March 28, 2023

An introduction to Bipolar Type I and Type II, and drug treatments available. Lithium remains the cornerstone therapy, with anti-convulsants available for adjunct or monotherapy.

Hello pharmacology friends i would like to talk to you today about bipolar disorder type 1 and 2 and mainly our top choice for treatment which is lithium first of all i just want to make a characterization there are two subtypes of bipolar disorder there’s bipolar one and bipolar two bipolar one is generally what’s portrayed i think in the media as main bipolar

Disorder and bipolar disorder is literally bipols two poles so you have the swinging of mood or the cycling of mood from these really intense manic states to depressive states and if there’s at least one observable manic episode at least in the year which generally people don’t seek treatment during and they don’t seek treatment during it because it generally feels

Good there’s euphoria the sense of grandiosity hypersexuality energy goes up the need for leap goes down if there is an episode that severely impacts life especially if it results in hospitalization that generally garners a diagnosis of bipolar type 1 disorder bipolar type 2 however doesn’t involve such intense bouts of mania instead what we see is hypomania and

Remember that hypo means below so hypomania falls below severe mania and to some patients they describe it more so as a really intense surge of energy or productivity or creativity but there’s no psychotic symptoms that go along with it and then there’s less social disruption so you might not see hospitalization or um or arrest like you might see in bipolar one

I want to make a note that in general about 70 percent of those diagnosed with bipolar disorder receive an incorrect diagnosis to begin with why is that again manic episodes generally don’t garner the need for somebody to go seek medical treatment they feel good they feel productive whereas mainly you’ll see people seeking treatment during a depressive episode

And if somebody presents with major depressive symptoms generally they’re treated for depression which is why usually there’s a misdiagnosis first why that’s important to take into account is that if somebody is misdiagnosed or mistreated we see that not only does having bipolar disorder take about two years off of lifespan in general but one out of four to five

Patients actually complete a suicide mostly when they’re misdiagnosed and mistreated because some medications used for depressive disorders can start a manic episode start a major depressive episode and we see really pour out comes that being said it’s important to get a correct diagnosis find a great tool there are several great screens that are available online

Through different organizations there’s also the dsm um once there is a good diagnosis pharmacologic therapy is important a lot of people that start these medications for bipolar disorder will be on them for life if they comply or adhere to their regimen the fact that generally manic episodes are experienced in positive light especially with bipolar type 2 where

Rather than the mania being the predominant symptom these depressive episodes um low-level depression that’s long-standing is the predominant feature so when a manic or hypomanic episode hits it’s definitely more preferable than a depressive episode so only a third of patients diagnosed with bpd one or two are on pharmacotherapy and when it is necessary to start

Pharmacotherapy is when again you have this episode of hypomania or mania and depressive symptoms that occur as episode so a depressive episode or a manic episode certain things can trigger these these mood fluctuations in episodes so they can be stress related either psychological or physiologic stress certain medications big life changes moving from night shift

To a day shift making a move starting a new job or school program drug and alcohol abuse and it is important for me as an addiction scientist to mention that alcoholism or alcohol misuse alcohol use disorder is comorbid with bipolar disorder 30 percent of patients with bipolar disorder also have a diagnosable alcohol use disorder so it meets criteria one of the

Biggest things that um that can maybe be if you are making this diagnosis so something that might clue you in that it may be bipolar depression rather than unipolar depression is whether or not it follows a seasonal pattern that’s something that’s overlooked quite a bit where somebody gets a lot of energy and they feel really great in the spring and they tend to

Get really depressed in the winter believe it or not that can be bipolar too not just typical seasonal changes so once there is a diagnosis the major medication goal is reducing the fluctuation of mood from these really extreme from hypomania or mania to depression we want to use something that will stabilize that and reduce the frequency then of episodes because

Remember for specially bipolar one when there is a manic episode they can be so severe that we get hospitalization there is only one true mood stabilizer on the market and it’s our old school medication lithium which remains the top choice of treatment for today not everybody can tolerate lithium and some people are treatment resistant with lithium alone so there

