The Advantages of Valproate for Bipolar Disorder

Valproate is an antiepileptic drug that has been proven to be effective in acute mania and is often used in the maintenance treatment of bipolar disorder (BPD). Valproate takes a shorter period than lithium before the patient may see benefits. Valproate can be useful as a short-term BPD treatment when rapid mood stabilization is warranted (Nemade & Dombeck, 2018).

Valproic acid is thought to be more effective than lithium for treating mania, rapid cycling, or mixed states BPD. However, it does not seem to be as effective as lithium for the treatment of depressive states (Nemade & Dombeck, 2018).

The Advantage of Oxcarbazepine over Carbamazepine

Oxcarbazepine is a mood stabilizer chemically related to carbamazepine. Oxcarbazepine is less likely to cause bone marrow suppression and therefore, unlike with carbamazepine, repeated complete blood counts are not essential. Repeated measurement of serum levels is not needed. However, oxcarbazepine can cause bone marrow suppression in rare cases (Hsiao, Wei & Huang, 2010). Oxcarbazepine is not metabolized to the 10,11-epoxide that is believed to be responsible for several adverse effects associated with carbamazepine (Hsiao, Wei & Huang, 2010).

Lamotrigine Use and Risks

Lamotrigine is an anticonvulsant drug that's applied in the treatment of bipolar I disorder. It's FDA-approved for the maintenance treatment of bipolar I disorder to retard the time of reoccurrence of mood episodes in patients treated for acute mood episodes with standard therapy ("Mood Stabilizers | Psych Education", 2018). According to "Lamotrigine - FDA prescribing information, side effects, and uses" (2018), the treatment of acute manic or mixed episodes is not recommended with lamotrigine. The FDA warns that the medicine lamotrigine (Lamictal), used for seizures and bipolar disorder, could cause a rare, life-threatening reaction that excessively activates the body's immune system, leading to severe, widespread inflammation in the body and could potentially lead to death. The immune system response, called hemophagocytic lymph histiocytosis (HLH), leads to an uncontrolled reaction by the immune system. HLH commonly presents as a persistent fever, usually greater than 101°F, and it can cause severe problems with blood cells and organs throughout the body, such as liver, kidneys, or lungs. It's crucial to monitor for Stevens-Johnson Syndrome (SJS). Therefore, Lamotrigine is slowly titrated up to the therapeutic dose amount. The literature from "Lamotrigine - FDA prescribing information, side effects, and uses" (2018) indicates it should not be restarted at the optimal dosage after the patient has stopped taking the drug. It needs to be reintroduced slowly until the therapeutic level is reached. There are also drug interactions with lamotrigine. Valproate increases lamotrigine concentrations more than 2-fold. Carbamazepine, phenytoin, phenobarbital, primidone, and rifampin decrease lamotrigine concentrations by approximately 40%. Estrogen-containing oral contraceptives decrease lamotrigine concentrations by approximately 50%. Protease inhibitors lopinavir/ritonavir and atazanavir/ritonavir decrease lamotrigine exposure by approximately 50% and 32% respectively. Dosage readjustments may be necessary in moderate and severe hepatic impairment. Reduced maintenance doses of lamotrigine may be required in substantial renal impairment ("Lamotrigine - FDA prescribing information, side effects and uses", 2018).

Mental Health Patients that Benefit from Gabapentin

Gabapentin is an analgesic and antiepileptic drug structurally associated with gamma-aminobutyric acid (GABA), the key inhibitory neurotransmitter in the cerebral cortex. While gabapentin isn't approved by the FDA for the treatment of any anxiety disorder, numerous clinicians prescribe it off-label. According to Murray (2018), off-label gabapentin could be especially effective as an adjunct to benzodiazepines or serotonergic antidepressant drugs in individuals with anxiety who experienced a partial response. Practice guidelines recommend gabapentin as a third-line adjunctive treatment for maintenance treatment of bipolar disorder (Murray, 2018). Additionally, gabapentin works for anxiety, insomnia, and alcohol use disorder.

