Bipolar Treatment

Question 1

Common meds that can precipitate a manic episode?

Answer 1

steroids, L-dopa, antidepressants, stimulants

Question 2

Only first-line psychological treatment recommendation for bipolar disorder?

Answer 2

Psychoeducation (first-line, Level 2) for maintenance of bipolar disorder.

“insufficient evidence” for depression (Psychoeducation does not
have any significant evidence of utility in either acute depressive
or manic episodes)

On average, adjunctive psychosocial treatments reduce recurrence rates by about 15%

Question 3

What are the 2 second-line recommendations for psychological treatment of bipolar disorder?

Answer 3

CBT and family-focused therapy (FFT), both second-line for maintenance and depression. (Both have level 2 evidence).

FFT focuses on
communication styles between patients and their families or marital relationships, with the goal of improving relationship functioning, and is delivered to the family and patient in 21 sessions over 9 months.

No evidence exists, and hence no recommendation is made, for CBT in mania or FFT in mania.

Question 4

What are the 2 third-line recommendations for psychological treatment of bipolar disorder?

Answer 4

Interpersonal and social rhythm therapy (IPSRT) and
Peer Support

IPSRT has Level 2 evidence for maintenance ad depression treatment. IPSRT expands on the IPT focus on grief, interpersonal role transition, role dispute, and interpersonal deficits by including regulation of social and sleep rhythms

Peer support only has level 2 evidence for maintenance, for depression is “insufficient evidence”. Peer support is
an important strategy believed to reduce self-stigma and isolation in BD, and to help improve engagement in treatment

Question 5

Recommendations for short-term pharmacological management of agitation in mania/mixed features?

Answer 5

Aripiprazole IM, lorazepam IM, loxapine (inhaled), olanzapine IM.

But not great evidence. and probably PO is fine if they will accept it, just no studies looking at this. Loxapine IM is third line.

Question 6

First line monotherapy treatments for manic episode in order?

Answer 6

Lithium
Quetiapine
Divalproex
Asenapine
Aripiprazole
Paliperidone (>6mg)
Risperidone
Cariprazine

(queen in the middle of Lady Di… Archie, Prince.. Really it’s all about Catherine)..

In general, combination therapy is preferred to mood stabilizer
monotherapy because clinical trials suggest that on average about 20% more patients will respond to combination therapy

Question 7

First line combination therapies in order for management of acute mania?

Answer 7

Quetiapine + Li/DVP
Aripiprazole + Li/DVP
Risperidone + Li/DVP
Asenapine + Li/DVP

Question 8

Second line treatments recommended for management of acute mania?

Answer 8

Olanzapine
Carbamazepine
Olanzapine + Li/DVP
Lithum + DVP
Ziprasidone
Haloperidol
ECT

Question 9

Third line treatments for acute mania (no order)?

Answer 9

Carmbazepine + Li/DVP
chlorpromazine
clonazepam
clozapine
haloperidol + Li/DVP
rTMS
tamoxifen
tamoxifen + Li/DVP

Question 10

What treatments are not recommended for use in acute mania?

Answer 10

Allopurinol
gabapentin
lamotrigine
omega-3 fatty acids
eslicarbazepine/licarbazepine
topiramate
valnoctamide
zonisamide

Question 11

First and second line treatments for acute bipolar I depressive episode in order?

Answer 11

First line
Quetiapine
lurasidone + Li/DBP
lithium
Lamotrigine
lurasidone
lamotrigine (adj)

second-line
divalproex
SSRIs/buproprion (adj)
ECT
cariprazine
olanzapine-fluoxetine

Question 12

what clinical features suggest you should use lithium vs divalproex in bipolar?

Answer 12

lithium is preferred over divalproex for individuals who:
1) display classical euphoric grandiose mania (elated mood in the absence of depressive symptoms)
2) few prior episodes of illness, a maniadepression-euthymia course
3) those with a family history
of BD, especially with a family history of lithium response

Lithium = bad for mixed features

Divalproex
is equally effective in those with classical and dysphoric mania.
Further, divalproex is recommended for those with:
1) multiple prior
episodes
2) predominant irritable or dysphoric mood
3) comorbid substance abuse
4) history of head trauma

Question 13

Third line treatments for depression in bipolar?

Answer 13

Aripiprazole (adj) Level 4
Armodafinil (adj) Level 4
Asenapine (adj) Level 4
Carbamazepine Level 2
Eicosapentaenoic
acid (EPA) (adj)
Level 2
Ketamine (IV) (adj) Level 3
Light therapy
+/− total sleep
deprivation (adj)
Level 3
Levothyroxine (adj) Level 3
Modafinil (adj) Level 2
N-acetylcysteine (adj) Level 3
Olanzapine Level 1
Pramipexole (adj) Level 3
Repetitive transmagnetic stimulation
(rTMS) (adj)
Level 2
SNRI/MAOI (adj) Level 2

Question 14

What has been found to be definitely not effective in treatment of depression in bipolar disorder?

Answer 14

Antidepressant monotherapy - Level 2 negative
Aripiprazole - Level 1 negative
Lamotrigine + folic acid - Level 2 negative
Mifepristone (adj) - Level 2 negative

Question 15

if you need a rapid response in bipolar depression (i.e. suicide risk, poor PO intake), how might this change your treatment?

Answer 15

quetiapine and lurasidone have separated from placebo in clinical trials at as early as week
1 -consider these.

ECT is second line but use earlier if need for rapid

probably don’t use lamotrigine bc of slow titration

Question 16

If someone has depression with anxious distress in bipolar disorder, how does this change your treatment?

Answer 16

use quetiapine
can also use lurasidone

don’t use ripseridone, divalproex, or lamotrigine - less helpful.

Question 17

if someone has depression with melancholic features in bipolar disorder what should you do?

Answer 17

no specific studies, but clinical evidence says ECT is very effective.

Question 18

if someone has depression with psychosis either mood incongruent or congruent, best treatment in bipolar?

Answer 18

no specific studies but clinical evidence says ECT and antipsychotics are highly effective for this population.

Question 19

bipolar depression with rapid cycling – treatment?

Answer 19

As described in Section 3, hypothyroidism, antidepressants and substance abuse may be associated with rapid cycling, thus making assessment of thyroid function and discontinuation of antidepressants,
drugs of abuse, stimulants, and other psychotropic agents imperative.
As there is no evidence to support any specific agent to treat acute
depression during a rapid cycling phase, appropriate pharmacotherapy
should be selected based on effectiveness in the acute and maintenance phases. Lithium, divalproex, olanzapine, and quetiapine all appear to have comparable maintenance efficacies in these patients.219
In contrast, lamotrigine did not separate from placebo in maintenance
treatment in patients with rapid cycling BDI.323 Antidepressants are
not recommended, as they have been shown to destabilize patients,
even with concurrent mood stabilizer use.

Question 20

first- and second-line treatments recommended for maintenance treatment in bipolar disorder?

Answer 20

first line
li
quetiapine
DVP
lamotrigine
asenapine
quetiapine + li/dvp
aripiprazole + li/dvp
aripiprazole

second line
olanzapine
risperidone lai
risperidone LAI (adj)
carmbamazepine
pali >6mg
lurasidone + li/dvp
ziprasidone +li/dvp

Question 21

good prognostic factors for BD according to CANMAT?

Answer 21

Factors associated with overall good prognosis of BD include:
1) good treatment adherence
2) lack of early adversity,
3) intermediate age at onset
4) good social support
5) the absence of spontaneous rapid
cycling
6) absence of features of a personality disorder