Special Considerations For Using Lithium In Older Age
It is recommended that therapeutic lithium levels should be lower in patients with BD and older age . Dehydration is common in older patients and should be prevented, particularly if lithium is prescribed. Special attention should be paid, if other substances are prescribed that carry a risk of increasing lithium blood levels. Medications that should be prescribed carefully under these circumstances are diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers , but also non-steroidal anti-inflammatory drugs . Lithium blood levels and renal parameters should be checked regularly, especially at the beginning of the treatment .
Comprehensive Treatment For Bipolar Disorder
A comprehensive treatment plan for bipolar disorder aims to relieve symptoms, restore your ability to function, fix problems the illness has caused at home and at work, and reduce the likelihood of recurrence.
A comprehensive bipolar treatment plan involves:
Medication. Medication is the cornerstone of bipolar disorder treatment. Taking a mood stabilizing medication can help minimize the highs and lows of bipolar disorder and keep symptoms under control.
Psychotherapy. Therapy is essential for dealing with bipolar disorder and the problems it has caused in your life. Working with a therapist, you can learn how to cope with difficult or uncomfortable feelings, repair your relationships, manage stress, and regulate your mood.
Education. Managing symptoms and preventing complications begins with a thorough knowledge of your illness. The more you and your loved ones know about bipolar disorder, the better able youll be able to avoid problems and deal with setbacks.
Lifestyle management. By carefully regulating your lifestyle, you can keep symptoms and mood episodes to a minimum. This involves maintaining a regular sleep schedule, avoiding alcohol and drugs, eating a mood-boosting diet, following a consistent exercise program, minimizing stress, and keeping your sunlight exposure stable year-round.
Criteria For Considering Studies For This Review
Types of studies
We will include individually randomized and clusterrandomized controlled trials. We will also include studies employing a crossover design using only data from the first active treatment . We will include studies published as full texts, studies published only as a summary and unpublished data.
Types of participants
We will include people with bipolar I or II disorder in remission, with a diagnosis based on the International Classification of Diseases 11th Revision coding system , or the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition tool . Study participants will be aged 18 years or older of either gender with concurrent primary diagnosis of Axis I or Axis II disorder. We will include participants with any comorbidities except for those with dementia and personality disorder or cyclothymia, which is defined as a disorder not meeting the requirements to be classified as a major episode of hypomanic and depressive state.
Types of interventions
We will include trials comparing lamotrigine with usual care, placebo or no treatment; the daily dosage of lamotrigine maintenance treatment will be 100 mg to 500 mg with a treatment duration of more than 12 weeks. We will investigate the following comparisons:
Types of outcome measures
-
Withdrawal from treatment due to any reason:
-
shortterm, up to 12 weeks after initiating the intervention;
-
longterm, six and 12 months after initiating the intervention.
Any reported adverse effects:
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Where Do I Start
;If you think you might have bipolar disorder or are unhappy with your medication, talk to your doctor as soon as you can. Write down a list of questions, and dont be afraid to share your concerns about side effects or past experiences. If youre currently experiencing a manic or depressive episode, you may need to consult with your doctor at least once a week to assess the effects of the medication. If you are feeling suicidal or experiencing psychotic symptoms, you can go to the hospital or call a loved one for help. You can also call the National Suicide Prevention Lifeline at 1-800-273-TALK or their TTY number at 1-800-799-4TTY .
The more information you give your doctor, the better they can help you find the right treatment for your bipolar disorder. What steps can you take today to take the best care of your mind, mood, and body?
Lithium In Maintenance Treatment
Preventing new episodes in BD is essential with regard to quality of life, participation in society and preventing long-term disability. Lithium remains the gold standard in achieving this goal. It is effective in both type I and type II BD ). Only for lithium, randomized controlled trials without an enriched design, favoring the substance to be investigated, have been performed . Several meta-analyses of randomized placebo-controlled, long-term trials could verify that lithium significantly reduces the risk of new episodes compared to placebo ). A Cochrane review found the risk of any relapse to be 36% for lithium and 61% for Placebo over the course of 1 year, corresponding to an absolute risk reduction of 25% . Kessing et;al. as well as Hayes et;al. found lithium monotherapy to be superior to monotherapy with other maintenance mood stabilizers in real life conditions . This is reflected by its status as the first-line drug in many international guidelines . For optimal efficacy in long-term treatment of BD, target serum levels should generally be around 0.60.8 mmol/L, while specific treatment situations and patients may require slightly higher or lower lithium levels .
