Selection and use of drugs The choice of the drug can be difficult because all drugs have significant adverse effects, drug interactions are common and no drug is universally effective. The selection should be based on what has so far been effective and well tolerated in a particular patient. Without prior experience (or if they are unknown), the choice is based on the medical history of the patient (in view of the adverse effects of the specific Stimmungsstabilisierers) and the severity of symptoms. In severe manic psychosis, in the immediate patient safety and fault management are at risk of acute behavioral control usually requires a sedating antipsychotic of 2nd generation that sometimes initially by a benzodiazepine such as lorazepam or clonazepam 2-4 mg i.m. or p.o. is 3 times supplemented / day. For less severe acute episodes in patients without contraindications (z. B. kidney disease) Lithium is a good choice for both mania and depressive episodes. Since the onset of action slowly (4-10 days), patients can receive significant symptoms and an anticonvulsant or an antipsychotic of 2nd generation. the anticonvulsant lamotrigine may be a good choice for patients with depression. In bipolar depression, the best indication suggests treatment with quetiapine or lurasidone alone or the combination of fluoxetine and olanzapine before. Upon reaching a remission preventive treatment is indicated with mood stabilizers for all patients with bipolar I disorder. If episodes recur during maintenance therapy, doctors should determine if adherence is low, and, if so, whether the lack of adherence occurred before or after the relapse. The reasons for lack of adherence should be elicited to determine whether could achieve more accepting of the treatment by switching to another mood stabilizer or dose modification. Lithium As many as two-thirds of patients with uncomplicated bipolar disorder respond to lithium, which attenuates bipolar mood swings, but does not affect the normal mood. Regardless of whether lithium or Stimmungsstabillisierer are used, breakthroughs are more likely in patients with mixed state images, rapid cycling, comorbid anxiety disorder, substance abuse or a neurological disorder. Lithium carbonate is p.o. 300 mg started 2- or 3 times / day, and up to a range of 0.8-1.2 mEq / l titrated on the basis of steady-state blood levels and tolerance. The levels should be determined after 5 days with a stable dose and 12 h after the last dose. The targeted drug levels in maintenance therapy are lower and are approximately 0.6 to 0.7 mmol / l. Higher levels in the maintenance treatment with better protection from manic (but not depressive) episodes, but they have more adverse effects. Adolescents with very good kidney function require higher, older patients lower doses. Lithium may directly or indirectly (by hypothyroidism caused) to sedation and cognitive impairment, often lead verschlimmtert acne and psoriasis. The most common acute mild side effects are: fine tremor, fasciculations, nausea, diarrhea, polyuria, polydipsia and weight gain (which is partly attributable to the consumption of high-calorie drinks). These effects are i. Gen. temporary and often respond to a slight reduction of the dose, the distribution of dose (eg., 3 times / day) or the use of sustained-release of. Once the dosage is established, the total dose after the evening meal should be taken. This dosage may improve adherence. A beta adrenergic receptor blocker (. Eg atenolol 25-50 mg p.o. once daily) can control severe tremor; some Betaezeptorenblocker (eg., propranolol) but can worsen the depression. First signs of acute lithium toxicity are grobschlägiger tremor, increased deep tendon reflexes, persistent headache, vomiting and confusion; they can develop into stupor, seizures and arrhythmias. Toxicity is more likely at the following page: Elderly Those help patients with reduced creatinine clearance with sodium loss (eg, due to fever, vomiting, diarrhea, or the use of diuretics) thiazide diuretics, ACE inhibitors and NSAIDs other than aspirin may experience a Hyperlithämie , The lithium blood levels should be determined every 6 months and dose changes. Unerwünsche long-term effects of lithium include hypothyroidism, especially if hypothyroidism kidney damage, which include the distal tubule is in the family history (v. A. In patients with a disease of the renal parenchyma in the history). Therefore, the TSH levels should be monitored at the start of lithium and annually thereafter for thyroid dysfunction in the family history or every 2 years for all other patients. The levels should be determined whenever symptoms thyroid dysfunction point (and also recurrence of mania), because hypothyroidism weakens the effect of mood stabilizers. Blood urea nitrogen and creatinine should as a base value, 2- or 3 times then off during the first 6 months and 2 times or diagnosed annually. Anticonvulsants anticonvulsants, which act as Stimmungsstabisierer, particularly valproate and carbamazepine, are frequently used in acute mania and mixed states (mania and depression). Lamotrigine is effective in