This has for decades, until very recently, been the drug of choice in treating the manic phase of bipolar disease and it is useful in preventing relapses of depression in some patients. Certain of the newer antipsychotic drugs, discussed in the next chapter, have overtaken lithium for the treatment of bipolar disease, with little evidence that they are superior. During an acute manic attack, hospitalization may be required to protect the manic patient from impulsive and aggressive behavior that might cause personal and interpersonal difficulty or jeopardize a career. Haloperidol (Haldol), or one of the newer antipsychosis agents discussed in Chap. 49—or electroconvulsive therapy (ECT, see further on) if these drugs are ineffective—can be used to control the mania until lithium carbonate becomes effective, usually a matter of 4 or 5 days. The usual dosage of lithium is 1,200 to 2,400 mg daily in divided oral doses, which produces a desired serum level of 0.9 to 1.4 mEq/L. The serum level of lithium must be checked frequently, both to ensure that a therapeutic dose is being taken and to guard against toxicity (see later).
The side effects of lithium are nausea and vomiting, diarrhea (especially if the dose is increased too rapidly), a feeling of mental dullness, action tremor, weakness, ataxia, slurred speech, blurred vision, dizziness, nystagmus (especially vertical or down beating), stupor, and coma. A confusional psychosis with polymyoclonus and ataxia-simulating Creutzfeldt-Jakob disease (including periodic sharp waves in the electroencephalogram) may occur at toxic levels. In patients who do not tolerate lithium, carbamazepine, valproate, or another antiepileptic may be substituted. A combination of lithium and a tricyclic or SSRI medication at the lowest effective level has been one of the most often used long-term preventive therapies for bipolar disease, and the same combination is useful for patients with mixed bipolar disorder in which depressive and manic manifestations occur within a single episode of illness.
Perhaps the most marked change in the treatment of bipolar disease is to initiate one of the approved antipsychotic medications (quetiapine, fluoxetine) rather than lithium to bring both the depression and episodic cycling into mania under control. Failing this, a “mood stabilizing” drug such as lamotrigine or divalproex has been used. As mentioned earlier, there is scant evidence that these approaches are superior to lithium. The point to be made is that the use of conventional antidepressants is currently less popular because of the risk of worsening depression to the point of a suicidal state or of inducing mania. Other combinations have been used such as olanzapine with a serotonergic antidepressant (e.g., fluoxetine). These are summarized in the review by Frye. Taken together the effectiveness of these new approaches serve to emphasize the importance of proper diagnosis of bipolar disease in contrast to unipolar depression. Haloperidol may be necessary to control a dangerous manic episode while one of these medications becomes effective.
In all patients with depression or bipolar disease, careful explanations of the patient’s illness, reassurance that the illness is self-limited, and encouragement and instruction of the family are of value in helping both the patient and family to understand the illness and cope with it. At the same time, there should be vigilance for suicidality, admittedly a difficult task given its unpredictability. As a general rule, bipolar illness is best managed by a physician who is willing to follow the patient over a long period of time and is available to reevaluate the patient on suspicion of a relapse. Although the prognosis for any individual attack is relatively good, it is wise to arrange for a plan of action that will be set in operation at the first hint of a recurrence.