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The Atypical Antipsychotics Are The Evidence
Dr. Ellen Leibenluft
In terms of treating bipolar disorder in children, the bulk of the evidence that we have is for medications called atypical antipsychotics, including risperidone, seroquel, aripiprazole, olanzapine, and others. And there are a number of such medications where there have been good studies, so-called double-blind, placebo-controlled studies, which show that these medications work, particularly for mania. Almost all of the trials focus on the manic side, and indeed some of these medications do have FDA indications for use in children, for mania.
Other medications that are used are the so-called mood stabilizers, such as lithium and valproate. There is some evidence that children with bipolar disorder may be somewhat less likely to respond to those medications than do the adults with bipolar disorder, although this is an area that certainly needs a lot more work.
One problem of course is that all of these medications have side effects, and the atypical antipsychotic medications in particular are often associated with weight gain and with children beginning to have difficulty with their so-called lipid profiles, this is called the metabolic syndrome, and we are concerned about long-term consequences. So youre always balancing whats effective versus the side-effect profile, trying to get as much effectiveness as you can and as few side effects as you can, and its really a very individualized kind of decision.
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The Importance Of Therapy For Bipolar Disorder
Research indicates that people who take medications for bipolar disorder are more likely to get better faster and stay well if they also receive therapy. Therapy can teach you how to deal with problems your symptoms are causing, including relationship, work, and self-esteem issues. Therapy will also address any other problems youre struggling with, such as substance abuse or anxiety.
Three types of therapy are especially helpful in the treatment of bipolar disorder:
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Treatment Of Bipolar Depression
The treatment of bipolar depression is a major challenge, with few treatments of proven efficacy and, in particular, substantial controversy about the role of antidepressant drugs. Authors of guidelines and consensus statements on this topic often ponder why antidepressants are so commonly used despite the scarce evidence for efficacy. Until recently, after the work of Emil Kraepelin, bipolar depressive episodes were deemed phenomenologically and biologically similar to unipolar depressive episodes. Even as late as the 1990s, inclusion and exclusion criteria in clinical trials of antidepressants in patients with depressive disorder did not usually either select or stratify according to polarity. Earlier trials suggested that when given with antimanic treatment, selective serotonin reuptake inhibitor antidepressants were more effective and no more likely to induce mania than placebo, and were less likely to induce mania than tricyclic antidepressants. In 2007, a large trial found no benefit associated with the addition of paroxetine or bupropion to a mood stabiliser; another reported that paroxetine was no better at achieving a durable recovery than placebo.
Whats The Standard Treatment For Bipolar Depression
Mood-stabilizing medication works on improving social interactions, mood, and behavior. It is recommended for both treatment and prevention of bipolar mood states that swing from the lows of depression to the highs of hypomania or mania. According to the American Psychiatric Association , lithium, lamotrigine, valproate, carbamazepine, and most atypical antipsychotic medications are approved by the FDA for treating one phases of bipolar disorder.
In some patients with bipolar disorder, a mood stabilizer may be all thats needed to modulate the depressed mood. However, in bipolar patients who do not respond to one mood stabilizer, another mood stabilizer or an atypical antipsychotic is sometimes added to the treatment regimen.
Some commonly prescribed antipsychotics include:
- Olanzapine
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Prescribing For Bipolar Disorder
Discrepancies remain with recommendations made by the PAPHSS and other guidelines for bipolar depression. The differences are largely due to the PAPHSS emphasis on long-term adverse effects associated with potential treatments. When providing recommendations, other guidelines do not weigh adverse effects heavily in making their recommendations.
