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Connecting scientific data with individuals who present to health care providers is not easy. This newsletter case series is designed to address real-world issues based on manic and mixed symptomology.

Case: Recognizing and treating a bipolar mixed episode in a patient Differential diagnosis of MDD or bipolar disorder. The complexity of the mixed-episode patient. Ziprasidone efficacy in acute manic and mixed episodes of bipolar disorder Faculty: Paul E. Keck, MD Professor of Psychiatry and Neuroscience Department of Psychiatry University of Cincinnati College of Medicine Cincinnati, OH Your feedback is important to us. After you read this newsletter, please click here to fill out a brief survey to help us provide you with the most current and relevant information to you and your practice.

Case: Consider a treatment change due to lack of efficacy on current antipsychotic treatment Patient experiencing a lack of efficacy or safety/tolerability issue that results in the need to switch medications. Maximizing efficacy with ziprasidone, focus on dosing: includes D2 occupancy, food absorption Faculty: Henry Chung, MD Clinical Associate Professor Department of Psychiatry New York University School of Medicine Executive Director New York University Student Health Center New York University New York, NY Jeffrey N. De Wester, MD Teaching Faculty St. Francis Family Practice Residency St. Francis Hospital Center De Wester Family Medicine Treatment and Research Indianapolis, IN Your feedback is important to us. After you read this newsletter, please click here to fill out a brief survey to help us provide you with the most current and relevant information to you and your practice.

Case: The Patient Newly Diagnosed with Bipolar Mixed Mania: Delivering the Diagnosis and Choosing Treatment Faculty: Jeffrey L. Susman, MD Professor and Chairman Department of Family Medicine University of Cincinnati Cincinnati, OH Tara A. Hayes, MS, PA Physician Assistant Department of Psychiatry Staten Island University Hospital Staten Island, NY Sherryl J. Rosen, APRN, BC Vice President - Psychiatric Clinical Nurse Specialist Psychiatric Associates of Lynn, PC Lynn, MA Neil S. Kaye, MD Assistant Clinical Professor of Psychiatry and Human Behavior   and Assistant Clinical Professor of Family Medicine Jefferson Medical College Philadelphia, PA Special Guest Lecturer Widener School of Law Wilmington, DE Joseph A. Lieberman III, MD, MPH Professor Department of Family Medicine Jefferson Medical College Philadelphia, PA Associate Editor Delaware Medical Journal Medical Society of Delaware Newark, DE Your feedback is important to us. After you read this newsletter, please click here to fill out a brief survey to help us provide you with the most current and relevant information to you and your practice.

Objectives:

• Improve the recognition of phases and presentations of bipolar disorder through case discussion
• Involve patients in the treatment plan to improve adherence
• Give practical information on recognizing, monitoring, and mitigating metabolic disturbances in patients being treated with an atypical antipsychotic
• Help give insight into expected timing and nature of outcomes of drug treatment for patients newly diagnosed with manic and mixed episodes of bipolar disorder

1. Garber AJ, Johnson DL, Krauss RM, et al. J Clin Psychiatry 2005;66:790-798.

Please click here to see ziprasidone full prescribing information. By clicking this link, you selected to read information for medical professionals.

Ziprasidone is indicated for the treatment of acute manic or mixed episodes associated with bipolar disorders with or without psychotic symptoms.

Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. Ziprasidone is not approved for the treatment of patients with dementia-related psychosis.

Ziprasidone is contraindicated in patients with a known history of QT prolongation, recent acute myocardial infarction, or uncompensated heart failure, and should not be used with other QT-prolonging drugs. Ziprasidone has a greater capacity to prolong the QT_c interval than several antipsychotics. In some drugs, QT prolongation has been associated with torsade de pointes, a potentially fatal arrhythmia. In many cases this would lead to the conclusion that other drugs should be tried first.

As with all antipsychotic medications, a rare and potentially fatal condition known as neuroleptic malignant syndrome (NMS) has been reported with ziprasidone. NMS can cause hyperpyrexia, muscle rigidity, diaphoresis, tachycardia, irregular pulse or blood pressure, cardiac dysrhythmia, and altered mental status. If signs and symptoms appear, immediate discontinuation, treatment, and monitoring are recommended.

Prescribing should be consistent with the need to minimize tardive dyskinesia (TD), a potentially irreversible dose- and duration-dependent syndrome. If signs and symptoms appear, discontinuation should be considered since TD may remit partially or completely.

Hyperglycemia-related adverse events, sometimes serious, have been reported in patients treated with atypical antipsychotics. There have been few reports of hyperglycemia or diabetes in patients treated with ziprasidone, and it is not known if ziprasidone is associated with these events. Patients treated with an atypical antipsychotic should be monitored for symptoms of hyperglycemia.

Precautions include the risk of rash, orthostatic hypotension, and seizures.

The most common adverse events associated with ziprasidone in bipolar mania were somnolence, extrapyramidal symptoms, dizziness, akathisia, and abnormal vision.

In short-term schizophrenia trials, the most commonly observed adverse events associated with ziprasidone at an incidence of
5% and at least twice the rate of placebo were somnolence and respiratory tract infection.

In short-term schizophrenia clinical trials, 10% of ziprasidone-treated patients experienced a weight gain of 7% of body weight vs 4% for placebo.