Unorthodox Use of Antipsychotics in Bipolar Disorder

[AD04]

Two questions:

1. I was reading UptoDate (Bipolar disorder in pregnant women: Treatment of mania and hypomania) and saw the following:

"The efficacy of haloperidol for treating mood elevated syndromes appears to be comparable to risperidone and olanzapine, and superior to quetiapine and lithium."

None of the attendings I work with prescribe typical antipsychotics for mania. Do you have experience doing so in non-pregnant patients? What was the result?

2. Do you use long-acting injectibles for bipolar? It isn't FDA approved, but it makes sense theoretically. If so, did it work?

---

Members don't see this ad.

 

[AD04]

Thank you.

It seems each region has its treatment preferences and I don't see the above used for mania where I am at.

 

[Merovinge]

SGAs are basically first line for treating BD these days. I'm pretty shocked you are somewhere that no one uses them. LAIs similarly work well, I use them a lot for bipolar disorder, particularly in poor insight cases. Ive increasingly had great results in adolescent bipolar where the teens refuse treatment but are actually willing to get the shot.

I'm a bit shocked you think its a regional thing though. The evidence base certainly isn't regional.

 

[Crayola227]

what's role of lithium in this?

when I did my INPT psych rotation, it seemed like there was no heavier-hitter than Haldol for manic or psychotic patients NOS for calming them the **** down fast, but for some reason I thought lithium was a reasonable choice for acute mania and also worked rapidly

also, since pregnancy was brought up, what are your guys' thoughts on:
1) maintenance
2) mania
3) depression
in that population
what's good, not so good, and really not usable?

 

[Armadillos]

Personally if someone is really manic and I'm using an antipsychotic I like zyprexa because its going to help them sleep. Granted, risperdal or haldol+ benzo is going to make someone sleep too

 

[Bartelby]

This is one of my favorite papers on the topic:

Cipriani, A., et al. (2011). "Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis." The Lancet 378(9799): 1306-1315.

First generation antipsychotics are a fine choice. Risperdal, Haldol, and Olanzapine are some good go-to options for mania.

 

[Ceke2002]

what's role of lithium in this?

when I did my INPT psych rotation, it seemed like there was no heavier-hitter than Haldol for manic or psychotic patients NOS for calming them the **** down fast, but for some reason I thought lithium was a reasonable choice for acute mania and also worked rapidly?

Non medical experience of course but a couple of my former friends with bonafide diagnosis of Bipolar Disorder were very much stabilised by the use of Lithium, in one case more so than any other medication. Unfortunately the only problem was one of them, who considered Lithium to practically be a life saver, developed severe renal function problems that eventually necessitated her having to be taken off the medication (she eventually committed suicide when other medications failed to be as effective), and with the other one Lithium worked so well that once he was completely stabilised on it he kept thinking he was 'cured' and would then stop taking the medication (at which point we'd all start a mental countdown as to how to quickly he'd end up being detained, yet again, in the state mental hospital after his inevitable relapse back into mania would eventually flip over into a violent state of florid psychosis - that was when Haldol became a real necessity, unless those working with him wanted to risk ending up with a few broken bones, or worse).

I'm actually surprised there's a question mark hanging over the use of antipsychotics in the treatment of Bipolar Disorder. If anything I would have perhaps expected the APs being used to perhaps have advanced a tad past something like Haloperidol, but when someone's both manic, and flordidly psychotic enough to be trying to beat the living daylights out of whoever happens to be closest to them then I don't really see how Lithium, or any other mood stabiliser for that matter, is going to be adequate under those circumstances.

 

[Liquid8]

The issue with haloperidol is the high rates of EPSE compared to alternatives so even though some might use it in an acute setting, it may not be suitable for ongoing maintenance.

To manage acute mania, I’d use a SGA + Benzodiazepam i.e. one of Olanzapine/Risperidone + Diazepam/Lorazepam.

If patients are very disturbed (eg. needing seclusion/restraints etc) and don’t look like settling on the above, then I’d look at zuclopenthixol acetate IM, although one has to be careful for cardiotoxic effects.

Would generally only use LAIs for maintenance in non-compliant patients or those under compulsory treatment orders, but I do have some on it by choice because it’s less of a hassle for them compared to taking something every day.

 

[Ceke2002]

The issue with haloperidol is the high rates of EPSE compared to alternatives so even though some might use it in an acute setting, it may not be suitable for ongoing maintenance.

To manage acute mania, I’d use a SGA + Benzodiazepam i.e. one of Olanzapine/Risperidone + Diazepam/Lorazepam.

If patients are very disturbed (eg. needing seclusion/restraints etc) and don’t look like settling on the above, then I’d look at zuclopenthixol acetate IM, although one has to be careful for cardiotoxic effects.

Would generally only use LAIs for maintenance in non-compliant patients or those under compulsory treatment orders, but I do have some on it by choice because it’s less of a hassle for them compared to taking something every day.

Yes, this does seem consistent with treatment protocols/management of SMI patients I've known over the years (although mind you most of my anecdotal experience dates back to the 90s). In the second case I mentioned in my post above, I don't believe Haldol was ever used for general ongoing maintenance, seeing as Lithium appeared to work quite adequately (when the patient took it that is). The use of Haldol only came into play when he was in a disturbed enough state to present a real and present danger to hospital staff.

 

[AD04]

SGAs are basically first line for treating BD these days. I'm pretty shocked you are somewhere that no one uses them. LAIs similarly work well, I use them a lot for bipolar disorder, particularly in poor insight cases. Ive increasingly had great results in adolescent bipolar where the teens refuse treatment but are actually willing to get the shot.

I'm a bit shocked you think its a regional thing though. The evidence base certainly isn't regional.

