ANTIMANIC DRUGS

Mood stabilizers

TREATMENT GOALS FOR BIPOLAR DISORDER

Remission Prevention Return to premorbid function

SIGNS AND SYMPTOMS OF BIPOLAR DISORDER MANIA

Elevated mood Increased in activities Flight of ideas Racing thoughts Inflated self-esteem Decreased need for sleep Agitation More talkative than is usual Pacing, hand wringling Extreme restlessness Loses temper often Significant irresponsible behavior Increased goal-directed activities (sexual, social) Impaired excessive, involvement in pleasureable activities, with high potential for painful consequences Delusions

LITHIUM
Used to treat bipolar disorder by stabilizing the clients mood, preventing or minimizing the highs and lows that characterize bipolar illness

Mechanism of action
Inhibits the release of norepinephrine, serotonin, and dopamine while facilitating their reuptake into presynaptic terminals

Therapeutic drug serum level: 0.6 1.2 mEq/L

Serum lithium levels should be checked every 1 2 months or whenever any behavioral change suggests an altered serum level Blood samples to check serum lithium levels should be drawn in the morning, 12 hours after the last dose was taken

CLIENT TEACHING
Administer medication with food minimize GI irritation Instruct client to maintain fluid intake of 6 8 glasses of water a day Instruct client to avoid excessive amounts of coffee, tea or cola Instruct client to maintain adequate salt intake

CLIENT TEACHING
Do not administer diuretics while the client is taking lithium Avoid alcohol Avoid OTC Client may take a missed dose within 2 hours of the scheduled time; otherwise, the client should skip the missed dose and take the next dose at the scheduled time

CLIENT TEACHING
Do not adjust the dosage without consulting the physician lithium should be tapered off and not discontinue abruptly Instruct signs and symptoms of lithium toxicity Notify physician if polyuria, prolonged vomiting, diarrhea or fever occur

CLIENT TEACHING
Therapeutic response to the medication will be noted 1 3 weeks Monitor electrocardiogram, renal function tests, and thyroid tests

Lithium Toxicity
Occurs when ingested lithium cannot be detoxified and excreted by the kidneys Serum lithium level : 1.5 mEq/L and above

Therapeutic Mild to Serum Levels Moderate (0.6 -1.2 mEq/L) Toxicity (1.5 2 mEq/L Hand tremor Diarrhea (fine) Vomiting Memory Drowsiness problems Dizziness Goiter Hand tremor Hypothyroidism (coarse) Mild diarrhea Muscular Anorexia weakness Nausea Lack of Weight gain coordination Polydipsia, Dry mouth polyuria

Moderate to Severe Toxicity (2 3 mEq/L) Previous symptoms and: Giddiness Tinnitus Blurred vision Large output of dilute urine Delirium Nystagmus

Severe Toxicity (>3mEq/L)

Previous symptoms and: Seizures Organ failure Renal failure Coma Death

Interventions:
Hold lithium and notify physician NO ANTIDOTE is available Monitor V/s and LOC Monitor cardiac status

Interventions:
Prepare to obtain lithium level; electrolytes, BUN, creatinine level and CBC Gastric lavage Parental normal saline Forced dieresis or hemodialysis

INTERACTIONS

Can elevate lithium serum levels Diuretics (except acetazolamide) NSAIDs

Low salt diet after treatment commences

Can decrease serum lithium levels

Acetazolaminde (Diamox) Caffeine Alcohol

ANTICONVULSANTS

Valproates
Used as an antiepilectic agent
Increase in the inhibitory role of GABA Suppression of sodium influx into the neuron Suppression of calcium influx through specific calcium channels

Advantages:
Have a rapid onset Can be used initially without attempting lithium and are welltolerated with little effect on cognition

Disadvantages:
Transient hair loss Weight gain Tremors GI upset Dose-related thrombocytopenia

Carbamazepine
Effective for most patients who do not respond to lithium or to the valproates Has a faster onset of action compared with lithium

Side effects:
Nausea Anorexia Occational vomiting Sedation and drowsiness Agranulocytosis most serious potential side effect

Lamotrigine
Approved for the treatment of bipolar disorder including bipolar depression
manipulating the GABA system, thus inhibiting neuronal firing blocking of voltage-gated sodium and calcium channels, further inhibiting neuronal conduction believed to inhibit the excitatory neurotransmitter glutamate

Oxcarbazepine
Does not cause some of the more serious adverse reactions associated withcarbamazepine Commonly prescribed agent for bipolar disorder

Gabapentin
Tends to be used in an adjunctive role and not as monotherapy It is believed to be particularly effective if the patient also experiences anxiety

Topiramate
It increases GABA activity, blocks voltagegated sodium and calcium channels, and inhibits the excitatiryneurotransmitter glutamate

ANTIPSYCHOTICS

 Olanzapine Risperidone

Quetiapine
Ziprasidone Clozapine Aripiprazole