Bipolar Disorder in Primary Care Part 2: Treatment 7/20/2017

It is important that primary care providers have a basic level of understanding of the medications used to treat bipolar disorder as they may be called upon to help maintain and monitor ongoing medication treatment or they may be the first person to identify the condition in a patient. Regardless of the context, the primary care provider should, in most cases, work in periodic collaboration with a psychiatrist and/or a psychotherapy professional to optimize assessment, treatment delivery and outcome monitoring.

As many patients with bipolar disorder have other medical conditions requiring treatment, it is important for both PCPs and other providers to be aware of possible drug-drug interactions. Finally, when a patient presents with new onset or recurrence of bipolar manic or hypomanic symptoms, it may be particularly helpful for treatment to begin in the primary care setting while waiting for linkage to mental health services. Early diagnosis and treatment/referral can improve prognosis and reduce the risk of relapse.

Medications are the primary treatment for all stages of bipolar disorder and many patients with bipolar symptoms may require more than one medication to fully treat their symptoms. Of course, when a patient is in an acute manic state with extreme agitation, psychotic symptoms, and/or presents as danger to him or herself or others, an emergency psychiatric assessment in an emergency room setting and possible inpatient hospitalization is recommended. In the more typical case of a non-acute situation, the medication choice is based on stage, previous response to medication and side effect profiles.

Acute mania can be treated with a mood stabilizer and/or an atypical antipsychotic medication. For severe cases, many patients require both types of medication for full stabilization of their mania. The classic mood stabilizers include lithium, depakote, carbamazepine, lamotrigine and oxcarbamazepine. Most require regular periodic lab monitoring, for medication levels (lithium and depakote) or renal, thyroid and liver function. Some are better for acute treatment and others are better for maintenance treatment. Lithium generally is more effective than depakote and carbamazepine but has a slower onset of action. Depakote has been found to be more helpful in mixed states than lithium. The atypical antipsychotics  (e.g., risperidone, quetiapine, aripiprazole, etc.) have a more rapid onset of action than the mood stabilizers and can be particularly effective at controlling manic symptoms, psychotic symptoms and sleep disturbance during the acute phases of treatment. If used for extended periods of time, they also require regular lab monitoring, for blood sugar and lipid profiles.

Depression in the bipolar patient can be treated in a variety of ways. In generally, antidepressant medications should not be used alone for a patient with confirmed bipolar disorder as they may contribute to the development of a hypomanic or manic episode, but when needed, they can be used for a depressed patient along with a mood stabilizer. There are some medications that have FDA indications for bipolar depression, including the mood stabilizer lamotrigine and the antipsychotics quetiapine and lurasidone – the antipsychotic agents can be used either alone or in combination with a traditional mood stabilizer like lithium or Depakote. Lamotrigine has been shown to be more effective for bipolar II disorder than bipolar I disorder. Lithium has been shown to reduce the risk of suicide in patients with bipolar disorder.

Given the high rate of recurrence of mood episodes in bipolar disorder, maintenance medication is strongly encouraged and this is an arena where primary care providers may be called upon to assist in the care of an otherwise stable patient with bipolar disorder. In addition to providing medication prescriptions and monitoring for appropriate symptom control, this is also an opportunity to provide ongoing psycho-education about medication compliance — consistency with medications is linked to a lower rate of relapse in patients maintaining good medication compliance.

It is our hope that this primer on treatment of bipolar disorder and brief introduction to the mood stabilizer and antipsychotic medications has been helpful. Future e-weekly articles with go into more details on mood stabilizer and antipsychotic dosing, indications and side effect profiles.

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