Bipolar Disorder
(F30) Manic episode
(F30.0) Hypomania
(F30.1) Mania without psychotic symptoms
(F30.2) Mania with psychotic symptoms
(F30.8) Other manic episodes
(F30.9) Manic episode, unspecified
(F31) Bipolar affective disorder
(F31.0) Bipolar affective disorder, current
episode hypomanic
(F31.1) Bipolar affective disorder, current
episode manic without psychotic symptoms
(F31.2) Bipolar affective disorder, current
episode manic with psychotic symptoms
(F31.3) Bipolar affective disorder, current
episode mild or moderate depression
(F31.4) Bipolar affective disorder, current
episode severe depression without psychotic
symptoms
(F31.5) Bipolar affective disorder, current
episode severe depression with psychotic
symptoms
(F31.6) Bipolar affective disorder, current
episode mixed
(F31.7) Bipolar affective disorder, currently in
remission
(F31.8) Other bipolar affective disorders
• Bipolar II disorder
• Recurrent manic episodes NOS
(F31.9) Bipolar affective disorder, unspecified
Depressive Disorders
(F32) Depressive episode
(F32.0) Mild depressive episode
(F32.1) Moderate depressive episode
(F32.2) Severe depressive episode without
psychotic symptoms
(F32.3) Severe depressive episode with
psychotic symptoms
(F32.8) Other depressive episodes
• Atypical depression
• Single episodes of "masked"
depression NOS
(F32.9) Depressive episode, unspecified
(F33) Recurrent depressive disorder
(F33.0) Recurrent depressive disorder, current
episode mild
(F33.1) Recurrent depressive disorder, current
episode moderate
(F33.2) Recurrent depressive disorder, current
episode severe without psychotic symptoms
(F33.3) Recurrent depressive disorder, current
episode severe with psychotic symptoms
(F33.4) Recurrent depressive disorder, currently
in remission
(F33.8) Other recurrent depressive disorders
(F33.9) Recurrent depressive disorder,
unspecified
Other Mood Disorders
(F38) Other mood (affective) disorders
(F38.0) Other single mood (affective)
disorders
• Mixed affective episode
(F38.1) Other recurrent mood (affective)
disorders
• Recurrent brief depressive
episodes
(F38.8) Other specified mood (affective)
disorders
(F39) Unspecified mood (affective) disorder
Adjustment Disorders
(F43.20) Adjustment disorder, Unspecified
(F43.22) Adjustment disorder, With anxiety
(F43.21) Adjustment disorder, With depressed
mood
(F43.24) Adjustment disorder, With disturbance
of conduct
(F43.25) Adjustment disorder, With mixed
anxiety and depressed mood
(F43.25) Adjustment disorder, With mixed
disturbance of emotions and conduct
Antidepressants
Drug Dosage FDA
indication
Benefits Risk/side effects PEARLS Special Considerations
SSRIs
Fluoxetine
(Prozac)
10-80mg/day
(start 20mg)
Depression,
Bulimia,
OCD, Panic
disorder
Activating, non-
selective,
inexpensive, long ½
life, little to no
discontinuation
syndrome
Headache,
Nausea, Tremor,
Sweats, Sexual
Side Effects,
Dulling of affect;
long ½ life with
active
metabolite; most
likely to induce
mania
Great for those with
substance abuse disorder or
long term depression
and/or treatment resistance
depression.
Dose in the morning
Not very serotonin
selective, also works on
norepi. Get big “bang for
your buck”
Potent 2D6 inhibitor
Citalopram
(Celexa)
10-40mg/day
(over 40mg
black box
warning). Start
20mg
Depression Mildly sedating,
Well tolerated, does
not interact with
most meds, easy
dosing range,
intermediate ½ life
Headache,
Nausea, sexual
side effects,
sedating; may
not be as
effective since it
is very selective;
QT prolongation
Great for those with mild
depression, or first episode
depression. Extremely
serotonin selective, no
norepi effects.
Can dose morning or
bedtime
Impairs Platelet Aggregation;
Risk of SIADH
Escitalopram
(Lexapro)
10-20mg/day;
10mg Lexapro=
20mg celexa
Depression,
Generalized
Anxiety
Disorder
Mildly sedating,
Very selective,
minimal side effects,
well tolerated, least
sexual side effects of
SSRIs
Headache,
Nausea
Will use when need a very
selective serotonin agent
but moderate-severe
depression.
