f you’re being tormented by a mood or anxiety disorder, you’re likely interested in the happenings on the meds front. Who could blame you?! Often, unipolar depression and anxiety get top billing. But we’re going to take a look at the scoop from 2019 for bipolar disorder meds. Let’s roll…
Compared with other mood stabilizers, those using lithium had 50% fewer suicide attempts, better functioning, and less depression and aggression.
The piece was written by Chris Aiken, MD. Dr. Aiken is the director of the Mood Treatment Center and an instructor in clinical psychiatry at the Wake Forest University School of Medicine. It’s important to know that Dr. Aiken doesn’t accept honoraria from pharmaceutical companies.
Now, Dr. Aiken has written another article pertaining to the bipolar disorder meds scoop from 2019. I was going to review it here, but it would have made for a very long piece. So stay tuned, I’ll be back with “Part 2” in a handful of days.
Bipolar Disorder: Practice-Changing Trials from 2019
As in the original article, we’re going to do quick highlight summaries. Of note, Dr. Aiken points-out that in addition to official FDA decrees, over a dozen randomized controlled trials on bipolar disorder meds were released in 2019.
Cariprazine in Bipolar I Depression
Cariprazine (Vraylar) has been studied for bipolar depression since 2009. Results have been largely positive for the 1.5 mg daily dose. Interestingly enough, raising the dose to 3 mg daily doesn’t increase efficacy. There was a new trial in 2019 that produced essentially the same findings.
It seems compared to other atypical antipsychotics, cariprazine’s advantage is its tolerability, as well as proven efficacy in relieving both depression and mania.
Atypical Antipsychotic Augmentation Post-Mania
According to an analysis of a 2016 study, when risperidone (Risperdal) was used to augment a mood stabilizer in the treatment of mania it prevented relapses for up to six months. Longer use (up to a year) only resulted in additional weight gain.
Dr. Aiken says this provides a different spin on the maintenance story, because earlier studies stopped the antipsychotic after two to three months. So it wasn’t clear if the med could be safely stopped at a later point. Now we know that discontinuation at six months is feasible – with a slow taper. Dr. Aiken recommends lowering the dose every two weeks, keeping the original mood stabilizer in place.
Lithium & Children
In a trial of children aged seven to twelve, lithium, in contrast to risperidone, kept working to prevent manic episodes after six months.
Separately, lithium performed well in a large study from 2019 that followed youth with bipolar disorder for an average of ten years. Compared with other mood stabilizers, those using lithium had 50% fewer suicide attempts, better functioning, and less depression and aggression.
Carbamazepine (Tegretol) and valproate (Depakote) have been used to augment lithium for years. Thing is, the two were never compared head-to-head until 2019.
The number of study subjects was small, but validity was supplied by a long duration. Pertaining to mania and depression, both anticonvulsants performed similarly. However, carbamazepine was better tolerated in terms of weight gain, fatigue, and sexual dysfunction.
Thyroid Augmentation for Anxiety
Supraphysiologic (greater than normally present in the body) thyroid doesn’t sound like a good idea for someone struggling with anxiety. However, a 2019 study – analyzing a 2014 trial – found it didn’t worsen anxiety, and anxiety symptoms didn’t predict antidepressant effects. So it appears as though levothyroxine (Synthroid) may be helpful for bipolar depression.
TMS Doesn’t Harm Cognition – Might Even Help
Bipolar depression responds to both electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). But ECT is limited by its cognitive effects. Not only did a 2018 study show that TMS in bipolar disorder didn’t cause cognitive deficits, a 2019 study found that for euthymic bipolar patients, TMS actually improved cognitive measures.
Rivastigmine & Memantine
Dr. Aiken quickly mentions the anti-dementia drugs rivastigmine (Exelon) and memantine (Namenda) for the treatment of bipolar mania. He says the trial results were either not significant or not clinically significant. He’ll pass on both until more data is available.
Dr. Aiken created and included the following chart in his article. Great reference material…
So There You Have It
If you’re doing all you can to manage bipolar disorder, I’m thinking you found what we reviewed relevant and helpful. Knowledge always is, not to mention all-out powerful.
As I said, look for Part 2 of this series in several days. It includes even more valuable information from Dr. Aiken.
Dr. Aiken’s article in Psychiatric Times: Bipolar Disorder: Practice-Changing Trials from 2019
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