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Questions and Answers
Olanzapine is ranked 3rd for efficacy among antimanic drugs.
Olanzapine is ranked 3rd for efficacy among antimanic drugs.
True (A)
Lithium is ranked higher for acceptability than haloperidol.
Lithium is ranked higher for acceptability than haloperidol.
False (B)
Benzodiazepines can be used as an adjunct to enhance the effects of mood stabilizers.
Benzodiazepines can be used as an adjunct to enhance the effects of mood stabilizers.
True (A)
Valproate has a slower onset of action compared to lithium.
Valproate has a slower onset of action compared to lithium.
Carbamazepine is the least effective antimanic drug according to the ranking.
Carbamazepine is the least effective antimanic drug according to the ranking.
Patients not already taking mood stabilizers should begin treatment with haloperidol.
Patients not already taking mood stabilizers should begin treatment with haloperidol.
Risperidone is ranked 3rd for acceptability among antimanic drugs.
Risperidone is ranked 3rd for acceptability among antimanic drugs.
The progress of a manic episode can be evaluated solely by mental state.
The progress of a manic episode can be evaluated solely by mental state.
Lithium is equally effective in preventing both manic and depressive episodes in bipolar disorder.
Lithium is equally effective in preventing both manic and depressive episodes in bipolar disorder.
About 50% of bipolar patients treated with lithium respond well to the treatment.
About 50% of bipolar patients treated with lithium respond well to the treatment.
Valproate has been shown to have superior long-term maintenance effects compared to lithium.
Valproate has been shown to have superior long-term maintenance effects compared to lithium.
Lamotrigine has a clearer prophylactic effect against mania compared to lithium.
Lamotrigine has a clearer prophylactic effect against mania compared to lithium.
Carbamazepine is considered to be more effective than lithium for treating rapid-cycling disorders.
Carbamazepine is considered to be more effective than lithium for treating rapid-cycling disorders.
Use of lithium is associated with a significant reduction in mortality from suicide in patients with recurrent mood disorders.
Use of lithium is associated with a significant reduction in mortality from suicide in patients with recurrent mood disorders.
Patients treated with valproate reported fewer side effects compared to those on placebo, including tremors and weight gain.
Patients treated with valproate reported fewer side effects compared to those on placebo, including tremors and weight gain.
The combination of lithium and valproate has the lowest relapse rate among the treatments assessed.
The combination of lithium and valproate has the lowest relapse rate among the treatments assessed.
Lithium and valproate have significant differences in the patient dropout rate due to severe mood episodes.
Lithium and valproate have significant differences in the patient dropout rate due to severe mood episodes.
The efficacy of carbamazepine in treating bipolar disorder is well-documented with a high number of randomized controlled studies.
The efficacy of carbamazepine in treating bipolar disorder is well-documented with a high number of randomized controlled studies.
Antipsychotic drug treatment for mania should be stopped immediately to prevent relapse.
Antipsychotic drug treatment for mania should be stopped immediately to prevent relapse.
Antidepressant treatments are equally effective for both bipolar I and bipolar II depression.
Antidepressant treatments are equally effective for both bipolar I and bipolar II depression.
ECT is still widely used as the first-line treatment for mania today.
ECT is still widely used as the first-line treatment for mania today.
Short courses of ECT may help reduce symptoms enough to continue treatment with drugs.
Short courses of ECT may help reduce symptoms enough to continue treatment with drugs.
Tricyclic antidepressants do not increase the risk of manic switching in bipolar depressed patients.
Tricyclic antidepressants do not increase the risk of manic switching in bipolar depressed patients.
Recent meta-analyses suggest that there is no benefit to using conventional antidepressants in treating bipolar depression.
Recent meta-analyses suggest that there is no benefit to using conventional antidepressants in treating bipolar depression.
Careful monitoring for depressive symptoms is unnecessary in patients experiencing mania.
Careful monitoring for depressive symptoms is unnecessary in patients experiencing mania.
Lithium has been found to be more effective than quetiapine in acute bipolar depression.
Lithium has been found to be more effective than quetiapine in acute bipolar depression.
The NICE guidance suggests offering haloperidol or similar antipsychotics if a person is not taking any mood stabilizer.
The NICE guidance suggests offering haloperidol or similar antipsychotics if a person is not taking any mood stabilizer.
Atypical antipsychotic drugs like quetiapine are ineffective in treating bipolar depression.
Atypical antipsychotic drugs like quetiapine are ineffective in treating bipolar depression.
If an antipsychotic is poorly tolerated, the next step includes switching to a different antipsychotic from the same class.
If an antipsychotic is poorly tolerated, the next step includes switching to a different antipsychotic from the same class.
Lithium should be considered for addition if no improvement occurs from a maximum dose of the primary antipsychotic.
Lithium should be considered for addition if no improvement occurs from a maximum dose of the primary antipsychotic.
The risk of inducing mania is higher with selective serotonin reuptake inhibitors (SSRIs) than with tricyclic antidepressants.
The risk of inducing mania is higher with selective serotonin reuptake inhibitors (SSRIs) than with tricyclic antidepressants.
Both lamotrigine and valproate are anticipated to pose a risk of inducing mania or rapid cycling in bipolar patients.
Both lamotrigine and valproate are anticipated to pose a risk of inducing mania or rapid cycling in bipolar patients.
Continuation treatment for mania should last for a minimum of six months regardless of symptoms.
Continuation treatment for mania should last for a minimum of six months regardless of symptoms.
Withdrawal of lithium does not require caution and can be done quickly.
Withdrawal of lithium does not require caution and can be done quickly.
The number needed to treat (NNT) for antidepressants in bipolar depression is approximately six.
The number needed to treat (NNT) for antidepressants in bipolar depression is approximately six.
Depression episodes are rare during bipolar illness and are typically mild.
Depression episodes are rare during bipolar illness and are typically mild.
Venlafaxine is less likely to destabilize mood compared to SSRIs in bipolar depression treatment.
Venlafaxine is less likely to destabilize mood compared to SSRIs in bipolar depression treatment.
Research indicates that aripiprazole appears useful in treating bipolar depression.
Research indicates that aripiprazole appears useful in treating bipolar depression.
It is essential to take the patient's history solely from the patient in order to assess the severity of mania.
It is essential to take the patient's history solely from the patient in order to assess the severity of mania.
Compulsory admission is likely necessary in cases of severe mania.
Compulsory admission is likely necessary in cases of severe mania.
Development of a therapeutic alliance with the manic patient is unimportant in treatment.
Development of a therapeutic alliance with the manic patient is unimportant in treatment.
Sleep deprivation may trigger mania in susceptible individuals.
Sleep deprivation may trigger mania in susceptible individuals.
Antipsychotic drugs are typically used as primary agents to manage acute mania in the UK.
Antipsychotic drugs are typically used as primary agents to manage acute mania in the UK.
A urine screen for illegal substances is not recommended in the assessment of mania.
A urine screen for illegal substances is not recommended in the assessment of mania.
Patients usually find it easy to care for a manic individual at home for extended periods.
Patients usually find it easy to care for a manic individual at home for extended periods.
Reality-oriented psychotherapy may need to be extended to the patient’s family during treatment.
Reality-oriented psychotherapy may need to be extended to the patient’s family during treatment.
Manic patients consistently maintain self-control during medical interviews.
Manic patients consistently maintain self-control during medical interviews.
Educational sessions are important to limit the legal, financial, and occupational repercussions of mania.
Educational sessions are important to limit the legal, financial, and occupational repercussions of mania.
Psychological treatment approaches for bipolar disorder primarily focus on dietary changes.
Psychological treatment approaches for bipolar disorder primarily focus on dietary changes.
Effective psychological approaches include identifying early subjective signs of relapse.
Effective psychological approaches include identifying early subjective signs of relapse.
Psychoeducational programs have been shown to be ineffective in treating bipolar disorder.
Psychoeducational programs have been shown to be ineffective in treating bipolar disorder.
Avoidance of illegal drugs is suggested as a lifestyle change in bipolar disorder treatment.
Avoidance of illegal drugs is suggested as a lifestyle change in bipolar disorder treatment.
The lack of drug therapies makes psychological approaches the only option for treating bipolar disorder.
The lack of drug therapies makes psychological approaches the only option for treating bipolar disorder.
Discussion about medication side effects is not relevant in the management of bipolar disorder.
Discussion about medication side effects is not relevant in the management of bipolar disorder.
Patients with bipolar disorder are primarily treated with typical antipsychotic drugs to effectively manage depressive episodes.
Patients with bipolar disorder are primarily treated with typical antipsychotic drugs to effectively manage depressive episodes.
Atypical antipsychotic drugs such as olanzapine and quetiapine have been shown to prevent both depression and mania in bipolar patients.
Atypical antipsychotic drugs such as olanzapine and quetiapine have been shown to prevent both depression and mania in bipolar patients.
Cognitive behaviour therapy has not been studied in bipolar patients due to its theoretical limitations.
Cognitive behaviour therapy has not been studied in bipolar patients due to its theoretical limitations.
Family-focused therapy aims to enhance family dynamics and reduce expressed emotion, which can negatively impact the clinical course of bipolar patients.
Family-focused therapy aims to enhance family dynamics and reduce expressed emotion, which can negatively impact the clinical course of bipolar patients.
