Bipolar and Related Disorders: Treatment Overview

Lithium in Mood Stabilization

• First Drug of Choice:
  • Initially lithium carbonate
  • Shifted to other medications due to better effectiveness
  • Some patients still prescribed lithium
• Mechanism of Action (MOA):
  • Affects neurotransmitters: serotonin, norepinephrine, glutamate, GABA, dopamine
• Target Diseases:
  • Bipolar mood swings, bipolar depression, antimanic
• Onset Time:
  • 10-21 business days for onset, therapeutic levels in 7-14 days
• Administration Frequency:
  • 2-3 times a day due to short half-life
• Common Side Effects:
  • T: Mild thirst
  • LA: Loss of appetite
  • W: Weight gain/loss
  • D: Dry mouth
  • C: Constipation
  • R: Restlessness
  • S: Stomach irritation
  • "The LAW of Dry Constipation, Restless Stomach"
• Pre-Treatment Requirements:
  • Baseline renal & thyroid function labs
  • Monitor: BUN, creatinine, GFR, TSH, T3, T4
• Therapeutic Range:
  • 0.8-1.2 mEq/L

Lithium Toxicity and Management

• 1.3-1.5 mEq/L:
  • Symptoms: Nausea, vomiting, diarrhea, sedation, fine hand tremors
  • Actions: Hold medication, notify M.D., repeat labs
• 1.5-2.0 mEq/L:
  • Symptoms: Confusion, sedation, incoordination, coarse hand tremors
  • Actions: Hold medication, notify M.D., repeat labs, promote excretion
• 2.0-2.5 mEq/L:
  • Symptoms: Ataxia, blurred vision, seizures, stupor, hypotension
  • Actions: Hold medication, notify M.D., repeat labs, promote excretion
• Above 2.5 mEq/L:
  • Symptoms: Convulsions, oliguria, death

Patient Education on Lithium

1. Increase fluid intake: 1500-3000ml daily
2. Monitor sodium levels: 1.5-2g Na+/day
3. Weight gain: Possible in first week
4. Take with meals to prevent GI upset
5. Avoid dehydration and medications causing N/V/D
6. Avoid OTC/NSAIDs without consultation

Antiepileptics as Mood Stabilizers

1. Valproate/Divalproex (Depakote):
   • MOA: Inhibits sodium channels, enhances GABA
   • Side Effects: N/V/D, dizziness, somnolence
   • Serious Effects: Hepatotoxicity, thrombocytopenia, blood dyscrasias, pancreatitis
2. Carbamazepine (Equetro, Tegretol):
   • MOA: Inhibits sodium channels
   • Side Effects: N/V, dizziness, ataxia
   • Severe Effects: Stevens-Johnson syndrome, blood dyscrasias
3. Lamotrigine (Lamictal):
   • MOA: Inhibits sodium channels, modulates neurotransmitters
   • Side Effects: N/V, dizziness, headache
   • Serious Effects: Stevens-Johnson syndrome

Anticonvulsants for Mood Stabilization

• Clonazepam, Gabapentin, Oxcabazepine, Topiramate

Second-Generation Antipsychotics (SGA)

• Combination with: Mood stabilizers
• Examples: Aripiprazole, cariprazine, olanzapine, quetiapine, ziprasidone, risperidone, asenapine
• Role in Bipolar Treatment:
  • Treat acute mania and stabilize mood
  • Sedative properties for insomnia, anxiety, agitation

Differentiating Schizophrenia from Bipolar

• Schizophrenia: Persistent psychosis and mood-independent symptoms
• Bipolar: Episode and mood-congruent hallucinations/delusions
• Example: Waxy flexibility in schizophrenia, not in bipolar mania