Role of Atypical Antipsychotics in the Management of Mania and Depression in Bipolar Disorder Patients

Roumen Milev
US Psychiatry, 2010;3:28-31
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Abstract

Bipolar disorder is a serious and long-lasting mental disorder and is associated with significant disability. There are a number of effective treatments available, but many people are left with significant residual symptoms or impaired functioning. Therefore, any new treatment methods and medications are welcomed. Antipsychotics have long been used in the treatment of acute psychotic bipolar mania, but their side-effect burden and questionable efficacy in bipolar depression made them less desirable as a first line of treatment. The atypical (second-generation) antipsychotics have been increasingly used for a variety of non-psychotic conditions, including mood and anxiety disorders. In this article we will review their use in bipolar disorder in acute manic and mixed episodes, in acute depressive episodes, and also for maintenance of the therapeutic effect and prevention of new episodes. Special attention is devoted to the side-effect burden and recommended monitoring of long-term use.
Keywords
Atypical antipsychotics, bipolar disorder, bipolar mania, bipolar depression, psychopharmacology
Disclosure Roumen Milev, MD, PhSD, FRCPsych, FRCPC, has received speaker’s bureau funding from Eli Lilly, Janssen, AstraZeneca, Wyeth, and Biovail, consultancy/advisory board funding from Eli Lilly, AstraZeneca, Wyeth, Shire, Janssen, and Biovail, and research support from CIHR, OMHF, Queen’s, AstraZeneca, Eli Lilly, Lundbeck, Janssen, and Biovaila.
Received: July 30, 2009 Accepted February 01, 2010
Correspondence: Roumen Milev, MD, PhD, FRCPsych, FRCPC, Professor of Psychiatry and Psychology, and Head, Department of Psychiatry, Queen’s University, 752 King Street West, Kingston, ON, K7L 4X3, Canada. E: milevr@providencecare.ca

Bipolar disorder is a long-lasting and debilitating mental disorder. It is characterized by recurrent episodes of mania (type I) and/or hypomania (type II) and episodes of depression. Bipolar disorder is a complex and multifaceted illness. It is a common disorder with a lifetime prevalence of over 2%, and somewhat higher if bipolar spectrum forms are taken into consideration.1 People with bipolar disorder have significant comorbidity with other psychiatric disorders, most commonly anxiety disorders, alcohol and other substance use disorders, and impulsecontrol disorders.1 There is also a significant comorbidity with medical disorders, including cardiovascular disorder, obesity, diabetes, etc.2,3 Bipolar disorder is associated with high personal and societal cost, and is one of the leading causes of disability: in 2004 it was ranked sixth and eighth for men and women, respectively, contributing 2.4% to the total years lived with disability (YLD) from all causes worldwide.4

Although there is no definitive cure for bipolar disorders, there are a number of effective treatments available. Psychoeducation and cognitive behavioral therapy are examples of effective non-pharmacological therapies. In this article we will focus on pharmacological treatments in more detail. Traditionally, lithium salts and some antiepileptic medications (divalproex, carbamazepine, lamotrigine) have been used for the treatment of bipolar disorders; they are commonly referred to as mood stabilizers. The ‘ideal’ mood stabilizer should have several features: be effective as a monotherapy, possess good antimanic and antidepressant efficacy, be able to prevent or reduce the number and severity of future episodes, and have a minimal side-effect profile. In the real world, however, such a unique combination of therapeutic effects and favorable side effects is very difficult to achieve. Although effective for some, traditional mood stabilizers leave many people with bipolar disorders with residual symptoms. Bipolar disorder patients often end up taking a number of medications, with potentially harmful drug–drug interactions and a significant side-effect burden. In the STEP-BD study, 40% of the participants were using three or more medications, and 18% were receiving four or more agents.5 Management of patients with bipolar disorders is complicated by the numerous psychiatric and medical comorbidities. Therefore, any new pharmacological agents, or new indications for existing ones, are welcome additions to the therapeutic armamentarium and may offer relief to patients.

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