Bipolar disorder

1. Bipolar disorder July 2006

2. Why implement NICE guidance? • NICE guidelines are based on the best available evidence • The Department of Health asks NHS organisations to work towards implementing guidelines • Compliance will be monitored by the Healthcare Commission

3. Bipolar disorder is complex • Bipolar disorder is an episodic, potentially life-long, disabling disorder that can be difficult to diagnose • Need to improve recognition, reduce sub-optimal care and improve long-term outcomes • There is variation in management of care across healthcare settings

4. How to diagnose • Bipolar disorder is a cyclical mood disorder • Abnormally elevated mood or irritability alternates with depressed mood • bipolar I – at least one manic or mixed episode • bipolar II – at least one major depressive episode and at least one hypomanic episode

5. Look for key features

6. Incidence and prevalence • Annual incidence 7 per 100,000 • Estimated lifetime prevalence – bipolar I 4–16 per 1000 • Peak onset between 15 and 19 years of age • Suicide bipolar I – 17% attempt suicide bipolar disorder – 0.4% die annually by suicide

7. Comorbidity is common • Anxiety 30–50% • Substance misuse disorders (drugs and alcohol) 30–50% • Personality disorders, in particular borderline personality disorder (exercise caution when diagnosing)

8. What this guideline covers • Diagnosis in adolescents • Pharmacological treatment for: • acute phase • long term management • rapid cycling • use of antidepressants • women of child bearing potential • Psychological therapy • Weight gain management • Annual physical health check

9. Diagnosis in adolescents • Diagnosing bipolar I disorder • Use adult criteria, except that: • mania must be present • euphoria must be present most of the time (for the past 7 days) • note irritability if it is episodic, severe, results in impaired function and is not in character or is out of keeping with the context

10. Supporting diagnosis in adolescents • Increase knowledge and awareness in primary care and community settings • Ensure prompt referrals to secondary care • Use modified adult criteria to diagnose children and adolescents • Consider alternative diagnoses and other possible causes

11. Treat the acute phase • Consider an antipsychotic if: • manic symptoms are severe • there is marked behavioural disturbance • Consider valproate or lithium if: • there has been previous response and good compliance with one of these drugs • Consider lithium if: • symptoms are less severe

12. Initiate long-term pharmacological treatment • After a manic episode with significant risk and adverse consequences • Bipolar I: two or more acute episodes • Bipolar II: evidence of significant functional impairment or risk of suicide or frequently recurring episodes

13. Choose long-term drugs • Base choice of lithium, olanzapine or valproate* on: • previous response • risk and precipitants of manic versus depressive relapse • physical risk factors • patient preference and history of adherence • cognitive state assessment if appropriate • * Valproate should not be prescribed routinely for women of child-bearing potential

14. Try alternatives if needed • If continuing symptoms or relapse, use alternative monotherapy or add second prophylactic agent: • lithium and valproate • olanzapine and lithium • valproate and olanzapine • If this proves ineffective: • consult, or refer to, an expert in pharmacological treatment of bipolar disorder • prescribe lamotrigine or carbamazepine

15. Support long-term pharmacological treatment • Ensure prescribing advisers are aware of NICE guidance, and what to consider when choosing treatment • Focus on optimising appropriate long-term treatment • Support service user education and empowerment in pharmacological treatment and management decisions • Make use of early intervention teams, regional mental health trusts and CAMHS teams

17. Modify treatment for rapid cycling • For an acute episode base treatment on that for manic and depressive episodes and: • review previous treatments; if inadequately delivered or adhered to, consider a further trial of previous treatments • optimise long-term treatment; each trial of medication should usually last at least 6 months • encourage patients to keep a mood diary

18. Use antidepressants with care • Acute manic phase • Stop antidepressants at onset of acute manic phase and decide if discontinuation is abrupt or gradual based on: • current clinical need • previous experience of discontinuation/withdrawal symptoms • the risk of discontinuation/withdrawal symptoms

19. Consider need for treatment • Is long-term antidepressant treatment needed after an acute depressive episode? • No evidence for reduced relapse rates • May be associated with increased risk of mania

20. Educate staff and service users • Raise awareness of effective antidepressant prescribing • Highlight the importance of a thorough review of pharmacological history • Support patient fears about antidepressant withdrawal • Review prescribing policies and formularies, update as appropriate

21. Consider psychological therapy • For those who are stable, individual structured psychological therapy should include: • at least 16 sessions over 6 to 9 months • psychoeducation • promotion of medication adherence • monitoring of mood, detection of early warnings and prevention strategies • coping strategies

22. Implement psychological therapy • Offer individual structured psychological therapy • Identify key people to support mood monitoring and coping strategies • Identify training needs • Review access to services • Work collaboratively and engage the client, family or carers

23. Take possible pregnancy into account • Valproate should not be used routinely for women who may become pregnant. It may: • cause foetal abnormalities • affect the child’s cognitive development • If prescribed, ensure adequate contraception. Explain risks during pregnancy and to the health of the unborn child • An antipsychotic may be used with caution

24. Provide care for women of child-bearing potential • Review care pathways and management of bipolar disorder in women of child-bearing potential • Raise awareness of the effects of bipolar disorder and treatment on: • conception • pregnancy • child • Engage with patients, discuss contraception and family planning

25. Mitigate drug-related weight gain • Review medication strategy and consider: • dietary advice and support • advising regular increased aerobic exercise • referring to a specialist mental health diet clinic or health delivery group • referring to a dietitian if needed for people with complex comorbidities

26. Support patients in controlling weight • Review risk of weight gain when prescribing, offer early dietary advice and support • Offer diet clinics or health delivery groups locally • Identify a named key worker with appropriate training, use the care programme approach (CPA) • Document in clinical notes/individualised care plan

27. Review annually Over the course of the year an annual review should include: • lipid levels, including cholesterol, in patients over 40 • plasma glucose levels • weight • smoking status and alcohol use • blood pressure

28. Establish review systems • Agree responsibility locally • Establish monitoring and early warning systems • Develop systems for responsibility and intervention • Communicate results • Follow up non attendance

29. Target resources • Recommendations considered to have greatest impact on resources are: • pharmacological management of women of child-bearing potential • psychological management • weight management • annual review of physical health

30. Costs and savings

31. Access tools online • Costing tools • costing report • costing template • Implementation advice • Available from: www.nice.org.uk/CG038

32. Access the guideline online • Quick reference guide – a summary www.nice.org.uk/CG038quickrefguide • NICE guideline – all of the recommendations www.nice.org.uk/CG038niceguideline • Full guideline – all of the evidence and rationale www.nice.org.uk/CG038fullguideline • Information for the public – a plain English version www.nice.org.uk/CG038publicinfo