Transcript treatment of a manic episode

BIPOLAR DISORDER,
MANAGEMENT GUIDELINES
DR GIAN LIPPI
CONSULTANT PSYCHIATRIST
UNIVERSITY OF PRETORIA & WESKOPPIES HOSPITAL
FORENSIC UNIT
CONTENTS
MANAGEMENT FRAMEWORK
TREATMENT
PHARMACOTHERAPY PRINCIPLES
TREATMENT OF BIPOLAR DEPRESSION
TREATMENT OF A MANIC EPISODE
TREATMENT OF A HYPOMANIC EPISODE
TREATMENT OF A MIXED EPISODE
MEDICATIONS USED IN THE MAINTENANCE PHASE
NEW TREATMENT OPTIONS
MOSTLY INEFFECTIVE TREATMENT OPTIONS
MANAGEMENT FRAMEWORK
INPATIENT vs OUTPATIENT CARE REQUIRED
(RISK ASSESSMENT)
HOSPITALIZATION
- RISK OF SUICIDE/HOMICIDE
- RELAPSE WITH GROSSLY IMPAIRED ABILITY TO GET FOOD & SHELTER IN THE
ABSENCE OF A PROPER SUPPORT SYSTEM
- RAPIDLY PROGRESSING SYMPTOMS
- PSYCHOSIS
- VOLUNTARY vs INVOLUNTARY ADMISSION
- MOSTLY FOR MANIC, MIXED OR SEVERE DEPRESSIVE EPISODES
OUTPATIENT TREATMENT
- HYPOMANIC & MILD TO MODERATELY SEVERE DEPRESSIVE EPISODES
- EVALUATE PATIENT FREQUENTLY
2 TREATMENT APPROACHES
- PSYCHOTHERAPY
- PHARMACOTHERAPY
BOTH FORMS OF TREATMENT ARE EFFECTIVE BY
THEMSELVES BUT ARE MORE EFFECTIVE WHEN
USED IN COMBINATION WITH EACH OTHER
TREATMENT
PSYCHOTHERAPY
- DURING MAINTENANCE PHASE / EPISODES OF HYPOMANIA OR MILD DEPRESSION
- NOT DURING MANIC, MIXED OR SEVERE DEPRESSIVE EPISODES OR IF
PSYCHOSIS IS PRESENT
- COGNITIVE BEHAVIOUR THERAPY (CBT) IS TREATMENT OF CHOICE
- INTERPERSONAL THERAPY & FAMILY THERAPY ALSO USEFUL
- REMEMBER OTHER PSYCHOSOCIAL INTERVENTIONS LIKE PSYCHOEDUCATION &
OCCUPATIONAL THERAPY
PHARMACOTHERAPY
- SPECIFIC ACCORDING TO DIFFERENT PHASES OF THE DISORDER
PHARMACOTHERAPY PRINCIPLES
MOOD STABILIZERS ARE THE MAINSTAY OF TREATMENT
TREATMENT OF A MANIC EPISODE (TREAT FROM ABOVE)
PREVENTING A MANIC EPISODE (STABILIZE FROM ABOVE)
TREATMENT OF A DEPRESSIVE EPISODE (TREAT FROM BELOW)
PREVENTING A DEPRESSIVE EPISODE (STABILIZE FROM BELOW)
NO MOOD STABILIZER IS EFFECTIVE IN ALL 4 DOMAINS
- COMBINATION MOOD STABILIZERS ARE BECOMING THE RULE RATHER THAN THE
EXCEPTION (DEPENDING ON SYMPTOM PRESENTATION; MONOTHERAPY IS
STILL PREFERABLE)
TREATMENT OF BIPOLAR DEPRESSION
AVOID USE OF ANTIDEPRESSANTS, EXCEPT AS A LAST RESORT
- RISK OF INDUCING HYPOMANIA & RAPID CYCLING
USE MOOD STABILIZERS EFFECTIVE IN TREATING DEPRESSION
- LAMOTRIGINE
- OLANZAPINE / QUETIAPINE / ARIPIPRAZOLE
- POSSIBLY LITHIUM
ELECTROCONVULSIVE THERAPY (ECT)
ANTIDEPRESSANTS
- LAST RESORT
- ALWAYS IN COMBINATION WITH AT LEAST 1 MOOD STABILIZER
- MAY NEED TO BE USED IN COMBINATION WITH 2 MOOD STABILIZERS, 1 EFFECTIVE
IN TREATING DEPRESSION, & 1 EFFECTIVE AT PREVENTING MANIC EPISODES
PSYCHOTIC DEPRESSION
- ADD AN ANTIPSYCHOTIC IF NOT ALREADY ON 1
- PREFERABLY AN ATYPICAL ANTIPSYCHOTIC
- PREFERABLY OLANZAPINE / QUETIAPINE / ARIPIPRAZOLE
- AVOID HALOPERIDOL, CAUSES DYSPHORIA
TREATMENT OF A MANIC EPISODE
1) START A MOOD STABILIZER EFFECTIVE IN TREATING MANIA
- VALPROATE (ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY)
