A MEDICATION ALGORITHM FOR TREATMENT OF BIPOLAR RAPID-CYCLING

Individuals with the rapid cycling form of bipolar disorder represent 13% to 20% of the bipolar population. Although lithium remains the tre atment of choice for classic bipolar disorder, failure rates as high a s 72% to 82% have been reported for lithium among those who have the r apid cycling variant. Treatment alternatives, including the use of div alproex sodium and carbamazepine, have shown promise for this often tr eatment-refractory group of patients. Predictors of positive outcome f or the acute and prophylactic management of mania with divalproex sodi um have emerged; they include nonpsychotic mania, the occurrence of de creasing or stable episode frequencies, mild mania, and mixed states. Predictors for positive acute and prophylactic antidepressant response s to divalproex sodium include nonpsychotic mania, increasingly severe mania, and the absence of borderline personality. Mixed results have been reported for studies using carbamazepine therapy for the treatmen t of rapid cycling bipolar disorder. Some investigators have reported success with carbamazepine in conjunction with other medications, whil e others have not. A psychopharmacologic algorithm for the treatment o f rapid cycling bipolar disorder is proposed. There is a growing opini on among psychiatrists that patients who rapidly cycle should be treat ed with an anticonvulsant prior to lithium. However, until homogeneous cohorts of rapid cyclers undergo at least random assignment to differ ent open treatments, these recommendations remain controversial.