Bipolar Affective Disorder🙂🙁

Question 1

Bipolar disorder

Answer 1

• Episodes of depression and elation (mania or hypomania).

• Bipolar I - one manic episode with or without depressive episodes. Slightly more common.

• Bipolar II - one hypomanic episode (hypo mania) , one depressive episode.

• Highest lifetime risk for suicide attempts and completion.

• Detrimental effects of disinhibition (impact of actions on life)

• Mixed episodes

• Rapid-cycling - four episodes within 12 months

Question 2

Treatment aims

Answer 2

• Manage acute episodes of elation or depression - bring the person’s mood
back to baseline.
- What is baseline?
- How does the patient feel about this? It’s long term medication

• Prevent further episodes -
maintenance treatment.

Question 3

Medication

Answer 3

Antipsychotics
Antiepileptics
Antidepressants

Acute treatment
• mania/hypomania: antipsychotics - Haloperidol, Risperidone, Quetiapine, Olanzapine.
• depression: antipsychotics - Olanzapine, Quetiapine - antiepileptic - Lamotrigine
- antidepressants (a bit) - Fluoxetine

Maintenance treatment (mood stabilisers)
• Lithium
• Antipsychotics
• Valproate

Question 4

Lithium

Answer 4

• Salts - Carbonate, Citrate

• Don’t switch brands as alters lithium levels, check conversions between tablets and liquid

• Dose titration - narrow therapeutic window

• Side effects - hypothyroidism, fine tremor, metallic taste, polyuria, nephrotoxicity

• Hydration, renal function (cleared through kidneys)

• Avoid stopping abruptly (quicker relapse) - reduce over at least 4 weeks - NICE advises preferably up to 3 months.

• Purple booklet for patient to refer to for questions

Question 5

Monitoring lithium

Answer 5

Started at low dose (200mg)

Titrated up to right level

Levels done weekly until stable. Taken at night for 4-7 days so by the time level is taken it has reached at steady state and dose can be accurate if needed changing etc

• Levels - done weekly (4-7 days to reach steady state) until dose and level stable. Then every 3 months for a year, and after that every 3 (if high risk of relapse, elderly, renal function) or 6 months. (3-4 levels. Level and dose isn’t changing = patient is stable)

• Target level - between 0.4 (0.6) and 0.8 mmol/I. Up to 1mmol/l in exceptional circumstances (if patient could do better).

• Level must be taken 12 hours post dose - take the dose at night, take the level in the morning. If taken at the wrong time, can be misinterpreted.

• Signs of toxicity - coarse tremor, diarrhoea and vomiting (can become dehydrated and another cause of toxicity, drowsiness, unsteadiness, dizziness, blurred vision. Urgent lithium level.

• Interactions - ACE inhibitors (impact renal function) , diuretics (impacts water levels) , NSAIDs (impacts renal function) = (increases lithium levels)

Viscous cycle: as lithium levels increase, renal function deteriorates

• Additional physical health monitoring at baseline: U&Es, eGFR , Calcium (can increase calcium levels), TFTs (can cause hypothyroidism), Weight (can cause weight gain) , BMI, - every 6 months
FBC, and ECG at baseline too as can cause QTC prolongation

Question 6

Valproate

Answer 6

• Depakote (Semisodium Valproate) - mania and continuation

• Monitoring - levels not routine

• Be alert to blood disorders, liver disorders, pancreatitis - medical attention

• Side effects - G.I., lethargy, weight gain, hair loss

• Teratogenicity - counselling, prescribing, review, documentation

• Valproate use for bipolar disorder is BANNED in PREGNANCY.

• “MHRA Valproate” - up to date information and guidance

• 10% risk of congenital malformations
- Cleft lip and palate
- Spina bifida
- Malformation of limbs, heart, kidney, urinary tract and sexual organs

• 30 - 40% risk of developmental abnormalities
- Late in learning to walk and talk
- Lower intelligence than children of same age
- Poor speech and language skills
- Memory problems

• More likely to have autism or autistic spectrum disorders

• children may be more at risk of developing ADHD

• Valproate not to be started in females or males under 55 years old (as can potentially become pregnant) , unless 2 specialists agree and document that there is no other treatment, or risks do not apply (under 55 but post menopausal)

• If used in females, pregnancy prevention programme (PPP) must be in place.
PPP ensures that patient is informed and regularly reminded of the risks, that the need for treatment and risks are reviewed every year, and that the patient understands the need for highly effective contraception (years of contraception advised instead of those dependant on memory)

• An Annual Risk Acknowledgement form must be completed by the specialist and patient. (Agrees not to have a baby after discussing risks)

• Identify risks at prescribing, dispensing, review.

