New treatment options for use in bipolar mania

1
New treatment options for use in bipolar mania

• Dr C Verster
• Dept Psychiatry
• Uuniversity of Stellenbosch

2
The Mind is its own place and in itself can
make a Heaven a Hell, a Hell a Heaven
John Milton
3
Normal Mood
HIGH
LOW
4
Unipolar Depression(The Common Garden Variety)
HIGH
LOW
5
Bipolar (II) Disorder
HIGH
LOW
6
Bipolar (I) Disorder
MANIA
HIGH
LOW
7
Trying to describe bipolar disorder
The cogs of my mind are not all working together
8
Case study

• 32yr old female patient (Pt AB)
• Going through divorce 1 child (4yrs old)
• Working as secretary
• Known with diagnosis of Bipolar I Disorder
• On medication Lithium 750mg at night
• Progressively less sleep x 2 weeks
• Irritability

9

• On day of evaluation
• Grandiose
• Refusing medication
• Refusing to go to work
• Dont need psychiatrist
• Praying to random people in the street
• Giving away money
• Family at wits end
• This is the 3rd such episode in 18 months
• She will lose her child
• Employer is fed-up

10
What now?

• Admission
• She refuses
• Family unable to deal with her
• Irresponsible behaviour (childs safety)
• Danger to self / reputation

11
Approach to Patient with acute manic relapse

• Admission
• Sedation
• Stabilization
• Prevention of relapse

12
Admission

• MHCA
• Voluntary
• Involuntary

Pt AB Needs admission ?Involuntary -
certified
13
Sedation

• Benzodiazepines
• Oral/Sublingual
• IMI/IVI
• Antipsychotics (IMI)
• Zuclopenthixol decanoate
• Olanzapine IMI
• Ziprasidone IMI
• Haloperidol IMI
• Clothiapine IMI

Pt AB Lorazepam IMI OR Olanzepine/
Ziprasidone
IMI (NB Avoid IMI Benzo/Olanzepine combination)
14
Stabilization

• Behaviour / Sleep / Psychosis / Mood

15
What is a mood stabilizer?
16

• Bowden (2002) A drug that
• benefits at least one primary aspect of bipolar
  illness
• is effective in both acute and maintenance phases
• does not worsen any aspect of the illness
• Traditional mood stabilizers
• lithium, valproate, carbamazepine (recently
  lamotrigine)
• Stahl 2010
• Includes atypical antipsychotics
• Antipsychotics always used in mania
• Atypicals also have effect on bipolar depression
• (Antidepressants mood destabilizers)

17
FDA Approved Bipolar Treatment Regimens
Generic Name Trade Name Manic Mixed Maintenance Depression
Valproate Depakote(Epilim) X
Carbamazepine extended release Equetro (Tegretol) X X
Lamotrigine Lamictal (Lamictin) X
Lithium X X
Aripiprazole Abilify X X X
Ziprasidone Geodon X X
Risperidone Risperdal X X
Asenapine Saphris (N/A) X X
Quetiapine Seroquel X X
Chlorpromazine Thorazine (Largactil) X
Olanzapine Zyprexa X X X
Olanzapine/fluoxetine combination Symbyax (N/A) X
Gutman DA, Nemeroff C. Atypical Antipsychotics in
Bipolar Disorder. Medscape. Available at
http//www.medscape.com/viewarticle/554128.
Accessed June 27, 2007
18
2011 (Sachs et al J Clin Psych)

• Category A evidence (Double blind placebo
  controlled trials adequate sample)
• Efficacy for acute mania
• Lithium
• Valproate
• Carbamazepine
• Olanzapine
• Risperidone
• Ziprasidone
• Haloperidol
• Quetiapine
• Aripirazole
• Paliperidone
• Asenapine

19
Lithium

• Used since the 1950s
• Effective mood stabilizer
• Narrow therapeutic range
• (Blood levels monitored)
• Toxicity
• Acute
• Chronic
• Thyroid
• Kidneys

Pt AB No use as sedative Why did she
relapse? Why did she refuse
medication? May still be of use in long term
management
20
Anti Epileptics

• Carbamazepine / Valproate / Lamotrigine

Pt AB Limited efficacy in mania Side effect
profile Pregnancy?
21
Antipsychotics

• Typicals
• Haloperidol
• Zuclopenthixol
• Chlorpromazine
• Effective, but poor side-effect profile

22
Atypical antipsychotics
23
Why maintenance therapy?

• Prevention of relapse
• 80 relapse within 1 year without medication
• 20 relapse within 1 year with medication
• In practice 50 relapse within 1st year
• Because of poor treatment adherence

24
Cost of relapse

• Hospitalization (may be for weeks)
• R700-2000 per day
• PMB
• Social occupational consequences

25
Reason for poor adherence

• Poor psychoeducation
• Lack of insight
• Poor understanding of illness
• Side-effects
• Cost factors
• Social pressure/stigma
• Dosage interval / amount of tablets
• Religious / cultural factors
• Availability of medication
• Substance abuse
• Severity of illness

26
Stabilization/Maintenance
Evidence EPS Prol. Sed. Weight Gain TD NMS CVS Risk Other Cost
Typicals (?potency) ()
Typicals (?potency)
Amisulpiride -
Aripiprazole / (Akathisia) - - ?-
Clozapine - - Agranulocyt. Miocarditis Hypersaliv. ()
Olanzapine - Rash
Quetiapine - - ()
Risperidone/ Paliperidone
Ziprasidone - Food effect
Stahl, SM. The Prescribers Guide 3rd ed 2009
27
Pt AB

• Stabilize!
• Psychoeducation also family!
• Lithium levels ? discontinue or not?
• Monotherapy or combination?
• Illness profile
• Sleeping pattern
• Depressive episodes?
• Cost factors

28
NB Bipolar Disorder should be managed by a
psychiatrist