Clinical Practice Guidelines for Bipolar Disorder

MANAGEMENT OF PERSONS WITH PSYCHOSES
Bipolar Disorder with Psychotic Features Annotations

MODULE H

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A. Assess Need for Antipsychotic Medication

Mood stabilizers often require several weeks to elicit a clinical response. During this period, if a client has psychotic features, agitation, or disruptive behavior, adjunctive antipsychotic medication may be necessary (Frances et al. 1996; Bowden 1996; Kane 1988; Prien et al. 1972).

B. Initiate Antipsychotic Treatment

Acute Phase

In bipolar disorder with psychotic features, a high- or medium-potency conventional antipsychotic or an atypical antipsychotic should be tried first as an adjunct to mood stabilizer therapy (Frances et al. 1996; Gelenberg & Hopkins 1996). If necessary, low potency antipsychotics may be used. Newer atypical antipsychotics may represent promising treatment alternatives to conventional neuroleptics in the acute management of psychotic features in bipolar disorder, as there is low risk of extrapyramidal side effects (Marder & Meibach 1994; Kane 1988), and clozapine has been reported to be particularly efficacious in treatment of refractory mania (Suppes et al. 1992). Following is a representative summary of adjunctive antipsychotic treatments for acute psychosis in bipolar disorder:

Subacute Phase

Consideration should be given to discontinuing or reducing antipsychotic medication as acute psychotic features or agitation resolves. Risks of continuing antipsychotic medications (primarily development of tardive dyskinesia) must be weighed against benefits of continuing antipsychotic treatment (continuing symptomatic improvement).

C. Does the Person Meet Criteria for Schizoaffective Disorder?

Schizoaffective disorder is a complex and poorly understood clinical entity. Operationalized diagnostic criteria for schizoaffective disorder were not formalized and adopted until 1987 (DSM-III-R).

Consider the diagnosis of schizoaffective disorder if:

1. Mood episode is concurrent with the active phase symptoms of schizophrenia. These consists of two or more of the following:
   a. Delusions
   b. Hallucinations
   c. Disorganized speech
   d. Grossly disorganized or catatonic behavior
   e. Negative symptoms
   
   AND
2. During the same period of illness, there have been delusions or hallucinations in the absence of prominent mood symptoms for at least 2 weeks.
   
   AND
   
3. Mood symptoms are present for a substantial portion of the total duration of illness
   
   AND
   
4. The symptoms are not due to substance abuse or a general medical condition.

If 1 through 4 are not met, the person may require maintenance antipsychotic therapy (Frances et al. 1996). The long-term use of neuroleptics may also be indicated in some bipolar persons, specifically in those whose psychotic symptoms have not responded adequately to mood stabilizing agents (Sernyak & Woods 1993), or those persons who have severe worsening of symptoms or inability to function when neuroleptics are discontinued (Keck et al. 1996).

The term "schizoaffective" is often mistakenly used for persons who suffer from a major depressive disorder with psychotic features, or a bipolar disorder with psychosis, particularly when the psychotic symptoms are mood incongruent. Also, persons with schizophrenia who experience a depressive episode are often classified as "schizoaffective." These diagnoses are not accurate and may reflect cross-sectional rather than longitudinal person evaluations.

Long-term studies have found that a large number of persons who initially receive the diagnosis of schizoaffective disorder are more accurately diagnosed as bipolar or schizophrenic on follow-up. This suggests that the diagnosis of schizoaffective disorder should be used conservatively and reserved for persons who do not meet criteria for schizophreniform or mood disorders. However, it is clear that there also exists a subgroup that behave more like schizophrenics in long-term follow-up.

Pharmacologic treatment of schizoaffective disorder has not been extensively studied. In persons with schizoaffective disorder, bipolar type, the combination of lithium and antipsychotics appears to be more efficacious to antipsychotic alone (Keck et al. 1996). Although the combination of antidepressant and antipsychotic medications is common practice in the treatment of schizoaffective clients, the clinical efficacy has not been studied in controlled trials. Some persons may not improve with mood stabilizers and may best be treated according to the schizophrenia guidelines if a trial of multiple mood stabilizers under these guidelines is ineffective.

Recently, clozapine has shown some promise in the treatment of schizoaffective disorder. Research is needed with newer antipsychotic agents such as risperidone and olanzapine in schizoaffective disorder.

D. Continue Previous Treatment and Consider Tapering Neuroleptics

Little research supports the routine use of neuroleptics alone as maintenance treatment for bipolar disorder (APA guidelines, bipolar disorder 1994). Some investigators have suggested that neuroleptics may exacerbate postmanic major depressive episodes and induce rapid cycling in some bipolar persons (Kukopulos et al. 1980). In addition, persons with primary mood disorders may be particularly prone to the development of tardive dyskinesia after neuroleptic treatment (Tardive Dyskinesia, APA task force 1991; Shopsin et al. 1975; Mukherjee et al. 1986). Approximately 2 to 6 months after a manic episode has ended, consideration should be given to tapering antipsychotic medication in clients who have had stabilization of mood/psychotic symptoms and who are maintained on a mood stabilizer (Frances et al. 1996; Sernyak & Woods 1993). Reduction of antipsychotic medication should be done gradually to reduce risk of relapse (Schooler 1991). Clients with chronic psychosis in addition to mood symptoms may have schizoaffective disorder.

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