The Advantages of Topiramate

Topiramate is utilized to address posttraumatic stress disorder, mood disorders, and eating disorders. It's an anti-convulsive drug that stands apart from all other drugs used to treat convulsions or mood disorders, for it doesn't share the same chemical composition. There are two factors that set Topiramate apart from other drugs in its class. First, MDs sometimes prescribe it when other mood-stabilizing drugs fail to be effective for a patient. Secondly, the kinds of side effects that patients might experience are quite different with Topiramate compared to other mood stabilizers. Topiramate is most beneficial for people who have bipolar mood disorders that other mood stabilizers have been incapable of controlling (Lieber, 2018). It can relieve symptoms and make taking antidepressants possible for people who were not able to use them before without experiencing mania or a mixed state. Topiramate has a good side effect profile (Lieber, 2018).

The Advantage of using Chlorpromazine

This medicine is utilized to address disorders such as schizophrenia, psychotic disorders, the manic phase of bipolar disorder, and severe behavioral problems in children ("Chlorpromazine - DrugBank", 2018). Chlorpromazine is a phenothiazine and conventional antipsychotic agent with anti-emetic action. Chlorpromazine maintains its antipsychotic effect by blocking postsynaptic dopamine receptors in cortical and limbic regions of the brain, thereby preventing the overabundance of dopamine ("Chlorpromazine - DrugBank", 2018). This contributes to a decrease in psychotic symptoms. Chlorpromazine assists the patient to think more clearly and experience less anxiety. It can reduce aggressive behavior and the desire to harm oneself or others.

The Advantage of Olanzapine

Olanzapine is an atypical antipsychotic currently indicated for the treatment of schizophrenia, acute mania, and the prevention of relapse in bipolar disorder (Narasimhan, Bruce & Masand, 2007). Olanzapine-fluoxetine compound (OFC) therapy and quetiapine are the only FDA authorized medications for the treatment of acute bipolar depression. Acute mania trials have shown superior efficacy from olanzapine to placebo, equivalent or superior efficacy to valproate, and superior efficacy in combination therapy with lithium or valproate compared to mood stabilizer monotherapy (Narasimhan, Bruce & Masand, 2007). Olanzapine is an effective antipsychotic with fewer EPS, and has the potential to reduce positive and negative symptoms to a greater degree than some conventional antipsychotics and other 'atypical' antipsychotics. It also has good tolerability.

The Uses for Risperidone

Risperidone is an atypical antipsychotic, serotonin-dopamine antagonist, and second-generation antipsychotic utilized to address symptoms of schizophrenia in adolescents and adults. The medication is sometimes used to treat bipolar disorder. Second-generation antipsychotics, including risperidone, are efficacious in the treatment of manic symptoms in acute manic or mixed exacerbations of bipolar disorder (Yildiz, Vieta, Leucht & Baldessarini, 2014). In children and adolescents, risperidone may be more effective than lithium or divalproex, but has several metabolic side effects (Gitlin & Frye, 2012). As maintenance therapy, long-acting injectable risperidone is efficacious for the prevention of manic episodes but not depressive episodes (Gitlin & Frye, 2012). The long-acting injectable configuration of risperidone may be beneficial over long-acting first-generation antipsychotics because it's better tolerated (less extrapyramidal issues), and the long-acting injectable preparations of first-generation antipsychotics could increase the chance of depression (Gitlin & Frye, 2012).

Aripiprazole use in the patient population

Aripiprazole is an atypical antipsychotic. It's recommended and chiefly utilized for the treatment of schizophrenia and bipolar disorder. Additional uses include treatment in major depressive disorder (MDD), as an add-on, tic disorders, and irritability related to autism. Additionally, a 2014 systematic review concluded that add-on therapy with low-dose aripiprazole is an effective treatment for obsessive-compulsive disorder (OCD) that doesn't improve on SSRIs alone. The determination was supported by the outcomes of two relatively small, short-term trials, each of which exhibited improvements in symptoms (Veale et al., 2014).

