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Bipolar Disorder: Treatment

by Helen Farrell, MD
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    00:01 The goal of treatment in bipolar disorder is remission.

    00:05 This is defined as the resolution of the mood symptoms or improvement to the point that only one or two symptoms of mild intensity persist.

    00:16 So once somebody has bipolar disorder, you're probably not going to get rid of it entirely, but it is a very treatable disease and again remission is possible.

    00:26 If psychotic features are present, such as delusions or hallucinations, then your goal is resolution of the psychosis, and you really need to resolve psychosis before you can start targeting the mood symptoms.

    00:42 So in any patient who has bipolar or psychotic features, your first step is going to be really getting rid of the psychotic symptoms which are the most dangerous of the symptoms to have.

    00:53 Some patients don’t achieve remission and in these cases, a reasonable goal is to look for response to treatment, and this would be defined as stabilization of the patients safety and substantial improvement in the number, intensity and frequency of mood and psychotic symptoms.

    01:14 When it comes to the setting and monitoring of your bipolar patient, you need to consider whether to have them as an inpatient in the hospital or outpatient care.

    01:23 So, the appropriate setting is really going to depend on the severity of the symptoms, comorbid psychopathology meaning are there any other mental illnesses that play here and how are they being controlled, the level of your patient’s psychosocial functioning and their available supports.

    01:40 So, inpatient hospitalization is going to be required to manage safety and monitor for suicidal ideation when it’s present.

    01:49 Partial hospitalization where the patient will go into the hospital during the day, but then go back home at night to sleep is for the moderately ill patient or those with suicidal thoughts, but who are feeling safe and don’t have an intent or plan to harm themselves.

    02:06 In an outpatient setting, which is where most patients with a mood disorder are in fact treated is a very suitable setting for people who are safe and who are not risk to harm themselves or others.

    02:18 Let’s talk a little bit about the treatment of bipolar disorders.

    02:22 Mood stabilizers are great way to start, an example being lithium, which is a gold standard in the treatment of bipolar.

    02:30 Let’s talk a little bit more in depth about lithium because it’s such an important medication.

    02:35 So, lithium is one of these medicines that has to be kept within a narrow therapeutic range for your patient.

    02:42 If it goes below that range, it’s basically going to be ineffective.

    02:45 If it goes above that range, it’s extremely dangerous, because patients can become toxic.

    02:51 So here’s a list of medications that can actually increase lithium levels, so you have to be very cautious in combining these.

    02:59 So NSAIDs are one example.

    03:02 Tetracycline, metronidazole, ACE inhibitors, diuretics, theophylline, osmotic diuretics like mannitol and acetazolamide, all of these can increase your lithium level, making the patient toxic, so very important to note.

    03:18 And lithium toxicity presents in a few different ways.

    03:22 So your patient may come to you and they may just say they are incredibly thirsty.

    03:27 They might show you that they have a tremor in their hand.

    03:30 They might complain of being very weak or having pretty severe stomach upset.

    03:34 This can really start progressing to the point where your patient becomes really dizzy, weak.

    03:40 They can develop nystagmus and it can eventually lead to stupor, coma, delirium, seizures, blurry vision and a heart arrhythmia.

    03:50 In extreme cases, it could lead to death.

    03:53 How would you manage lithium toxicity in your patient? Well, a few things, mild toxicity can be managed by correcting the electrolyte disturbance through IV hydration.

    04:08 And if the serum lithium level is above 3 mmol/L, then we’ll actually need to do hemodialysis to protect the kidneys.

    04:18 Of course, lithium is one of these unique medicines that’s not metabolized in the liver.

    04:23 In fact, it’s metabolized in the kidney, so very important to protect those kidneys.

    04:29 And as well, in pregnant women, there is a very specific teratogenic effect that can result from taking lithium.

    04:38 Do you know what that is? It’s Ebstein’s anomaly, of course a cardiac condition in the fetus.

    04:46 So some more common side effects of lithium even before a patient becomes toxic, things your patient might just complain of day-to-day would be things like weight gain, some stomach upset, feeling tired and fatigued.

    04:59 They may actually develop increased thirst.

    05:03 They may complain of their hair falling out and can develop a metallic taste in their mouth.

    05:08 Other things that they may not complain of, but you need to be cautious to monitor for are things like kidney disruption by checking a baseline and then follow up BMP or kidney panel.

    05:21 You also want to check their thyroid function by getting a baseline and then follow up thyroid tests.

    05:28 When patients again become toxic, things can get more severe where the patient starts to look delirious.

    05:33 They can develop some seizure disorder, arrhythmia, and even coma.

    05:40 Other mood stabilizers include anticonvulsant medications, also antipsychotic medications.

    05:47 Let’s talk a little bit more about some of the mood stabilizers.

    05:50 Examples include valproic acid, carbamazepine, and lamotrigine.

    05:55 Well, all of these are anti-seizure medicines.

    05:58 It actually works really well for mood disorders as well.

    06:03 Can you tell me what fetal anomalies are caused by valproic acid and carbamazepine? Spina bifida, very important to note and to screen for before starting your patient on these medications.

    06:20 Antipsychotic treatment can also be helpful as mood stabilization.

    06:25 We divide the antipsychotics into typical neuroleptics and newer generation or atypical neuroleptics.

    06:33 So tell me, in which category would you put risperidone, clozapine, quetiapine, aripiprazole and ziprasidone? And in which category would you put chlorpromazine, thioridazine, fluphenazine, and haloperidol? All antipsychotics, however, the risperidone and other medicines fall under the group of atypicals, meaning they are newer second generation medications.

