Bipolar disorder is characterized by episodes of mania, hypomania, and depression. Recurrences of manic or (more frequently) depressive symptoms are common. About 15-20% of patients with bipolar disorder die by suicide.

Nonopioid drugs can be used in the treatment of many nociceptive and neuropathic pain conditions. For severe pain, especially severe chronic cancer pain, use of opioids may be necessary. Noninvasive nonpharmacologic treatments, including physical and psychological therapies, have been shown to improve pain and function in patients with some common chronic pain conditions and are unlikely to cause serious harms. A multimodal approach to analgesic therapy can increase pain control while reducing opioid use and adverse effects.

Nonopioid drugs can be used in the treatment of many nociceptive and neuropathic pain conditions. Use of opioids for pain will be reviewed in a future issue.

Treatment of epilepsy should begin with a single antiepileptic drug (AED), increasing its dosage gradually until seizures are controlled or adverse effects become intolerable. If seizures persist, specialists generally recommend trying at least one and sometimes a second alternative drug as monotherapy before considering use of two drugs concurrently. When used for the appropriate seizure type, AEDs are roughly equivalent in efficacy. Drug choice is usually based on factors such as ease of use, adverse effects, drug interactions, presence of comorbidities, and cost.

View the Comparison Table: Some Oral Antiepileptic Drugs

Bipolar disorder is characterized by intermittent episodes of mania and/or depression. Even with maintenance treatment, recurrences of manic or (more frequently) depressive episodes are common. Some of the drugs and dosages recommended here have not been approved by the FDA for use in bipolar disorder.

Drugs are not the only treatment for psychiatric illness. Psychotherapy remains an important component in the management of these disorders, and cognitive behavioral therapy (CBT) can be used for many of them as well. Electroconvulsive therapy (ECT) has a long history of efficacy and safety when drugs are ineffective or cannot be used.

Drugs are not the only treatment for mood disorders. Psychotherapy remains an important component in the management of these disorders, and electroconvulsive therapy (ECT) has a long history of efficacy and safety when drugs are ineffective, poorly tolerated or cannot be used. Some drugs are recommended here for indications that have not been approved by the FDA.

Treatment of epilepsy should begin with a single drug, increasing the dosage gradually until seizures are controlled or adverse effects become unacceptable. If seizures continue and further dosage increases appear inadvisable because of adverse effects, most Medical Letter consultants generally prescribe at least one and sometimes a second alternative drug as monotherapy before considering use of two drugs at the same time. Most antiepileptic drugs initially approved by the FDA only as adjunctive therapy for partial seizures may also be effective for other types of seizures and as monotherapy. Studies suggest that when used for the appropriate seizure type, antiepileptic drugs are roughly equivalent in efficacy. The choice of a drug is usually based on factors such as ease of use, adverse effects and cost.

Genetic Test for Carbamazepine-Induced Stevens-Johnson Syndrome Carbamazepine (Tegretol, Carbatrol, Equetro, and others), which is now used to treat not only epilepsy but also trigeminal neuralgia and manic episodes in patients with bipolar disorder,1 is a known cause of Stevens-Johnson syndrome (SJS). The incidence of carbamazepine-induced SJS in countries with mainly white populations is 1 to 6 per 10,000 new users of the drug, but Asian patients have a 10-fold higher incidence of this reaction. An association has been found between the human leukocyte antigen (HLA)-B*1502 allele and carbamazepine-induced SJS in a Chinese population.2 This allele occurs almost exclusively in Asians.3,4 The FDA is now recommending that Asian patients be tested for genetic susceptibility to carbamazepine-induced SJS before starting the drug. The genetic test should be available in most clinical chemistry labs.

1. Extended-release carbamazepine (Equetro) for bipolar disorder. Med Lett Drugs Ther 2005; 47:27.
2. WH Chung et al. Medical genetics: a marker for Stevens- Johnson syndrome. Nature 2004; 428:486.
3. C Lonjou et al. A marker for Stevens-Johnson syndrome. . . : ethnicity matters. Pharmacogenomics J 2006; 6:265.
4. A Alfirevic et al. HLA-B locus in Caucasian patients with carbamazepine hypersensitivity. Pharmacogenomics 2006; 7:813.

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Drugs are not the only treatment for psychiatric illness. Psychotherapy remains an important component in the management of these disorders, and cognitive behavioral therapy (CBT) is used for many of them as well. Electroconvulsive therapy (ECT) has a long history of efficacy and safety when drugs are ineffective or cannot be used.

An extended-release formulation of carbamazepine, available since 1997 for treatment of epilepsy, has now been approved under a new name, Equetro, for acute mania and mixed episodes of bipolar disorder. Although the drug was effective in some patients for up to 6 months, it has not been approved for maintenance treatment. Carbamazepine has not been shown to be more effective than lithium or valproate, and it can cause serious adverse effects.