How Would You Treat Bipolar Mania and Anxiety

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Here's an interesting theoretical case running through my head:

Middle-aged man with diagnosis of bipolar with acute mania and anxiety. No other comorbidities. No allergies. Normal labs. This is your first time seeing the patient. How would you treat pharmacologically? If using benzodiazepines, what would you give for maintenance for anxiety?

Some possibilities from the top of my head:

- treat bipolar only and hope anxiety goes away once mania subsides
- give monotherapy that treats bipolar and anxiety
- mood stabilizer + antidepressant
- mood stabilizer + non-antidepressant
- other

Please explain what medication(s) you would use and your rationale as to why you chose what you did.

 

[birchswing]

I can't help because I'm not a doctor, but isn't it more likely someone has anxiety or mania rather than both? And how can you tell the difference?

 

[AD04]

Yes, you can have both. From the DSM-5:

"Co-occurring mental disorders are common, with the most frequent disorders being any anxiety disorder (e.g., panic attacks, social anxiety disorder [social phobia], specific phobia), occurring in approximately three-fourths of individuals ..."

 

[splik]

sort of. as many as 93% of bipolar patients will meet the criteria for at least one anxiety disorder during their lifetime. However unless you have a clear longstanding history of anxiety neurosis in the absence of mood symptoms, you cannot diagnose a co-occuring anxiety disorder (nor should you) in someone who is acutely manic. No one in their right mind is going to give an antidepressant to an acutely manic patient. You treat the mania. These drugs will likely suppress anxiety sx regardless of whether related to mania or not. If there is clear ongoing anxiety after the fire is out, then the treatment of choice is going to be some sort of psychotherapy. Otherwise sprinkling a bit of gabapentin wouldn't be out of the question. several atypical antipsychotics like quetiapine which we wouldn't ordinarily use for anxiety (I hope) would be reasonable in a truly bipolar patient.

 

[Armadillos]

Here's an interesting theoretical case running through my head:

Middle-aged man with diagnosis of bipolar with acute mania and anxiety. No other comorbidities. No allergies. Normal labs. This is your first time seeing the patient. How would you treat pharmacologically? If using benzodiazepines, what would you give for maintenance for anxiety?

Some possibilities from the top of my head:

- treat bipolar only and hope anxiety goes away once mania subsides
- give monotherapy that treats bipolar and anxiety
- mood stabilizer + antidepressant
- mood stabilizer + non-antidepressant
- other

Please explain what medication(s) you would use and your rationale as to why you chose what you did.

Treat the mania however you want to so you can get him out of hospital where he can do therapy for anxiety.

Maybe im misreading, but your question strikes me a little bit like "how do you treat osteoarthritis in a patient currently having a heart attack?"

 

[Blitz2006]

Great question.

Is there good data that atypicals treat anxiety? Otherwise, I can't think of any "monotherapy" that treats both bipolar + anxiety.

 

[Blitz2006]

Treat the mania however you want to so you can get him out of hospital where he can do therapy for anxiety.

Maybe im misreading, but your question strikes me a little bit like "how do you treat osteoarthritis in a patient currently having a heart attack?"

I presumed OP meant treatment chronically....for Bipolar + Anxiety disorder

 

[AD04]

Great question.

Is there good data that atypicals treat anxiety? Otherwise, I can't think of any "monotherapy" that treats both bipolar + anxiety.

The one I'm thinking of has been mentioned: quetiapine.

 

[Blitz2006]

But seroquel isn't really effective for anxiety... It just sedates you...

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[AD04]

Treat the mania however you want to so you can get him out of hospital where he can do therapy for anxiety.

Maybe im misreading, but your question strikes me a little bit like "how do you treat osteoarthritis in a patient currently having a heart attack?"

I worded it wrong and Blitz got the meaning behind the question. I meant to say bipolar I disorder, most recent episode mania, in remission. I wanted to word it in a way where olazapine / fluoxetine isn't an answer.

 

[st2205]

But seroquel isn't really effective for anxiety... It just sedates you...

Which is usually what people mean by anxiety anyway, that they're not sedated enough or that they can still feel distress or discomfort so "it ain't workin' or you gotta up the dosage, doc, or put me back on the Klonopins!"

[ETA: above referencing generalities and not necessarily mania as they likely won't be wanting sedation.]

 

[clausewitz2]

Which is usually what people mean by anxiety anyway, that they're not sedated enough or that they can still feel distress or discomfort so "it ain't workin' or you gotta up the dosage, doc, or put me back on the Klonopins!"

[ETA: above referencing generalities and not necessarily mania as they likely won't be wanting sedation.]

This is why you can have study after study suggesting that vistaril and buspirone are effective for anxiety and still be hard-pressed to find people on the real world who feel they are even vaguely helpful for their own anxiety.

Though have now seen some people with anxiety that I think was seperable from a desire to just not feel things, and for that n = 3 vistaril was kinda magical.

 

[Shikima]

I have a few of these on my panel, usually are older women 60+ y/o.

Mania which is uncontrolled exacerbates their anxiety, which they're prone towards being a 'worrywart' to begin with.

 

[PistolPete]

I would treat the bipolar disorder with whatever second-generation anti-psychotic you want, and hope that it also treats any chronic anxiety, as mentioned above. If not, augment with therapy. Wouldn't prescribe any SSRI/SNRI/benzo. Could try buspar and vistaril as was mentioned above. Could also try gabapentin.

 

[smalltownpsych]

Treat the mania with medication and either provide or refer for psychotherapy to deal with the anxiety and also many of the other significant psychosocial problems that people with Bipolar Disorder often have.

