Bipolar Face: Most people with bipolar illness experience severe, persistent depression throughout their lives. Actually, they will spend more time in either a depressed or euthymic state than in mania, hypomania, or mixed mood states.

Mixed episodes, which can occur in as many as 40% of patients and provide a therapeutic problem, frequently necessitate augmentation strategies. Due to the scarcity of research on bipolar depression, people with a history of mixed episodes or rapid cycling are frequently excluded from clinical trials, which restricts the evidence supporting treatment.

Face Review for Bipolar Disorder

Previously known as manic-depression, bipolar disorder (BPD) is marked by repeated shifts in mood, energy, and conduct, which negatively impact overall functioning. This complicated illness, which affects around 3.8% of the population, is influenced by both the environment and genetics. Because the clinical presentation is so varied, a comprehensive symptom history is crucial for diagnosis.

There are four types of illness episodes in BPD: hypomania, depression, mania, and mixed (when symptoms of mania and depression occur at the same time). Hypomania (bipolar II illness) or mania (bipolar I disorder) is the central symptom of BPD, and only one occurrence is necessary for a diagnosis.

An ongoing state of elevated, expansive, or irritable mood that lasts for at least a week or necessitates hospitalization is what is meant by the word “mania.” The start is often sudden, and the symptoms worsen over the course of weeks or months. Increased goal-directed activity, reckless conduct, distractibility, flight of ideas, pressured speech, less need for sleep, and grandiosity are all symptoms. Hypomania is less severe, lasting for at least four days, and does not significantly impair functioning.

Parameters for Monitoring Antipsychotics

• Lipid profile for fasting
• Hemoglobin A1C/Fasting blood glucose
• The Body Mass Index
• Diabetes runs in the family
• Waist size
• Blood pressure
• Weight

Depression in Bipolar Disorder

In addition to using quetiapine or olanzapine/fluoxetine therapy, some evidence backs the use of an antidepressant if the patient is on an antipsychotic or mood stabilizer. According to reports, the chance of experiencing a manic episode is as high as 40%.

Bipolar Treatment Options

Clinicians can use a number of published recommendations to help them choose the right course of therapy. The FDA has authorized the use of lithium, valproate, and carbamazepine as treatment alternatives for severe mania/mixed episodes connected with bipolar I disorder (see the online table at BipolarDisorders.com for details). Because of its hematologic safety issues, carbamazepine is not regarded as a first-line medication.

Lamotrigine (Lamictal) is exclusively used for the upkeep of BPD therapy. Due to the need to titrate lamotrigine gradually (target dose 200 mg/day) in order to reduce the chance of Stevens-Johnson rash, it is not a good choice for emergency treatment. Although there is still little evidence, lamotrigine is believed to play a role in the depression associated with BPD.

The cornerstone for attaining and maintaining remission is still ongoing treatment with a mood stabilizer. Many patients find that a single mood stabilizer is insufficient, since monotherapy response rates can be as low as 30%.

Second-Generation Antipsychotics

Second-generation antipsychotics (SGAs), such risperidone [Risperdal], have enhanced tolerability over first-generation antipsychotics (FGAs) such haloperidol [Haldol]. SGAs produce less hyperprolactinemia and fewer extrapyramidal side effects than haloperidol and other FGAs at conventional dosages. Because few studies explicitly compare any SGA to conventional mood stabilizers, it is impossible to conclude that any therapy is better at treating BPD.

In bipolar I illness, risperidone has shown effectiveness in treating acute mania or mixed episodes and can be administered as monotherapy or with lithium or valproate. The dosage range is 2 to 6 mg/day. Adverse effects include drowsiness, worry, vertigo, and extrapyramidal symptoms that are dose-dependent. With this SGA, hyperprolactinemia is at its highest, even if it doesn’t happen frequently. You can also experience metabolic problems and weight gain.

The treatment of both acute and mixed manic episodes related to bipolar I illness and maintenance therapy is indicated for olanzapine (Zyprexa). It might be given alone or in combination with valproate or lithium. Weight gain, elevated cholesterol levels, other metabolic alterations, and drowsiness are all common side effects. In BPD, the usual beginning dosage is 15 mg taken orally once a day at bedtime, which is titrated up to 20 mg as necessary. Depressive episodes linked to BPD are treated with a combination of fluoxetine and olanzapine, with the key benefit being that there is no evidence of an elevated risk of mania.

In a similar vein, quetiapine (Seroquel) is recommended for acute manic episodes, either alone or with lithium or valproate. Additionally, quetiapine is permitted for the treatment of depressive episodes linked to BPD. Common adverse effects of quetiapine include dry mouth, headache, sedation, and weight gain. The recommended dose for depressive episodes is 300 mg, while the dose for mania can be up to 800 mg per day.

Ziprasidone (Geodon) is yet another alternative for individuals suffering from severe mania or mixed episodes linked to BPD. The initial dose for mania is 80 mg per day, divided into two doses, which can be quickly increased to 160 mg per day. Taking at least 500 calories along with it increases absorption by a factor of two. Drowsiness, headache, and dizziness are the most frequently reported negative effects.

Despite the bad press ziprasidone has received for extending QTc, this seldom has any clinical relevance. Electrocardiogram is not routinely used for monitoring because its usefulness has not been established. However, its usage is advised in individuals with cardiovascular risk factors or in those who are on medications known to prolong the QTc interval.

The use of aripiprazole (Abilify) is indicated for the treatment of acute manic or mixed episodes and for maintenance therapy in BPD. It is also approved for usage as a backup therapy when lithium or valproate monotherapy is ineffective.

Although paliperidone (Invega) is sometimes used in severe instances, the danger of agranulocytosis with clozapine has prevented extensive research into its use as a BPD treatment.

Treatment for Maintenance

People with BPD frequently need ongoing medication therapy because it’s a chronic fluctuating disease. Even with continuous pharmacological treatment, the 5-year relapse rate is 73%, and if wanted, the dosage(s) can be reduced once remission is attained.

The Bottom Line

With this patient group, getting an accurate medication history is crucial in order to help direct therapy selection or identify an underlying cause. Pharmacists are essential in maximizing a patient’s BPD treatment.

For individuals with borderline personality disorder, educating the patient is crucial. Teaching patients to recognize the early signs of depression and mania might enable them to seek help before their condition gets severe. Giving the patient the information they need to avoid or manage any possible side effects increases medication therapy compliance.