Fast Five Quiz: Bipolar Disorder With Agitation

W. Clay Jackson, MD, DipTh; Heidi Moawad, MD


February 23, 2023

Bipolar disorder is a lifelong illness that typically requires long-term, continuous treatment because of the risk for patient relapse. When de-escalation fails to reduce agitation, pharmacologic therapy may be necessary. The goal of pharmacologic therapy in the management of agitation aims to rapidly calm the patient without causing excessive sedation. Four classes of drugs most frequently used for agitation include typical antipsychotics, atypical antipsychotics, benzodiazepines, and selective alpha 2A–adrenergic receptor agonists. If possible, the selection of medication should be determined using a patient-centered approach to incorporate the patients' beliefs and values regarding their health and treatment.

Until recently, treatments could only be administered orally, via inhalation, or parenterally. However, in 2022, the FDA approved a sublingual film formulation of dexmedetomidine — a selective alpha 2A–adrenergic receptor agonist — for agitation in patients with bipolar disorder and schizophrenia. A recent randomized clinical trial concluded that among patients with mild to moderate agitation associated with bipolar disorder, treatment with dexmedetomidine resulted in significantly greater reduction in agitation compared with placebo.

In patients with severe mental illness, such as bipolar disorder, electroconvulsive therapy (ECT) is typically considered when other treatments, including medications and psychotherapy, have not worked. ECT may be an effective option in patients when rapid treatment response is required, such as patients at high risk for suicide.

Anticonvulsants, such as valproate, have proven to be effective in the treatment and prevention of mania but are not used for the management of agitation.

Learn more about bipolar disorders.


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