Bipolar disorder

Razan M. Sweidan
Course objectives

 To identify Bipolar disorder

 To illustrate the types and symptoms related to bipolar disorder

 To learn the drugs that are used to treat the bipolar symptom, their mechanism of action,
side effects, drug-drug interaction
 Bipolar disorder

01 definition

02 types

03 Sign and symptom

04 Treatments
Psychiatric illness
Bipolar disorder
 Bipolar disorder

Bipolar disorder is characterized by extreme mood swings. These can range from extreme highs (mania) to
extreme lows (depression). Episodes of mania and depression often last for several days or longer.

Bipolar disorder is a syndrome in which patients suffer from episodes of mania and depression

Bipolar disorder is characterized by a manic phase where the patient is highly excitable, hyperactive,
impulsive, requires little sleep, and has cognitive impairment. This manic phase is usually followed by a
depressive phase similar to major depression.
 Bipolar disorder

Mania is described as
 at least a 1-week period of a continuously elevated or irritable mood, although shorter durations of
symptoms are acceptable if the patient is hospitalized.
 In addition to elevated mood, the patient should experience at least three of the following
symptoms:
• elevated self-esteem or grandiose ideations,
• reduced need for sleep,
• pressured speech, r
• acing thoughts or flight of ideas,
• easily distracted,
• psychomotor agitation,
• and excessive involvement in high-risk activities

Hypomania has similar symptoms to that of mania; however,

Hypomania is diagnosed by an elevated mood present for at least 4 days, with at least three of the same symptoms as
described for mania. these symptoms should not interfere with social or occupational functioning and should not cause
hospitalization
 Bipolar disorder

To meet the criteria for a major depressive episode, patients should experience at least five or more persistent
symptoms for at least 2 weeks. These symptoms include
• depressed mood
• loss of interest or pleasure in activities
• change in appetite
• unintentional weight gain or loss
• insomnia or excess sedation
• psychomotor agitation or retardation
• decreased energy or fatigue
• feelings of worthlessness or inappropriate guilt
• decreased ability to concentrate
• and recurrent thoughts of suicide, death, or
suicide attempt.
 Bipolar disorder

The mixed disorder is diagnosed when the criteria for both mania and a major depressive episode are met
every day for nearly 1 week, affects social and occupational functioning, and is not caused by a general
medical condition or substance
 Bipolar disorder

bipolar disorder may be classified into bipolar I disorder, bipolar II disorder, cyclothymia, and rapid cycling.

Bipolar I disorder. Patients are classified with bipolar I disorder with a history of at least one mixed or manic
episode and at least one major depressive episode. b. Bipolar II disorder.

Patients are classified with bipolar II disorder with a history of at least one episode of hypomania and one major
depressive episode but have never experienced mania or a mixed episode
 Clinical course.
• The course of bipolar disorder is lifelong, episodic, and patient-specific

• Episodes vary in length and severity but may last from days to months if untreated.

• The duration of time between episodes varies. Commonly, 4 years or more may separate the first and second
episodes but subsequent episodes are more frequent.
 Treatment of mania and bipolar disorder

 The treatment of bipolar disorder has increased in recent years due to increased recognition
of the disorder and also an increase in the number of available medications for the treatment
of mania.

Mood stabilizers have historically been the mainstay of therapy for bipolar disorder. Agents
include lithium, valproic acid and its derivatives (divalproex sodium), and carbamazepine

A. Lithium
 Lithium salts are used acutely and prophylactically for managing bipolar patients. Lithium
is indicated for the acute and chronic treatment of mania. Lithium may also be effective in
the treatment of mixed episodes and depressive episodes

 The mechanism of action for lithium is currently unknown, although several theories exist

• Lithium can inhibit NE release and accelerate its metabolism.

 lithium has a narrow therapeutic index, with a therapeutic range of 0.5 to 1.0 mEq/L. Toxicity is associated with levels
1.5 mEq/L

 Serum concentrations may be monitored 5 days after initial therapy or changing doses. release lithium. Once a patient
is stabilized, follow-up lithium levels can occur less frequently (every 6 to 12 months

 Prior to starting lithium, baseline monitoring should include a medical history, medication history, physical
examination, basic metabolic panel, renal function panel, pregnancy test, thyroid panel, complete blood count, and
ECG

 Follow-up labs should include a renal function panel, basic metabolic panel, complete blood count, and a thyroid
function panel. These labs can occur less frequently ( every 6 to 12 months) in stabilized patients

 Patients are generally started on 300 mg two to three times daily of lithium and titrated up by 300 mg increments as
needed to achieve therapeutic effects and minimize toxicity.

 Clinical response may be seen within 1 to 2 weeks aft er lithium initiation for the treatment of acute mania. When used
in depression, responses may not occur for 6 to 8 week
 Treatment of mania and bipolar disorder

• Lithium has an absolute contraindication in patients experiencing acute renal failure or women in their first
trimester of pregnancy.

• Lithium has the following relative contraindications: renal impairment, cardiovascular disease, dehydration,
pregnancy, seizure disorder, and thyroid disease

• If toxicity occurs, lithium should be immediately discontinued, the patient should be properly hydrated,
stomach contents should be emptied with gastric lavage, and if severe toxicity occurs (level 3 mEq/L),
hemodialysis may be indicated.
 Treatment of mania and bipolar disorder

• Antidepressants should be used cautiously in patients with bipolar disorder because of the risk of inducing mania.

• When possible, patients should be receiving mood stabilizers at goal doses before initiating antidepressants and
should be cautiously monitored.

• Bupropion and paroxetine have been associated with less risk of inducing mania than other antidepressants and may
be preferable.
Bipolar disorder
 Treatment of mania and bipolar disorder

B. Other drugs:

 Several antiepileptic drugs, including carbamazepine, valproic acid, and lamotrigine are approved as mood
stabilizers for bipolar disorder.

 Other agents that may improve manic symptoms include the older (chlorpromazine and haloperidol) and
newer antipsychotics.

 All atypical antipsychotics except clozapine and iloperidone are approved for the treatment of bipolar, The atypical
antipsychotics risperidone, olanzapine, ziprasidone, aripiprazole, asenapine, cariprazine, and quetiapine are also
used for the management of mania.

 Quetiapine, lurasidone, and the combination of olanzapine and fluoxetine have been approved for bipolar
depression.
 Treatment augmentation

• Patients with no or partial response to monotherapy may receive combination therapy with two agents.
Agents that can be combined include lithium, VPA, and atypical antipsychotics.
• Atypical antipsychotics, if used, should be combined with either VPA or lithium and not combined with
another atypical antipsychotic.

• For depressive episodes, lamotrigine may be combined with another mood stabilizer as first-line
therapy, and the olanzapine–fluoxetine
 Treatment options in pregnancy

• .Multiple agents used in the treatment of bipolar disorder have been associated with birth defects.
• (1) Lithium, VPA, and CBZ are pregnancy category D medications.
• (2) Lithium has been associated with birth defects, primarily in the first trimester.
• (3) VPA and CBZ should be used during pregnancy only if the benefits outweigh the risks. If the
decision is made to use these medications during pregnancy, folic acid should be given to minimize the
risk of defects.
• (4) Lamotrigine and oxcarbazepine are pregnancy category C medications
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