Sertraline
(Zoloft)
50-200mg Day
(usually start
100mg/day)
Depression,
Panic, OCD,
PMDD,
PTSD, Social
Anxiety
Activating, only
SSRI safe in
cardiac disease,
short ½ life
Most GI side
effects; Sexual
Side Effects,
Large dose
range, BID
dosing for
tolerance at
200mg/day; max
absorption
requires full
stomach
Caution: May cause
agitation in the first week-2
weeks of treatment
especially in SSRI naïve
patients. Start low, go slow,
warn patients. Only take in
the morning to start.
Antidepressants
Paroxetine
(Paxil)
10-60mg/day Depression,
GAD, OCD,
Panic,
PMDD,
PTSD, Social
Anxiety
Mildly sedating;
short ½ life; no
active metabolite
Headache,
Nausea, sexual
side effects,
anticholinergic
side effects;
weight gain;
discontinuation
syndrome
I usually do not use as a
first line agent because of
side effects and drug
interactions.
Potent 2D6 inhibitor
Can potentiate bradycardia with
metoprolol; can decrease
analgesic effects with tramadol
SNRIs
Venlafaxine
(Effexor)
XR: 37.5-
225mg Daily
(don’t
recommend IR)
Depression,
GAD, Social
Anxiety,
Panic
Works well with
anxiety, depression,
ADD; Best 5HT to
NE ratio; usually
will know quickly if
effective; weight
neutral; short ½ life;
renal clearance
Severe
discontinuation
syndrome; Can
raise BP; Risk
with seizures;
Many people
cannot tolerate;
some QT
prolongation
Start low, go slow. Warn
about first week side
effects: sweating, agitation,
jaw clenching, dizziness,
problems with sleep.
About 10% of my patients
can’t tolerate for various
reasons
Can take several weeks to wean
off;
Desvenlafaxine
(Pristiq)
50mg/day (can
increase to
100mg/day but
limited benefit)
Depression,
Generalized
Anxiety
Disorder
Better tolerated than
Effexor; easy
dosing; quick
efficacy; works well;
weight neutral
Same as Effexor Will use when Effexor is
clinically effective, but side
effects are unbearable
Same as effexor
Duloxetine
(Cymbalta)
30-120mg/day Depression,
Generalized
Anxiety
Disorder;
Fibromyalgia;
Chronic Pain
Calming; quick
efficacy
Can increase
blood pressure;
can be overly
sedating; poorly
tolerated in some
Great to use with chronic
pain, fibromyalgia. Usually
my first line for these
people.
Moderate 2D6 inhibitor
Avoid in Renal and Hepatic
Dysfunction
TCAs
Amitriptyline 25-300mg/day
(QD or BID)
Depression Sedating; very
effective; can use to
augment SSRI
Sedating; cardiac
effects;
anticholinergic
effects;
orthostatic
hypotension
Works very well for sleep
or pm anxiety. Can use in
junction with SSRI
(monitor for serotonin
syndrome). Has serotonin,
norepi and dopamine
effects. Good for problems
with concentration
Major substrate of 2D6; avoid
with Alpha-1 antagonists or
Alpha-2 agonists; C/I in h/o MI
Antidepressants
Nortriptyline 25-150mg/day Depression Sedating; very
effective in chronic
pain/migraines; can
use with SSRI
Same Great for chronic pain. Has
serotonin, norepi and
dopamine effects
same
Imipramine 25- 300mg Depressio Stimulant effects;
can work as well or
better than
amphetamines in
ADHD
Some may not
tolerate; cardiac
effects;
anticholinergic
effects;
orthostatic
hypotension
same
Clomipramine 25-250 Depresion,
OCD
Same as
amitriptyline
Same as
amitriptyline
same
Others
Mirtazapine 15-45mg/day Depression Sedating, stimulates
appetite, very
effective, well
tolerated, can use to
augment SSRI
+++Weight gain Great first line drug for
mod-severe
depression/anxiety. Great
for elderly when appetite
stimulation needed.
Rare Agranulocytosis
Buspirone 5mg-20mg TID Anxiety Well tolerated;
calming; serotonin
effects
Headache,
nausea
3A4 substrate
Vortioxetine
(Brintellix)
10mg x 4 days
then 20mg
MDD Easy dosing; well
tolerated; no sexual
side effects
Still very new;
unknown
mechanism of
action; SIADH
Have not used on anyone
yet.
