Treatment of agitation in bipolar disorder across the life cycle

Abstract

Agitation is a common and difficult problem in psychiatric patients; patients with bipolar disorder constitute a substantial proportion of the agitated psychiatric population. Agitation is often seen in bipolar patients during acute manic states, when increased energy levels and reduced need for sleep lead patients to collide with the limits of others. Agitation also occurs during mixed and depressive states, which are characterized by fluctuating energy levels and periods of irritability. Although the prevalence 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 the manifestations 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 decreases their suffering and maintains their safety and the safety of those around them. Considerations of speed and predictability tend to drive decisions in this setting more than concerns about tolerability. Oral or parenteral benzodiazepines, alone or in combination with an antipsychotic, are recommended as first-line treatment for the termination of behavioral emergencies in mania. Once behavioral control is restored, evidence suggests the combination of orally loaded divalproex sodium with an atypical antipsychotic is associated with more rapid improvement. Medication treatment of children and of geriatric patients must take into account developmental influences on the presentation of bipolar disorder in these different patient groups.