10 Things You May Not Know About the Treatment of Bipolar Disorder in Women

Dr. Sharon Orrange
Dr. Orrange is an Associate Professor of Clinical Medicine in the Division of Geriatric, Hospitalist and General Internal Medicine at the Keck School of Medicine of USC.
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Bipolar disorder is just as common in men as in women, yet women are more likely to experience mixed episodes. Bipolar disorder can have many types of mixed episodes but the most common are manic episodes with mixed features, and depressive episodes with mixed features.

What does that mean? Women more often experience mixed episodes. These can be manic episodes with at least three depressive symptoms (depressed mood, fatigue, suicidal ideation, etc) or depressive episodes with at least three manic symptoms. It is important to know which one you have, because treatment is different.

  1. In women, a mixed episode (manic and depressive) should be considered when opposite symptoms are occurring together, such as hypersexuality and suicidality or hypertalkativeness and depressed mood.
  1. Anxiety symptoms, including panic attacks, are very common in mixed episodes and can be the presenting complaint.
  1. Bipolar women are more likely to have major depressive episodes and be treated with antidepressants. This is not good.
  1. Treatment with an antidepressant can trigger a manic episode and if this happens, the appropriate treatment is to stop the anti-depressant and begin an anti-manic agent.
  1. Know this: no data from clinical trials supports the use of antidepressants in mixed mania (mania with depression).
  1. The treatment for mixed mania is very similar to the treatment for pure mania. There are 10 medications approved by the FDA for the treatment of acute mania, and 6 of them are approved for treating mixed mania (Abilify, Saphris, Carbatrol, Zyprexa, risperidone, and ziprasidone).
  1. Drugs approved for mania but not for mixed mania include chlorpromazine, lithium, quetiapine, and valproate. All of these are generics and thus more affordable.
  1. Antidepressants are not used to treat mixed mania. In fact, they have been reported to increase depressive symptoms in mixed states. Even antidepressants used with mood stabilizers do not appear to be effective for depression.
  1. Three meds that should be used for the treatment of bipolar I depression (depression in bipolar patients) are: Latuda, Symbyax (the generic is olanzapine/fluoxetine), and quetiapine. These all seem to work the same, yet have different side effect profiles.
  1. Benefits of those three therapies listed in #9 include decreases in relapse rates, mood fluctuations, need for medications, and hospitalizations.

Dr O.

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