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Bipolar disorder. July 2006. 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. Bipolar disorder is complex.
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Bipolar disorder July 2006
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
Establish review systems • Agree responsibility locally • Establish monitoring and early warning systems • Develop systems for responsibility and intervention • Communicate results • Follow up non attendance
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
Access tools online • Costing tools • costing report • costing template • Implementation advice • Available from: www.nice.org.uk/CG038
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