I've seen SGA. But not FGA and not LAI.

I know you have more experience than me, but there isn't a need to be an ass about it. If I didn't see something, snark isn't going to change it.

 

[HarryMTieboutMD]

I don't think any of these uses are unorthodox. The data suggest haldol is as good as it gets for treating acute mania. The reason I would discourage use of FGAs in bipolar where possible is bipolar patients have a greater risk of EPSEs than "schizophrenics" and FGAs cause depression so you might manage the mania, but will make your patients depressed. I am not convinced at all that SGAs treat bipolar depression as been much hyped, but they certainly don't appear to cause it. For patients with a mania predominant illness, or who request it, LAIs are certainly indicated. I have seen abilify maintena used more often and more successfully in bipolar patients than psychotic pts.

I have not seen any evidence of typical neuroleptics causing depression. Yes, they cause blunting, amotivation, anhedonia, etc but I have never had a case of a patient with bipolar treated with Haldol who subsequently develops an episode of depression. I have, however had bipolar depressed patients respond nicely to Seroquel and Latuda.

To the OP, as othe rpeople have stated Haldol is a good antimanic treatment, and when a patient is at risk for noncompliance Haldol D is a good, cheap "insurance" policy. A lot of the higher functioning bipolars will realize the need for compliance after a few hospitalizations, at which point I like to keep them on a monotherapy (Lithium, lamictal, or abilify are my go tos)

 

[splik]

It is common knowledge that FGAs cause depression in bipolar patients (or anyone in fact), or at least it used to be. One of the more recent studies to confirm this: https://www.ncbi.nlm.nih.gov/pubmed/14702269

 

[Crayola227]

I have not seen any evidence of typical neuroleptics causing depression. Yes, they cause blunting, amotivation, anhedonia, etc but I have never had a case of a patient with bipolar treated with Haldol who subsequently develops an episode of depression.

I would point out that those symptoms, while alone don't qualify for a DSM dx of MDD, certainly could feel very depressing to a patient.

Unable to feel pleasure, and no motivation? Strong emotions, like joy, happiness, even anger, blunted?

Yikes. Sounds depressing.

After seeing some bipolar and schizophrenics brought down to planet Earth with Haldol, I can see why they were begging to come off/dose lessened. I don't think they were yearning for their psychosis to come back or anything, but the above symptoms are a bitch.

If you don't want to do anything, can't feel much pleasure in anything, and feel a sort of robotic response to life situations that should trigger emotional responses, why would you want to? Why even live?

Sorry, just thought I'd challenge the ideas that patients would experience those symptoms and not likely find them distressing, if not outright "depressing."

I know someone whose anhedonia triggered an almost suicide attempt. Again, that's not depression, but certainly dangerous.

 

[clausewitz2]

I would point out that those symptoms, while alone don't qualify for a DSM dx of MDD, certainly could feel very depressing to a patient.

Unable to feel pleasure, and no motivation? Strong emotions, like joy, happiness, even anger, blunted?

Yikes. Sounds depressing.

After seeing some bipolar and schizophrenics brought down to planet Earth with Haldol, I can see why they were begging to come off/dose lessened. I don't think they were yearning for their psychosis to come back or anything, but the above symptoms are a bitch.

If you don't want to do anything, can't feel much pleasure in anything, and feel a sort of robotic response to life situations that should trigger emotional responses, why would you want to? Why even live?

Sorry, just thought I'd challenge the ideas that patients would experience those symptoms and not likely find them distressing, if not outright "depressing."

I know someone whose anhedonia triggered an almost suicide attempt. Again, that's not depression, but certainly dangerous.

Aaaand this is maybe a relevant point to the other thread about psychiatrists trying psychotropic drugs.

 

[HarryMTieboutMD]

It is common knowledge that FGAs cause depression in bipolar patients (or anyone in fact), or at least it used to be. One of the more recent studies to confirm this: https://www.ncbi.nlm.nih.gov/pubmed/14702269

No, it is not "common knowledge." It is conjecture based on low quality studies. I really like Zarate and some of the cutting edge stuff he has done (gave grand rounds for us last year) but this is purely pilot data. The sample size is tiny and there are obvious issues with neuroleptic dosing s/p mania resolution (ie, could the dose be safely lowered as is done in practice- the authors raise this) course of illness prior to index manic episode, etc etc etc Also, though the clinical endpoint is time to relapse until depression, the HAM D scores vary by 3 (which can be explained by the neuroleptic burden itself).

Bottom line, one cannot infer causality given equally possible (and according to Hume and his billiards, probable) outcomes.

I would point out that those symptoms, while alone don't qualify for a DSM dx of MDD, certainly could feel very depressing to a patient.

Unable to feel pleasure, and no motivation? Strong emotions, like joy, happiness, even anger, blunted?

Yikes. Sounds depressing.

After seeing some bipolar and schizophrenics brought down to planet Earth with Haldol, I can see why they were begging to come off/dose lessened. I don't think they were yearning for their psychosis to come back or anything, but the above symptoms are a bitch.

If you don't want to do anything, can't feel much pleasure in anything, and feel a sort of robotic response to life situations that should trigger emotional responses, why would you want to? Why even live?

Sorry, just thought I'd challenge the ideas that patients would experience those symptoms and not likely find them distressing, if not outright "depressing."

I know someone whose anhedonia triggered an almost suicide attempt. Again, that's not depression, but certainly dangerous.

You are missing the point. The claim that was raised was that typical antipsychotics cause depression in bipolar patients (meaning, it alters the course of the illness compared to what it would have been), which I refuted because it is nonsense. You are making the clinical point that taking them still sucks (though sometimes necessary) for a lot of patients, which is obvious.