Download Bipolar disorder

2007
BIPOLAR DISORDER
Statistics
 2-4 new cases per 100,000/year
 1 in 200 people will have an episode of
hypomania
 Peak age of onset 25-30 yrs
 May have had a previous episode of
depression in late adolescence
 15-20% commit suicide
Bipolar Disorder 1
 Life time prevalence 0.4 – 1.6%
 Characterised by episodes of
 Depression, mania or mixed states separated by
periods of normal moods
 Mania
 Features include elevated expansive euphoric
mood, irritability, hyperactivity, decreased need
for sleep, disorganised behaviour, delusions,
hallucinations and functional impairment
Bipolar Disorder 2
 Life time prevalence 0.5%
 No mania but episodes of hypomania, depression
or mixed states.
 Hypomania
 Characterised by milder elevated mood, over
activity, without psychotic features and no
functional impairment.
Aetiology Genetic

Unipolar depression:
 risk of severe depression in first degree relatives of a severely
depressed patient is 10-15 % (1-2% in the general population)
 The evidence for a genetic aetiology of bipolar disorder is
stronger:
 the concordance in twin studies is:
 70% for monozygotic twins reared together
 70% for monozygotic twins reared apart
 23% for dizygotic twins
 in adoption studies, risk for bipolar affective disorder stems
more from the genetic rather than the adoptive parent
 The inheritance is probably non-Mendelian.
Aetiology
 More common in cyclothymic
personalities
 Depression 6x more common in
6/12 after severe life event
Management
New patients
 Refer urgently
 Pts with mania or severe depression who are a
danger to themselves
 Refer for assessment
 Pts with periods of overactive disinhibited
behaviour lasting at least 4 dayswith or without
periods of depression
 3 or more depressive episodes and a history of
overactive disinhibited behaviour
Management
Existing patients
 Refer urgently
 Any acute exacerbation of symptoms
 An increase in the degree
 of risk to themselves or others
 Consider review in secondary care
 Functioning declines significantly or response to
treatment is poor
 Treatment adherence is poor
 Patient considering stopping prophylactic
medication
Managing acute mania or
hypomania
 STOP antidepressants abruptly or gradually
 If not on antimanic medication
 Consider antipsychotic – olanzapine, quetiapine or
risperidone.
 Valproate avoid in women of childbearing age
 Consider adding short term benzodiazepine
 Carbamazepine, lamotrigine, gabapentin and
topiramate are no recommended for acute mania
Managing acute mania or
hypomania
 STOP antidepressants abruptly or gradually
 If already on antipsychotic medication
 Increase dose if possible
 Consider adding lithium or valproate
 If taking lithium
 Check blood levels if low increase dose, if response not
adequate consider adding antipsychotic
 If taking valproate
 Increase dose till improvement starts or side effects
limit dose consider adding antipsychotic
Managing depressive symptoms
 At risk of switching to mania when
antidepressant medication started
 Therefore if not already on antimanic medication
start antimanic drug at same time as
antidepressant which should be started at low
dose and increased gradually
 SSRI do not use paroxetine in pregnant women
consider adding quetiapine if patient already
taking anitmanic drug that is not antipsychotic
Long term management
 Consider long term treatment in
 After a manic episode involving considerable risk
and adverse consequences
 A patient with bipolar 1 disorder who has had 2 or
more acute episodes
 A aptient with bipolar 2 disorder who has
significant functional impairment, is at risk of
suicide or has frequent episodes.
Long term management
 Choice of drug
 Lithium
 Olanzapine
 Valproate do not use in women of
childbearing potential
Long term management
 Length of treatment
 At least 2 years
 Up to 5 years if risk factors for
relapse i.e. Frequent relapses,
severe psychotic episodes,
comorbid substance misuse,
ongoing stressful life events or poor
social support
Long term management
 After an acute depressive episode
 Stop antidepressant as no evidence it prevents
relapse rates and may increase risk of switching to
mania
 Chronic and recurrent depressive episodes
and have not had a recent manic or
hypomanic episode consider
 Long term treatment with SSRI’s
 CBT
 Quetiapine or lamotrigine
Long term management
 Pregnant women
 Avoid
 Valproate
 Carbamazepine
 Lithium
 lamotrigine
 Long term benzodiazepines
 paroxetine
Long term management
 Pregnant women
 Acute psychotic symptoms
 Consider atypical or typical antipsychotic
 Keep dose as low as possible
 If there is no response and mania severe consider
 ECT
 Lithium
 Rarely valproate if no alternative must explain about
risks to fetus and give folic acid 5mg/day
Long term management
 Depression
 Mild symptoms
 Guided self help
 Brief psychological interventions
 Antidepressant medication
 Moderate or severe symptoms consider
 CBT
 Combined medication and structured psychological
interventions
 Drugs – quetiapine or SSRI not paroxetine advise re
short lived effectsof SSRI on neonate
Long term management
 Breast feeding
 Do not breast feed with
 Lithium
 Benzodiazepines
 Lamotrigine
 Fluoxetine
 Citalopram
 Clozapine