- LITHIUM (DISADVANTAGE OF SLOW TITRATION DUE TO TOXICITY RISK)
- CONSIDER ATYPICAL ANTIPSYCHOTIC
2) ADD ANTIPSYCHOTIC IF NEEDED (ALWAYS IF PSYCHOTIC)
- HALOPERIDOL
- ATYPICAL ANTIPSYCHOTIC (OLANZAPINE GOOD CHOICE)
3) ADD LONG ACTING BENZODIAZEPINE IF NEEDED
- CLONAZEPAM 2mg po tds
4) ECT IF NEEDED
APPROPRIATE ADDITIONAL MEASURES
- STOP ANTIDEPRESSANT IF PATIENT IS ON 1
- EMERGENCY SEDATION AS NEEDED AS PER USUAL PROTOCOL
(IM LORAZEPAM, HALOPERIDOL, OLANZAPINE, ZIPRASIDONE,
CLOPIXOL ACUPHASE ETC)
TREATMENT OF A
HYPOMANIC EPISODE
1) START A MOOD STABILIZER EFFECTIVE IN TREATING MANIA
- VALPROATE (ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY)
- LITHIUM (DISADVANTAGE OF SLOW TITRATION DUE TO TOXICITY RISK)
- CONSIDER ATYPICAL ANTIPSYCHOTIC
2) ADD ANTIPSYCHOTIC IF NEEDED (USUALLY NOT NECESSARY)
- HALOPERIDOL
- ATYPICAL ANTIPSYCHOTIC
3) ADD LONG ACTING BENZODIAZEPINE
(USUALLY NOT NECESSARY)
- CLONAZEPAM 2mg po tds
APPROPRIATE ADDITIONAL MEASURES
- STOP ANTIDEPRESSANT IF PATIENT IS ON 1
TREATMENT OF A MIXED EPISODE
1) START A MOOD STABILIZER EFFECTIVE IN TREATING MIXED
EPISODES
- VALPROATE (ADVANTAGE OF BEING ABLE TO TITRATE DOSE UPWARDS RAPIDLY)
- MAY NEED TO USE 2 MOOD STABILIZERS, 1 EFFECTIVE IN TREATING DEPRESSION & 1
EFFECTIVE IN TREATING MANIA (EG VALPROATE + LAMOTRIGINE)
- CONSIDER ATYPICAL ANTIPSYCHOTIC
2) ADD ANTIPSYCHOTIC IF NEEDED (ALWAYS IF PSYCHOTIC)
- ATYPICAL ANTIPSYCHOTIC
MEDICATIONS FOR MAINTENANCE PHASE
LITHIUM
- MOST EFFECTIVE IN TREATING & PREVENTING MANIC EPISODES
- CAN BE CONSIDERED FOR TREATMENT OF MIXED EPISODES & RAPID CYCLING,
BUT NOT 1ST LINE
- QUESTIONABLE EFFICACY IN TREATMENT, NOT PREVENTION OF DEPRESSION
VALPROATE
- MOST EFFECTIVE IN TREATING & PREVENTING MANIC EPISODES
- TREATMENT OF CHOICE FOR MIXED EPISODES & RAPID CYCLING
- NOT EFFECTIVE IN TREATMENT & PREVENTION OF DEPRESSION
CARBAMAZEPINE / OXCARBAZEPINE / ESLICARBAZEPINE
- FALLEN OUT OF FAVOUR, NO LONGER ROUTINELY USED, ONLY SPECIFIC CASES
- SAME USE PROFILE AS VALPROATE BUT SEEMS TO BE LESS EFFECTIVE
LAMOTRIGINE
- EFFECTIVE IN TREATING DEPRESSIVE EPISODES
- TREATMENT OF CHOICE FOR PREVENTING DEPRESSIVE EPISODES
- EFFECTIVE IN PREVENTING MANIC EPISODES
- NOT EFFECTIVE IN TREATMENT OF MANIC EPISODES
- POSSIBLE / QUESTIONABLE EFFICACY IN TREATMENT OF MIXED
EPISODES & RAPID CYCLING
NEW OPTIONS & INEFFECTIVE OPTIONS
ATYPICAL ANTIPSYCHOTICS
- EFFECTIVE IN TREATMENT OF MANIC EPISODES
(RISPERIDONE, QUETIAPINE, ZIPRASIDONE, ARIPIPRAZOLE & ESPECIALLY OLANZAPINE)
- EFFECTIVE IN PREVENTING MANIC EPISODES
- EFFECTIVE IN TREATING DEPRESSIVE EPISODES
(OLANZAPINE, QUETIAPINE & ARIPIPRAZOLE)
- NOT EFFECTIVE IN PREVENTING DEPRESSIVE EPISODES
- CAN BE CONSIDERED FOR TREATMENT OF MIXED EPISODES & RAPID CYCLING,
BUT NOT 1ST LINE
MEDICATIONS MOSTLY INEFFECTIVE AS MOOD STABILIZERS
- TOPIRAMATE
- GABAPENTIN
- LEVETIRACETAM
- PREGABALIN
- ZONISAMIDE
- RILUZOLE
- MEMANTINE
- KETAMINE
- AMANTADINE
- CALCIUM CHANNEL BLOCKERS
THE END