Bipolar disorder
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Transcript 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