Advances in the pharmacological treatment of bipolar affective disorders.

TOPIC. Advances in the psychopharmacologic treatment of bipolar affective disorders (BPAD). PURPOSE. To increase advanced practice nurses' ability to match prescribing practices with known etiological factors and the neurobiology of this complex set of disorders. SOURCES. Published literature. CONCLUSIONS. A wide array of pharmacological agents exist that can be useful to manage BPAD symptoms. APRNs play a critical role in helping patients and their families to use these drugs effectively. Search terms: Anticonvulsant drugs, antimania drugs, bipolar disorder, manic depression Bipolar mood affective disorders (BPAD) are a common, often debilitating class of mental disorders that have been estimated to cost our society $15.5 billion per year in lost work productivity (Greenberg, Stiglin, & Finkelstein, 1993; Keck, Bennett, & Stanton, 1995). Recent advances in understanding the pathophysiology of BPAD have led to renewed hope for improved symptom control, decreased complications, and improved health outcomes for those suffering from bipolar disorders. Improved care practices, increasingly the standard of care, rely on the use of new drugs and the off-label use of older drugs to address the pathophysiologic deficits presumed to be common in BPAD. But these advances, and the concomitant increased use of a much wider array of drugs, also have increased the complexity of efficacious pharmacological management of BPAD disorders. This article discusses advances in the psychopharmacologic treatment of BPAD, the pharmacodynamic actions of these drugs, the link between the action of the drugs, the suspected etiology of BPAD, and the neuroanatomical sites the drugs target. Pharmacokinetic differences between commonly used mood stabilizing drugs are presented to assist nurses in understanding the underlying rationale for choosing one type of drug over another in the management of BPAD, and to safely assist patients and their families in using these drugs to stabilize symptoms. Understanding BPAD BPAD is estimated to affect 1% to 2% of adults, with the incidence increasing to 3% to 7% if all identified BPAD subtypes are included (Hilty, Brady, & Hales, 1999; Weissman, Bland, & Canino, 1996). Many experts believe this number is still a low estimate and that many patients experiencing refractory depressive disorders have undiagnosed BPAD. It is known that 10% to 15% of adolescents with recurrent major depressive episodes go on to be diagnosed with BPAD (American Psychiatric Association [APA], 2000), and one longitudinal study by the National Institute of Mental Health found that of 559 adult unipolar depressive patients followed over a 10-year period, 12.5% were eventually diagnosed with BPAD (Akiskal, Mase, & Zeller, 1995). More recent studies have suggested that bipolar disorders may account for 30% to 50% of all major depressions (Akiskal, 2000). Symptomatology. The diagnostic label of BPAD, historically referred to as manic depressive illness, is an umbrella term used to characterize a group of illnesses with cyclic, recurrent, polarizing mood disturbances that range from euphoria, elation, and mania at one pole, to irritability, dysphoria, and depression at the other (U.S. Department of Health and Human Services, 1999). Three types of bipolar affective disorders (Types I, II, and II) are well identified and differ mainly in the dominant polarity of displayed mood disturbance, as well as in the intensity and duration of mood and other symptoms. As new research emerges, more subtypes of BPAD are being discussed in the professional literature. Understanding the different subtypes of BPAD is critical to effective care management, because different subtypes respond differently to different drugs. Effective pharmacological intervention for patients with BPAD depends on matching the BPAD subtype to drugs known to be effective for the type. …