Management of Bipolar disorder
Management of acute mania
Hospitalisation
• For protection of patient and family
• Usually involuntary admission necessary
Drugs of choice
1 Cooperative patient—use mood stabiliser: lithium carbonate
750–1500 mg (o)/d
• this is the initial dose
• give in 2–3 divided doses
• monitor by plasma levels
• therapeutic plasma level 0.8–1.4 mmol/L
• required daily dosage usually 1000–2500 mg
• arguably the prime mood stabiliser
or
sodium valproate 400–800 mg (o)/d
• give in 2 divided doses
• introduce stepwise
• therapeutic plasma level 350–700 μmol/L
or
carbamazepine 200–400 mg (o)/d
• give as above
• therapeutic plasma level 20–50 μmol/L
or
olanzapine 5–20 mg (o) daily, in 1 dose nocte, or 2 divided doses
2 Uncooperative patients and manic behaviour problematic:
haloperidol 10–20 mg (o) as single dose
• can be repeated up to 40 mg daily, depending on response
• there is a risk of tardive dyskinesia
If parenteral antipsychotic drug required: haloperidol 5–10 mg IM or IV
• repeat in 15–30 mins if necessary
• change to oral medication as soon as possible
Oral diazepam will complement haloperidol.
If not responding to medication consider ECT.
Maintenance/prophylaxis
• lithium carbonate—continue for 6 mths
If not tolerated or ineffective, use:
• carbamazepine or sodium valproate: these antiepileptics can be fi rst
option or used with lithium
• lithium + sodium valproate effective for rapid cycling illness (4 or
more episodes per yr)
Management of bipolar depression
• The mood stabilisers may have a bimodal (antidepressant and
antimania effect) but add an antidepressant (e.g. SSRI, SNRI or
MAOI)
• Withdraw antidepressant within 1–2 months because tend to
precipitate mania. ECT is a proven effective treatment.
Management of acute mania
Hospitalisation
• For protection of patient and family
• Usually involuntary admission necessary
Drugs of choice
1 Cooperative patient—use mood stabiliser: lithium carbonate
750–1500 mg (o)/d
• this is the initial dose
• give in 2–3 divided doses
• monitor by plasma levels
• therapeutic plasma level 0.8–1.4 mmol/L
• required daily dosage usually 1000–2500 mg
• arguably the prime mood stabiliser
or
sodium valproate 400–800 mg (o)/d
• give in 2 divided doses
• introduce stepwise
• therapeutic plasma level 350–700 μmol/L
or
carbamazepine 200–400 mg (o)/d
• give as above
• therapeutic plasma level 20–50 μmol/L
or
olanzapine 5–20 mg (o) daily, in 1 dose nocte, or 2 divided doses
2 Uncooperative patients and manic behaviour problematic:
haloperidol 10–20 mg (o) as single dose
• can be repeated up to 40 mg daily, depending on response
• there is a risk of tardive dyskinesia
If parenteral antipsychotic drug required: haloperidol 5–10 mg IM or IV
• repeat in 15–30 mins if necessary
• change to oral medication as soon as possible
Oral diazepam will complement haloperidol.
If not responding to medication consider ECT.
Maintenance/prophylaxis
• lithium carbonate—continue for 6 mths
If not tolerated or ineffective, use:
• carbamazepine or sodium valproate: these antiepileptics can be fi rst
option or used with lithium
• lithium + sodium valproate effective for rapid cycling illness (4 or
more episodes per yr)
Management of bipolar depression
• The mood stabilisers may have a bimodal (antidepressant and
antimania effect) but add an antidepressant (e.g. SSRI, SNRI or
MAOI)
• Withdraw antidepressant within 1–2 months because tend to
precipitate mania. ECT is a proven effective treatment.