Advantage of Quetiapine with Patients Experiencing Mania

Quetiapine is a second-generation dibenzothiazepine that received Food and Drug Administration (FDA) approval for use as monotherapy or adjunctive therapy for acute mania, particularly when sensitivity to extrapyramidal effects limits treatment options (Brahm, Gutierres & Carnahan, 2018). Pharmacotherapy for acute mania typically involves a mood stabilizer, such as lithium or certain anticonvulsants, and often an antipsychotic is given to reduce excessive psychomotor agitation. Combination therapy with these agents during acute mania is quite common due to the need to rapidly stabilize patients (Brahm, Gutierres & Carnahan, 2018). The goal of treatment is to restore normal or near-normal functioning as quickly as possible and prevent further deterioration (Monson & Schoenstadt, 2018). Quetiapine is effective for treating episodes of mania or depression and helps prevent symptoms of bipolar disorder from returning (Monson & Schoenstadt, 2018). For bipolar mania episodes, it helps decrease the manic symptoms (Monson & Schoenstadt, 2018).

Reducing the Risk of Suicide with Bipolar Patients

"Risk factors could assist in distinguishing patients at increased suicidal risk, but ongoing clinical appraisal is crucial to limit the risk. Empirical short-term interventions to manage acute suicidal risk include close clinical oversight, rapid hospital care, and electroconvulsive therapy (ECT). However, evidence of the long-term effectiveness of most treatments against suicidal behavior is scarce. A notable exception is lithium (Li) prophylaxis, which is linked with consistent evidence of significant (approximately 80%), sustained reductions in the risk of suicides and attempts. These benefits are unproven for other treatments typically used to treat bipolar disorder patients, including anti-convulsants, antipsychotics, antidepressants, and psychosocial interventions." (Baldessarini, Pompili & Tondo, 2006).

The Difference Between Bipolar Depression and Unipolar Depression

Patients with bipolar disorder are oftentimes misdiagnosed with major depressive disorder (unipolar depressive disorder) (Hirschfeld, Lewis & Vornik, 2003). Whenever these patients are treated with antidepressants for unipolar depression, this could prove to be an ineffectual treatment and could exacerbate their condition by bringing on rapid cycling or activating a change over to a manic/mixed, manic, or hypomanic episode (Hirschfeld, Lewis & Vornik, 2003). Olanzapine, quetiapine, aripiprazole, and olanzapine-fluoxetine have been found to be efficacious in treating bipolar depression. If antidepressant drugs are used to address bipolar depression, they're compounded with the use of a mood stabilizer or atypical antipsychotic medicine to prevent the appearance of bipolar mania ("Mood Stabilizers | Psych Education", 2018). The biological science of these disorders is dissimilar, efficacious treatments are different, and in a way, the symptoms are as well different. Both forms of depressive disorder can be very serious and carry a danger of suicide. However, the fundamental difference is that people with bipolar depression also undergo episodes of either mania or hypomania. Bipolar depression is more likely to be accompanied by more substantial symptoms of anxiety. One-half to two-thirds of patients with bipolar depression have a co-occurring anxiety disorder such as obsessive-compulsive disorder (OCD), panic disorder, or social anxiety disorder ("Mood Stabilizers | Psych Education", 2018). According to "Mood Stabilizers | Psych Education" (2018), there are three specifically approved medications for bipolar depression treatment: Lurasidone HCI (Latuda), Olanzapine-fluoxetine combination (Symbax), Quetiapine (Seroquel). There are four medications approved for the maintenance of bipolar disorder symptoms: Lithium, Lamotrigine (Lamictal), Aripiprazole (Abilify), and Olanzapine (Zyprexa).

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