Bipolar disorder

1. Bipolar disorder

2. 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

3. 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

4. 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.

5. 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.

6. Aetiology • More common in cyclothymic personalities • Depression 6x more common in 6/12 after severe life event

7. ManagementNew 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

8. ManagementExisting 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

9. 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

10. 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

11. 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

12. 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.

13. Long term management • Choice of drug • Lithium • Olanzapine • Valproate do not use in women of childbearing potential

14. 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

15. 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

16. Long term management • Pregnant women • Avoid • Valproate • Carbamazepine • Lithium • lamotrigine • Long term benzodiazepines • paroxetine

17. 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

18. 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

19. Long term management • Breast feeding • Do not breast feed with • Lithium • Benzodiazepines • Lamotrigine • Fluoxetine • Citalopram • Clozapine