disorder Characterized by recurrent episodes of mania (at least one manic episode to meet criteria) Theoretical mechanisms Sensitization: Recurrent stressors and episodes can both predispose an individual to increased vulnerability to future episodes in a long-lasting fashion. Kindling: repeated intermittent subthreshold stimulation of a given region of the brain eventually leads to full-blown amygdala seizures (affective episodes). Support: Anticonvulsants and lithium have anti-kindling effects. Post (2003). Pediatric bipolar disorder.

Manic Episode Psychotic symptoms may also be present Period of abnormally and persistently elevated, expansive, or irritable mood and abnormally goal- directed activity or energy, which persists for at least 1 week with presence of 3 or more of the following symptoms: Inflated self esteem or grandiosity Decreased need for sleep (and feels rested) More talkative, rapid or pressured speech Flight of ideas, racing thoughts Distractibility Increased goal directed activity or psychomotor hyperactivity Excessive involvement in activities that have high potential for painful consequences (buying sprees, sexual indiscretions, foolish investments, etc.) Any duration if hospitalization is necessary Psychotic symptoms may also be present

Behaviors Associated with Mania Resistance to treatment efforts Disorganized thinking and bizarre behavior Psychotic features, primarily delusions Alteration in mode of dress and appearance Impulsive, high risk behavior such as gambling, spending, sex, driving fast, drugs Pacing and hyperactive Behaviors & mood cause marked impairment in function

Comparing BD I & II Bipolar I Bipolar II Manic episode, which causes marked impairment in function or includes psychosis Duration 7 days or less if need of hospitalization May or may not include h/o depression, but likely Hypomanic episode, same symptoms as mania, but duration is shorter (4 days), episode does not impair function, nor include psychotic symptoms Requires lifetime episode(s) of depression

Treatment of Bipolar Disorder Pharmacology Psychotherapy (CBT, Family-focused therapy, Interpersonal) Psychoeducation ECT

Treatment--Pharmacology Lithium Carbonate: Eskalith, Lithobid- gold standard Anticonvulsants: Lamotrigine, Valproic acid (Depakote), Carbamazepine (Tegretol) Antipsychotics: risperidone (Risperdal), aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), ziprasidone (Geodon)

Nursing Care Safety Sleep hygiene Low stress level Maintain medication regimen Exercise and nutrition Mood chart Avoid alcohol and drugs

Bipolar Disorder: Acute / Initiation Phase Goals: Control symptoms of agitation, aggression, and impulsivity. Return to usual levels of psychosocial functioning. If depressed, avoid precipitation of manic episode. Treatment: Severe mania or mixed episodes: initate lithium or valproate in combination with an antipsychotic. For less severely ill: monotherapy with lithium, valproate, or an atypical antipsychotic. If symptoms are inadequately controlled after 10-14 days, add another first-line medication. Baseline: Lithium: BUN, creatinine, thyroid, ECG, pregnancy. Valproate: Assess for hepatic, hematological and bleeding abnormalities and pregnancy.

Bipolar Disorder: Stabilization and Maintenance Goals: Prevent relapse and recurrence, reduce subthreshold symptoms, reduce suicide risk, reduce cycling frequency or milder degrees of mood instability, and improve overall function. Treatment: Maintenance medication is recommended following a manic or depressive episode. Monitor lithium or valproic acid levels, hemotologic, and hepatic functioning at least every 6 months.

Medication Management of Bipolar Disorders in Children and Adolescents Current approach is to treat acute mania with lithium or divalproex sodium (Depakote, valproic acid), and Risperidone or Abilify. Have more weight gain than adults on all mood stabilizing agents: lithium, anticonvulsants, atypical antipsychotics Polypharmacy is often necessary for stability: atypical antipsychotics are useful due to more rapid onset of action than lithium and the mood stabilizers.

