Bipolar Disorder Flashcards
What 5 types of medications/intervetions are used to treat an acute depressive episode in patients with bipolar disorder?
- “Antidepressants”
- Lithium
- Anticonvulsants
- Second generation antipsychotics
- ECT
What specific antidepressants are used to treat an acute depressive episode in patients with bipolar disorder? (1)
Fluoxetine (Prozac) + Olanzapine (Zyprexa) = combination drug called Symbyax
What specific anticonvulsants are used to treat an acute depressive episode in patients with bipolar disorder? (3)
- Lamotrigine (Lamictal)
- Lamotrigine (Lamictal) + Lithium
- Valproate (Depakote)
What specific second-generation antipsychotics are used to treat an acute depressive episode in patients with bipolar disorder? (4)
- Quetiapine (Seroquel)
- Lurasidone (Latuda)
- Cariprazine (Vraylar)
- Olanzapine (Zyprexa)
Are other antidepressants beyond the Symbyax combination medication used in treatment of acute bipolar disorder?
Antidepressants have a limited role as an adjunct treatment of acute bipolar depression. Use of antidepressants for acute and maintenance treatment of bipolar depression is controversial because of concerns the medications are not effective and may harm patients by causing switches from depression to mania as well as rapid cycling.
Discuss the evidence regarding the possible role of antidepressants in switching in patients with bipolar disorder.
Switching often occurs in bipolar disorder in the absence of antidepressant treatment. The natural switch rate is 41% (depression to mania, no antidepressants). Evidence is not completely clear that antidepressants as a class increase switching during acute or maintenance treatment.
- Increased rapid cycling when TCAs were introduced
- Mania rates over 2 years were highest with imipramine (vs. placebo vs. lithium)
- Antidepressants induce reversible rapid cycling in double-blind placebo-controlled studies
Randomized trials indicate that switching during the treatment of bipolar depression occurs more often with ___ or ___ compared with bupropion (Wellbutrin), SSRIs, or placebo, which have a switch rate of 3-5%.
TCAs (10-11% switch rate)
Venlafaxine (Effexor) - 12-15%
What are the most commonly prescribed medications for bipolar depression?
Antidepressants
Bupropion seems to have the least risk of switching
What historical information about patients may help determine if an antidepressant could be used for treating bipolar depression?
- History of responding favorably in the past
2. Has never taken antidepressants
What historical information about patients may help determine if an antidepressant should be avoided for treating bipolar depression?
- Previously experienced poor outcomes (switching, rapid cycling, suicidal ideation and behavior)
- Concurrent manic symptoms
- SUD
- Early age of onset for bipolar disorder
- Recent history (past 2-3 months) of mania or hypomania
Are there any predictors of a better response to antidepressants in bipolar depression?
Depressed patients with comorbid anxiety are less likely to respond to treatment than patients without anxiety.
Which anti-manic drugs should be used with an antidepressant so as to prevent switching?
- Lithium
- Valproate (Depakote)
- Carbamazpeine (Tegretol)
- Second generation antipsychotics - Olanzapine (Zyprexa), Quetiapine (Seroquel), Lurasidone (Latuda)
Switching to mania occurs less often when the aforementioned anti-manic drugs are used with an antidepressant. While it is unclear how long after remission of depression that antidepressants should be continued, in general, they are continued for ___ after remission, unless the patient has a history of what 4 things?
2-4 months
- Antideprssant associated switching to hypomania/mania
- Increases in mood cycle frequency
- History of frequent and/or severe manic episodes
- Concurrent course of rapid cycling
True or false - avoiding antidepressant monotherapy is consistent with practice guidelines.
True
Are antidepressants used in maintenance treatment of bipolar depression?
No - this does not appear to reduce the risk of depressive episodes
In treating a manic or hypomanic episode of bipolar disorder, what is the goal?
The goal is remission such that at most only 1-2 symptoms of mild intensity persist. Resolution of psychosis is required.
Patients with ___ symptoms of mania are at increased risk of relapse.
Subsyndromal
What is the difference between a severe acute manic episode and a moderate acute manic episode?
While there is no established criteria for what is a severe acute manic episode, a manic episode is considered severe if there is dangerousness (SI or behavior; HI or behavior; aggressive behavior; poor judgment that places the patient or others at imminent risk of being harmed) or psychotic features (hallucinations or delusions)
What drug classes are commonly used in the treatment of acute mania or hypomania?
- Lithium
- Anticonvulsants
- Antipsychotics
- Benzodiazpines
How are benzodiazepines used in the treatment of acute mania or hypomania?
Primarily as adjunctive treatments for insomnia, agitation, or anxiety
What is the general approach to treatment of a severe manic episode?
Combination therapy:
- Lithium + antipsychotic
- Valproate (Depakote) + antipsychotic
What is the general approach to treatment of a mild/moderate manic episode or hypomanic episode?
Monotherapy:
- Lithium
- Anticonvulsants
- Antipsychotics
How long does a medication regimen need to be given to tell if it is working for treatment of a manic or hypomanic episode?
While there is no formally established timeline, you generally need to allow for 2 weeks. Most research studies and randomized trials last 3 weeks and the superior efficacy of the medication compared with placebo generally begins to be seen within the first week
What are predictors of a good response to medication in the treatment of bipolar disorder?
Clinical features that consistently predict a good response have not been identified.
Some studies show mixed features predict a poorer response, but other studies did not replicate this finding.