Ask the Pharmacist – July 27, 2018

Q) I have a family member who has been diagnosed with bipolar disorder. Is there a preferred treatment option at this point or is it pretty much a guessing game as to which drugs are likely to work better?

A) The Canadian guidelines for treating bipolar disorder (also known to many as manic depressive disorder) have recently been updated and now contain a system that ranks the different treatment options in order to give healthcare professionals, patients and caregivers greater clarity in selecting possible therapy.

Before listing the treatment options, let’s start with a short synopsis of just what bipolar is. There are in fact 4 types of bipolar disorder and all of them involve significant changes in mood, energy and activity levels often in a very abrupt manner.

Bipolar 1 disorder is characterized by episodes that last at least 7 days or are so severe that the patient requires hospitalization. Depressive episodes typically occur as well and generally last at least 2 weeks and some have what is known as depression with mixed features meaning that they can simultaneously exhibit both depressive and manic symptoms at the same time.

These individuals may also be in a stable mood (known as euthymic) at some points as well. A manic episode in bipolar 1 can be characterized by an individual exhibiting exaggerated self-esteem, sleeplessness, racing thoughts, easily distracted, agitated, risk-taking and may include psychosis.

In Bipolar disorder II the patients have at least one manic episode and one depressive episode but the manic episode is far less extreme (known as hypomania) and these people tend to stay depressed for far longer periods of time then people who are in type I.

The third class is known as cyclothymia have numerous periods of mild hypomania and depressive episodes lasting at least 2 years but there symptoms do not meet the criteria for a diagnosis of depression.

The last class of bipolar disorder is known by the ambiguous term of bipolar disorder not otherwise specified (or in the new guidelines the equally vague other specified bipolar and related disorder) and is basically a category that was designed to put all those who did not fit the strict criteria of the previous 3 subtypes into. It is important to have fairly strict guidelines because in truth just about all of us exhibit behaviour that could be roughly classified as manic or depressive, sometimes on the same day.

Over the years, I have had more than one person express concerns about a loved one whose behaviours, while perhaps temporarily erratic, did not appear to meet the standards of this disorder. As for treatment, if the person is currently suffering from mania the list of possible options that should be tried begins with the drug lithium, as it has for decades. If that does not work, it is suggested that the next drug to try would be, in order, quetiapine/ Seroquel, divalproex/ Depakene and then asenapine/ Saphris.

These rankings are based on the drug’s effectiveness, potential for side effects and safety record which is what one would expect a ranking system to prioritize. About half will respond to one of these drugs within 3 to 4 weeks and if said patient does not exhibit significant improvement the next option should be considered.

In cases where the patient fails to respond to any of the options used on their own or if the patient presents with severe mania (i.e. severe risk taking behaviour) multiple drugs may be tried at the same time. Common combinations include lithium or divalproex with either quetiapine or aripiprazole/ Abilify.

Combo therapy brings with it a better chance of success but is also more difficult to take correctly (more pills to take in a patient group that is notorious for being non-compliant with their medications) and comes with a higher chance of suffering side effects from the additional drugs. For patients who have exhibited manic behaviour but are currently in a depressive state, quetiapine is the preferred option. Failure to respond to this would leave lithium or lamotrigine as good single drug options or a combination of lithium or divalproex with lurasidone could be tried instead.

Antidepressants should be used with caution in bipolar patients. They should never be used alone due to the potential of these drugs to “flip” the patient into a manic state of mind with all of the attendant risks this brings with it.

For those bipolar patients who are currently in a depressive frame of mind, classic antidepressants (like Prozac or citalopram) can be added to one of the drugs mentioned earlier but only as a fall-back option after all the other single agents and combination therapies have been tried. While it is great to have guidelines to help doctors (and patients!!) make better choices, it is important to remember that these are only guidelines and not hard fast rules.

It is absolutely fine to skip over a drug in the ranking for a good reason such as other medical conditions the patient may also have, a prior bad experience with a particular drug, symptoms that the patient is presenting with that may not match that of the typical bipolar patient or simply based upon the patient’s preference.

Overall, while bipolar disorder is a lifelong battle, an effective treatment plan based upon both medications and talk therapy can help many people gain better control of their symptoms and lead lives that are fulfilling.