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• Olanzapine
• Risperidone
• Ziprasidone
• Aripiprazole
• Quetiapine
• Carbamazepine (extended release formulation)

A significant concern that is raised by the APA regarding second generation antipsychotics is their metabolic effects. Clozapine and olanzapine increase the risk of diabetes and dyslipidemia. Clozapine and olanzatine are also associated with more weight gain than other medications. Risperidone and quetiapine are associated with moderate weight gain, while ziprasidone and aripiprazole are associated with minimal weight gain.

As a result, the APA advises clinicians to monitor their patients who are taking any of these medications for weight, waist circumference, blood pressure, and glucose/lipids at baseline and monthly thereafter.

To read more about the 2005 Guideline Watch published by the APA, please click on the following link:

http://www.psych.org/psych_pract/treatg/pg/Bipolar.watch.pdf

Depression

The primary goal of treatment for acute bipolar depression is to minimize or eliminate the symptoms and return the patient to normal functioning levels.

There is relatively little research that has been done regarding depression in bipolar disorder even though depression often is the dominant symptom and is associated with functional impairment, suicide, and other aspects of suffering. It may be considered even worse than manic episodes in terms of the duration of depressive episodes and impact on quality of life. Unfortunately, to date, no medications have been approved by the U.S. Food and Drug Administration for bipolar depression.

First-line therapy for severe depression, according to the American Psychiatric Association, is lithium or lamotrigine as monotherapy, and lithium combined with antidepressants as a second line therapy. Electroconvulsive therapy (ECT) is recommended for treatment of severe depression, pregnant women with severe symptoms, or those with psychotic symptoms. If a breakthrough episode occurs, first line medications need to be optimized. Antidepressants must be combined with mood stabilizers since, if taken alone, they may cause an increase in cycling and/or may overshoot the depression and result in mania.

Bipolar patients may take antidepressants for several weeks before they feel the therapeutic effect. It is common for the doctor to have to prescribe 2 or 3 different drugs before finding one that is most effective and does not cause bothersome side effects. A sedative may be added to relieve insomnia, anxiety, or agitation.

Psychotherapy may be helpful in an acute bipolar depression but it should always be combined with a regimen of medication.

The Guideline Watch published by the APA in 2005 notes that the following drugs have shown the strongest evidence of efficacy for acute depression in Bipolar I:

• Combination of fluoxetine and olanzapine
• Quetiapine
• Lamotrigine

There is "suggestive evidence" that pramipexole, a dopamine agonist, may be helpful as an adjunct medication. Antidepressants in combination with mood stabilizers offer only modest efficacy.

Rapid Cycling

It is important to evaluate and address any medical issue that could be the source of rapid cycling, (e.g. hypothyroidism, use of drugs or alcohol, or prior use of antidepressants).

First line medications used for rapid cycling include lithium, divalproex, and/or lamotrigine. In many cases, combinations of medications are required.