As with most aspects of late-life BPD, scant evidence guides SGA use. Avoid low-potency neuroleptics such as chlorpromazine, which can cause severe sedation and orthostatic hypotension. For Mr. B, a more-tolerable SGA such as aripiprazole or ziprasidone might be prudent, given his propensity for orthostatic hypotension and history of diabetes. Olanzapine or clozapine can cause anticholinergic effects and—in Mr. B’s case—lead to weight gain and worsen diabetes.
Antidepressant use in BPD usually is reserved for depressive symptoms that impair occupational or social functioning and exceed DSM-IV-TR diagnostic criteria.8,9 Consider later-generation antidepressants such as selective serotonin reuptake inhibitors (SSRIs), because tricyclics pose a greater risk of triggering a switch into hypomania or mania and can cause sedation and orthostatic, cardiac, anticholinergic, and anti-alpha 1 effects.
Among SSRIs, consider citalopram, escitalopram, or sertraline for older patients taking one or more other medications, as these antidepressants have less potential for drug-drug interactions than fluoxetine and paroxetine.11 In a recent comparison of newer antidepressants,20 venlafaxine showed the highest relative risk of mood polarity switching and bupropion the lowest.
Consider ECT for older patients with refractory mania or depression or who show evidence of suicidality or inadequate nutrition.5
Follow-up: ongoing issues
Three months after his admission, we discharge Mr. B to a board-and-care facility because family members will not take him in. Several weeks later, he again ignores his prescriptions and decompensates with worsening depression.
Family members have Mr. B admitted to an inpatient psychiatric facility closer to their home. He remains depressed, stays at the facility on and off for almost 1 year, and is eventually conserved by the county. Adverse side effects—mostly constipation and orthostatic hypotension—continue to complicate treatment.
Before Mr. B’s most recent discharge, another psychiatrist restarts lithium, 300 mg bid, and nortriptyline, 100 mg at bedtime—the combination that kept Mr. B relatively stable for more than 2 decades.
- National Institute of Mental Health—depression information. www.nimh.nih.gov/healthinformation/depressionmenu.cfm.
- Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). www.stepbd.org.
- Medicinenet.com. Medicines that cause depression. www.medicinenet.com/depression/index.htm. Click on “Medicines that cause depression.”
- Aripiprazole • Abilify
- Bupropion • Wellbutrin
- Chlorpromazine • Thorazine
- Citalopram • Celexa
- Clozapine • Clozaril
- Divalproex • Depakote
- Escitalopram • Lexapro
- Fluoxetine • Prozac
- Haloperidol • Haldol
- Lamotrigine • Lamictal
- Lithium • Various
- Mirtazapine • Remeron
- Nortriptyline • Pamelor
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Sertraline • Zoloft
- Venlafaxine • Effexor
- Ziprasidone • Geodon
The authors report no financial relationship with any company whose products are mentioned in this article, or with manufacturers of competing products.