Navigating Bipolar Disorder Treatment: Exploring the Role of Second-Generation Antipsychotics

Andrew Penn, MS, PMHNP, and Julie Carbray, PhD, FPMHNP-BC, PMHCNS-BC, APRN, explore the nuanced role of second-generation antipsychotics in bipolar disorder treatment. They discuss the complexities of managing mania and depression phases and uncover the considerations for long-term maintenance alongside classic mood stabilizers like lithium.

Andrew Penn, MS, PMHNP: Hi, I'm Andrew Penn. I'm a psychiatric nurse practitioner and a clinical professor at the University of California San Francisco in the School of Nursing.

Julie Carbray, PhD, FPMHNP-BC, PMHCNS-BC, APRN: Hi, I'm Julie Carbray clinical professor of nursing and psychiatry at the University of Illinois at Chicago and the College of Nursing.

Andrew: Julie, lithium is a classic drug in psychiatry. We've had it for a long time—years now, and it's remained a favorite because it's effective and it works for many patients. Still, in recent decades, we've seen much more use of things like divalproex, but more specifically, anesthetics, particularly in the manic stage of the illness. Then, what often happens is people are kept on them for long periods of time after the mania has subsided back into euthymia or depression.

I think a lot of clinicians wonder what is the role of second-generation antipsychotics in the treatment of bipolar. Let's start with mania, and then we can move on to depression and whether it should be maintained over time in the same way that a classic mood stabilizer like lithium, lamotrigine, or valproic might be.

Julie: That's a great question, Andrew.

Bipolar disorder treatment really has phases of treatment. You have some patients who have a depressive phase, there's a manic phase, and each of our mood-stabilizing options has a phase of illness where they'll have FDA approval, and we have safety and efficacy. We also have this maintenance phase where less effective data is there for SGAs than our mood stabilizers when we're thinking about maintenance.

Atypical antipsychotics have a place for acute mania and a place for bipolar depression; there's developing literature around using some of these medications for mixed states, but when we think about rapid cycling, when we think about maintenance medications, lithium continues to be a gold standard. Really, capitalizing on the cycling features of bipolar illness, as well as continuing to maintain a mood state without elevation of mood or depression.

Andrew: Which is the definition of a mood stabilizer, right?

Julie: Absolutely. And from a tolerability standpoint, if you think about lamotrigine or lithium, [when] well monitored, [and when] continuing to manage things like labs and getting levels, they're really well tolerated. They do not carry the metabolic risk that you may have with some of the atypical antipsychotics. So when we think about keeping our patients on medications for a longer term, the consideration is the phase of illness, whether we're looking at maintenance and protecting our patients from an acute episode of illness again, and ongoing management of adverse effects.

Andrew: Yeah, it's really tricky with bipolar disorder because some patients, when they get sick, they get so sick. Then when we get them, there's this fear of, "oh gosh, I don't want to upset the apple cart here," and so the fear is if I take anything off or change anything, it's all going to come crashing down.

What I see happening is patients end up on a lot of medications for a long period of time, sometimes with questionable utility. They're on maybe 2 antipsychotics from when they were really manic, and now they're even slightly euthymic or even slightly depressed, and are those antipsychotics helping them? It's an important question.

Julie: Absolutely, and that's because there was an acute episode of illness where they may have been effective. Whether they still offer efficacy is a good question a clinician should have. So, always ask yourself, "Do we need all of these medications on board?" "What is the purpose, particularly in this illness state?" because there are so many fluctuations.

Andrew: Yeah. And when we do make changes, we do so gradually and monitor closely so that we can see if there's gonna be a change, but sometimes we can take people off of things, and they're okay.

Julie: And strategically.

Andrew: Yes, absolutely.

Thanks for joining us today. I hope you'll check back again for more updates on this channel.

Andrew Penn, MS, PMHNP, has practiced as a psychiatric/mental health nurse practitioner, treating veterans and training residents at the San Francisco Veterans Administration Hospital. As a researcher, he collaborates on psychedelics studies of psilocybin and MDMA in the Translational Psychedelics Research (TrPR) lab at UCSF, serving as Co-PI on a phase 2 study of psilocybin for depression and is currently working on a study using psilocybin to treat depression in patients with Parkinson's disease. He is a cofounder of the Organization of Psychedelic and Entheogenic Nurses, he has published on psychedelics in the American Journal of Nursing, Frontiers in Psychiatry, and The Journal of Humanistic Psychotherapy. Penn has also lectured at SXSW, Aspen Health Ideas Festival, the Singapore Ministry of Health, TEDx, and Oxford University.

Julie Carbray, PhD, FPMHNP-BC, PMHCNS-BC, APRN, holds her PhD (93) and Master of Science (88) degrees from Rush University, Chicago and her Bachelor of Science (87) degree from Purdue University in West Lafayette, Indiana. A Clinical Professor of Psychiatry and Nursing at the University of Illinois Chicago, she has been practicing as a Psychiatric Nurse Practitioner for over 35 years. Dr Carbray is a UIC faculty member and the director of the Pediatric Mood Disorder Clinic. Dr Carbray was recognized with the UIC Preceptor of the Year award, the Karen Gousman Excellence in Nursing Award, the American Psychiatric Nurses Association Best Practices in an Outpatient Program for Bipolar Disorder Award, the UIC Inspire Award, the APNA Distinguished Service Award and the Susan McCabe psychopharmacology lectureship from the International Society of Psychiatric Nurses.