 

[singasongofjoy]

Comorbidity is common, yes, but it would be an interesting thing to see what anxiety looks like in the context of an acute manic episode. Mania would seem to be the more pressing issue. I agree w/ @smalltownpsych.

 

[xavier2000]

But seroquel isn't really effective for anxiety... It just sedates you...

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https://www.ncbi.nlm.nih.gov/pubmed/25689246

 

[xavier2000]

Also read article recently using low dose Risperdal 0.25 mg

 

[Blitz2006]

Do you guys believe buspar works? We are taught that it is junk. Wrong?

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[splik]

Not sure it is anymore junk than any of the other treatments we use. Here's the thing. you're not going to convince a pt who is used to xanax that buspar is going to do anything for them. that said in benzo naive patients some report benefit. push up to 20mg tid, it is usually underdosed. Some people swear by prn buspar (which makes no sense - placebo maybe?) and some jails do not have it on formulary due to abuse and diversion. some patients snort buspar which just goes to show patients will try to abuse anything. opinions are mixed - some people say snorting it is the worst thing ever, while others still report a brief buzz from it.

 

[birchswing]

Since you all are talking about low dose antipsychotics for anxiety, I once had a psychiatrist recommend low dose Stelazine for anxiety. I always do my due diligence before agreeing to a med (well since I've been an adult I have) and in this case was actually invited by the doctor (challenged you might say) to see if I could find any side effects for low dose usage. Kind of a weird challenge because I found such side effects, even at low doses, almost immediately. I found that it actually had compelling evidence for anxiety, but I wasn't willing to risk the possibly permanent side effects. The doctor swore up and down there were "no side effects" at low doses, and questioned the quality of the material I came across saying otherwise. Doctors don't like "Dr. Googles" as they call them (even in this case when I was asked to research it); patients don't like hearing "no side effects" (well some might, I think most detect bull-****ting).

 

[clausewitz2]

Not sure it is anymore junk than any of the other treatments we use. Here's the thing. you're not going to convince a pt who is used to xanax that buspar is going to do anything for them. that said in benzo naive patients some report benefit. push up to 20mg tid, it is usually underdosed. Some people swear by prn buspar (which makes no sense - placebo maybe?) and some jails do not have it on formulary due to abuse and diversion. some patients snort buspar which just goes to show patients will try to abuse anything. opinions are mixed - some people say snorting it is the worst thing ever, while others still report a brief buzz from it.

Minor caveat re: benzo-naivete and buspar - I have seen some people who were on chronic benzodiazepenes transition successfully to it. BUT. These were uniformly the sort of people who started on something like 0.5 of Klonopin once a day and never really needed to escalate their dosing. That is to say, nobody who uses benzodiazepenes like the average person who winds up in an inpatient psych unit.

 

[Blitz2006]

Not sure it is anymore junk than any of the other treatments we use. Here's the thing. you're not going to convince a pt who is used to xanax that buspar is going to do anything for them. that said in benzo naive patients some report benefit. push up to 20mg tid, it is usually underdosed. Some people swear by prn buspar (which makes no sense - placebo maybe?) and some jails do not have it on formulary due to abuse and diversion. some patients snort buspar which just goes to show patients will try to abuse anything. opinions are mixed - some people say snorting it is the worst thing ever, while others still report a brief buzz from it.

I had no idea that Buspar could be abused. Good to know.

 

[675015]

I had no idea that Buspar could be abused. Good to know.

I think more in prisons than anywhere; lots more abused in prison than you would think because people are desperate.

I found this article interesting:
http://thecarlatreport.com/free_articles/psychopharmacology-jails-introduction-free-article

 

[clausewitz2]

I think more in prisons than anywhere; lots more abused in prison than you would think because people are desperate.

I found this article interesting:
http://thecarlatreport.com/free_articles/psychopharmacology-jails-introduction-free-article

Don't forget people in court-ordered D&A treatment.

 

[st2205]

BuSpar being abused? I'd naturally be a little cautious about most antiepileptics, Seroquel, Wellbutrin, Artane or Effexor in residential/correctional settings, but if someone wants to snort BuSpar, inhale Miralax or parachute metoprolol XL, who am I to take away whatever paltry euphoria they think they're getting from it?

 

[Blitz2006]

BuSpar being abused? I'd naturally be a little cautious about most antiepileptics, Seroquel, Wellbutrin, Artane or Effexor in residential/correctional settings, but if someone wants to snort BuSpar, inhale Miralax or parachute metoprolol XL, who am I to take away whatever paltry euphoria they think they're getting from it?

even Effexor?! Another drug I didn't know that could be "abused".

 

[splik]

seriously people will "abuse" anything they can get their hands on. with some exceptions idgaf and overly restrictive formularies tend to create more problems thanthey prevent. As long as the drug is genuinely indicated (which it usually isnt) and they are not vulnerable to manipulation (and thus unwittingly divert) just give them the drug!

 

[clausewitz2]

BuSpar being abused? I'd naturally be a little cautious about most antiepileptics, Seroquel, Wellbutrin, Artane or Effexor in residential/correctional settings, but if someone wants to snort BuSpar, inhale Miralax or parachute metoprolol XL, who am I to take away whatever paltry euphoria they think they're getting from it?

Honestly from a safety perspective snorting, I don't know, Keppra would be vastly preferable to snorting metoprolol.

 

[Merovinge]

Honestly from a safety perspective snorting, I don't know, Keppra would be vastly preferable to snorting metoprolol.

Keppra rage could be pretty exciting in a prison setting with a bunch of inmates snorting it. Seems like a premise for a movie...