Chapter Six
Summary
Bipolar disorder is characterized by cycling between extreme highs or mania, and extreme lows or
depression. For some, the mania may be less intense and troublesome, so we refer to this as hypomania. While the
typical age of onset is about 19, it may be several years before a definitive diagnosis is made. Although effective
treatments are available, most patients will fail to maintain treatment protocol in the first five years.
In contrast to unipolar depression, bipolar depression is thought to be endogenously caused. It may
however, be triggered by exogenous stimuli. The concordance rates among monozygotic twins can be as high as
70%. In many cases, physicians and others fail to obtain adequate history and treat the more obvious depressive
symptoms first. This may trigger a manic or hypomanic episode.
Many other diseases have been known to cause or exacerbate mania. These include brain tumors, syphilis,
CNS trauma, delirium and dementia, hyperthyroidism, cancer, MS, Parkinson’s, hemodialysis, stroke, epilepsy, and
vitamin deficiencies just to name a few. Furthermore, drugs of abuse and other medications may cause manic type
symptoms. These include antihypertensives, antidepressants, cimetidine, steroids, disulfiriam, cocaine,
hallucinogens, PCP, opioids, and various stimulants.
Treatment of bipolar conditions can be tricky. Medications include mood stabilizers like lithium and other
anticonvulsants, but they may also include atypical antipsychotics . The choice of medication depends on which
phase of depression or mania the patient is exhibiting. Lithium is the “gold standard” as it may be used to control
both the manic and depressive aspects of the illness. Careful monitoring of lithium levels is essential to prevent toxic
levels, which is very close to the actual therapeutic level.
Specific Discussion Questions:
1. Explain the major differences between Bipolar Type I and II. How would a medication regime change to
address the differences?
2. Explain why Bipolar illness is thought to have a genetic predisposition.
3. Why is good patient education and family therapy so important when working with Bipolar patients?
4. Aside from anticonvulsants, which anti psychotics have been approved for treating manic symptoms?
5. Review the various steps of treatment based on the phase of the patient’s illness. When would one consider a
two or three-drug combination?
6. Which drugs may be best suited for a “mixed” presentation?
7. Why is good history taking so important when decided to medicate a depressed or manic patient?
Possible True/False Questions:
1. SSRI medications alone may trigger a manic episode in a bipolar patient.
2. Topamax or topiramate is believed to increase GABA and block glutamate receptors .
3. Both lithium and olanzepine are FDA approved as mono-therapies for Bipolar illness.
4. Most atypical antipsychotics and neuroletics are approved for use with bipolar patients.
5. For acute manic states, lithium or valproate would be approved medications.
6. Olanzepine and Lamictal ODT are also available as an orally disintegrating tablet.
7. Most anticonvulsants and other medications like lithium are safe to use during pregnancy.
8. Medications like lithium, carbamazepine, and clozapine require blood monitoring.
Multiple Choice Questions:
1. Which of the following drugs is thought to be the “gold standard” for treating Bipolar Illness?
a. Lamictal
b. Topamax
c. Lithium
d. Tegretol
2. Oxcarbazepine or Trileptal is similar to ________, but does not cause agranulocytosis or aplastic anemia?
a. Lithium
b. Tegretol
c. Neurontin
d. none of these
3. Which of the following is not associated with significant weight gain?
a. Lithium
b. Zyprexa
c. Topamax
d. Depakote
4. Which of the following may cause a toxic rash?
a. Lamotrigine
b. Gabapentin
c. Topiramate
d. None of these
5. Which of the following benzodiazepines is often used for its mood–stabilizing properties?
a. Xanax
b. Ativan
c. Klonopin
d. All of the above
6. Typically, we should wait about ____ days to see if a particular anti-manic medication is working before we
consider another.
a. 2-5 days
b. 5-10 days
c. 5-15 days
d. 15-20 days
7. Typical two-drug combinations for Bipolar Illness include:
a. An SSRI plus an MAOI
b. An SSRI plus a neuroleptic
c. Lithium plus an anticonvulsant
d. All of the above
8. Typical three drug combinations include:
a. An SSRI, a benzo, and an anticonvulsant.
b. An MAOI, A benzo, and an anticonvulsant.
c. Lithium, a stimulant and a benzo.
d. Lithium, an anticonvulsant, and an atypical antipsychotic.
Alternative Class Assignments and Essay Questions:
1. Explain why bipolar patients abuse drugs/alcohol in both the depressed and manic phase of their illness.
2. Why is good history taking so important in deciding if a patient has a Bipolar Type I or II presentation?
3. Can bipolar patients demonstrate aggressive even assaultive behaviors, explain?
4. Have students pair off with one person playing the therapist role and the other posing as a parent of a patient
with Bipolar Illness. What facts or points should be stressed and what suggestions could be given?
5. How can couple’s counseling help a spouse or partner cope with a loved one’s illness?
6. When considering poly-pharmacy for your client. Which prescribing professional offers the best options for
accuracy and knowledge concerning complex bipolar conditions?
Read the Case Vignette in this chapter and answer the following questions:
Case Vignette Discussion Questions:
1. What is the major pathology or diagnosis presented in the case?
2. Is there another disorder that may apply or should be ruled-out?
3. Do you agree with the medication suggestions made in this case?
4. Any other medications that might be considered…what is the rationale?
5. If you were asked to follow-up on this case as the treating therapist, would you offer any additional
suggestions or approaches?
Chapter Six
Answer Key
True/False Questions:
Multiple Choice Questions: