Transcript Management of Bipolar Affective Disorders

Management of Bipolar Affective
Disorders
Manic Episode
• Persistently elevated,expansive or irritable mood for at
least a week
• Presence of at least 3 typical symptoms:
decreased need for sleep, flight of ideas,grandiosity,
uncharacteristic risk taking, distractibility, agitation,
increase in pleasurable activities
• Marked impairment of functioning, necessity for
hospitalisation, or psychotic features
Hypomania
• Impairment is less severe
• Psychotic features are absent
• Social and occupational functioning are not significantly
impaired
• Hospitalisation is usually not required
Mixed Episode
• Depressive symptoms occur in the context
of manic thinking
• Depressive and manic symptoms alternate
from day to day or even hour to hour
• Unpleasant agitation is common
Bipolar Affective Disorder
• Bipolar I Disorder
A recurrent mood disorder featuring one or more manic or mixed
episodes, or both manic and mixed episodes and at least one major
depressive episode
• Bipolar II Disorder
Characterised by one or more episodes of major depression and at least
one hypomanic episode
• Cyclothymia
Persistent instability of mood (> 2 years duration) featuring numerous
periods of mild depression and elation, none of which meet the criteria
for depression or mania
Cycle Frequency
• Manic episodes last between 2 weeks and 5 months
• Depressive episodes have a mean duration of 6 months
• 10-20% of people with bipolar disorder experience rapid
cycling, characterised by 4 or more episodes of depression
or mania per year and only short euthymic episode in
between
• A rapid cycling pattern is often associated with a poor
prognosis
Epidemiology
• Bipolar disorder (I +II) has a prevalence of 1.3% in the UK
• Estimates suggest that approximately 0.5 million people
over 15 in England and Wales are affected
• Bipolar I disorder affects men and women equally, but
bipolar II is commoner in women
• Unlike schizophrenia, it is prevalent in higher social
classes
• In the USA, an average delay to diagnosis of 6 years is
common
Course of the Illness
• Peak age of onset is 15-24 years
• If onset occurs >60 years think of an organic cause
• More than 90% of people who have a single manic episode
will have a recurrence
• 10-15% will have more than 10 episodes in their lifetime
• Lifetime suicide risk is 15-19%
• Co-morbid drug and alcohol misuse is common
Aetiological Factors
• Genetic
– Mode of inheritance is complex, likely to involve several genes
– Lifetime risk of developing bipolar disorder
• First degree relatives
• Monozygotic twins
• Dizygotic twins
11%
79%
19%
Birth Effects
• Excess of spring and winter births and maternal fever
Pathophysiology
• Neurotransmitter Dysfunction
– ? deficits in Na+K+ATPase and second messenger
systems
– ?serotonin system dysfunction
Neuroendocrine Dysfunction
– Grade II hypothyroidism is found in 25% of rapid
cycling bipolar patients compared with 2-5% in
depression
Pathophysiology (cont)
Brain Structural Changes
Gross pathology associated with a poor prognosis
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smaller temporal lobes and caudate nuclei
Patchy white matter lesions on MRI
Pre-frontal-limbic subcortical abnormalities
reduced blood flow in the pre-frontal cortex
– hypofrontal pattern of glucose metabolism
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frontal lobe dysfunction in BPD I
Fundamentals of Patient
Management
• Diagnosis
• Access to services and safety
• Enhanced Care
Delays to Diagnosis
• Irritability or aggression may be
misdiagnosed as personality disorder in the
absence of mood elevation
• Adolescent behavioural disturbance
• Substance misuse
• Exclude causes of 2o mania
Access to Services and Safety
• Involve a psychiatrist in assessment and
management
• Mania or psychotic depression are
psychiatric emergencies
• Hospital admission or intensive community
management
• The Mental Health Act is often required
• Early Intervention Teams
Assessment of Risk
• Ideally involve an informant
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Suicide
Excessive spending
Sexual promiscuity
Driving
Violence
Enhanced Care
• Establish and maintain a therapeutic alliance
– Treatment adherence
– Education
Awareness of early signs of relapse
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recognise stressors
manage sleep disturbance
promote regular patterns of activity
involve the family
• Manage functional impairments
– withdrawal from work (average 12 weeks)
– discourage major decisions
– consider needs of children and carers
Treatment of different phases of
bipolar disorder
• Acute manic or mixed episode
• Acute depressive episode
• Long-term treatment
• Pregnancy and the post-partum period
Acute Manic/Mixed Episode
• Use atypical antipsychotics + mood
stabiliser
• Benzodiazepines are useful short term to
promote sleep
• Additional medications should be tapered
and stopped as symptoms improve
Acute Depressive Episode
• Risk of mania or rapid cycling with use of
antidepressant
• Ideally treat with mood stabiliser alone
• SSRIs are less likely to promote manic
switch
• Discontinue the antidepressant when
symptoms remit (e.g. 12 weeks)
Treatment of bipolar depression
• Aim to treat depression without causing switching
or destabilising mood
• Ideally use a mood stabiliser or a combination of 2
• Lamotrigine is an antidepressant mood stabiliser
• Use antidepressants with caution
– modern antidepressants (SSRI, SNRI)
– short courses
– long term treatment is only suitable for those who
repeatedly relapse on withdrawal
Mental Health Register
• Regular (annual) physical health checks
• Relevant blood tests
• Need to establish between primary and
secondary care respective responsibilities
Longterm Treatment:Drugs
• Mood stabilisers are drugs that prevent
relapse to either pole of the illness
• Some mood stabilisers are more effective
against mania (lithium, olanzapine) or
depression (lamotrigine)
Lithium
– response rate 70-80%
– associated with reduced suicide rate compared with
other mood stabilisers
– associated with weight gain, polyuria, polydipsia
– toxic side effects and potentially fatal in overdose
– risk of irreversible renal and thyroid damage
– rapid discontinuation is linked to marked affective
instability and suicide risk
Monitoring Lithium Therapy
• Serum Lithium levels 3-6 monthly
• U+E, Thyroid function and calcium every 6
months
Anticonvulsants as mood stabilisers
• Anticonvulsants as mood stabilisers
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sodium valproate (Epilim, Depakote)
carbamazepine (tegretol)
lamotrigine (lamictal)
gabapentin
topiramate
Monitoring of full blood count and liver function are
required 6 monthly
Potential for drug interactions
Atypical Antipsychotics
• Recently licensed for acute and
maintenance treatment
– Olanzapine
– Quetiapine
– Risperidone
6 monthly glucose monitoring required with
atypical antipsychotics
Combination therapies
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Combination of two mood stabilisers
An antipsychotic and a mood stabiliser
An antidepressant and a mood stabiliser
Short term add-ons (hypnotics and
antipsychotics)
Non-pharmacological strategies
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Facilitate acceptance of the disorder
Identify and manage psychosocial stressors
Improve medication adherence
Recognition of early signs of relapse
Empower the individual
Identify and modify maladaptive thinking patterns
Does Cognitive Therapy improve Outcome in
BPD?
• CBT has been shown to
– improve compliance with medication
– reduce admissions / bed days for mania
– improve social functioning
Bipolar Disorder and Pregnancy
• Compliance with treatment during
pregnancy
– maintenance of mental health
– normal bonding
– risk of teratogenesis
– neonatal side effects
Risk of congenital malformation
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Normal population
Lithium exposed
Valproate exposed
Carbamazepine exposed
2-4%
4-12%
11%
6%
Specific teratogenic associations
• Lithium
0.05-0.1% risk of
cardiovascular anomalies
• Valproate and Carbamazepine
1-2 % risk of congenital abnormality
including neural tube defect and foetal
hydantoin syndrome
Pregnancy and bipolar disorder
Pregnancy should be planned
Treatment options depend on patient history and preference
– withdrawal of medication
– change of medication
– lowering dose (slow release formulations)
Those exposed to teratogens in the first trimester should be offered
high resolution ultrasound scan at 16-18 weeks gestation
Maternal physiological changes result in variable serum levels of
mood stabilisers especially lithium
Postpartum
• Toxic and withdrawal effects of mood
stabilisers in neonates
• All drugs enter breast milk. Breast feeding
not advised for lithium takers
• Increased risk of first admission postpartum
• Increased risk of suicide (and infanticide)
Evidence Based Guidelines for
Treating Bipolar Disorder
• www.bap.domainwarehouse.com/consensus
/FinalBipolarGuidelines.pdf