Figure 2 describes the use of antipsychotics in patients with mania. If response to a primary mood stabilizer such as lithium, valproate, or their combination in the context of a bipolar or schizoaffective disorder is insufficient—or if patients have severe manic or psychotic symptoms—an antipsychotic may be added to the primary mood stabilizer.
Alternatively, when mood stabilizers are not tolerated or a clinical situation such as pregnancy precludes their use, a novel agent such as olanzapine or risperidone may be given as monotherapy. While the safety of these agents in pregnancy is not clearly established, clinical experience thus far indicates they may be safer than agents such as valproate or carbamazepine. These agents would be the first choice given their diminished propensity for extrapyramidal symptoms; absence of clozapine-related adverse effects such as agranulocytosis and seizures; and growing evidence of possible mood stabilizing effects.
Figure 1 ANTIPSYCHOTICS IN THE TREATMENT OF MAJOR DEPRESSION
Figure 2 ANTIPSYCHOTICS IN THE TREATMENT OF MANIA
For patients who remain nonresponsive, clozapine should be considered either as monotherapy or combined with valproate and/or lithium. Combining this agent with carbamazepine is not recommended because of the possibility of an increased risk of hematotoxicity.
Electroconvulsive therapy may be used safely and effectively in patients who are severely ill (e.g., those with manic delirium); pose an immediate danger because of their potential for violence; are in medical crisis; or have medical contraindications to pharmacotherapy. There is preliminary evidence that ECT can be safely administered with novel antipsychotics such as clozapine, risperidone, or olanzapine to produce additional benefit in patients insufficiently responsive to either therapy alone.
Related resources
- International Society for Bipolar Disorders www.isbd.org
Drug brand names
- Amitriptyline • Elavil
- Amoxapine • Asendin
- Aripiprazole • (in development)
- Carbamazepine • Tegretol, Epitol
- Clozapine • Clozaril
- Haloperidol • Haldol
- Iloperidone • (in development)
- Imipramine • Tofranil
- Lorazepam • Ativan
- Olanzapine • Zyprexa
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Valproate sodium • Depacon
- Ziprasidone • Geodon
Disclosure
The author reports that he receives research/grant support from, serves as a consultant for, and on the speaker’s bureau of Janssen Pharmaceutica. He also receives research/grant support from Genentech Inc. and Bristol-Myers Squibb Co.; serves as a consultant for Pfizer Inc., Sepracor, and Novartis Pharmaceuticals Corp.; and is on the speaker’s bureau of Abbott Laboratories, Eli Lilly and Co., Pfizer Inc., Forest Pharmaceuticals, Bristol-Myers Squibb Co., and Wyeth-Ayerst Pharmaceuticals.