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Treatment of Agitation in Bipolar Disorder Across the Life Cycle

Benjamin S. Alderfer, MD, and Michael H. Allen, MD

Published: April 1, 2003

Article Abstract

Agitation is a common and difficult problem in psychiatric patients; patients with bipolar disorderconstitute a substantial proportion of the agitated psychiatric population. Agitation is often seen inbipolar patients during acute manic states, when increased energy levels and reduced need for sleeplead patients to collide with the limits of others. Agitation also occurs during mixed and depressivestates, which are characterized by fluctuating energy levels and periods of irritability. Although theprevalence of agitation is similar in men and women, its presentation often differs between the sexes.In addition, the presentations of bipolar disorder in children and in geriatric patients, and thus themanifestations of illness-related agitation, differ both from each other and from that of younger adults.Intensive treatment is required to manage agitated bipolar patients in a manner that rapidly decreasestheir suffering and maintains their safety and the safety of those around them. Considerations of speedand predictability tend to drive decisions in this setting more than concerns about tolerability. Oralor parenteral benzodiazepines, alone or in combination with an antipsychotic, are recommended asfirst-line treatment for the termination of behavioral emergencies in mania. Once behavioral controlis restored, evidence suggests the combination of orally loaded divalproex sodium with an atypicalantipsychotic is associated with more rapid improvement. Medication treatment of children and ofgeriatric patients must take into account developmental influences on the presentation of bipolar disorderin these different patient groups.

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