1. Management of Bipolar Affective Disorders

2. 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

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

4. 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

5. 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 (> 2 years duration) featuring numerous periods of mild depression and elation, none of which meet the criteria for depression or mania

6. 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

7. 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

8. Course of the Illness Peak age of onset is 15-24 years
If onset occurs >60 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

9. Aetiological Factors Genetic Birth Effects
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

10. Pathophysiology Neurotransmitter Dysfunction
? deficits in Na+K+ATPase 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

11. 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

12. Fundamentals of Patient Management
Diagnosis
Access to services and safety
Enhanced Care

13. 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

14. 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

15. Assessment of Risk Ideally involve an informant Suicide
Excessive spending
Sexual promiscuity
Driving
Violence

16. 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

17. Treatment of different phases of bipolar disorder
Acute manic or mixed episode
Acute depressive episode
Long-term treatment
Pregnancy and the post-partum period

18. 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

19. 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)

20. 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

21. Mental Health Register
Regular (annual) physical health checks
Relevant blood tests
Need to establish between primary and secondary care respective responsibilities

22. Longterm Treatment:Drugs
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)

23. 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

24. Monitoring Lithium Therapy
Serum Lithium levels 3-6 monthly
U+E, Thyroid function and calcium every 6 months

25. 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

26. Atypical Antipsychotics
Recently licensed for acute and maintenance treatment
Olanzapine
Quetiapine
Risperidone
6 monthly glucose monitoring required with atypical antipsychotics

27. 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)

28. 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

29. 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

30. Bipolar Disorder and Pregnancy
Compliance with treatment during pregnancy
maintenance of mental health
normal bonding
risk of teratogenesis
neonatal side effects

31. Risk of congenital malformation
Normal population 2-4%
Lithium exposed %
Valproate exposed 11%
Carbamazepine exposed 6%

32. Specific teratogenic associations
Lithium % risk of cardiovascular anomalies
Valproate and Carbamazepine
1-2 % risk of congenital abnormality
including neural tube defect and foetal hydantoin syndrome

33. 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 weeks gestation
Maternal physiological changes result in variable serum levels of mood stabilisers especially lithium

34. 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)

35. Evidence Based Guidelines for Treating Bipolar Disorder