A 27-year-old man is brought to the emergency department by his wife. She says that he has been "acting crazy" for the last 2 weeks. He has hardly slept for the past 7 days and instead has worked on miscellaneous projects around the house. The patient spent several thousand dollars on new power tools to accomplish these tasks. When questioned, his speech is rapid and frenzied. He feels "spectacular" and is creating an "architectural masterpiece." The patient has had 2 previous depressive episodes. Which of the following medications is the most appropriate agent for long-term management of this patient?
Mood stabilizers in bipolar disorder | ||
Indications | Adverse effects | |
Lithium |
|
|
Valproate |
|
|
Carbamazepine |
|
|
Lamotrigine |
|
|
SIADH = syndrome of inappropriate antidiuretic hormone secretion. | ||
This patient's euphoric mood, decreased need for sleep, hyperactivity, grandiosity, and pressured speech lasting more than a week are characteristic of an acute manic episode of bipolar disorder. Bipolar disorder is a highly recurrent illness requiring maintenance treatment with mood-stabilizing medications to decrease the risk of recurrent mood episodes. Preferred medications for bipolar maintenance treatment include lithium, the anticonvulsants valproate and lamotrigine, and the second-generation antipsychotic quetiapine.
(Choices A and E) Bupropion, a norepinephrine dopamine reuptake inhibitor, and paroxetine, a selective serotonin reuptake inhibitor, are antidepressants that have the potential to precipitate manic episodes. Antidepressant monotherapy should be avoided in bipolar maintenance treatment due to the risk of mood destabilization.
(Choices B and C) Chlorpromazine and haloperidol are first-generation antipsychotics (FGAs) used in the treatment of schizophrenia. FGAs may be used in combination with lithium or valproate for treatment of severe mania, but are not used as monotherapy for maintenance treatment of bipolar disorder.
(Choice D) Lorazepam is a benzodiazepine that can be used as an adjunct to mood stabilizers in the treatment of acute mania; it is not recommended for maintenance treatment.
Educational objective:
The anticonvulsant valproate has mood-stabilizing properties and is an effective maintenance treatment for bipolar disorder. Other maintenance options for bipolar disorder include lithium, lamotrigine, and quetiapine.