Mood Stabilizers
Drug Dosage FDA
indication
Benefits Risk/side effects PEARLS Special Considerations
Antiepileptics (AED)
Divalproex Valrpoic Acid (Depakote, Depakote ER, Depakene) (blocks voltage-gated Na channels; increases GABA concentrations)
Load: 20mg/kg/day IR 500mg ER Adjust to VPA level of 50-125
Bipolar Disorder (acute Manic/Mixed) Approved for bipolar mania in children/teens Off label: anger, aggression, bipolar depression
Works great in individuals with anger, aggression, mania. ER dosing is once daily. IR formulation is cheap. Can be combined with lithium or Seroquel.
Hard on the liver, must monitor LFTs (monitor monthly, then q 3-6 mths). Must monitor drug levels q 3-6 mths. Weight gain.
Nausea, vomiting, tremor (treat with propranolol)
My go to med for males with bipolar d/o. Great for criminal population (anger, aggression, impulsivity control). Works well for control of anxiety. Can help with PTSD. Need higher dosing for ER as only 80% bioavailable Helpful with migraine control
Pregnancy Category D Do not use in pancreatitis/liver failure Must Taper to wean off (risk of withdrawal seizures) May lead to PCOS in females
Carbamazepine (Tegretol, tegretol XR) (Voltage gated Na-channel blockade; inhibits glutamate release)
Load: 200mg BID to max of 1600mg/day Goal CBZ level of 6-12
Bipolar Disorder Off label: anger, aggression
Works great in individuals with anger, aggression, mania. Works with irritability and anger in PTSD/Dissociative ID disorder.
Titrate slowly. Monitor LFTs/BMP/CBC/ EKG. It induces its own metabolism at first so may take up to a month for steady state
Most often used 2nd line. Will use when failed other mood stabilizers or in conjunction with lithium or antipsychotic. Some help with control of anxiety and PTSD. Helpful with neuropathic pain
Pregnancy Category D Must Taper to wean off (risk of withdrawal seizures) Risk of hyponatremia Risk of aplastic anemia, agranulocytosis Risk of Stevens-Johnson Syndrome 3A4 inducer
Oxcarbazepine (Trileptal) (Voltage gated Na-channel blockade; inhibits glutamate release)
300mg BID up to 1200mg BID Do not have to monitor drug levels, but drug levels can be tested
Off label: Bipolar Disorder
No weight gain. No drug monitoring needed.
Same risks as CBZ, but to less extent.
Great when carbamazepine works, but pt will not comply with drug level testing. Some help with control of anxiety and PTSD.
Decreases effectivness of BCP *Use highest dose estrogen BCP Risk of Hyponatremia Must Taper to wean off (risk of withdrawal seizures)
Mood Stabilizers
Lamotrigine (Lamictal) (Voltage gated Na-channel blockade; inhibits glutamate release)
25mg / day x 2 weeks 50mg / day x 2 weeks 75mg/day x 2 weeks 100mg / day x 2 weeks Max: 200mg/day Decrease by ½ when using with valproic acid Double dose if used with carbamazepine
Bipolar disorder
Works very well in bipolar depression. Weight neutral. No drug monitoring. Useful in treating aggression/agitation in TBI or dementia
Few adverse effects (headaches, dizziness, somnolence, nausea).
Works well in women, especially women with borderline PD in addition to bipolar. More effective than lithium for preventing depressive episodes. Will use for treatment resistant major depression. Also effective in treating anxiety. Will use in PTSD.
Risk of Stevens-Johnsons (< 1%, highest risk is during initial loading) Must Taper to wean off (risk of withdrawal seizures) Oral BCP may increase clearance
Topiramate (Topamax)
25mg BID up to 200mg BID
Off label for bipolar d/o
Rarely use as monotherapy in bipolar disorder
Mood Stabilizers
Other
Lithium (carbonate and Eskalith) (unknown MOA)
300 mg bid or tid 900 – 1200 mg maintence 1800 mg day ~ acute episode Serum Drug Levels: > 0.5mEq/L therapeutic 0.8 – 1.2mEq/L for acute episode 0.6 – 1.2mEq/L for maintenance > 1.5mEq/L is toxic
Bipolar maintenance, mania and depression
Inexpensive and effective. Neuroprotective effects (activates trophic actions at the synapse) Antisuicide properties
Weight gain, tremor (treat with Vit E 400mg BID), hair loss, polyuria, nausea/diarrhea Caution in renal disease √ renal function tests / thyroid / CBC with diff / lytes/ sp. gravity if renal disease do 24 h Cr clearance √ lithium level biweekly to start √ every 3-6 months… Use ER formulation if side effects problematic
My go to drug in females especially those with borderline PD and/or self harm, suicidal ideation. Use to augment antidepressant when chronic suicidal ideation is present. Also good for anger and irritability
