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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.

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New treatment options for use in bipolar mania

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  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 • “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”

  10. What now? • Admission • She refuses • Family unable to deal with her • Irresponsible behaviour (child’s safety) • Danger to self / reputation

  11. Approach to Patient with acute manic relapse • Admission • Sedation • Stabilization • Prevention of relapse

  12. Admission Pt AB: Needs admission ?Involuntary - certified • MHCA • Voluntary • Involuntary

  13. Sedation Pt AB: Lorazepam IMI OR Olanzepine/ Ziprasidone IMI (NB Avoid IMI Benzo/Olanzepine combination) • Benzodiazepines • Oral/Sublingual • IMI/IVI • Antipsychotics (IMI) • Zuclopenthixol decanoate • Olanzapine IMI • Ziprasidone IMI • Haloperidol IMI • Clothiapine IMI

  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: 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 Pt AB: No use as sedative Why did she relapse? Why did she refuse medication? May still be of use in long term management • Used since the 1950’s • Effective mood stabilizer • Narrow therapeutic range (Blood levels monitored) • Toxicity • Acute • Chronic • Thyroid • Kidneys

  20. Anti Epileptics Pt AB: Limited efficacy in mania Side effect profile Pregnancy? • Carbamazepine / Valproate / Lamotrigine

  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 Stahl, SM. The Prescriber’s 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

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