Treatment-Resistant Bipolar Disorder

A Review of Psychotherapeutic Approaches

By James C-Y Chou, MD | July 6, 2011

Dr Chou is associate professor, department of psychiatry, Mount Sinai School of Medicine in New York; and attending psychiatrist at the James J. Peters VA Medical Center in the Bronx. Dr Chou reports that he has received research grants and speakers’ honoraria from Abbott Laboratories, AstraZeneca Pharmaceuticals LP, Bristol-Myers Squibb Company, Eli Lilly and Company, Janssen Pharmaceutica Products, LP, Novartis, and Pfizer Inc.

Several novel approaches have been suggested for treatment-resistant bipolar maintenance
(either depression or cycling) including clozapine(Drug information on clozapine), at either low or standard doses, and maintenance ECT.^35-38Other approaches include augmentation with hypermetabolic thyroid supplementation, diltiazem, aripiprazole(Drug information on aripiprazole), topiramate, gabapentin, mexiletine, levetiracetam(Drug information on levetiracetam), and chromium, as well as vagus nerve stimulation.^19,39-46Efficacy has also been reported for levetiracetam monotherapy and a combination of topiramate(Drug information on topiramate) and clozapine.^47,48

Conclusion

Bipolar disorder is associated with significant morbidity. Numerous evidence-based treatments exist for all phases of bipolar disorder, and these should be optimized and fully explored before resorting to treatments with limited evidence of efficacy. Medication dosage should be titrated to response and emergence of adverse effects.

Combinations of evidence-based treatments are often used. When a treatment has failed, careful consideration should be made about whether it should be discontinued before adding another. Comorbidities such as substance abuse that complicate treatment must be minimized. Often, lithium(Drug information on lithium) or an anticonvulsant is used initially and an antipsychotic is added if response is not adequate. However, antipsychotics have been shown to be efficacious in nonpsychotic moderately ill bipolar manic and depressed patients. If evidence-based treatments are truly unsuccessful, clozapine and ECT have some evidence of efficacy as an augmentation to standard treatments. If these too fail, then novel treatments may be considered.

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by RICHARD EISENSTEIN | August 05, 2011 7:24 AM EDT

cme?

by Scott Weigold | December 12, 2011 2:49 PM EST

This was one of the most blatant sales pitches for big pharma that I've seen in Psych Times.
Do NOT believe this article. Lithium is still the Gold Standard and will remain so until there are multiple head-to-head comparisons among real-world patients with atypicals AND typicals (which probably work equally well but don't create millions in profits).

Also in this Special Report

Introduction Underlying Causes and Implications

Chronic Eating Disorders

Treatment-Resistant Bipolar Disorder

Treatment-Resistant Depression

Borderline Personality Disorder and Resistance to Treatment

Psychodynamic Psychopharmacology

Treatment-Resistant Schizophrenia

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Treatment-Resistant Bipolar Disorder

A Review of Psychotherapeutic Approaches

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