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Module 3 Indications for Antipsychotics Bipolar Disorder

Flavio Guzmn, MD

Outline
Indications of antipsychotics in different phases of bipolar disorder:
Mania/mixed states Bipolar depression Maintenance treatment

FDA approved agents for each phase

Use of antipsychotics in bipolar disorder


Mania

Mixed states

Maintenance

Bipolar depression

Mania Management

Acute mania pharmacotherapy


Patients with BD spend much less time in mania, hypomania, or mixed states than they do in depression. Many effective treatments for mania, fewer for maintenance treatment or treatment of bipolar depression.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

Acute mania pharmacotherapy


FGAs SGAs

Anticonvulsants

Lithium

Antipsychotics for mania


FGAs are effective in the treatment of mania, but are frequently avoided due to the risk of EPS. Antipsychotics work as well as lithium in acute mania, even in the absence of psychotic symptoms.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

FGAs treatment
Patients with mood disorders might more vulnerable to developing TD than schizophrenia patients.

Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

Mixed Episodes

FDA approved SGAs for manic/mixed episodes

Manic/mixed episodes Aripiprazole Asenapine Quetiapine and quetiapine XR Risperidone Olanzapine Ziprasidone

Frye MA. Clinical practice. Bipolar disorder--a focus on depression. N Engl J Med. 2011;364(1):51-9.

The role of SGAs in the treatment of manic/mixed episodes


Manic/mixed episodes

Approved as

monotherapy

Aripiprazole Asenapine Quetiapine and quetiapine XR Risperidone Olanzapine Ziprasidone

Manic/mixed episodes

Approved as

adjunctive

Aripiprazole Asenapine Quetiapine and quetiapine XR Risperidone Olanzapine Ziprasidone

Lithium

Divalproex sodium

Bipolar Depression

Bipolar depression
Depression is the predominant mood state in bipolar disorder. Some clinicians argue that this state is the most difficult to treat. There are few proven strategies for bipolar depression.
Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.

FDA approved SGAs for bipolar depression

Bipolar depression
Quetiapine Olanzapine/ fluoxetine

Frye MA. Clinical practice. Bipolar disorder--a focus on depression. N Engl J Med. 2011;364(1):51-9.

Maintenance treatment

FDA approved SGAs for maintenance treatment

Maintenance treatment Aripiprazole Olanzapine Quetiapine and quetiapine XR Risperidone (LAI) Ziprasidone

Frye MA. Clinical practice. Bipolar disorder--a focus on depression. N Engl J Med. 2011;364(1):51-9.

Maintenance treatment: SGAs


Advantages Titration is rapid and easier. (Compared to lamotrigine and lithium) Safer in overdose Disadvantages Weight gain Metabolic side effects Sedation

Take home points


Antipsychotics are effective for mania, mixed states and bipolar depression.
Manic/mixed episodesc Aripiprazole Asenapine Quetiapine and quetiapine XR Risperidone Olanzapine Ziprasidone

Maintenance treatment Aripiprazole Olanzapine Quetiapine and quetiapine XR Risperidone (LAI) Ziprasidone Bipolar depression Quetiapine Olanzapine / fluoxetine

References and further reading


Frye MA. Clinical practice. Bipolar disorder--a focus on depression. N Engl J Med. 2011;364(1):51-9. Schatzberg, AF., Cole, JO, and DeBattista, C. Manual of Clinical Psychopharmacology. 7th ed.American Psychiatric Publishing, 2010.