Bipolar Disorder

Posted by Carla Rothaus

Are antidepressants typically used for bipolar depression?

The main characteristic separating bipolar disorders from other affective disorders is the presence of recurring manic or hypomanic episodes that may alternate with depressive episodes. Read the NEJM Review Article here.

Clinical Pearls

Q: How are bipolar I disorder and bipolar II disorder defined?

A: Bipolar I disorder is defined by the presence of overt manic episodes with a range of manifestations, including overconfidence, grandiosity, talkativeness, extreme disinhibition, irritability, decreased need for sleep, and highly elevated mood. Psychotic symptoms such as delusions and hallucinations occur in up to 75% of manic episodes, and episodes of any severity may compromise psychosocial functioning to the point that hospitalization is required. Bipolar II disorder is characterized mainly by episodes of depression but alternating with hypomania rather than mania.

Q: What are some of the features of bipolar disorder?

A: The onset of bipolar disorder typically occurs at around the age of 20 years. An earlier onset is often associated with a poorer prognosis, longer treatment delays, more severe depressive episodes, and higher prevalences of concurrent anxiety and substance use disorders. The first episode of bipolar disorder is usually depressive, and for most persons with either bipolar I or bipolar II disorder, depressive episodes last considerably longer than manic or hypomanic episodes throughout the course of illness. For this reason, bipolar disorder is often misclassified as major depressive disorder.

Morning Report Questions

Q: What therapies are used for acute mania and hypomania?

A: Pharmacologic treatment with antipsychotic agents or mood stabilizers is the mainstay of treatment for acute mania and hypomania. For patients with acute mania, if there is no response to a medication after 1 to 2 weeks, a different medication may be considered. The combination of an antipsychotic agent and a mood stabilizer, especially for severe mania, appears to be more efficacious than either medication alone. In a trial involving children, the antipsychotic agent risperidone was more effective than lithium or divalproex sodium. However, the higher efficacy of such treatment approaches must be weighed against their metabolic adverse effects, especially with atypical (second-generation) antipsychotic agents (e.g., risperidone) in both children and adults. Other antipsychotic agents have been effective in the management of acute mania — for example, haloperidol and paliperidone. However, these drugs have not been approved by the FDA for this indication. Bifrontal electroconvulsive therapy (ECT), either as monotherapy or as an adjunctive treatment, has been reported to be effective for patients with refractory mania and aggressive behavior or psychotic symptoms.

Q: Are antidepressants typically used for bipolar depression?

A: Even though patients with bipolar disorder are depressed more of the time than they are manic or hypomanic, few studies have focused on the treatment of depression in this population, and only four drugs are currently approved by the FDA for the management of acute episodes of depression in patients with a bipolar disorder. There is controversy regarding the efficacy and risks of antidepressant agents in managing bipolar depression. Treatment with antidepressants may carry a risk of switches to hypomania or mania during treatment and acceleration of the cycling between them. In view of these uncertainties, an expert panel concluded that evidence for the efficacy of antidepressants in the treatment of bipolar depression is limited but that individual patients may benefit from these drugs. Also, the risk of switches to mania appeared to be higher among patients with bipolar I disorder than among those with bipolar II disorder. Therefore, antidepressants are generally avoided in patients with type I bipolar disorder, but when necessary, they may be concomitantly prescribed with mood-stabilizing agents.

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