What is bipolar disorder?

From the Guidelines

Bipolar disorder should be treated with a combination of medication and psychotherapy, prioritizing mood stabilizers like lithium or valproate, and atypical antipsychotics, to improve outcomes and quality of life. The primary goal of treatment is to manage symptoms, prevent relapse, and improve functioning. According to 1, traditional mood stabilizers and/or atypical antipsychotic medications are the primary treatment, with other psychotropic agents and psychotherapies used as adjunctive therapy.

Treatment Options

• Mood stabilizers: lithium (600-1200 mg daily) or valproate (750-1500 mg daily) are commonly used, as they have demonstrated efficacy in treating acute manic symptoms in adults 1.
• Atypical antipsychotics: quetiapine (300-800 mg daily), olanzapine (5-20 mg daily), or aripiprazole (10-30 mg daily) are often used in combination with mood stabilizers.
• Psychotherapy: cognitive behavioral therapy (CBT), interpersonal therapy, and family-focused therapy can help patients manage symptoms and improve functioning.

Diagnosis and Classification

The diagnosis of bipolar disorder has undergone changes, with the ICD-11 providing updated criteria, including the definition of Bipolar Type II Disorder as the occurrence of at least one hypomanic episode and at least one depressive episode 1.

Lifestyle Management

Lifestyle management is crucial, including:

• Regular sleep patterns
• Stress reduction
• Avoiding alcohol and recreational drugs
• Maintaining a consistent daily routine Early diagnosis and consistent treatment significantly improve outcomes and quality of life for those with bipolar disorder.

From the FDA Drug Label

1. 2 Bipolar I Disorder (Manic or Mixed Episodes) Monotherapy — Oral ZYPREXA is indicated for the acute treatment of manic or mixed episodes associated with bipolar I disorder and maintenance treatment of bipolar I disorder Efficacy was established in three clinical trials in adult patients with manic or mixed episodes of bipolar I disorder: two 3- to 4-week trials and one monotherapy maintenance trial. In adolescent patients with manic or mixed episodes associated with bipolar I disorder (ages 13-17), efficacy was established in one 3-week trial

Bipolar Disorder Treatment: Olanzapine (PO) is indicated for the treatment of bipolar I disorder, specifically for the acute treatment of manic or mixed episodes and for maintenance treatment.

• The efficacy of olanzapine in treating bipolar I disorder was established in three clinical trials in adult patients and one clinical trial in adolescent patients.
• Olanzapine can be used as monotherapy or as adjunctive therapy to lithium or valproate for the treatment of manic or mixed episodes associated with bipolar I disorder 2 2.

From the Research

Overview of Bipolar Disorder

• Bipolar disorder affects approximately 8 million adults in the US and approximately 40 million individuals worldwide 3.
• The disorder is characterized by recurrent episodes of depression and mania or hypomania, with depression being the most frequent initial presentation 3.
• The age of onset is usually between 15 and 25 years, and approximately 75% of symptomatic time consists of depressive episodes or symptoms 3.

Diagnosis and Treatment

• Early diagnosis and treatment are associated with a more favorable prognosis, but diagnosis and optimal treatment are often delayed by a mean of approximately 9 years following an initial depressive episode 3.
• First-line therapy includes mood stabilizers, such as lithium, anticonvulsants, such as valproate and lamotrigine, and atypical antipsychotic drugs, such as quetiapine, aripiprazole, asenapine, lurasidone, and cariprazine 3, 4.
• Olanzapine + fluoxetine should be first-line treatment, and olanzapine, quetiapine, lurasidone, valproate, and selective serotonin re-uptake inhibitors are also recommended 4.
• Lithium may be effective in treating acute mania, and lithium efficacy is maximized when used to prevent both manic and depressive episodes 5, 6.

Treatment Options

• Valproate may be more effective as an antimanic rather than prophylactic agent, and valproate might be a better choice in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities 5.
• Quetiapine, lurasidone, and olanzapine have shown efficacy in treating bipolar depression, while ziprasidone, aripiprazole, and risperidone have limited or no therapeutic activity in bipolar depression 4, 7.
• Antidepressants are not recommended as monotherapy, and tricyclic antidepressants and lithium are worthy of consideration but with caution 3, 4.

Adherence and Outcomes

• More than 50% of patients with bipolar disorder are not adherent to treatment, and life expectancy is reduced by approximately 12 to 14 years in people with bipolar disorder 3.
• The annual suicide rate is approximately 0.9% among individuals with bipolar disorder, compared with 0.014% in the general population, and approximately 15% to 20% of people with bipolar disorder die by suicide 3.