Sleep deprivation in bipolar patients is beneficial as it helps trigger episodes of mania.
Sleep deprivation in bipolar patients is beneficial as it helps trigger episodes of mania.
Group psychoeducation has proven to be effective in reducing the average number of relapses in bipolar patients over a long-term follow-up.
Group psychoeducation has proven to be effective in reducing the average number of relapses in bipolar patients over a long-term follow-up.
Interpersonal and social rhythm therapy emphasizes the need for maintaining irregular sleep-wake patterns in bipolar patients.
Interpersonal and social rhythm therapy emphasizes the need for maintaining irregular sleep-wake patterns in bipolar patients.
Structured psychotherapy is mostly directed towards patients during acute episodes of mood disturbance.
Structured psychotherapy is mostly directed towards patients during acute episodes of mood disturbance.
Lithium is the first choice of mood stabilizer in the USA.
Lithium is the first choice of mood stabilizer in the USA.
Patients with bipolar disorder often embrace long-term medication treatment with ease.
Patients with bipolar disorder often embrace long-term medication treatment with ease.
Quetiapine is effective in preventing both depression and mania.
Quetiapine is effective in preventing both depression and mania.
Regular monitoring of renal and thyroid function is unnecessary for patients taking long-term lithium.
Regular monitoring of renal and thyroid function is unnecessary for patients taking long-term lithium.
Lamotrigine is primarily effective in preventing mania rather than depression.
Lamotrigine is primarily effective in preventing mania rather than depression.
Patients may fear that medication will enhance their emotional experiences.
Patients may fear that medication will enhance their emotional experiences.
Regular clinical monitoring of physical health is stressed in current guidelines for bipolar disorder.
Regular clinical monitoring of physical health is stressed in current guidelines for bipolar disorder.
A fear of personal weakness can contribute to the reluctance to seek treatment for bipolar disorder.
A fear of personal weakness can contribute to the reluctance to seek treatment for bipolar disorder.
Antidepressant drugs are considered a first line choice for the treatment of bipolar depression.
Antidepressant drugs are considered a first line choice for the treatment of bipolar depression.
Lamotrigine is indicated as a monotherapy and can be added to ineffective quetiapine.
Lamotrigine is indicated as a monotherapy and can be added to ineffective quetiapine.
In patients not receiving mood stabilizer treatment, olanzapine can only be administered with fluoxetine.
In patients not receiving mood stabilizer treatment, olanzapine can only be administered with fluoxetine.
Valproate should be prescribed to women of childbearing age for bipolar disorder treatment.
Valproate should be prescribed to women of childbearing age for bipolar disorder treatment.
Short-term treatment with conventional antidepressants can be justified in some patients with bipolar disorder.
Short-term treatment with conventional antidepressants can be justified in some patients with bipolar disorder.
Patients taking lithium may not benefit from increasing the dose if they develop moderate or severe bipolar depression.
Patients taking lithium may not benefit from increasing the dose if they develop moderate or severe bipolar depression.
Lamotrigine can induce mania in bipolar disorder patients.
Lamotrigine can induce mania in bipolar disorder patients.
Structured psychotherapy has been extensively studied in acute bipolar depression.
Structured psychotherapy has been extensively studied in acute bipolar depression.
ECT is an option for patients with severe depressive symptoms requiring urgent treatment.
ECT is an option for patients with severe depressive symptoms requiring urgent treatment.
Long-term maintenance treatment for bipolar disorder is recommended for patients with one episode every three years.
Long-term maintenance treatment for bipolar disorder is recommended for patients with one episode every three years.
Study Notes
Medication for Bipolar Disorder
- Lithium is effective in maintenance treatment of recurrent mood disturbances in patients with bipolar disorders, with a mean relative risk of 0.65 for preventing relapses of all mood disorders.
- Lithium is effective in preventing manic relapse, but its effect in preventing depressive episodes is more equivocal.
- Predictors of a relatively poorer response to lithium maintenance treatment include rapid-cycling disorders or chronic depression, mixed affective states, alcohol and drug misuse, and mood-incongruent psychotic features.
- Valproate is increasingly used in the treatment of acute mania, with evidence of its longer-term maintenance effects showing that it is associated with a lower relapse rate compared to lithium.
Antimanic Drugs Ranked by Efficacy and Acceptability
- Haloperidol, risperidone, olanzapine, and quetiapine are ranked as the top four antimanic drugs by efficacy and acceptability.
- Lithium and aripiprazole are ranked 5th and 6th, respectively, while carbamazepine, ziprasidone, lamotrigine, and topiramate are ranked lower.
