Practice Question # 37.
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- Question 1 of 1
Which of the following medications would be considered fi rst-line monotherapy for an acute episode of mania?Correct
The answer is B
Lithium is considered to be fi rst-line monotherapy for euphoric mania. Gabapentin has demonstrated utility as a mood stabilizer but is considered only an adjunctive therapy. Lamotrigine is an anticonvulsant that currently has data supporting its use in depressive episodes of bipolar disorder but not as fi rst-line monotherapy for mania. Haloperidol is a traditional antipsychotic that may be used parenterally to manage acute agitation but is not appropriate as fi rst-line monotherapy.Incorrect
The answer is B
Lithium is considered to be fi rst-line monotherapy for euphoric mania. Gabapentin has demonstrated utility as a mood stabilizer but is considered only an adjunctive therapy. Lamotrigine is an anticonvulsant that currently has data supporting its use in depressive episodes of bipolar disorder but not as fi rst-line monotherapy for mania. Haloperidol is a traditional antipsychotic that may be used parenterally to manage acute agitation but is not appropriate as fi rst-line monotherapy.
TREATMENT OF BIPOLAR DISORDER
Bipolar disorder is a syndrome in which patients suff er from episodes of mania and depression.
Bipolar disorder is diagnosed using DSM-IV-TR criteria. Th e symptoms should impair social or occupational functioning and should not be related to a general medical condition or use of a substance.
- Mania is described as at least a 1-week period of a continuously elevated or irritable mood, although shorter durations of symptoms are acceptable if the patient is hospitalized. In addition to elevated mood, the patient should experience at least three of the following symptoms: elevated self-esteem or grandiose ideations, reduced need for sleep, pressured speech, racing thoughts or fl ight of ideas, easily distracted, psychomotor agitation, and excessive involvement in high-risk activities.
- Major depressive episode is diagnosed using the same diagnostic criteria in patients presenting with unipolar depression (see previous section titled Major Depressive Disorder). Depressive episodes are more frequent, last longer, and occur more in bipolar II disorder.
- Hypomania has similar symptoms to that of mania; however, symptoms are not as severe. Hypomania is diagnosed by an elevated mood present for at least 4 days, with at least three of the same symptoms as described for mania. Th ese symptoms should not interfere with social or occupational functioning and should not cause hospitalization.
- A mixed disorder is diagnosed when the criteria for both mania and a major depressive episode are met every day for nearly 1 week, aff ects social and occupational functioning, and is not caused by a general medical condition or substance.
- Bipolar disorder may be classifi ed into bipolar I disorder, bipolar II disorder, cyclothymia, and rapid cycling.
- Bipolar I disorder. Patients are classifi ed with bipolar I disorder with a history of at least one mixed or manic episode and at least one major depressive episode.
- Bipolar II disorder. Patients are classifi ed with bipolar II disorder with a history of at least one episode of hypomania and one major depressive episode but have never experienced mania or a mixed episode.
- Cyclothymic disorder. Patients are classifi ed with cyclothymic disorder with at least a 2-year history of multiple episodes of hypomania and depressive symptoms. Th ese patients have never met full criteria for a major depressive or manic episode.
- Rapid cycling. Patients that experience at least four depressive, manic, hypomanic, or mixed episodes within a 12-month period are described as rapid cycling.
Th e course of bipolar disorder is lifelong, episodic, and patient specifi c.
- Patients usually experience episodes of depression initially. Men are more likely to initially present with mania, but both men and women are more likely to have a fi rst episode of depression. Approximately 95% of bipolar patients will experience a depressive episode during their lifetime.
- Episodes vary in length and severity; however, they may last from days to months if untreated.
- Th e duration of time between episodes varies. Commonly, 4 years or more may separate the fi rst and second episode but subsequent episodes are more frequent.
- Th e management of this disorder can be complicated by mixed episodes, rapid cycling, and substance abuse. It is imperative to screen patients for substance use disorders, medical illnesses, medications, and risk-taking behavior as possible causes for acute mood changes. Substance abuse occurs in approximately 45% of patients.
- Suicide rates are high in bipolar disorder. Approximately 50% of bipolar patients attempt suicide with completed suicide rates of 10% to 15%. Suicide is more likely to be attempted in patients experiencing a depressive or mixed episode.
- Pharmacotherapeutic options. Mood stabilizers have historically been the mainstays of therapy for bipolar disorder. Agents include lithium, valproic acid and its derivatives (divalproex sodium), and carbamazepine. Recent literature has supported the use of atypical antipsychotics as