2.2 Bipolar disorder and mania
Mania and hypomania 08-Jun-2018
Overview
Antimanic drugs are used to control acute attacks and to
prevent recurrence of episodes of mania or hypomania.
Long-term treatment of bipolar disorder should continue for
at least two years from the last manic episode and up tofive
years if the patient has risk factors for relapse.
An antidepressant drug may also be required for the
treatment of co-existing depression, but should be avoided
in patients with rapid-cycling bipolar disorder, a recent
history of hypomania, or with rapid moodfluctuations.Benzodiazepines
Use of benzodiazepines may be helpful in the initial stages of
treatment for behavioural disturbance or agitation; they
should not be used for long periods because of the risk of
dependence.
Antipsychotic drugs
Antipsychotic drugs (normally olanzapine p. 251 , quetiapine
p. 252 , or risperidone p. 253 ) are useful in acute episodes of
mania and hypomania; if the response to antipsychotic drugs
is inadequate, lithium or valproate may be added. An
antipsychotic drug may be used concomitantly with lithium
or valproate in the initial treatment of severe acute mania.
SeeImportant safety information,Conception and
contraception, andPregnancyin the valproic acid p. 213 and
sodium valproate p. 208 monographs.
Atypical antipsychotics are the treatment of choice for the
long-term management of bipolar disorder in children and
adolescents; if the patient has frequent relapses or
continuing functional impairment, consider concomitant
therapy with lithium or valproate. An atypical antipsychotic
that causes less weight gain and does not increase prolactin
levels is preferred.
When discontinuing antipsychotics, the dose should be
reduced gradually over at least 4 weeks if the child is
continuing on other antimanic drugs; if the child is not
continuing on other antimanic drugs, or has a history of
manic relapse, a withdrawal period of up to 3 months is
required.Carbamazepine
Carbamazepine p. 196 may be used under specialist
supervision for the prophylaxis of bipolar disorder (manic-
depressive disorder) in children unresponsive to a
combination of other prophylactic drugs; it is used in
patients with rapid-cycling manic-depressive illness ( 4 or
more affective episodes per year). The dose of
carbamazepine should not normally be increased if an acute
episode of mania occurs.
Valproate
Valproic acid (as the semisodium salt) is licensed in adults
for the treatment of manic episodes associated with bipolar
disorder. Sodium valproate is unlicensed for the treatment of
bipolar disorder. Valproate (valproic acid and sodium
valproate) can also be used for the prophylaxis of bipolar
disorder [unlicensed use]. It must be started and supervised
by a specialist experienced in managing bipolar disorder.
Because of its teratogenic risk, valproate must not be used in
females of childbearing potential unless the conditions of
the Pregnancy Prevention Programme are met and
alternative treatments are ineffective or not tolerated.
Valproic acid and sodium valproate must not be used during
pregnancy in bipolar disorder. The benefit and risk of
valproate therapy should be carefully reconsidered at regular
treatment reviews. For further information, seeImportant
safety information,Conception and contraception, andPregnancyin the valproic acid and sodium valproate
monographs.
In patients with frequent relapse or continuing functional
impairment, consider switching therapy to lithium or an
atypical antipsychotic, or adding lithium or an atypical
antipsychotic to valproate. If a patient taking valproate
experiences an acute episode of mania that is not
ameliorated by increasing the valproate dose, consider
concomitant therapy with olanzapine, quetiapine, or
risperidone.Lithium
Lithium salts are used in the prophylaxis and treatment of
mania, in the prophylaxis of bipolar disorder (manic-
depressive disorder), and bipolar depression, and as
concomitant therapy with antidepressant medication in
children who have had an incomplete response to treatment
for acute depression in bipolar disorder [unlicensed
indication]. It is also used for the treatment of aggressive or
self-harming behaviour [unlicensed indication].
The decision to give prophylactic lithium requires
specialist advice, and must be based on careful consideration
of the likelihood of recurrence in the individual child, and
the benefit of treatment weighed against the risks. The full
prophylactic effect of lithium may not occur for six to twelve
months after the initiation of therapy. An atypical
antipsychotic or valproate (given alone or as adjunctive
therapy with lithium) are alternative prophylactic
treatments in patients who experience frequent relapses or
continued functional impairment.Other drugs used for Bipolar disorder and mania
Aripiprazole, p. 249 .Perphenazine, p. 246ANTIPSYCHOTICS›LITHIUM SALTS
Lithium salts f
lCONTRA-INDICATIONSAddison’s disease.cardiac
insufficiency.dehydration.family history of Brugada
syndrome.low sodium diets.personal history of Brugada
syndrome.rhythm disorder.untreated hypothyroidism
lCAUTIONSAvoid abrupt withdrawal.cardiac disease.
concurrent ECT (may lower seizure threshold).diuretic
treatment (risk of toxicity).epilepsy (may lower seizure
threshold).myasthenia gravis.psoriasis (risk of
exacerbation).QT interval prolongation.review dose as
necessary in diarrhoea.review dose as necessary in
intercurrent infection (especially if sweating profusely).
review dose as necessary in vomiting.surgery
CAUTIONS, FURTHER INFORMATION
▶Long-term useLong-term use of lithium has been
associated with thyroid disorders and mild cognitive and
memory impairment. Long-term treatment should
therefore be undertaken only with careful assessment of
risk and benefit, and with monitoring of thyroid function
every 6 months (more often if there is evidence of
deterioration).
The need for continued therapy should be assessed
regularly and patients should be maintained on lithium
after 3 – 5 years only if benefit persists.
lSIDE-EFFECTS
▶Rare or very rareNephropathy
▶Frequency not knownAbdominal discomfort.alopecia.
angioedema.appetite decreased.arrhythmias.
atrioventricular block.cardiomyopathy.cerebellar
syndrome.circulatory collapse.coma.delirium.
diarrhoea.dizziness.dry mouth.electrolyte imbalance.
encephalopathy.folliculitis.gastritis.goitre.
hyperglycaemia.hyperparathyroidism.hypersalivation.
hypotension.hypothyroidism.idiopathic intracranial
hypertension.leucocytosis.memory loss.movement232 Mental health disorders BNFC 2018 – 2019
Nervous system4