Lithium Indicated for acute mania and mood stabilization Routine lab and physical exams required Usual adult dosage: 900-1800 mg/day in divided doses Long half-life yet narrow therapeutic index Response in acute mania may take 7-14 days Narrow therapeutic index requires frequent physical exams and labs. Serum blood levels should be: Acute episode: 0.8 - 1.2 mEq per L. Maintenance: 0.4 - 1.0 mEq per L. Teratogenic in the first trimester of pregnancy. Can cause hypothyroidism,renal damage Armstrong, C. (2008). ACOG Guidelines on psychiatric medication use during pregnancy and lactation. American Family Physician, 15, 772-778. Accessed 11/05/2012 at http://www.aafp.org/afp/2008/0915/p772.html

Lithium Side Effects Potential Side Effects ***Toxicity*** Polyuria/polydipsia Weight gain Hair loss Acne Cognitive dullness Hypothyroidism Indigestion Renal insufficiency (LT) Serum levels > 1.5 mEq/L Early: coarse hand tremor, severe GI upset (N,V,D) blurred vision, vertigo, ataxia Late: seizures, coma, dysrhythmias, permanent neurological impairment—may need hemodialysis Death

Management of Lithium Toxicity Obtain history of incident Check VS, LOC-stabilize as needed Li level, electrolytes, EKG-monitor if needed Hydrate: 5-6 L Adequate NaCL intake Dialysis in severe cases with decreased UO & increased CNS depression

Health Teaching Health conditions may increase Li+ resorption toxicity Diet: caffeinediuresis Side effects may nonadherence Take with meals to decrease GI irritation PREVENT DEHYDRATION-- 8-10 glasses water/day (2.5L), Do not change Na+ intake Do not change brands No OTC’s without provider OK NO NSAIDS due to renal toxicity

Management with Anticonvulsant Mood stabilizers Therapeutic effects on mania begin after days but mood stabilization may take weeks to months. Common transient adverse effects of the anticonvulsants Nausea, diarrhea, sedation Common maintained adverse effects: Weight gain: monitor weight and BMI; diet and exercise (lamotrigene and topiramate have lowest risk) Tremor: consider low dose beta-blocker Increased risk for thrombocytopenia: monitor prothrombin time Risk for agranulocytosis (especially carbemazepine): monitor WBC

Anticonvulsants Valproic acid (Valproate, Depakote): 1200-1500 mg/day (adult); up to 20mg/kg/day (child/adol) Useful for acute mania. Less effective for maintenance and bipolar depression. MOA: Increases GABA availability Pregnancy: D Need blood levels (therapeutic= 50 -100) Side Effects: Inhibits platelet aggregation Overdose (OD) lethal Adverse hormone changes in teenage girls Polycystic ovary syndrome in women who began taking the medication before age 20 Black Box Warnings for Hepatic Failure, Pancreatic Failure

Anticonvulsant Mood Stabilizers Carbamazepine (Tegretol): 400-1200 mg/day; up to 20-30 mg/kg/day (child/adol) Many drug-drug interactions- induces P450 enzyme breakdown Need blood levels Risk for agranulocytosis: monitor WBC q 2 wks X 2 mo then q 3 mo Lamotrigene (Lamictal): 100-200 mg /day Risk of rare toxic necrolysis skin condition (Steven Johnsons Syndrome). Start very low and go slow. Start at 25mg q o day X 2 wk then increase by 50 mg every two weeks. Takes 6 weeks to get to a therapeutic dose. Children and adolescents have higher incidence of life threatening rash than in adults. Do not need blood levels Topiramate (Topomax): 50-300 mg/day May be a useful adjunct in bipolar disorder. Not effective as first-line. Significant sedation

Management of Bipolar Disorder: Antipsychotics Atypical antipsychotics: Olanzepine (Zyprexa), Quetiapine (Seroquel), Ziprasidone (Geodon), Risperidone and Abilify are FDA approved for bipolar maintenance.

Adverse Effects of Antipsychotics Liver toxicity and blood dyscrasias Sedation Hypotension (mild) EPS Seizures Anticholinergic effects (moderate-marked) Risperidone: increased Prolactin which can lead to gynecomastia, galactorhea, mentrual changes and osteoporosis. Weight gain Neuroleptic malignant syndrome

Antipsychotic side effects Metabolic syndrome Weight gain, especially abdominal Hyperlipidemia Hyperglycemia Collectively increase the risk for diabetes and cardiovascular disease Monitor: weight, BMI, glucose and lipids, blood pressure