    07:00 And chlorpromazine and the other medications are actually older neuroleptics and so they are typical agents.

    07:07 Which neuroleptics provide D2 or dopamine 2 antagonism through high potency versus low potency? Well the high potency medications are the typical neuroleptics, and the lower potency medications are the atypicals.

    07:26 The atypicals tend to work a little bit more and have stronger affinity for serotonin receptors as well as histamine receptors, less so for the dopamine.

    07:37 So what’s better at treating positive symptoms than negative symptoms? Well, it’s the typical agents will treat positive symptoms and this is one reason why atypicals are such great medications because they actually will target the negative symptoms of a psychotic episode and the negative symptoms are really the core of psychosis, and they’re extremely difficult to treat.

    08:00 So, the atypical agents are very helpful here.

    08:02 And of course, negative symptoms, as a review, are things like having a flat affect, avolition or withdrawal, low motivation, sometimes alogia or poverty of speech and people who have a lot of psychomotor retardation.

    08:19 These are all examples of negative symptoms of psychosis.

    08:24 So, which group can cause anticholinergic and metabolic side effects? What causes are the newer generation antipsychotics and whereas the older generation antipsychotics are the ones that because of their strong affinity for dopamine 2 receptors, they are more likely to cause extrapyramidal side effects.

    08:45 As a review, the extrapyramidal side effects from medication include things like acute dystonia, which can be seen as stiffness in the neck or torticollis.

    08:56 It can be oculogyric crisis, where the eyes kind of roll around in the sockets and get stuck looking upwards.

    09:05 Other extrapyramidal symptoms include akathisia or sense of restlessness.

    09:10 The patient will describe to you that they want to sort of jump out of their skin.

    09:14 Another extrapyramidal side effect would be parkisonian symptoms.

    09:18 Things like a masked face, where there is a little expression that is shown or a tremor or a slowed walking, something called bradykinesia.

    09:29 Those are other signs of extrapyramidal symptoms.

    09:32 Other medications that are really helpful in treating bipolar disorder include the benzodiazepines.

    09:37 There are short and long-acting benzodiazepines and while a lot of people with bipolar, often not all the time, but often will have a comorbid substance abuse problem.

    09:49 We do want to be careful in using benzodiazepines in this group because they’re extremely addictive agents.

    09:56 However, because they can work so quickly especially medications like lorazepam and alprazolam, they can often be helpful during an acute mania to help bring people down from that manic and very dangerous high.

    10:11 Other things that are worth considering are ECT or electroconvulsive therapy.

    10:17 So, a quick review about ECT, it’s a very controlled seizure delivered through a patient’s brain.

    10:24 It’s done in the setting of an operating room under control with general anesthesia where the patient is put to sleep or given a muscle relaxant so their body is essentially paralyzed momentarily, therefore they don’t break any bones or hurt themselves during the seizure.

    10:41 And the seizure is delivered, and patient wakes up after the procedure, and this is extremely effective in resetting their mood.

    10:51 Usually, we will use this during cases of acute mania and it’s also a very good treatment when a patient has bipolar disorder not responding to medication and the patient is pregnant.

    11:05 Because as we learned earlier, a lot of these medications come with some teratogenic side effects, but ECT is actually quite safe.

    11:12 One of the biggest risk factors of it, of course, is retrograde amnesia to the patient.

    11:17 Irritability is usually the predominant mood state in a mixed episode.

    11:22 Something to note as a clinical pearl and that brings us to the conclusion of our bipolar disorder discussion, and you’ve now learned a little bit about the various types of bipolar, how to diagnose it, a little bit about what treatment settings are most appropriate and how to go about making good recommendations for your patient.

    11:45 Thank you.


    About the Lecture

    The lecture Bipolar Disorder: Treatment by Helen Farrell, MD is from the course Major Psychiatric Disorders. It contains the following chapters:

    • Treatment of Bipolar Disorder
    • Treating Bipolar Disorders
    • Anticonvulsants and Antipschotics

    Included Quiz Questions

    1. Hallucinations
    2. Mood
    3. Impulsivity
    4. Pressured speech
    5. Insomnia
    1. Inpatient admission.
    2. Partially hospitalize the patient.
    3. Observe him in the emergency department for the next 4 days.
    4. Request the neighbor who brought him to take care of the patient.
    5. Allot a care taker and send him home.
    1. Cetirizine
    2. Metronidazole
    3. Diuretics
    4. ACE inhibitors
    5. NSAIDs
    1. Flumazenil can be used if the blood levels go above 3 mmol/L.
    2. Mild toxicity can be managed by IV hydration.
    3. The teratogenic abnormality of Lithium during pregnancy is called Ebstein’s anomaly.
    4. Co-administration of NSAIDs increase the levels of Lithium in the blood.
    5. Lithium toxicity presents as coarse tremors, ataxia and slurred speech.
    1. Carbamazepine
    2. Clonazepam
    3. Diazepam
    4. Ethosuximide
    5. Gabapentin
    1. A small dose of Diazepam is given to relax the patient.
    2. It is done in a setting of an operating room.
    3. A controlled seizure is delivered to the brain.
    4. A muscle relaxant is used to paralyze the body for short time.
    5. General anesthesia is used.

    Author of lecture Bipolar Disorder: Treatment

     Helen Farrell, MD

    Helen Farrell, MD


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