Transcript New treatment options for use in bipolar mania

New treatment options
for use in bipolar mania
Dr C Verster
Dept Psychiatry
Uuniversity of Stellenbosch
The Mind is its own place
and in itself can make
a Heaven a Hell,
a Hell a Heaven
John Milton
Normal Mood
HIGH
LOW
Unipolar Depression
(The Common Garden Variety)
HIGH
LOW
Bipolar (II) Disorder
HIGH
LOW
Bipolar (I) Disorder
MANIA
HIGH
LOW
Trying to describe bipolar disorder
“The cogs of my mind are
not all working together”
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++
► On






day of evaluation:
Grandiose
Refusing medication
Refusing to go to work
“Don’t 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”
What now?
► Admission

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
She refuses
Family unable to deal with her
Irresponsible behaviour (child’s safety)
Danger to self / reputation
Approach to Patient with acute manic
relapse
► Admission
► Sedation
► Stabilization
► Prevention
of relapse
Admission
► MHCA
 Voluntary
 Involuntary
Pt AB:
Needs admission
?Involuntary
- certified
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)
Stabilization
► Behaviour
/ Sleep / Psychosis / Mood
What is a mood stabilizer?
► 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,
► Stahl
valproate, carbamazepine (recently: lamotrigine)
2010:
 Includes atypical antipsychotics
► Antipsychotics
always used in mania
► Atypicals also have effect on bipolar depression
 (Antidepressants = mood destabilizers)
FDA Approved Bipolar Treatment Regimens:
Generic Name
Trade Name
Manic
Depakote(Epili
m)
Carbamazepine Equetro
extended release (Tegretol)
X
Valproate
Lamotrigine
Lithium
Aripiprazole
Mixed
X
Depression
X
Lamictal
(Lamictin)
X
Abilify
X
X
X
Ziprasidone
Geodon
X
X
Risperidone
Risperdal
X
X
Asenapine
Saphris (N/A)
X
X
Quetiapine
Seroquel
X
Chlorpromazine
Thorazine
(Largactil)
Zyprexa
X
Olanzapine
Maintenance
X
X
X
X
X
X
Olanzapine/fluox Symbyax (N/A)
etine
Gutman DA, Nemeroff C. Atypical Antipsychotics in Bipolar Disorder. Medscape. Available at
combination
http://www.medscape.com/viewarticle/554128. Accessed June 27, 2007
X
2011
►
►
(Sachs et al; J Clin Psych)
Category A evidence (Double blind placebo controlled
trials; adequate sample)
Efficacy for acute mania:
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









Lithium
Valproate
Carbamazepine
Olanzapine
Risperidone
Ziprasidone
Haloperidol
Quetiapine
Aripirazole
Paliperidone
Asenapine
Lithium
► Used
since the 1950’s
► Effective mood stabilizer
► Narrow therapeutic range
(Blood levels monitored)
Pt AB:
► Toxicity
 Acute
 Chronic
►Thyroid
►Kidneys
No use as sedative
Why did she relapse?
Why did she refuse
medication?
May still be of use in long
term management
Anti Epileptics
► Carbamazepine
/ Valproate / Lamotrigine
Pt AB:
Limited efficacy in mania
Side effect profile
Pregnancy?
Antipsychotics
► Typicals
 Haloperidol
 Zuclopenthixol
 Chlorpromazine
► Effective,
but poor side-effect profile
Atypical antipsychotics
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
Cost of relapse
► Hospitalization
(may be for weeks)
 R700-2000 per day
 PMB
► Social
& occupational consequences
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
Stabilization/Maintenance
Evide
nce
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 Prescriber’s Guide 3rd ed; 2009
++++
Pt AB
► Stabilize!
► Psychoeducation
– also family!
► Lithium levels → discontinue or not?
► Monotherapy or combination?
► Illness profile
 Sleeping pattern
 Depressive episodes?
 Cost factors
NB Bipolar Disorder should be
managed by a psychiatrist