6. MIXED BIPOLAR EPISODE-SYMPTOMS MIXED EPISODE SYMPTOMS

9. MIXED EPISODE COURSE

14. MEDICATIONS Carbamazepine Aripiprazole Ziprasidone Quetiapine Risperidone Aripiprazole Olanazapine Olanazapine Divalporex Lamotrigine Chlorpromazine Olanazapine-fluoxetine comb Lithium Lithium AC. DEPRESS. MAINT. ACUTE MANIA

15. FDA APPROVED BIPOLAR TREATMENT OPTION-MOOD STABILIZER _ + _ _ Lamotri _ _ + + DivaER/Carb ER - - - + Divalpro - - - + LITHIUM DEPRES MAINT. MIXED MANIA

16. FDA APPROVED BIPOLAR TREATMENT OPTION-antipsych _ + + + Aripipra _ _ + + Ziprasid _ _ _ + Quetia _ _ + + Risperi _ + + + Olanazapine DEPRES MAINT. MIXED MANIC

17. FDA APPROVED BIPOLAR TREATMENT OPTION-other + _ _ _ Olanaza/ Fluoxetin Depre Mainte Mixed Mania

18. Consensus Guidelines: Initial Treatment Regimen Bipolar I Add BZD to either agent MS alone MS + AP AP alone Mania with psychosis Combination of two MS Add a BZD to either agent AP alone MS + AP MS alone Mania with history of rapid cycling Add BZD to either agent AP alone Combination of two MS MS + AP MS alone Dysphoric mania or true mixed mania AP alone MS alone MS + AP Add a BZD to other agents Euphoric mania Alternate Strategies Preferred Initial Strategies Clinical Presentation

19. Consensus Guidelines: Inadequate Response to Initial Treatment Add different MS Replace the MS with different MS Replace the current AAP with a different AAP MS + AAP Switch to a MS Add a MS Monotherapy With an AAP Add an AAP Add a different MS Monotherapy With a MS Alternate Strategies Preferred Strategies Initial Treatment

20. TREATMENT OF MANIA Lithium and Anticonvulsant ++ 0.8-1.2 mEq/L 300-900 mg Level of 1.2 mEq/l Lithium EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE

21. TREATMENT OF MANIA Lithium and Anticonvulsant ++ 125 microgra/ml 250-500 HS for 2 days Oral load 30 mg/kg/d DVP EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE

22. TREATMENT OF MANIA Lithium and Anticonvulsant _ 125 microgra/ml 750 mg/day Oral load 30 mg/kg/d DVP ER EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE

23. TREATMENT OF MANIA Lithium and Anticonvulsant ++ 125 microgra/ml 250-500 HS for 2 days Oral load 30 mg/kg/d DVP EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE

24. TREATMENT OF MANIA Lithium and Anticonvulsant + 1600 mg/day 200 mg HS, BID or TID 800-1000mg CBZ EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE

25. TREATMENT OF MANIA Lithium and Anticonvulsant + 1600 mg/day 400 mg/day 800-1000mg CBZ ER EFFICA IN MAINTE MAX. DOSE START DOSE ADULT DOSE/ DAY DRUG MAINT. ACUTE ACUTE ACUTE

27. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING 30 mg 5-15 m/day 15-30 mg Aripriprazole Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute

28. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING + 30 mg 12.5-25 mg BID 100-900 QD or BID Cloz Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute

29. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING ++ 40 mg 5-10 mg HS; also 40 mg dis 15-30 mg QD or BID OLZ Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute

30. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING _ 800 mg 25-200 mg HS 400-800 mg QD or BID Queti Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute

31. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING _ 6 mg 1-6 mg Ris Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute

32. TREATMENT OF MANIA: ANTIPSYCHOTIC DOSING _ 160 mg 20-40 mg BID 40-160 mg QD or BID Zip Efficacy In Maint. Tx Max. Rec. Doses Starting Dose Adult dose/day Drug Mainten. Acute Acute Acute

33. Tolerability of Bipolar agents Other than antipsychotics = ++ 0 + + Lamotrigene ++ +++ 0 +++ + Cabamazepin ++ + 0 ++ ++ Divaloprex +++ ++ 0 +++ ++ Lithium GI Derm EPS CNS Weight gain Drugs

44. GUIDELINES FOR TREATMENT OF BIPOLAR DISORDER Utilize life charting Monitor patient and recognize that the course may change over time Educate patient and significant others Restore psychosocial functioning

45. GUIDELINES FOR TREATMENT OF BIPOLAR DISORDER Explore aggressive treatment strategies (eg loading strategies, ER formulations ) Individual treatment Treat entire illness, not just episode Accurate diagnosis-remission and ultimate recovery

46. GUIDELINES

51. SUMMARY