For example, here is a brief look at other clinical practice guidelines for treating bipolar disorder:
- The Canadian Network of Mood and Anxiety Treatments and International Society for Bipolar Disorders 2018 guideline update recommends quetiapine, lurasidone plus lithium or divalproex, lithium, lamotrigine, lurasidone, or adjunctive lamotrigine as first-line therapies for bipolar I.21
- The International College of Neuro-Psychopharmacology 2016 treatment Guidelines for Bipolar Disorder in Adults recommends lurasidone and quetiapine as first-line options. They note fluoxetine, escitalopram, olanzapine, and OFC as second-line recommendations with lithium recommended only after other options have failed.22
Why Does How Long You Try A Bipolar Medication Matter
As I have said, not trying a bipolar medication long enough will make you cross it off the list of possibilities prematurely, and you really don’t want to do that. If that’s the one medication that works for you, and you aborted the trial and never found it, that’s a very bad outcome.
Because while for some people, multiple medications may work, some of us aren’t that lucky. Some of us are delicate little flowers that can only be touched by exactly the right medication at the right time.
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How Is Bipolar Disorder Treated
Bipolar disorder can be treated. For best results, medication needs to be combined with therapy sessions and the instigation of good routines.
The most effective treatment for bipolar disorder is a mood stabilizing agent. These medications even out the troughs and the peaks of mood swings to keep you on a more even keel. Other treatments may include antipsychotics or antidepressants.
Medications should be combined with nonpharmacological treatments, such as:
- Cognitive-behavioral therapy: This looks into any negative thought patterns you may have and challenges them in order to change your behavior.
- Interpersonal and social rhythm therapy: This aims to improve disruptions to your biological or social rhythms .
- Family focused therapy: This involves your family in your treatment, educating them and allowing them to support you fully.
Medication Treatment For Bipolar Disorder
Most people with bipolar disorder need medication in order to keep their symptoms under control. When medication is continued on a long-term basis, it can reduce the frequency and severity of bipolar mood episodes, and sometimes prevent them entirely. If you have been diagnosed with bipolar disorder, you and your doctor will work together to find the right drug or combination of drugs for your needs. Because everyone responds to medication differently, you may have to try several different medications before you find one that relieves your symptoms.
Check in frequently with your doctor. Its important to have regular blood tests to make sure that your medication levels are in the therapeutic range. Getting the dose right is a delicate balancing act. Close monitoring by your doctor will help keep you safe and symptom-free.
Continue taking your medication, even if your mood is stable. Dont stop taking your medication as soon as you start to feel better. Most people need to take medication long-term in order to avoid relapse.
Dont expect medication to fix all your problems. Bipolar disorder medication can help reduce the symptoms of mania and depression, but in order to feel your best, its important to lead a lifestyle that supports wellness. This includes surrounding yourself with supportive people, getting therapy, and getting plenty of rest.
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Management Of Bipolar Disorder
KIM S. GRISWOLD, M.D., M.P.H., and LINDA F. PESSAR, M.D., State University of New York at Buffalo, Buffalo, New York
Am Fam Physician.;2000;Sep;15;62:1343-1353.
; See related patient information handout on bipolar disorder, written by the authors of this article.
;This article exemplifies the AAFP 2000 Annual Clinical Focus on mental health.
Bipolar disorder most commonly is diagnosed in persons between 18 and 24 years of age. The clinical presentations of this disorder are broad and include mania, hypomania and psychosis. Frequently associated comorbid conditions include substance abuse and anxiety disorders. Patients with acute mania must be evaluated urgently. Effective mood stabilizers include lithium, valproic acid and carbamazepine. A comprehensive management program, including collaboration between the patient’s family physician and psychiatrist, should be implemented to optimize medical care.
Bipolar disorder is characterized by variations in mood, from elation and/or irritability to depression. This disorder can cause major disruptions in family, social and occupational life. Bipolar I disorder is defined as episodes of full mania alternating with episodes of major depression. Patients with mania often exhibit disregard for danger and engage in high-risk behaviors such as promiscuous sexual activity, increased spending, violence, substance abuse and driving while intoxicated.
Criteria for Major Depressive Episode and Manic Episode
Major depressive episode
Family And Psychosocial Issues
Significant issues for the patient and family members include the stigma that is frequently associated with mental illness and the need for support and education. Because patients with bipolar disorder lose judgment early in the course of the illness and often engage in high-risk behavior, family members may be interacting with the legal system, the police and the health care system simultaneously. Guilt, anger, grief and ambivalence are frequent feelings among family members as they cope with the difficulties.
