APA Practice Guidelines

C. Concurrent General Medical Conditions

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In the presence of a severe medical disorder, the disorder itself or the medications used to treat it should always be considered as possible causes of a manic episode. Neurological conditions commonly associated with secondary mania are multiple sclerosis, lesions involving right-side subcortical structures, and lesions of cortical areas with close links to the limbic system. L-Dopa and corticosteroids are the most common medications associated with secondary mania.

The presence of a general medical condition may also exacerbate the course or severity of bipolar disorder or complicate its treatment. For example, the course of bipolar disorder may be exacerbated by any condition that requires intermittent or regular use of steroids (e.g., asthma, inflammatory bowel disease) or that leads to abnormal thyroid functioning. In addition, treatment of patients with bipolar disorder may be complicated by conditions requiring the use of diuretics, angiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, or salt-restricted diets, all of which affect lithium excretion. Conditions or their treatments that are associated with abnormal cardiac conduction or rhythm or that affect renal or hepatic function may further restrict the choice or dosage of medications. In HIV-infected patients, lower doses of medications are often indicated because of patients' greater sensitivity to side effects and because of the potential for drug-drug interactions. Special considerations in the treatment of HIV-infected patients are presented in the APA Practice Guideline for the Treatment of Patients With HIV/AIDS.

Whenever patients are taking more than one medication, the possibility of adverse drug-drug interactions should always be considered. Patients should be educated about the importance of informing their psychiatrist and other physicians about their current medications whenever new medications are prescribed. Clinicians should also inquire about patient use of herbal preparations and over-the-counter medications.

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Written 4/02. Reviewed: 03/2006