Bipolar Disorder Flashcards
(41 cards)
What is bipolar disorder?
A chronic mental disorder with periods of mania/ hypomania alongside episodes of depression
What is the peak age incidence?
20-30 years, 1:1 sex ratio, first degree relatives 7x increased incidence
What are the two types of bipolar disorder?
- Type 1: mania and depression (most common)
- Type 2: hypomania and depression
If this is their first episode of mania/ hypomania, you can’t diagnose bipolar disorder - they need at least 2 episodes of mood disturbance for a diagnosis
What is the difference between mania and hypomania?
- Mania: severe functional impairment or psychotic symptoms for 7 days or more (unless it’s severe enough for hospital admission)
- Hypomania: decreased or increased function for 4 days or more
Psychotic symptoms such as delusions of grandeur or auditory hallucinations suggest mania
When, in a primary care setting, should an urgent referral to CMHT for specialist mental health assessment be made?
If mania or severe depression is suspected, or the patient is a danger to themselves or others
What management should patients with bipolar depression be offered in primary care?
- A psychological intervention developed specifically for bipolar disorder with a published evidence-based manual describing how it should be delivered or
- A choice of psychological intervention (CBT, interpersonal therapy, behavioural couples therapy)
What is CBT?
- Goal oriented and structured
- Focuses on resolving current issues
- Focuses on how thoughts, beliefs, attitudes, feelings and behaviour interact and teaches coping skills to deal with things in life differently
What should not be started in primary care?
- Lithium for people who have not taken lithium before
- Valproate (anti-convulsant)
When should patients be referred to the community mental health team (CMHT) if their bipolar disorder is managed solely in primary care?
- Poor or partial response to treatment
- Functioning declines significantly
- Treatment adherence is poor
- Person developes side effects from medication
- Comorbid alcohol or drug misuse is suspected
- Person is considering stopping medication after a period of relatively stable mood
- Patient is pregnant or planning a pregnancy
How often should the physical health of patients with bipolar disorder be checked?
At least annually, focussing on:
- Cardiovascular health
- Diabetes
- Obesity
- Respiratory disease
What needs to be monitored in patients taking long term lithium?
Renal, thyroid function and calcium levels
What risk assessment should be carried out for patients with bipolar disorder?
- Self-neglect
- Self-harm
- Suicidal thoughts or intent
- Risk to others
- Driving
- Spending money excessively
- Financial or sexual exploitation
- Disruption in family and love relationships
- Disinhibited and sexualised behaviour
- Risks of STIs
How is mania or hypomania managed in a patient taking antidepressants?
- Consider stopping the antidepressant
- Offer antipsychotic
What pharmacological inteventions should be offered in an acute episode (or first presentation) of mania/ hypomania?
Prescribe an antipsychotic
First line antipsychotics:
- Olanzapine
- Quetiapine
Alternative antipsychotics:
- Risperidone
- Haloperidol
Often with an adjunctive benzodiazapine
If the patient’s on an antidepressant, stop and/or add an antipsychotic
If the patient’s already taking a mood stabiliser, optimise the dose and add an antipsychotic
What is the management if the patient doesn’t tolerate the first line antipsychotic and an alternative isn’t effective at the maximum dose?
Consider adding a mood stabiliser like lithium, however these are rarely used in the acute setting as the patient needs to give consent and doses are titrated up slowly
It tends to be the prolonged management for BPAD
What is the management if the patient doesn’t tolerate the first line antipsychotic, an alternative isn’t effective at the maximum dose and adding lithium is ineffective?
Consider adding valproate (anti-convulsant) instead (same guidance applies as with lithium)
What is the guidance for offering valproate to fertile people of childbearing potential?
Only used in these patients if there’s no affective alternative
- Must have a second opinion from another doctor (at least 2 opinions to prescribe)
- The patient and doctors have to sign that the patient is aware they must use 2 forms of contraception whilst taking the medication
If someone with a BPAD diagnosis is taking lithium long-term and developes mania, what are the next steps?
- Check plasma lithium levels to optimise treatment
- Consider adding olanzepine or quetiapine (or one of the alternatives) depending on preference and response to treatment
What should be done if a woman or girl of childbearing potential is taking valproate?
Advise to gradually stop the drug due to risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure in pregnancy
If the drug is continued, they should be prescribed a folate supplement
What should not/ is very rarely offered to treat mania?
Lamotrigine, as it’s good for treating the depressive symptoms but has significant side effects
Can lead to stevens-johnsons syndrome (associated with rapid increase in dose)
When should the treatment for mania be reviewed?
Within 4 weeks
What are the guidelines for reviewing a patient on continued lithium treatment for BPAD?
- Weekly monitoring of serum lithium levels when first prescribed
- Once stable, 3 monthly monitoring of Us&Es, eGFR, 12 hr-serum lithium level, TFTs
- If patients are lower risk, this is reduced to every 6 moths
What is the first line pharmacological management if a patient presents with a severe depressive episode that’s not controlled with mood stabilisers?
- Olanzapine with fluoxetine
- Lamotrigine can be used instead of fluoxetine, but isn’t as good
Don’t use SSRIs alone
What should be offered if there is no response to fluoxetine combined with olanzapine (or quetiapine on its own)?
Lamotrigine on its own
Same guidance applies if the patient is taking lithium or valproate
