Although considered highly prevalent, bipolar disorder is routinely misdiagnosed. Psychiatric literature is replete with data about over-diagnosis — particularly in pediatric populations — but this disorder is frequently under-recognized also.

Below are the major headwinds combating effective identification and treatment:

  • psychologistTime from onset of symptoms to accurate identification — if there even is such a thing — can be 10-15 years, because manic symptoms tend to bob and weave and often duck for cover. Mania is hard to recognize when there is considerable time between episodes and the uncooperative nature of affected individuals means they tend not to seek treatment while immersed in the throes of mania.
  • Bipolar depressive symptoms are far more prevalent than manic symptoms and thus provide additional cover for mania to hide.
  • There is now very credible evidence that 60-plus percent of bipolar I individuals experience symptoms of depression during episodes of mania. Therefore bipolar I and II classifications are time-worn and increasingly irrelevant.
  • The etiology of the disorder is quite the conundrum. Excitotoxicity, metabolic issues and neuroplasticity are all parts of the explanatory equation, yet neuroscience is not able to adequately address them so as to have a positive impact on treatment direction.
  • There are no animal models with validity. Therefore diagnosis is all over the place.
  • The major limitation to novel drug discovery is that there is no consensus on neuropathology, thus pharmacology is all over the place.
  • Except for lithium, most treatments for bipolar symptoms were not developed as “anti-polar” therapies (anticonvulsants, second-generation antipsychotics). As such, bipolar disorder has yet to find a good drug fit; the agents readily employed today have been merely repurposed and are best utilized for treating other disorders — physical and mental.
  • Even with optimal care, 50 percent of those who achieve symptom remission will relapse within two years. Relapse is influenced by suicide risk and alcohol use. The risk of suicide is highest among all psychiatric disorders at 25 percent. Ditto alcohol problems, also at 25 percent.

Because of these headwinds, creativity is all but a must in the treatment and management of bipolar disorder, rendering polypharmacy as not only necessary but also warranted because of treatment resistance, co-morbidities and substance abuse. Creativity though can open its own can of worms — worms that can crawl all over the bipolar sufferer in the form of intolerable side effects such as weight gain, sedation, malaise, derealization, cognitive fog, new onset type 2 diabetes, hyperlipidemia and hypercholesterolemia.

Irrespective of treatment modality, outcomes disappoint; so we’ll have to continue to plow forward and figure out ways to shine more light into the dark spaces of this mystifying mental health condition.

Contemporary best practices for managing bipolar disorder pharmacologically are as follows:

  • Lithium is clearly the most efficacious single agent for managing bipolar mania.
  • Combining lithium with Depakote does increase efficacy — although not markedly.
  • The lithium/Depakote combination therefore is optimal in bipolar mania.
  • Although FDA approved, second-generation antipsychotics are not yet considered first line treatment for mania.
  • Seroquel, Seroquel XR, Latuda (although very expensive) and the Prozac/Zyprexa combination Symbyax, stand out for bipolar depression. Make no mistake, bipolar depression is tough to treat effectively — much tougher than manic episodes. Don’t underestimate lithium’s effectiveness in bipolar depression.
  • Traditional antidepressants have practically nothing to offer for bipolar depression. They don’t necessarily cause a switch to mania but can induce hyperexcitability which masquerades as mania-like.

Treatment-resistant bipolar disorder:

  • In conjunction with the lithium/Depakote combination for mania, add a second-generation antipsychotic – Clozaril is best.
  • Creativity is required for bipolar depression. Lithium, Seroquel and Lamictal combinations are common.

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Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.

To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.