Treatment Considerations for Patients Experiencing Rapid-Cycling Bipolar Disorder

Perspectives in Psychiatric Care, Feb 2006 by Antai-Otong, Deborah

A thorough psychosocial history is crucial to accurate diagnosis and treatment. A detailed suicide and homicide risk assessment is crucial during the initial evaluation and throughout treatment. In addition, a detailed substance abuse and treatment history must be obtained. Because hypomanic and manic symptoms are rarely disclosed by patients, it is imperative to ask about:

* Distinct mood swings characterized by a reduced need for sleep

* Difficulty concentrating

* Agitation

* Increased energy

* Impulsivity

* Relationship or career problems

* Duration of symptoms

* Duration of euthymia

Several structured tools are also useful diagnosing rapidcycling bipolar disorder such as the Mood Disorder Questionnaire, which is a 13-item, self-report tool for bipolar (Hirschfield et al., 2000) and the Schedule for Affective Disorders and Schizophrenia-Lifetime Version (SADS-L) (Endicott & Spitzer, 1978). Once a diagnosis of rapid-cycling bipolar disorder is confirmed, pharmacotherapy interventions are considered.

Pharmacotherapy

As previously implied, rapid-cycling bipolar disorders are difficult to treat. Treatment must be based on current practice guidelines and expert consensus panels on the treatment of bipolar disorder. Historically, rapid-cycling has been generally unresponsive to lithium or carbamazepine (Denicoff et al., 1997; Maj, Pirozzi, Magliano, & Bartoli, 1998). Data from the largest prospective placebo-controlled study of rapidcycling bipolar disorder demonstrated the efficacy of lamotrigine in patients experiencing euthymia or a mood episode. A 6-week titration of lamotrigine up to 200 mg/day was used. The results of these data showed lamotrigine monotherapy was a useful treatment, particularly for patients with rapid-cycling bipolar II disorder. More recent data comparing lithium and valproic acid show no major differences of efficacy between lithium and divalproate in the long-term treatment of rapid-cycling bipolar disorder, but showed that lamotrigine has the potential to complement both drugs in treating depression (Calabrese et al., 2005). These findings support the APA (2002) Practice Guideline for the Treatment of Patients with Bipolar Disorder (Revision), which suggests initial treatment for patients with rapid-cycling bipolar disorder should include lithium or valproic acid and lamotrigine as second-line treatment. Adjunct therapy with these agents or an atypical antipsychotic agent is indicated in some cases.

The Expert Consensus Guideline Series on Medication Treatment of Bipolar Disorder (Sachs, Printz, Kahn, Carpenter, & Docherty, 2000) recommends divalproex as first-line treatment for monotherapy for patients who present with rapid-cycling bipolar, in any type of episode. Lithium is first choice for patient with a current episode of depression, mania, or hypomania and second-line for mixed mania. Lamotrigine is recommended as first-line treatment for rapid-cycling for patients presenting with depression.

Growing data indicate the efficacy of monotherapy using novel mood stabilizers and adjunct strategies combining conventional and novel mood stabilizers in the treatment of rapid-cycling bipolar disorder. Precise treatment of rapid-cycling bipolar disorder continues to be explored. Questions concerning what precipitates switching or mood acceleration and strategies to prevent them continue to be researched.