Bipolar Disorder

Bipolar Disorder Treatment

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There is no known cure for bipolar disorder, but its long-term course can have a positive prognosis, even if, to the person suffering from the short-term effects of the disorder, the outlook seems bleak (Clayton, p. 83, 1977). Most people with bipolar disorder, even those with the most severe forms, can achieve substantial stabilization of their symptoms with proper treatment. In order to prevent recurrence, the emphasis of treatment is on management of the symptoms. Without treatment and over a long enough time frame, virtually every patient with bipolar disorder experiences more than one episode (Clayton, p. 83, 1977), so long-term preventative treatment is recommended. A treatment plan which combines psychosocial therapy and medication is optimal for managing bipolar disorder over time. Medications known as mood stabilizers are used to prevent manic or depressive episodes. Mood stabilizers are more effective in treating mania than bipolar depression. Until recently, depression was largely overlooked in the treatment of bipolar disorder. Much more emphasis has been placed on the treatment of acute mania. Very little is known about the treatment of hypomania. Recent clinical trials are finding that certain antipsychotics such as olanzapine (Zyprexa) and quetiapine (Seroquel) show some beneficial effect in treating bipolar depression. During an episode of depression, mood stabilizers are often used in combination with antidepressants in order to reduce the risk of inducing mania. In cases where mania is severe enough to cause psychosis, antipsychotic drugs may also be used. Compliance with medications can be a problem, because some people becoming manic lose awareness of having an illness and stop taking their medications.

The use of lithium salts as a treatment of bipolar disorder was first discovered by Dr. John Cade. Dr. Cade was originally investigating the hypothesis that mania was related to urea, and using lithium citrate as part of an experiment. His experiments revealed that lithium salt had a calming effect. A small-scale trial revealed that lithium had a powerful effect on mania in people. Despite the highly promising early results, the toxicity of lithium led to several deaths of patients undergoing lithium treatment. Lithium is a naturally-occurring chemical, so lithium salt cannot be patented. Consequently, manufacturing and sales were not considered commercially viable. Despite these early difficulties, lithium salts have been used as the preferred first-line treatment for bipolar disorder since they were approved for the treatment of acute mania in 1970 by the Food and Drug Administration (FDA). They are unique in bipolar therapy because along with the prevention of mania, they also have an antidepressant effect. The two lithium salts used for bipolar therapy are lithium carbonate and lithium citrate. Lithium treatment is believed to produce its stabilizing effect by inhibiting the enzyme inositol monophosphatase' (IMPase), an enzyme that splits inositol monophosphate into free inositol and phosphate. IMPase is involved in signal transduction and creates an imbalance in neurotransmitters in bipolar patients. The lithium ion substitutes for one of two magnesium ions in IMPase's active site, slowing down the enzyme. For the treatment of mania, the traditional method of treatment was as used in the order as follows: lithium; a neuroleptic plus lithium; a neuroleptic; & electrotherapy (Clayton, p. 84, 1977). Most studies comparing lithium with chlorpromazine treatment or lithium, chlorpromazine, and haloperidol treatment indicate that lithium is superior to either in terms of earlier discharge. While chlorpromazine, haloperidol, and other such neuroleptics control the hyperactivity and excitement of the acutely manic patient more quickly than lithium does, the end result of lithium is superior (Clayton, p. 84, 1977). Improvement with lithium treatment usually occurs in eight to ten days, while a manic episode without lithium treatment usually lasts approximately three months (Clayton, p. 84, 1977).

Prior to beginning treatment with lithium, patients should have thyroid function tests. Lithium should also be avoided during pregnancy. When lithium treatment is not recommended, electrotherapy has been shown to be an effective alternative treatment in the treatment of mania versus no treatment at all.
Valproate (Depakote and Depakene) received FDA approval for the treatment of acute mania in 1995. It is sometimes seen as preferable because of a less severe list of side effects, which also contributes to better compliance with the medication. However, Depakote is not as effective as lithium in preventing or managing depressive episodes, so patients taking Depakote may also need a selective-serotonin reuptake inhibitor (SSRI) or other antidepressant.

The treatment of a depressed episode includes the following, in combination with psychosocial therapy: a tricyclic antidepressant, a monoamine oxidase inhibitor (MAOI), electrotherapy, and lithium alone or in combination with the other treatments (Clayton, p. 85-86, 1977).


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