#14089 - Manic Disorder - Psychology

3.What are the main clinical features of a manic episode? What is the evidence base for current treatment approaches?

Treatment

First-line—Each of the following medications are considered first-line monotherapy because each has consistently demonstrated its efficacy in multiple randomized trials; the drugs are presented in our general order of preference based upon the number of trials conducted, risk of side effects, and cost:

Lithium

Valproate (divalproex)

Quetiapine

Lamotrigine

Lithium—Lithium has been more widely studied than any other maintenance treatment for bipolar disorder. Evidence for the efficacy of lithium includes the following:

A meta-analysis of five randomized trials (753 patients) that evaluated lithium for one to two years found relapses occurred in fewer patients who received lithium compared with placebo (risk ratio 0.7, 95% CI 0.5-0.9) [25]. Lithium appeared especially effective in preventing manic recurrences. However, discontinuation of treatment due to adverse events was three times greater with lithium than placebo (risk ratio 3, 95% CI 1-8).

For patients who are unresponsive to or intolerant of lithium, we suggest valproate, quetiapine, or lamotrigine (Grade 2B). For patients who do not respond to or cannot tolerate these drugs, aripiprazole, olanzapine, or long acting injectable risperidone are reasonable alternatives. (See 'First-line' above and 'Second-line' above.)

For patients who have a history of multiple recurrences or have a partial but inadequate response to a maintenance drug that is tolerated, we suggest adding a second medication (Grade 2B). Common combinations include lithium or valproate, plus a second-generation antipsychotic, such as quetiapine, long-acting injectable risperidone, ziprasidone, or olanzapine. Other combinations that are useful include lithium plus valproate or carbamazepine. (See 'Patients who relapse often' above.)

Group psychoeducation as adjunctive treatment with pharmacotherapy can prevent recurrent mood episodes and enhance medication adherence. For patients with bipolar disorder, we suggest adjunctive psychoeducation for euthymic patients rather than no psychotherapy (Grade 2C).

Psychoeducation is a structured, time-limited program that teaches patients and family members about bipolar disorder, including its pathogenesis, clinical features, course of illness, and treatment; the program also addresses detecting prodromal symptoms. Nearly all other types of psychotherapy used for bipolar disorder include an element of psychoeducation because of its demonstrated success and the ease of administration. Several randomized trials indicate that group psychoeducation is efficacious both for preventing recurrent mood episodes and improving adherence to pharmacotherapy. The efficacy, administration, and content of group psychoeducation are discussed separately

21 week trial compared group psychoeducation with a nonspecific support group as add-on treatment in 120 euthymic bipolar patients who were receiving pharmacotherapy [10]. Both groups met weekly for 90 minutes. Patients were followed for up to two years after treatment, during which relapse occurred in fewer patients who received psychoeducation than nonspecific support (67 versus 92 percent). Follow-up assessments for up to five years after treatment found that the average number of recurrences per patient was lower in the group that received psychoeducation rather than nonspecific support (four versus eight) [11]. In addition, psychoeducation led to fewer hospitalizations per patient. Subgroup analyses in patients with bipolar II disorder (n = 20) [12] and in patients with comorbid personality disorders (n = 37) [13] also found that psychoeducation was superior to nonspecific support

Maintenance electroconvulsive therapy (ECT) has been used for patients who responded to ECT for treatment of acute mood episodes and failed many (eg, five) other maintenance medication regimens and psychotherapies [17]. Most of the evidence supporting the effectiveness and tolerability of maintenance ECT comes from small observational studies; the frequency of maintenance ECT ranged from once a week to once a month [90-98]. Maintenance medications, including anticonvulsants, are often prescribed in conjunction with maintenance ECT.

Monitoring bipolar patients with rating scales during ongoing treatment may identify nonresponders, detect residual symptoms, and help patients recognize improvement. Clinicians can track symptoms of mania/hypomania with the first 13 items of the Mood Disorder Questionnaire (table 8), and symptoms of depression with the nine-item Patient Health Questionnaire (table 9).