Management of Bipolar Affective Disorders

1. Management of Bipolar Affective Disorders

2. 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

3. Hypomania • Impairment is less severe • Psychotic features are absent • Social and occupational functioning are not significantly impaired • Hospitalisation is usually not required

4. 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

5. 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

6. 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

7. 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

8. 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

9. Aetiological Factors • Genetic • Mode of inheritance is complex, likely to involve several genes • Lifetime risk of developing bipolar disorder • First degree relatives 11% • Monozygotic twins 79% • Dizygotic twins 19% Birth Effects • Excess of spring and winter births and maternal fever

10. 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

11. Pathophysiology (cont) Brain Structural Changes Gross pathology associated with a poor prognosis • 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 • frontal lobe dysfunction in BPD I

12. Fundamentals of Patient Management • Diagnosis • Access to services and safety • Enhanced Care

13. 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

14. 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

15. Assessment of Risk • Ideally involve an informant • Suicide • Excessive spending • Sexual promiscuity • Driving • Violence

16. Enhanced Care • Establish and maintain a therapeutic alliance • Treatment adherence • Education Awareness of early signs of relapse • 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

17. Treatment of different phases of bipolar disorder • Acute manic or mixed episode • Acute depressive episode • Long-term treatment • Pregnancy and the post-partum period

18. 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

19. 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)

20. 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

21. Mental Health Register • Regular (annual) physical health checks • Relevant blood tests • Need to establish between primary and secondary care respective responsibilities

22. 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)

23. 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

24. Monitoring Lithium Therapy • Serum Lithium levels 3-6 monthly • U+E, Thyroid function and calcium every 6 months

25. Anticonvulsants as mood stabilisers • Anticonvulsants as mood stabilisers • 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 Antipsychotics

26. Atypical Antipsychotics • Recently licensed for acute and maintenance treatment • Olanzapine • Quetiapine • Risperidone 6 monthly glucose monitoring required with atypical antipsychotics

27. Combination therapies • Combination of two mood stabilisers • An antipsychotic and a mood stabiliser • An antidepressant and a mood stabiliser • Short term add-ons (hypnotics and antipsychotics)

28. Non-pharmacological strategies • 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

29. 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

30. Bipolar Disorder and Pregnancy • Compliance with treatment during pregnancy • maintenance of mental health • normal bonding • risk of teratogenesis • neonatal side effects

31. Risk of congenital malformation • Normal population 2-4% • Lithium exposed 4-12% • Valproate exposed 11% • Carbamazepine exposed 6%

32. 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

33. 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

34. 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 post-partum • Increased risk of suicide (and infanticide)

35. Evidence Based Guidelines for Treating Bipolar Disorder • www.bap.domainwarehouse.com/consensus/FinalBipolarGuidelines.pdf