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Special Features Influencing Treatment
As noted earlier, several reversible “organic” factors may cause mood episodes, either de novo or in the course of already es-tablished manic–depressive disorder. For instance, removal of pro-manic drugs, both illicit and prescribed, is advisable in the treatment of substance-induced manic episodes. Treatment of general medical conditions, such as hypothyroidism, that may complicate course or treatment is also important.
Several conceptual approaches, not always explicit, un-derlie the choice of approach to managing comorbid disorders. Psychiatrists may assume that the comorbid disorder is caused by manic–depressive disorder and consequently that treatment of the manic–depressive disorder will lead to resolution of the comorbidity. For instance, panic attacks might be considered a consequence of mood episodes, or alcohol use a means of self-medication of depressive symptoms or a function of increased appetitive drive due to mania. On the other hand, psychiatrists may assume that the mood instability of manic–depressive dis-order is due to the comorbid illness. For instance, mood episodes may be thought to be due to alcohol or drug intoxication or with-drawal or to intrapsychic or psychophysiological effects of prior trauma. There are few data available to support either approach. Even the temporal sequence of onsets (e.g., manic–depressive disorder preceding substance abuse or vice versa) provides little information and in fact may be misleading in planning treatment.
The literature on alcohol dependence comorbidity, which is per-haps the most extensively studied of the comorbidities, provides no data with which to plan treatment strategy.
It stands to reason, however, that some type of parallel (simultaneous) treatment is preferable to sequential treatment (treating one disorder until resolution and then attending to the other), as the prognosis of manic–depressive disorder is worse when complicated by substance use and the course of alcoholism is worse when complicated by mood disorders. It is also likely that the highly confrontative approaches of some traditional sub-stance dependence treatment programs will not likely serve the needs of often highly impaired depressed or manic persons.
Although the somatotherapeutic and psychotherapeutic mainstays of treatment endure across the life-cycle, several phases of life present particular challenges. There is mounting data on treat-ment of manic–depressive disorder in childhood. Treatments arechosen by extension from the adult literature, with the one caveat that there have been rare cases of liver failure in conjunction with valproic acid use in children younger than 10 years of age who have been exposed to multiple anticonvulsants (Dreifuss, 1989).
In pregnancy, there is some early evidence that lithium may be teratogenic, associated with increased rates of cardiac abnormalities although more recent data indicate that this risk may be overestimated. Valproic acid and perhaps have been asso-ciated with neural tube defects leaving the neuroleptics, antide-pressants and ECT as the preferable management strategies dur-ing pregnancy, particularly during the first trimester. It should be kept in mind, however, that treatment decisions are based on risk, not certainty. Risk of fetal malformation, parental attitude toward raising children with birth defects, severity of illness and ease of management with alternative therapies all need to be con-sidered in conjunction with the woman and her partner.
Aging also presents certain treatment concerns. Tricyclic antidepressants may be associated with clinically significant car-diac conduction abnormalities, hypotension, sedation, glaucoma and urinary retention, particularly in the presence of prostatic hypertrophy. These are of even greater concern in the elderly. The risk of sedation due to neuroleptics and benzodiazepines and of hypotension due to low-potency neuroleptics can also particularly complicate treatment of elderly persons with manic–depressive disorder. Such side effects can cause far-reaching and serious complications, such as hip fracture which is not infrequently the initial event in a cascade of complications that can be terminal.
By contrast, lithium, carbamazepine and valproic acid are relatively well tolerated in the elderly once attention is given to the slower clearance of drugs in general in this population group. The risk of clinically significant renal toxicity with appropriately dosed lithium is not great. Although glomerular filtration rate decreases with age in persons treated with lithium, the rate of decline does not appear to be accelerated by lithium treatment. Nonetheless, careful monitoring of renal function is needed in the elderly. In addition, increasing age is clearly a risk factor for hypothyroidism as is lithium use. Thus, elderly persons taking lithium should be followed up carefully for decrements in thyroid function, although hypothyroidism is not an indication for lithium discontinuation but rather simply for thyroid hormone supplementation.
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