J Korean Neuropsychiatr Assoc.  2018 Nov;57(4):301-307. 10.4306/jknpa.2018.57.4.301.

Strategies of Using Antipsychotics in Patients with Bipolar Disorders

• Jeon HJ

• KMID: 2426858
• DOI: http://doi.org/10.4306/jknpa.2018.57.4.301

Abstract

Bipolar disorder is a recurrent chronic condition and patients usually continue long-term medication from young age to prevent the recurrence of mood episodes. Antipsychotics play an important role in acute and maintenance treatment of bipolar disorder, even when patients experience no psychotic symptoms. Antipsychotics are also used in monotherapy and combination therapy involving mood stabilizers such as lithium or valproate. However, limited antipsychotics are currently approved by the US Food & Drug Administration ; 10 kinds of antipsychotics were approved for manic or mixed episodes, 3 for bipolar depression, and 5 for maintenance therapy. Before and after the use of antipsychotics, psychiatrists should carefully monitor baseline weight, pulse, blood pressure, fasting blood glucose or HbA1c, blood lipid profile, and electrocardiogram to evaluate QTc prolongation. During manic episodes or mixed features, antipsychotics rapidly control agitation, aggression, and impulsivity. Repetitive injections of typical antipsychotics are not implemented in bipolar patients as this practice is not evidence-based. However, long-acting injectable atypical antipsychotics are approved and feature support on maintenance therapy for bipolar patients. Although recent studies have shown the benefits of aripiprazole and olanzapine on rapid-cycling bipolar patients, few studies support the effectiveness of antipsychotics in suicide prevention. Moreover, while there is extensive evidence on the effectiveness of lithium in suicide or self-harm prevention. In conclusion, antipsychotics, especially aripiprazole, quetiapine, olanzapine, and risperidone, are effective to manage bipolar disorder in clinical settings. But weight gain and cardiac conductance should be carefully monitored before and during the use of antipsychotics.

Keyword

Bipolar disorder; Food & Drug Administration; QTc prolongation; Metabolic syndrome; Mania; Mixed; Depression; Maintenance

MeSH Terms

Aggression
Antipsychotic Agents*
Aripiprazole
Bipolar Disorder*
Blood Glucose
Blood Pressure
Depression
Dihydroergotamine
Electrocardiography
Fasting
Humans
Impulsive Behavior
Lithium
Psychiatry
Quetiapine Fumarate
Recurrence
Risperidone
Suicide
Valproic Acid
Weight Gain
Antipsychotic Agents
Aripiprazole
Blood Glucose
Dihydroergotamine
Lithium
Quetiapine Fumarate
Risperidone
Valproic Acid

Figure

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  Fig. 1 Flow to start antipsychotics medication in patients with bipolar disorders from the National Institute for Health and Care Excellence guideline.12) HbA1c : Glycosylated hemoglobin, BMI : Body mass index, BP : Blood pressure.

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  Fig. 2 Clinical Practice Guidelines of the American Psychiatric Association for antipsychotics in patients with bipolar disorders.32) ECT : Electroconvulsive therapy, R/O : Rule-out.

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