Bipolar Therapy Protects Against Recurrences

By Brigitte M. Gensthaler, Munich / People with a bipolar disorder sway between extreme high and low feelings. Without treatment, they repeatedly suffer through phases of mania and depression. Psychotropic drugs can significantly reduce this risk.

At least two million people in Germany suffer from a bipolar disorder, also known as manic-depressive illness. The name refers to the extremes that patients experience alternately: Depression and mania (see box). However, they do not constantly oscillate between “heaven and hell”. Rather, there are also long phases with normal moods. “The progressions vary very strongly. In terms of time, most patients are depressed three times longer than manic. But two thirds of the time they have a normal mood,” explained Professor Dr. Hans- Peter Volz, Medical Director of the Hospital for Psychiatry, Schloss Werneck, at a regular journalists’ table in Munich supported by Lundbeck Pharma.

According to Volz, this diagnosis is always based on a correct assessment of the long-term course of the disease. Doctors often have to rely on information from patients or their relatives about their medical history for this purpose. The typical misdiagnosis: depression.

While the correct diagnosis is usually made within two to three years in the case of recurrent depression, it takes an average of eight to ten years in the case of bipolar disorders. Typical symptoms are an early onset of the disease before the age of 25, often before the age of 20, and several episodes of depression in a relatively short period of time.

Treat unconditionally

“The longer a bipolar disorder is not treated, the worse the prognosis”, the psychiatrist reminded. Untreated, the emotional states change more and more frequently. Doctors speak of a “rapid cycle” when the patient suffers four or more changes per year.

Psychotherapy as monotherapy is not helpful for bipolar disorders according to Volz. Instead, a drug therapy appropriate to the phase is necessary. The psychotropic drugs reduce the symptoms, but some increase the “switch risk”. This means that the patient “slips” from depression into mania or vice versa due to medication.

Caution with tricyclica

In the depression phase, an antidepressant is combined with a drug to stabilize the mood. Classic mood stabilizers are lithium and valproic acid; carbamazepine is also given. “Tricyclic and venlafaxine have a high switch risk, so selective serotonin reuptake inhibitors or bupropion should be preferred in patients with bipolar disorder,” said Volz. After the depression subsides, the antidepressant is discontinued and the patient continues to take the stabilizing medication for phase prophylaxis.

The clinical picture

The chronic disease is characterised by manic or manic-depressive mixed phases lasting at least seven days and depressive episodes typically lasting at least two weeks. Bipolar disorders affect both men and women. Typical of mania: Patients have a high level of energy and energy, are overactive, aroused and euphoric, even delusions of grandeur, hardly sleep and feel invulnerable.

Short periods with high charisma and charismatic appearance soon turn into irritability, aggressiveness and impulsive, uncritical and ruthless behaviour. In case of severe manic symptoms, hospitalization is necessary. In the depressive phase, the patient suffers from intense sadness, despair and listlessness, feels neither joy nor interest, is plagued with feelings of guilt and often suicidal thoughts. It is estimated that one fifth of patients try to take their own lives; 15 percent die in suicide.

In the manic phase, doctors give mood stabilizers such as lithium and valproic acid or atypical neuroleptics as monotherapy or in combination. Several substances are approved for the acute treatment of mania: Aripiprazole, olanzapine, quetiapine, risperidone and ziprasidone. The youngest in the alliance is asenapine, which has been available as a sublingual tablet since May 2011. Clozapine is only used when other active ingredients do not help, added Volz. This is an off-label use.

The atypics usually do not trigger a switch from mania to depression, Volz reported. This used to be very feared when classical neuroleptics such as haloperidol were administered.

The newcomer Asenapine was less effective than Olanzapine in two short-term studies over three weeks, but significantly better than placebo (read New on the market: Asenapine, Bazedoxifen, Bilastin, Conestat alfa and…, PZ 01/2011). Patients had fewer extrapyramidal motor side effects than among olanzapine and virtually no prolactin increase, reported Volz. The weight gain was about half as high. Most frequently, patients complained of drowsiness and anxiety.

Asenapine only sublingual

Since asenapine is subject to a high first pass effect, it is not given perorally, but sublingually (twice daily 10 mg). Placed under the tongue, the sublingual tablet dissolves within seconds. The patient is not allowed to eat or drink for ten minutes.

Antimanic therapy usually works well, even for a long time. After three weeks of therapy 80 percent of the patients respond, after 80 days it is 90 percent, the doctor reported. One in five, however, falls ill again despite correct phase prophylaxis. However, the risk without treatment is much higher. “Whoever has had two to three episodes and is bipolar has an untreated risk of 95 percent for a new episode.”