1. 2007

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. Management New 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. Management Existing 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