Pregnancy Cat D 3% of patients develop goiter 5% of patients develop hypothyroidism Lithium is sodium bound ~ high serum sodium lowers lithium level low serum sodium elevates lithium level AVOID DEHYDRATION ~ SWEATING Risk for Lithium Toxicity (as low as 1- 1.5 mEq/L) Symptoms: tremors, cognitive impairment, fatigue, N/V/D, thirst, indigestion, weight gain, rash, hair loss, edema of legs (may need to stop med) *diarrhea can be severe / Δ lytes! *risk of diabetes insipidus *NOT with thiazide diuretic or NSAIDS Spironolactone if diurectic is needed *NOT in patients with renal failure
Antipsychotics in mood disorders
Drug Dosage FDA
indication
Benefits Risk/side effects PEARLS Special Considerations
Atypicals (2nd generation)
Blocks D2 hyperactivity; reduces glutamate activity by different mechanisms; Serotonin 2A antagonism which causes efficacy in bipolar mania and psychosis Multiple mechanisms cause increased availability of serotonin, dopamine and norepinephrine which cause efficacy in bipolar depression
*CAUTION in folks with DM, hyper and hypglycemia weight gain is problamatic , cardiac problems / stroke akathesia, EPS, tartive dyskansia Monitor weight, lipids and A1C
Risperidone (Risperdal)
0.5mg – 6mg Consta – 25mg-75mg IM q 2 wks
Bipolar mania/mixed /maintenance
few anticholinergics side effects. Mild sedation. Once a day or BID dosing time to peak: 1 hr
↑ risk for movement disorders ↑prolactin
Most “typical” of the atypicals as dose rises Cheap and very effective, usually well tolerated. One of my first lines as it has less sedation/weight gain of other inexpensive atypicals
2D6 substrate Primarily renal excretion (care in renal disease) Caution in hepatic impairment
Olanzapine (Zyprexa)
5mg – 20mg, but frequently used up to 30mg/day
Bipolar mania/ mixed depression/ maintenance
↓ EPS Mildly sedating Does not raise prolactin Time to peak: 6 hrs
↑ ↑ weight gain, greatest cardiometabolic effects
Improves mood in bipolar and depression especially when combined with fluoxetine. Available in ODT, but time to onset no quicker
2D6 substrate Rare DKA/HHNK Smoking will reduce levels Caution in hepatic impairment
Quetiapine (seroquel)
25mg-800mg/day
Bipolar mania/ depression/ maintenance XR formulation: depression augmentation
Virtually NO EPS / TD. No prolactin. helps with sleep onset
very sedating weight gain cardiometabolic effects (less than Zyprexa) QTC prolongation risk (ave 12ms): monitor EKG and care with other QTC prolonging agents
Lack of EPS makes it preferred in parkinsons and bipolar/schizophrenia. Good antidepressant action Start low and go slow in naïve patients.
3A4 substrate (fluoxetine will increase levels, CBZ will decrease levels) Primarily renal excretion (care in renal disease) Caution in hepatic impairment Caution in seizure disorder
Antipsychotics in mood disorders
Ziprasidone (Geodon)
20mg to 80mg BID
Bipolar mania/mixed/ maintenance
Low EPS Low prolactin effects no weight gain lowers lipid levels mild sedation
NOT with electrolyte problems QTC prolongation risk (ave 20ms): monitor EKG and care with other QTC prolonging agents
Works better at higher doses than lower, so quick uptitration increased uptake with food Antidepressant and anxiolytic effects Good less expensive alternative to abilify if metabolic effects are concerning
3A4 substrate(fluoxetine will increase levels, CBZ will decrease levels) Safer in renal disease (PO formulation) Caution in CHF
Aripriprazole (Abilify)
2.5mg – 5mg to 30mg / daily slowly
Bipolar mania/mixed/ maintenance Depression Augmentation
no weight gain little to no cardiometabolic effects
↑ risk for movement disorders/ akathisia Activating, very little sedation Now generic, but still VERY expensive ($20-$30 a PILL)
Works well in treating mania, aggression, agitation Slow time to steady state: ½ life is 75 hrs! Not effective as a single agent when speed is needed
2D6 substrate 3A4 substrate (fluoxetine will increase levels, CBZ will decrease levels)
Lurasidone (Latuda)
201-120mg/day Bipolar Depression
No weight gain little to no cardiometabolic effects little risk for EPS
Well tolerated Mild sedation Nausea Brand only so expensive
Must take with small meal (400cal) Minimal cognitive effects Anxiolytic effects For some reason I have had the best result in African American females.
Caution in renal and hepatic impairment
Top Related