Treatment of Bipolar Depression
- Antidepressant drugs may be effective in bipolar depression, but have a number of disadvantages, including a risk of inducing mania and rapid cycling.
- Lithium may have a role in the prevention of depression in bipolar disorder, but evidence for its effectiveness in acute bipolar depression is limited.
- Atypical antipsychotic drugs such as quetiapine and lurasidone have been shown to be effective in the treatment of bipolar depression.
- Anticonvulsants such as lamotrigine and valproate may also be effective in treating bipolar depression, with lamotrigine showing benefits in a large pragmatic trial.
Psychotherapy for Bipolar Disorder
- Studies of structured psychotherapies in bipolar disorder have aimed to improve and sustain recovery, with cognitive-behavioral techniques potentially valuable in helping patients accept their illness and manage emotionally stressful situations.
- Family-based therapy has been shown to improve relationships and support for patients within their families, reducing hospitalizations and symptomatology.
- Interpersonal and social rhythm therapy has been effective in reducing relapses by maintaining regular sleep-wake routines and careful attention to sleep hygiene.
- Group psychoeducation has been shown to be beneficial in reducing relapses, with treatment adherence an important treatment goal.
Practical Management of Bipolar Disorder
- Assessment of bipolar disorder involves deciding on the diagnosis, assessing the severity of the disorder, forming an opinion about the causes, assessing the patient's social resources, and judging the effects on other people.
- Management of mania involves hospital admission, general clinical management, medication, and electroconvulsive therapy (ECT) in some cases.
- Monitoring for depressive disorder is crucial, with careful monitoring for symptoms of depressive disorder and transient but profound depressive mood change with depressive ideas.
- NICE guidance for pharmacological treatment of mania and hypomania recommends haloperidol, olanzapine, quetiapine, or risperidone as first-line treatments, with lithium or valproate added if necessary.
Continuation Treatment and Bipolar Depression
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Continuation treatment should be continued for at least 6 months, with treatment not withdrawn until the patient has been asymptomatic for at least 8 weeks.
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Be cautious when withdrawing lithium to avoid rebound mania.
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Depressive episodes are common in bipolar illness and are associated with the majority of the illness burden in both bipolar I and bipolar II disorder.
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Assessment of depression should be carried out with particular attention to suicidal thinking, which may be especially prominent after a sudden switch from mania to depression or during the course of a mixed affective state.### Treatment of Bipolar Disorder
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Psychosocial measures can enhance treatment plans and randomized trials of approaches like psychoeducational programs and family intervention.
Psychological Approaches
- Advice on lifestyle, including regular social and sleep routines, and avoidance of illegal drugs
- Identification and avoidance of relapse triggers, such as sleep deprivation and substance misuse
- Identification of early subjective signs of relapse, like feeling driven or sleeping badly, with contingency plans
- Education about medication importance, discussion of sensitivity to side effects, and active measures to reduce them
Medication
- Antidepressant drugs should not be a first-line choice for treating bipolar depression
- Optimizing blood levels of mood stabilizers like lithium and valproate is important
- Initial treatment options for patients not taking mood stabilizers include quetiapine, olanzapine and fluoxetine, or lurasidone
- Lamotrigine can be used as a monotherapy or added to ineffective quetiapine, but slow dose escalation is required to minimize the risk of rash
- Conventional antidepressants can be used, but with caution and concomitant treatment with a mood stabilizer or an antimanic dose of an atypical antipsychotic
- ECT can be considered for patients with severe depressive symptoms requiring urgent treatment or where pharmacotherapy has been ineffective
Psychotherapy
- Structured psychotherapies like cognitive behavior therapy or interpersonal therapy can be offered to patients with bipolar depression, especially those with severe symptoms or a preference for psychotherapy
Prevention of Relapse and Recurrence
- Long-term maintenance treatment with a mood stabilizer or an atypical antipsychotic drug like quetiapine should be considered for patients with two or more episodes of illness in less than 5 years
- Valproate should not be prescribed to women of childbearing age due to the risk of neurodevelopmental defects during pregnancy
NICE Guidance on Pharmacological Treatment
- Fluoxetine combined with olanzapine or quetiapine alone can be offered to patients with moderate or severe bipolar depression not taking a mood stabilizer
- Olanzapine alone or lamotrigine alone can be considered as alternative options
- Lamotrigine can be used if there is no response to fluoxetine combined with olanzapine or quetiapine
Reluctance to Treatment
- People with bipolar disorder may be reluctant to consider long-term treatment with medication due to reasons like difficulty accepting a lifelong condition, believing they can control their mood without medication, or fearing medication will blunt their emotional life
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Learn about the effectiveness of lithium in maintaining treatment of recurrent mood disturbances in patients with bipolar disorders.
