1. Drugs for Bipolar Disorder
Chapter 33
Drugs for Bipolar Disorder 1

2. Bipolar Disorder Formerly known as manic-depressive illness
Afflicts an estimated 3.7% of the adult population
Mainstays of therapy
Lithium, valproic acid
Many also receive an antipsychotic
Chronic condition that requires lifelong treatment 2

3. Bipolar Disorder Definition of bipolar disorder (BPD) Treatment
Cyclic disorder
Recurrent fluctuations in mood
Episodes of mania and depression persist for months without treatment
Treatment
Drugs
Psychotherapy 3

4. Characteristics of Bipolar Disorder
Types of mood episodes seen in bipolar disorder (BPD)
Pure manic episode (euphoric mania)
Hypomanic episode (hypomania)
Major depressive episode (depression)
Mixed episode 4

5. Treatment of Bipolar Disorder
Drug therapy
Nondrug therapy 5

6. Drug Therapy Types of drugs employed
Mood stabilizers (Lithium) or Valproic acid
Relieve symptoms during manic and depressive episodes
Prevent recurrence of manic and depressive episodes
Do not worsen symptoms of mania or depression; do not accelerate the rate of cycling
Antipsychotics
Given during severe manic episodes
Antidepressants
Given during depressive episodes 6

7. Drug Therapy Drug selection Promoting compliance
Short-term therapy: manic episodes
Short-term therapy: depressive episodes
Long-term preventive treatment
Promoting compliance
Short-term hospitalization
Long-term prophylactic therapy
Education for both patient and family-patient may be resistant to being treated during manic phase 7

8. Mood-Stabilizing Drugs
Lithium
Antiepileptic drugs 8

9. Lithium (Lithonate, Lithotabs)
Chemistry
Simple inorganic ion
Found naturally in animal tissues
Therapeutic uses
Bipolar disorder
Other uses
Alcoholism
Bulimia
Schizophrenia
Glucocorticoid-induced psychosis 9

10. Lithium (Lithonate, Lithotabs)
Mechanism of action
Altered distribution of certain ions
Altered synthesis and release of norepinephrine, serotonin, and dopamine
Mediates intracellular responses to neurotransmitters
Shown to facilitate regeneration of damaged optic nerves
Can increase total gray matter in regions known to atrophy in BPD 10

11. Lithium (Lithonate, Lithotabs)
Pharmacokinetics
Absorption and distribution
Excretion
Short half-life
Excreted by the kidneys
Sodium levels: lithium excretion reduced when sodium level low
Plasma levels (need to be monitored, small therapeutic index, tricky dosing )
0.8–1.4 mEq/L 11

12. Lithium (Lithonate, Lithotabs)
Adverse effects
Excessive lithium levels
Greater than 1.5 mEq/L
Monitor levels q 2–3 days at initiation of therapy and then q 3–6 months
Therapeutic lithium levels
Gastrointestinal
Tremors
Polyuria
Renal toxicity
Goiter and hypothyroidism
Teratogenesis 12

13. Lithium (Lithonate, Lithotabs)
Drug interactions
Diuretics
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Anticholinergic drugs
Preparations, dosage, and administration
Lithium carbonate
Lithium citrate
Dosage is highly individualized 13

14. Antiepileptic Drugs Divalproex sodium (Valproate)
Considered somewhat safer than lithium
Adverse effects include liver and pancreatic toxicity, and hematologic effects- which may be serious
Carbamazepine
Lamotrigine 14

15. Antipsychotic Drugs in BPD
Used to acutely control symptoms during manic episodes
Used long term to help stabilize mood
Benefit patients with or without psychotic symptoms
Can be combined with mood stabilizer
Five antipsychotics approved for use
Olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), aripiprazole (Abilify), and ziprasidone (Geodon) 15