Are medications that can either be used alone or adjunct to lithium and these are medications that are typically used for epilepsy so they include valproic acid lamotrigine carbamazepine all medications used for seizures but bipolar disorder seems to share an etiology or at least a pathogenesis that is similar so what you see here on this table is the list of

Medications that are approved to treat bipolar disorder type 1 and type 2. we also have the doses there if you’re interested in that but i have starred look at that pretty star our lithium carbonate because that again that’s our only mood stabilizer and this is in contrast to all the other medications like our depakote lamotrigine gabapentin carbamazepine and then

Topamax and trileptal tegratol those not only are anti-convulsants but they’re also used in the treatment of migraine and maybe i’ll do a video on this pathogenesis it seems like migraine mania and seizures all go along with this interesting kindling theory and they seem to spread along the brain through gap junctions that um that make the neurobiology or the

Neurophysiology really interesting so you will see a lot of overlap in the treatment for those but i want to just focus on lithium for the time being because on lithium which remains the first line treatment especially in bipolar type one bipolar two has a little bit of a different presentation so we might see anti-convulsants used more often as a pharmacotherapy

That is primary whereas with bipolar one lithium remains the main choice so if you remember chemistry who doesn’t you might remember lithium is on the periodic table like that’s how small it is it’s this little you know light alkali metal and it looks really similar to sodium that’s important for later um it also looks really similar to iodine also important for

Later when you give a neurotypical individual lithium there are no psychotropic effects meaning there’s no brain or behavior effects there can still be general physiologic effects which is definitely true but that doesn’t mean that they have a psychologic response it is 60 to 80 percent effective in treating acute hypomanic in manic episodes meaning if somebody

Is hospitalized for mania or hypomania lithium is most of the time going to resolve that episode also going with the history of medications that i just love in the 20s it was used as an anti-convulsant it turns out it wasn’t great for that so it was shelved for a little bit in the 40s that’s when we started to see this link between diet and cardiovascular disease

So we started to see the rise of popularity in the low salt diet or you know limiting salt to limit blood pressure lithium because it’s a salty alkali metal it worked really well as a salt substitute so if you didn’t want to sprinkle salt on your food you could sprinkle some lithium on your food so you don’t get the hypertensive effects um turns out that did have

Some physiologic effects along with it for some individuals because lithium is also a mood stabilizer in 1949 it was involved in just a general lab trial so imagine an animal laboratory with cages all along the wall filled with guinea pigs and if you’ve ever been by a guinea pig they call them pigs for a reason when you walk by them and they think they’re going

To be fed they squeak and they make a ton of noise and they’re really excited about being fed what they found is that when guinea pigs had lithium in their drinking water they were far calmer so those people working in the lab thought hey if it works for these loud guinea pigs maybe it’ll work in suppressing mood or mania in people and in 1970 there was quite a

Bit of a jump there they had to convince some people but it was found to be clinically relevant in treating bipolar disorder why also it’s important that we have other medications like the anticonvulsants on the market is we can pretty much even though the numbers are you know off let’s round them about a third of patients discontinue lithium for a variety of

Reasons uh the second third a little over a third they take but they do have reoccurrences of mania or depressive episodes and the last like third a little less than a third they take lithium on its own and they have no further episodes so some individuals are fine on lithium on its own the other greater than a third might need an adjunct medication to enhance

The mood stabilization properties of lithium all right so just our toxicities of lithium because this is a metal as mentioned before all right we’re trying to get rid of this term non-compliance and use non-adherence so that it doesn’t sound so so terrible like you’re non-compliant it’s it’s non-adherence to the pharmacologic regimen and about one out of two

Patients against medical advice will stop taking their lithium the main reasons that are cited are the intolerance to the side effects like the cognitive issues the memory and energy issues the weight gain and then missing the euphoric manic episodes however even though there are side effects that are not desirable we have really important outcomes when we have an

Appropriately treated patient with a great you know on the nose diagnosis lithium reduces suicidal behavior by about 80 percent when somebody stops lithium the rates have completed so not attempted but completed suicides increases 13-fold so that’s huge so we want to make the medication as palatable as can be so that individuals continue taking it and once lithium

Treatment is started it may be necessary for the lifespan of that patient

Transcribed from video
Bipolar Disorder I and II By Dr. Kimberly Bernosky