Management of Bipolar Affective Disorders

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Management of Bipolar Affective Disorders
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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

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Hypomania

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

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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

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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 (gt 2 years
  duration) featuring numerous periods of mild
  depression and elation, none of which meet the
  criteria for depression or mania

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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

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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

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Course of the Illness

• Peak age of onset is 15-24 years
• If onset occurs gt60 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

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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

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Pathophysiology

• Neurotransmitter Dysfunction
• ? deficits in NaKATPase 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

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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

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Fundamentals of Patient Management

• Diagnosis
• Access to services and safety
• Enhanced Care

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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

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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

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Assessment of Risk

• Ideally involve an informant
• Suicide
• Excessive spending
• Sexual promiscuity
• Driving
• Violence

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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

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Treatment of different phases of bipolar disorder

• Acute manic or mixed episode
• Acute depressive episode
• Long-term treatment
• Pregnancy and the post-partum period

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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

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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)

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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

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Mental Health Register

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

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Longterm TreatmentDrugs

• 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)

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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

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Monitoring Lithium Therapy

• Serum Lithium levels 3-6 monthly
• UE, Thyroid function and calcium every 6 months

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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

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Atypical Antipsychotics

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

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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)

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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

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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

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Bipolar Disorder and Pregnancy

• Compliance with treatment during pregnancy
• maintenance of mental health
• normal bonding
• risk of teratogenesis
• neonatal side effects

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Risk of congenital malformation

• Normal population 2-4
• Lithium exposed 4-12
• Valproate exposed 11
• Carbamazepine exposed 6

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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

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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

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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)

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Evidence Based Guidelines for Treating Bipolar
Disorder

• www.bap.domainwarehouse.com/consensus/FinalBipolar
  Guidelines.pdf