Family members must be educated about possible relapses, what to look for and how to handle different situations. The recklessness that accompanies mania can have devastating consequencesincluding sexually transmitted diseases, financial ruin, traumatic injuries and accidents. Risk-taking causes significant distress to patients and families, and such behavior is a problem for which family physicians, psychiatrists and mental health professionals can intervene with appropriate medical, preventive, educational and social strategies .23 Initial intervention includes education for the patient and family, including informational pamphlets, videos and involvement in support and patient advocacy groups.
Psychosocial Issues to Address in the Acute and Maintenance Phases of Bipolar Disorder
Acute phase
Adapted with permission from Steering Committee. Treatment of bipolar disorder. The Expert Consensus Guideline Series. J Clin Psychiatry 1996;57:388.
Acute phase
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Dosing Strategies In Paediatric Bd
The elimination half-time of lithium is significantly shorter and the clearance of lithium significantly higher in paediatric patients. Therefore, Landersdorfer et;al. recommend a twice-daily dosing of lithium to achieve acceptable blood concentrations. Data are missing for once-daily dosing of lithium in paediatric BD and is thus not recommended.
To summarize, lithium is an effective treatment strategy in the treatment of paediatric BD in different phases of the disease, in mixed and manic episodes and in the maintenance phase.
Effective Personalized Strategies For Treating Bipolar Disorder
Stephen V. Sobel, MDPsychiatric Times
Effective personalized treatment recognizes bipolar disorder as a biopsychosocial disorder, but mood-stabilizing medications are the backbone of treatment. These medications fall into 3 categories: lithium, antikindling/antiepileptic agents, and second-generation antipsychotics.
Bipolar disorder causes havoc in patients lives. Even in the best of circumstances, successful treatment is challenging. Treatment targets constantly shift; patients are frequently nonadherent; and comorbidity is the rule, not the exception. Diagnosis of bipolar disorder is often difficult. Comorbidities need to be identified and addressed if treatment is to be effective.
The importance of an accurate diagnosis
With apologies to Charles Dickens, bipolar disorder is often experienced as the best of times and the worst of times. This polarity often causes bipolar disorder to be undiagnosed, overdiagnosed, or misdiagnosed. Bipolar disorder is associated with a significantly elevated risk of suicide. Moreover, bipolar patients often use highly lethal means for suicide.1 Contributing factors include early age at disease onset, the high number of depressive episodes, comorbid alcohol abuse, a history of antidepressant-induced mania, and traits of hostility and impulsivity.
A moving target needs moving treatment
TABLE
Factors that suggest bipolar depression rather than unipolar depression
The best treatment is prevention
The best mood stabilizer
Drug interactions
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Common Bd Medications And Their Side Effects
Many people with BD take more than one medication at a time, or transition from one drug to another. Lithium, for example, is a commonly prescribed mood stabilizer, but it doesnt work right away. Doctors may suggest taking an antipsychotic medication for an acute manic episode to give lithium time to do its job.
Another example is antidepressants. Clinicians generally only recommend people with BD take antidepressants along with a mood stabilizer or antimanic drug to avoid the risk the antidepressant might trigger an acute manic episode.
The most common medications for BD, used alone or in combination, include:
- Mood stabilizers. These include lithium, divalproex/valproic acid, and carbamazepine.
- Atypical antipsychotics. These include aripiprazole, asenapine, cariprazine, lurasidone, paliperidone, quetiapine, risperidone, ziprasidone, and olanzapine.
- Antidepressants.
Each of these has possible side effects. For some people, these side effects can be a barrier to continuing treatment. A 2019 study of people who took antipsychotic medication found that 70 percent had tried to stop the medication, and 64 percent of them cited side effects as the reason why. If youre troubled by side effects, it may help to know other people also have this experience.
Its important to keeping open communication with your doctor, adds Dr. Patricia Celan, MD, a postgraduate psychiatry resident at Dalhousie University.
Below are some side effects of medications for bipolar disorder.