• Males: not under 55. Risk of infertility and testicular toxicity. Increased risk of neurodevelopmental disorders in their children. Shouldn’t conceive children while on the medication and 3 months after stopping. Also shouldn’t donate sperm during this time. Risk acknowledgement form. Discuss with all name patients even over 55 ( as can also apply to them.

Question 7

Mania

Answer 7

• Mania - distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week, accompanied by at least 3 additional symptoms, and which:
- is severe enough to cause marked impairment or require hospital admission, or
- Includes psychotic features such as delusions or hallucinations

Additional symptoms:
• Increased energy or activity, restlessness, and a decreased need for sleep
• Pressure of speech / incomprehensible speech
• Flight of ideas or racing thoughts
• Distractibility, poor concentration
• Increased libido, disinhibition
• Extravagant or impractical plans

Consequences of their actions while on the episode can lead to shame and embarrassment when back at baseline

Question 8

Hypomania (less form of mania)

Answer 8

• Hypomania - symptoms of mania not severe enough to cause a marked impairment of functioning, without psychotic features, lasting at least 4 days.

• Mild elevation of mood, irritability
• Increased energy and activity
• Feelings of well-being, or physical and mental efficiency
• Increased sociability, talkativeness, over-familiarity

Question 9

Mania Management

Answer 9

1) If on antidepressant, consider stopping (may increase mood to high to mania)
Note risk of discontinuation

2) If on mood stabiliser (preventing episodes) check levels, optimise treatment (see if can increase levels)

3) Add antipsychotic if not on mood stabiliser/ it’s been optimised: haloperidol, risperidone, olanzapine, Quetiapine

If antipsychotic doesn’t work, switch with other
Add lithium or valproate

Can use benzodiazepines for short term to help calm

Question 10

Bipolar vs unipolar depression

Answer 10

• Assess for mania as part of screening when diagnosing depression.

• The symptoms of depression are the same whether it is unipolar depression (no other mood changes involved), or bipolar depression

• However, treatment is different.
Antidepressants - risk of mania

Question 11

Management of bipolar depression

Answer 11

On mood stabilisers: check levels, optimise

Add / start antipsychotic
Olanzapine (antipsychotic) along with Fluoxetine (antidepressant)
Quetiapine

Consider olanzapine alone
Consider lamotrigine (antiepileptic)

Question 12

Aim of maintenance treatment (long term)

Answer 12

Know from carers / family what they’re like at normal baseline

• Start thinking about within 4 weeks of episode resolving

• Prevent further episodes of mania and depression

• Long-term

• Aiming to keep a person’s mood at their normal functioning baseline

• Minimal disruption, minimal side effects

Episodes can cause further deterioration. Would patient like a maintenance treatment that’s long term to prevent episodes? Are they okay with needles?

Options:
Lithium - first line. Prevents both mania and depression. Ask if patient wants.

Antipsychotics if not - asenapine, aripiprazole, olanzapine, Quetiapine, risperidone- probably already tried for episode. How do they feel about it? Would they like to use it for prevention? How did they tolerate? Would like to switch? Normally would use the one that brought patient out of manic / depressive episode unless they don’t like it.

Valproate? If they’ve tried/ can’t have anything else

Question 13

EBL: Outline the specific reasons for referring Ms HS to the GP for her valproate medication, and how you would explain this to Ms HS. Lena

Answer 13

Pregnancy Risk: Valproate is highly teratogenic (risk of birth defects and developmental disorders) (fetal valproate syndrome)

Not using contraception, pregnancy risk cannot be ruled out

MHRA guidelines require a
Pregnancy Prevention Program (PPP) for women of childbearing age on valproate

Does not meet safety criteria, so urgent review is needed

Sleep disturbances may indicate ineffective mood stabilisation

Acknowledge sleep difficulties

Explain safety concern

Explain need for GP review

Empathise & reassure

Monitor Liver function tests due to risk of toxicity