At the National Institute of Mental Health, discharge data from the past 30 years (1970 to 2000) indicate that more medications are needed today to achieve acute improvement in bipolar patients. The data for the year 2000 shows a higher prevalence of rapid cycling and an earlier age of onset of illness compared to the 1970's. For patients with bipolar disorder, this means that their children may present with initial symptoms 8 to 10 years earlier than the parent. In addition, these children may experience rapid cycling 2 to 3 times as frequent as the parent. Dr. Post cited this as one reason bipolar disorder is currently harder to treat.

Dr. Post reviewed the current treatment choices. He noted that lamotrigine has antidepressant effects with little switch liability. In contrast, gabapentin is not an antimanic or mood stabilizing agent. Topiramate is promising as a mood stabilizer and has the positive side effect of weight loss. The atypical antipsychotics are widely used in bipolar illness. The efficacy of atypical antipsychotics in depression and long-term prophylaxis has not been adequately studied. These drugs may be associated with weight gain. Thyroid and other augmentation strategies such as omega-3 fatty acids are being used, but additional data are needed to determine the validity of these treatments.

Lithium, carbamazepine, and valproate are widely recognized mood stabilizers. Yet, even when they are used with antidepressants, benzodiazepines, and typical and atypical neuroleptics, there is a high incidence of insufficient response in bipolar patients. For example, a recent study demonstrated a low (25%) response to combination therapy of lithium and valproate in rapid cycling bipolar illness. In addition, depressed breakthrough days were approximately 2.5 times more frequent than the number of days spent in mania. For these reasons, new antidepressant strategies are needed for the treatment of bipolar disorder.

Dr. Post obtained better responses with combination therapy. The average number of medications needed for his patients to be discharged from the National Institute of Mental Health is currently 4.4.

Dr. Post remarked that this strategy is used in conjunction with mood charts. Mood charts are carefully prepared by his patients. Working together, the patient and doctor plan a treatment of action.

(abstract Symposia No. 55B)