From the Guidelines
Adjunctive treatment for bipolar disorder in adults should prioritize the use of second-generation antipsychotics, such as quetiapine, olanzapine, risperidone, aripiprazole, and lurasidone, due to their efficacy in managing acute manic or mixed episodes and their potential for maintenance therapy. The choice of medication should be based on evidence of efficacy, the phase of illness, the presence of confounding presentations, the agent's side effect spectrum and safety, the patient's history of medication response, and the preferences of the patient and their family 1.
Medication Options
- Second-generation antipsychotics: quetiapine (300-800 mg/day), olanzapine (5-20 mg/day), risperidone (1-6 mg/day), aripiprazole (10-30 mg/day), and lurasidone (20-120 mg/day) are commonly used adjunctive medications for managing acute manic or mixed episodes and may be continued for maintenance 1.
- For bipolar depression, lamotrigine (titrated slowly to 200 mg/day) is often added due to its strong antidepressant properties with minimal risk of triggering mania 1.
- Antidepressants like SSRIs may be used cautiously and always with a mood stabilizer to prevent switching to mania, typically for 6-8 weeks during acute depressive episodes 1.
- Benzodiazepines such as lorazepam (0.5-2 mg) or clonazepam (0.5-2 mg) can be used short-term for agitation or insomnia 1.
Non-Pharmacological Treatments
- Psychotherapy, particularly cognitive behavioral therapy and interpersonal social rhythm therapy, is equally important as an adjunctive treatment 1.
- Regular sleep schedules, stress management, and avoiding alcohol and recreational drugs are also crucial for comprehensive symptom control and improved functioning 1.
The selection of adjunctive treatments should be tailored to the individual patient's needs, taking into account their specific symptoms, medical history, and personal preferences, as well as the potential risks and benefits of each treatment option 1.
From the FDA Drug Label
Oral ZYPREXA is indicated for the treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder Adjunctive Therapy to Lithium or Valproate — Oral ZYPREXA is indicated for the treatment of manic or mixed episodes associated with bipolar I disorder as an adjunct to lithium or valproate. RISPERIDONE adjunctive therapy with lithium or valproate is indicated for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder.
Adjunctive treatment for bipolar disorder in adults can be achieved with:
- Olanzapine (PO) as an adjunct to lithium or valproate for the treatment of manic or mixed episodes associated with bipolar I disorder 2
- Risperidone (PO) as an adjunct to lithium or valproate for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder 3
From the Research
Adjunctive Treatment Options for Bipolar Disorder
- Adjunctive treatments are often required due to the complex nature of bipolar disorder, and combination regimens are typical 4
- Second-generation antidepressants can be used as adjunctive therapy with a mood stabilizer or an atypical antipsychotic to treat acute bipolar depression, but their efficacy and safety remain controversial 5
- Lamotrigine is a safe and effective mood stabilizer for bipolar disorder in reproductive-age adults, particularly in preventing depressive episodes 6
- Quetiapine is an atypical antipsychotic approved for use as monotherapy in both bipolar mania and depression, offering potential compliance advantages 7
Efficacy and Safety of Adjunctive Treatments
- Second-generation antidepressants are associated with a small but significant improvement in clinician-rated depressive symptom score, but do not increase clinical response or remission rates 5
- Adjunctive second-generation antidepressants should be used only in the short term because prolonged use is associated with an increased risk of treatment-emergent mania or hypomania 5
- Lamotrigine can cause rare, life-threatening adverse effects such as Stevens-Johnson syndrome, hemophagocytic lymphohistiocytosis, and drug reaction with eosinophilia and systemic symptoms syndrome 6
- Quetiapine is generally well tolerated in bipolar depression and is not associated with an increased risk of treatment-emergent mania 7
Treatment Considerations
- First-line therapy for bipolar disorder includes mood stabilizers, anticonvulsants, and atypical antipsychotic drugs 8
- Combination treatments are often required to successfully treat symptoms of bipolar disorder 4
- Treatment options are changing, and adjunctive therapies are being increasingly recognized as providing significant tools to improve patient outcomes 4