The Challenges of Medicating the Bipolar Client

bipolar_disorderWhile presenting a psychopharmacology seminar recently, I was asked a question that I had never encountered after teaching this material to over 10,000 clinicians in 46 states. After completing a discussion of bipolar disorder and its medication management a social worker asked this: “Do you believe that the pharmacological treatment of bipolar disorder is a mess?” After hesitating a bit and giving her what more than likely was a quizzical look, I answered “yes.” After elaborating on my answer, I realized that she had succinctly asked something that I myself had been concerned about for quite some time. To say the least, the medication management of bipolar disorder is all over the place with but few treatment protocols upon which clinicians reliably agree.

Typically we think of bipolar disorder as a cyclic process of mood, behavior and thought processes that fluctuate between mania or hypomania and depression. A challenge in diagnosing it is that it is a moving target. Initially, it can present with one or more episodes of depression before the first manic or hypomanic episode even occurs, and it is not uncommon for some people to spend as much as 30 percent of their lives with depression. As a result, clients are often initially prescribed antidepressants that can induce manic or hypomanic episodes.

Another challenge is distinguishing among the types of bipolar presentations, namely, bipolar I, bipolar II, and cyclothymia. This is further complicated by the rapid cycler, typically a person that experiences a minimum of four episodes (manic, depressive, hypomanic or mixed) within a 12 month period. So diagnosing the disorder is difficult as there is considerable variability in its course from client to client.

Bipolar disorder is considered a biologically based illness, and medication is considered the mainstay of effective treatment with psychotherapy and psycho-education considered adjuncts to care. Pharmacological management is complicated by the fact that some treatments employed in bipolar disorder are without FDA approval, fueling the controversy and confusion as to which drugs are effective for what type of presentation.

Lithium was the first mood-stabilizing medication approved by the FDA for the treatment of acute mania and hypomania. Lithium not only treats classic mania, but is effective in the management of bipolar depression and in the prevention of relapse in bipolar disorder. Its “gold standard” properties are offset by its slow onset of action, stringent requirements for blood level monitoring, and its toxicity profile.

Recent trends in the United States have migrated to the use of the anti-epileptic drugs with Depakote supplanting lithium as the first line agent in the treatment of mania, although the rationale for this switch arguably is not on firm scientific footing. Depakote however is unproven in managing bipolar depression and in relapse prevention. Tegretol is effective in treating mania, although it is not FDA approved for this indication. Like Depakote, Tegretol is unproven in bipolar depression and bipolar maintenance. The other anti-epileptics Lamictal, Neurontin, Topamax and Trileptal demonstrate little or no effectiveness in bipolar mania. Only Lamictal is effective in bipolar depression.

All of first generation antipsychotics (Thorazine, Prolixin, Trilafon, Haldol, etc.) are approved for mania. The second generation agents Risperdal, Zyprexa, Seroquel, Geodon and Abilify are also FDA approved for mania. Clozaril is not approved for mania, and the newest second generation agent, Invega, is seeking approval. Zyprexa and Seroquel have proven effectiveness in bipolar depression. Research shows robust results for the use of Abilify and Zyprexa in bipolar maintenance.

Are you confused yet? Hopefully not, but the above medication discussion is testimony to the fact that clinicians often disagree as to what is an appropriate course of action when it comes to stabilizing and maintaining remission of the constellation of symptoms associated with bipolar disorder. Do second generation antipsychotics really have mood stabilizing properties? They probably do, but it is unclear how they are distinct from one another, or what advantages they possess over lithium and the anticonvulsants.

So although that aforementioned social worker’s question was timely to say the least, we nevertheless have more options for treating bipolar disorder than ever before. And even more are on the horizon. The clinical management of this disorder and its challenges render it a particularly appropriate condition for a collaborative model of care. Prescribers and social workers must work closely together to ensure the best possible results. Medication treatment and psychotherapeutic interventions work hand in hand for providing hope to our clients, and well intentioned clinicians understand that when treatment collaboration is frequent, meaningful and goal-directed, treatment outcomes are enhanced.

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Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, Psychopharmacology: Straight Talk on Mental Health Medications is available at www.pesi.com. To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at www.thepharmatherapist.com, or e-mail him at joe@thepharmatherapist.com.