1. Module 3 Indications for Antipsychotics Bipolar Disorder
Flavio Guzmán, MD

2. Outline
Indications of antipsychotics in different phases of bipolar disorder:
Mania/mixed states
Bipolar depression
Maintenance treatment
FDA approved agents for each phase

3. Use of antipsychotics in bipolar disorder
Mania
Mixed states
Maintenance
Bipolar depression

4. Mania Management

5. Acute mania pharmacotherapy
Patients with BD spend much less time in mania, hypomania, or mixed states than they do in depression.
Many effective treatments for mania, fewer for maintenance treatment or treatment of bipolar depression.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

6. Acute mania pharmacotherapy
FGAs
SGAs
Anticonvulsants
Lithium

7. Antipsychotics for mania
FGAs are effective in the treatment of mania, but are frequently avoided due to the risk of EPS.
Antipsychotics work as well as lithium in acute mania, even in the absence of psychotic symptoms.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

8. FGAs treatment
Patients with mood disorders might more vulnerable to developing TD than schizophrenia patients.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

9. Mixed Episodes

10. FDA approved SGAs for manic/mixed episodes
Aripiprazole
Asenapine
Quetiapine and quetiapine XR
Risperidone
Olanzapine
Ziprasidone
Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
N Engl J Med. 2011;364(1):51-9.

11. The role of SGAs in the treatment of manic/mixed episodes
Aripiprazole
Asenapine
Quetiapine and quetiapine XR
Risperidone
Olanzapine
Ziprasidone
Approved as monotherapy
Manic/mixed episodes
Aripiprazole
Asenapine
Quetiapine and quetiapine XR
Risperidone
Olanzapine
Ziprasidone
Lithium
Divalproex sodium
Approved as adjunctive

12. Bipolar Depression

13. Bipolar depression
Depression is the predominant mood state in bipolar disorder.
Some clinicians argue that this state is the most difficult to treat.
There are few proven strategies for bipolar depression.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

14. Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
FDA approved SGAs for bipolar depression
Bipolar depression
Quetiapine
Olanzapine/ fluoxetine
Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
N Engl J Med. 2011;364(1):51-9.

15. Maintenance treatment

16. FDA approved SGAs for maintenance treatment
Aripiprazole
Olanzapine
Quetiapine and quetiapine XR
Risperidone (LAI)
Ziprasidone
FDA approved SGAs for maintenance treatment
Frye MA. Clinical practice. Bipolar disorder--a focus on depression.
N Engl J Med. 2011;364(1):51-9.

17. Maintenance treatment: SGAs
Advantages
Titration is rapid and easier. (Compared to lamotrigine and lithium)
Safer in overdose
Disadvantages
Weight gain
Metabolic side effects
Sedation

18. Take home points
Antipsychotics are effective for mania, mixed states and bipolar depression.
Manic/mixed episodesc
Aripiprazole
Asenapine
Quetiapine and quetiapine XR
Risperidone
Olanzapine
Ziprasidone
Maintenance treatment
Aripiprazole
Olanzapine
Quetiapine and quetiapine XR
Risperidone (LAI)
Ziprasidone
Bipolar depression
Quetiapine
Olanzapine / fluoxetine

19. References and further reading
Frye MA. Clinical practice. Bipolar disorder--a focus on depression. N Engl J Med. 2011;364(1):51-9.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.