A patient with bipolar disorder has been well controlled on lithium for 3 years. He has had severe symptoms in the past.
If lithium is discontinued, the most likely result would be:
Correct Answer C:
All available studies indicate a high risk of recurrence of bipolar illness after termination of lithium therapy. In one survey of 14 articles, the computed time to 50% failure of remission was 5 months, with the time of recurrence of mania being 5.2 times earlier than for depression. Mania tended to recur within 2.7 months, whereas depression was delayed for as long as 14 months. More than 50% of new episodes of illness occurred within 10 weeks of stopping therapy. In patients with mean cycle lengths before treatment of almost 12 months, their time to a new episode when off lithium therapy was less than 2 months. Studies indicate that the risk of early recurrence of bipolar illness, especially mania, evidently is increased following discontinuation of lithium use and may exceed that predicted by the course of the untreated disorder.
A 34 year old white male presents with a history and findings that satisfy DSM-IV criteria for bipolar disorder.
Which one of the following treatment options is the most effective for long-term management of the majority of patients with this disorder?
Correct Answer E:
Electroconvulsive therapy (ECT) is as effective as medication for the acute treatment of the severe depression and/or mania of bipolar disorder. However, ECT should be reserved for patients with severe mood syndromes who may be unable to wait for mood-stabilizing drugs to take effect. Neuroleptic (antipsychotic) drugs are effective in acute mania, but are not recommended for long-term use because of side effects. Bipolar depression generally responds to tricyclic antidepressants, SSRIs, and MAO inhibitors, but when used as long-term therapy these drugs may induce episodes of mania.
Anticonvulsants, such as carbamazepine, valproic acid, and benzodiazepines, have been useful adjuncts combined with lithium in patients with breakthrough episodes of mania and/or depression. Lithium is the classic mood stabilizer. It has been shown to have antimanic efficacy, prophylactic efficacy in bipolar disorder, and some efficacy in prophylaxis against bipolar depression. Lithium remains the drug of choice for long-term treatment of the majority of patients with bipolar illness.
Which one of the following anticonvulsant medications is preferred for the treatment of mania or hypomania in patients with bipolar disorder?
Anticonvulsant medications are used in the treatment of various psychiatric disorder. Valproic acid is FDA-approved for the treatment of manic episodes associated with bipolar disorder. It has been shown in controlled studies to be significantly more effective than placebo. The initial dosage is 750 mg daily given in divided doses, and most individuals require between 1000 and 2500 mg daily. Carbamazepine has also been used to treat mania and is an alternative for individuals who cannot tolerate lithium or valproic acid. Clonazepam is used in the treatment of panic attacks, and gabapentin is used to treat anxiety. Both phenytoin and gabapentin are also used to treat peripheral neuropathy. The primary use of Phenobarbital is as an anticonvulsant.
In patients with bipolar depression, monotherapy with which one of the following may trigger a manic episode?
Bipolar depression is characterized by unpredictable mood swings ranging from episodes of depression to periods of mania (psychomotor activity, euphoria, impaired judgment, impulsivity, grandiose ideas, and irritability). Specific classification and criteria for diagnosis are available in the DSM-V. Depressive symptoms can be controlled with an SSRI-type antidepressant such as fluoxetine (choice C), but if used alone the drugs can trigger a manic episode in some patients.
→ Mood stabilizers such as lithium carbonate (choice B), valproic acid (choice A), and carbamazepine (choice E) are used to control and prevent mania. Antipsychotics such as olanzapine (choice D) can also be used to control mania, particularly when psychotic features are clinically presented.
A 23-year-old female was recently diagnosed with bipolar disorder after experiencing her first episode of acute severe mania.
After excluding the need for hospitalization, which of the following should be administered?
Initiation of a mood-stabilizing drug is the critical first step. It may take several weeks for a mood stabilizer to take effect, and other drugs may be needed. Either valproate or lithium is the standard first drug for most manic episodes. Lithium is effective for most hypomanic and manic episodes.
→ Carbamazepine may be used in place of valproate to treat patients with multiple manic episodes, mixed episodes, and rapid cycling.
→ If the patient does not respond fully within a week and symptoms are more severe, antipsychotics may be added to mood stabilizers. Atypical antipsychotics are more likely to be used first. Include olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripriprazole (Abilify), and ziprasidone (Geodon).
→ Clozapine (Clozaril) is not generally used because of its potential for severe side effects.
→ Older antipsychotic drugs (also called typical antipsychotics), such as haloperidol (Haldol), may be used for acute mania. They may be more likely to cause extrapyramidal effects, which disrupt motor control and are not generally used on a long-term basis.
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