The goal of treatment in
bipolar disorder is remission.
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.
So once somebody has
you're probably not going
to get rid of it entirely,
but it is a very treatable disease
and again remission is possible.
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.
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.
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.
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.
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.
So, inpatient hospitalization is going
to be required to manage safety
and monitor for suicidal
ideation when it’s present.
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.
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.
Let’s talk a little bit about the
treatment of bipolar disorders.
Mood stabilizers are great way to
start, an example being lithium,
which is a gold standard in
the treatment of bipolar.
Let’s talk a little bit
more in depth about lithium
because it’s such an
So, lithium is one of these
medicines that has to be kept
within a narrow therapeutic
range for your patient.
If it goes below that range, it’s
basically going to be ineffective.
If it goes above that range,
it’s extremely dangerous,
can become toxic.
So here’s a list of medications that
can actually increase lithium levels,
so you have to be very
cautious in combining these.
So NSAIDs are one example.
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.
And lithium toxicity presents
in a few different ways.
So your patient may come to you and they
may just say they are incredibly thirsty.
They might show you that they
have a tremor in their hand.
They might complain of being very weak
or having pretty severe stomach upset.
This can really start
progressing to the point
where your patient becomes
really dizzy, weak.
They can develop nystagmus and it
can eventually lead to stupor,
coma, delirium, seizures, blurry
vision and a heart arrhythmia.
In extreme cases, it
could lead to death.
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.
And if the serum lithium
level is above 3 mmol/L,
then we’ll actually need to do
hemodialysis to protect the kidneys.
Of course, lithium is one
of these unique medicines
that’s not metabolized
in the liver.
In fact, it’s metabolized in the kidney, so
very important to protect those kidneys.
And as well, in pregnant women,
there is a very specific teratogenic effect
that can result from taking lithium.
Do you know what that is?
It’s Ebstein’s anomaly, of course
a cardiac condition in the fetus.
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.
They may actually develop
They may complain of
their hair falling out
and can develop a metallic
taste in their mouth.
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.
You also want to check
their thyroid function
by getting a baseline and
then follow up thyroid tests.
When patients again become toxic,
things can get more severe where the
patient starts to look delirious.
They can develop some seizure
disorder, arrhythmia, and even coma.
Other mood stabilizers include
also antipsychotic medications.
Let’s talk a little bit more about
some of the mood stabilizers.
Examples include valproic acid,
carbamazepine, and lamotrigine.
Well, all of these are
It actually works really well
for mood disorders as well.
Can you tell me what
are caused by valproic
acid and carbamazepine?
Spina bifida, very important to note
and to screen for before starting
your patient on these medications.
Antipsychotic treatment can also
be helpful as mood stabilization.
We divide the antipsychotics
into typical neuroleptics
and newer generation or
So tell me, in which category would you put
risperidone, clozapine, quetiapine,
aripiprazole and ziprasidone?
And in which category would
you put chlorpromazine,
All antipsychotics, however,
the risperidone and other medicines
fall under the group of atypicals,
meaning they are newer second
And chlorpromazine and the other medications
are actually older neuroleptics
and so they are typical agents.
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.
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.
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.
So, the atypical agents
are very helpful here.
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.
These are all examples of
negative symptoms of psychosis.
So, which group can cause anticholinergic
and metabolic side effects?
What causes are the newer
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.
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.
It can be oculogyric crisis, where
the eyes kind of roll around
in the sockets and get
stuck looking upwards.
Other extrapyramidal symptoms include
akathisia or sense of restlessness.
The patient will describe to you that they
want to sort of jump out of their skin.
Another extrapyramidal side effect
would be parkisonian symptoms.
Things like a masked face, where there
is a little expression that is shown
or a tremor or a slowed walking,
something called bradykinesia.
Those are other signs of
Other medications that are really
helpful in treating bipolar disorder
include the benzodiazepines.
There are short and
and while a lot of people with
bipolar, often not all the time,
but often will have a comorbid
substance abuse problem.
We do want to be careful in using
benzodiazepines in this group
because they’re extremely
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.
Other things that are worth considering
are ECT or electroconvulsive therapy.
So, a quick review about ECT,
it’s a very controlled seizure
delivered through a patient’s brain.
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.
And the seizure is delivered,
and patient wakes up after the procedure,
and this is extremely effective
in resetting their mood.
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.
Because as we learned earlier,
a lot of these medications
come with some teratogenic side effects,
but ECT is actually quite safe.
One of the biggest risk
factors of it, of course,
is retrograde amnesia
to the patient.
Irritability is usually the predominant
mood state in a mixed episode.
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.