mood swings and depression. The exact mechanism of action of anticonvulsants in bipolar disorder is not known, but it can GABAergic mechanisms (gamma-aminobutyric acid) and the G-protein signaling system be beiteiligt. Its main advantages over lithium are a greater therapeutic breadth and the absence of renal toxicity. Valproate is placed in a loading dose of 20-30 mg / kg, followed by 250-500 mg p.o. 3 times / day (Extended-release formulations can be used); the desired blood levels are 50-125 ug / ml. This approach does not lead to more adverse effects than with the gradual transfer of titration. Adverse effects include nausea, headache, sedation, dizziness and weight gain; rare serious side effects include hepatotoxicity and pancreatitis. Carbamazepine should not be initiated with a loading dose, but p.o. with 200 mg 2 times / day, gradually it should be increased in increments of 200 mg / day to target values ??between 4 and 12ug / ml (a maximum of 800 mg of 2 times / day). Adverse effects include nausea, dizziness, sedation, and discontinuity. Very serious adverse effects are aplastic anemia and agranulocytosis. Lamotrigine is 25 mg p.o. began once daily for 2 weeks, followed by 50 mg once daily for 2 weeks and then 100 mg / day for one week, and then can be increased if necessary to 50 mg per week up to 200 mg once daily. The dosage is lower for patients taking valproate, and higher for patients taking carbamazepine. Lamotrigine can a rash and rarely cause life-threatening Stevens-Johnson syndrome, especially if the dosage is increased faster than recommended. While taking lamotrigine, patients should be asked to each new skin rash, hives, fever, swollen glands, sores in the mouth and eyes and swelling of the lips or tongue to tell. Antipsychotics Acute manic psychosis will increasingly be managed, with the second-generation antipsychotics and risperidone (usually 2 to 3 mg po bid) olanzapine (usually 5 to 10 mg orally twice daily) quetiapine: po (200-400 mg 2 times a day) ziprasidone (40 to 80 mg po twice daily) aripiprazole (10 to 30 mg po 1-times a day) Moreover, there is some evidence that these drugs can enhance the action of mood stabilizers after the acute phase. Although each of these drugs have extrapyramidal side effects and can cause akathisia, the risk is lower with more sedating drugs such as quetiapine and olanzapine. Less immediate side effects are significant weight gain and the development of metabolic syndrome (including weight gain, extreme abdominal fat, insulin resistance and dyslipidemia.); the risk may be lower with the least sedating antipsychotics 2nd generation ziprasidone and aripiprazole. At extremely hyperactive psychotic patients with low nutrition and hydration an antipsychotic, in addition to treatment with lithium or an anticonvulsant i.m. be fitted plus supportive care. Precautions during pregnancy lithium use during pregnancy (particularly Ebstein’s anomaly) associated with an increased risk of cardiovascular malformations. However, the absolute risk for this particular malformation is quite low. The taking lithium during pregnancy appears to increase the relative risk of congenital anomalies approximately by 2 times; this risk is similar to the 2- to 3-fold increased risk of congenital malformations in connection with the use of carbamazepine or lamotrigine and substantially less than the risk associated with the use of valproate. With Valproatel the risk of neural tube defects and other congenital malformations appears to be higher 2 to 7 times than other commonly used anticonvulsant drugs. Valproate increases the risk of neural tube defects, congenital heart defects, urogenital abnormalities, musculoskeletal abnormalities and cleft lip or palate. Cognitive results (. Eg IQ scores) in children of women who have taken valproate during pregnancy, are worse than those with other antiepileptic drugs; the risk appears to be dose-dependent. Valproate appears to (1) increase the risk for attention deficit / hyperactivity disorder and autism spectrum disorders. Extensive studies on the use of antipsychotics of the first generation and tricyclic antidepressants in early pregnancy showed no cause for concern. The same applies to SSRIs, except for paroxetine. Data on the risks of antipsychotics of the second generation to the fetus have so far been sparse, although these drugs find wider use in all phases of bipolar disorder. Drug use (particularly lithium and SSRI) before birth can have on the newborn carry-over effects. Treatment decisions are complicated by the fact that an unplanned pregnancy teratogenic effects can be done already before the doctors are aware of the problem. The consultation of a perinatal psychiatrist should be considered. In any case, the discussion of risks and benefits of treatment with patients is important. Precautions during pregnancy reference 1. Tomson T, D Battino, Perucca E: Valproic acid after five Decades of use in epilepsy: Time to reconsider the indications of a time-Honored drug. Lancet Neurol 15 (2): 210-218, 2016. Epub ahead of print (3 December 2015). doi: 10.1016 / S1474-4422 (15) 00314-2.