Treatment oF BIPoLAR DisoRDERs IN PwE

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Bipolar disorder is an episodic lifelong disease which may begin with a manic, hypomanic or depressive episode. If the bipolar disorder goes untreated, patients may experience 10 or more episodes in the course of their lifetime. While 4-5 years may elapse between the first two episodes, intervals shorten between subsequent episodes. Bipolar patients constitute about 20% of patients with an affective disorder in non-epilepsy patients; the actual prevalence of bipolar disease in PWE remains unknown, however. A population survey carried out in 181 000 households in which 2900 individuals reported a history of epilepsy, found that symptoms of manic depressive illness were identified in 12.2% of PWE, in contrast to 2% of individuals who described themselves as being healthy [33].

The aims of pharmacotherapy in bipolar disorders are to suppress acute major depressive, hypomanic, manic and mixed manic/depressive episodes and reinstate and maintain a euthymic state. Just as in co-morbid depression in epilepsy, the treatment of bipolar disorder in PWE has to be based on data from studies done in non-epilepsy patients. The management of bipolar disorders is fraught with a significantly lower therapeutic success than (unipolar) major depressive and dysthymic disorders and with potential complications, including a higher suicidal risk, co-morbid drug abuse and the development of psychotic episodes. The pharmacologic treatment includes the use of mood stabilizing agents, such as lithium, valproic acid, carbamazepine and lamotrigine. Obviously, in the case of PWE, AEDs with mood-stabilizing properties should be considered before lithium. Furthermore, anti-depressants should be used with great caution in these patients as they increase significantly a risk of triggering manic and hypomanic episodes. Anti-depressant drugs should not be used without a mood-stabilizing drug. Atypical anti-psychotic drugs are also an alternative for these patients. The use of this type of class is reviewed in the section on treatment of psychosis of epilepsy, below.

Lithium is the first 'mood-stabilizing drug' used for the treatment of patients with bipolar disorders. Its use in epileptic patients with affective disorders, however, has been fraught with several problems, including changes in electroencephalogram (EEG) recordings and pro-convulsant effects at therapeutic serum concentrations in non-epileptic patients. Lithium's neurotoxicity and related increase in seizure risk increases with the concurrent use of neuroleptic drugs, in the presence of EEG abnormalities and of a history of central nervous system disorder [34].

Finally, ECT is not contraindicated in depressed PWE. It is a well-tolerated treatment and is worth considering in PWE with very severe depression that fails to respond to anti-depressant drugs [35].

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Bipolar Disorder Uncovered

Bipolar Disorder Uncovered

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