14. Summary of DSM-IV-TR Classification of Bipolar Disorders * Symptoms do not meet criteria for manic and depressive episodes. Bipolar features that do not meet criteria for any specific bipolar disorders At least 2 years of numerous periods of hypomanic and depressive symptoms* One or more major depressive episodes accompanied by at least one hypomanic episode FEMALE>MALE One or more manic or mixed episodes, usually accompanied by major depressive episodes MALE=FEMALE Bipolar Disorder Not Otherwise Specified Cyclothymic Bipolar II Bipolar I First, ed. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Rev. Washington, DC: American Psychiatric Association; 2000:345-428.
18. Approximate lifetime rates of mood disorder in various classes of relative of bipolar probands Owen M. et alJournal of Medical Genetics 1999; 36 :585-594 Degree of relationship to bipolar proband Risk of bipolar disorder (%) ( Additional) risk of unipolar depression (%) Monozygotic co-twin 40-70 15-25 First degree relative 5-10 10-20 General population (ie, unrelated) 0.5-1.5 5-10
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20. Genetics of Bipolar vs Schizophrenia Copyright restrictions may apply. Owen, M. J. et al. Schizophr Bull 2007 0:sbm053v1-1; doi:10.1093/schbul/sbm053
59. Geddes J, Burgess S, Hawton K, Jamison K, Goodwin G. American Journal of Psychiatry 2004 217-222 Efficacy of lithium – all relapse
60. Efficacy of lithium – Mania Geddes J, Burgess S, Hawton K, Jamison K, Goodwin G. American Journal of Psychiatry 2004 217-222
61. Efficacy of Lithium – Depression? Geddes J, Burgess S, Hawton K, Jamison K, Goodwin G. American Journal of Psychiatry 2004 217-222
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64. Metabolic effects of Lithium Lithium: a review of its metabolic adverse effects Callum Livingstone and Hagen Rampes Journal of Psychopharmacology, May 2006; vol. 20: pp. 347 - 355.
74. Psychological therapies Lam DH, Burbeck R, Wright K, Pilling S. Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention – a systematic review. Bipolar Disord 2009: 11: 474–482.
Summary of DSM-IV-TR Classification of Bipolar Disorders According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders , 4th edition (DSM-IV-TR), bipolar disorder can be divided into four classifications: Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder, and Bipolar Disorder Not Otherwise Specified. Bipolar I Disorder is characterized by one or more manic or mixed episodes usually accompanied by major depressive episodes. Bipolar II Disorder focuses on one or more major depressive episodes accompanied by at least one hypomanic episode. A diagnosis of Cyclothymic Disorder is made when a patient experiences at least 2 years of numerous periods of hypomanic symptoms that do not meet the criteria for a manic episode and numerous periods of depressive symptoms that do not meet the criteria for a major depressive episode. Bipolar Disorder Not Otherwise Specified is characterized by bipolar features that do not meet the criteria for any of the specific bipolar disorders described above or for bipolar symptoms about which there is inadequate or contradictory information. Each classification of bipolar disorder is further defined by the presence (or history) of manic episodes, mixed episodes, or hypomanic episodes, usually accompanied by the presence (or history) of major depressive episodes. First, ed. Diagnostic and Statistical Manual of Mental Disorders . 4th ed. Text Rev. Washington, DC: American Psychiatric Association; 2000:345-428.
Mean effect sizes for six cognitive domains based on demographically-adjusted t -scores produced by patients with schizophrenia (SZ) and bipolar I disorder (BD) compared to healthy adults. Multivariate analysis of variance (MANOVA) planned contrasts confirmed that each patient group differed significantly from healthy controls on every cognitive domain ( p < .01). Bonferroni-corrected post hoc comparisons showed the SZ and BD groups differed significantly ( p < .05) on all domains except divided and sustained attention.
If antimanic medication is not being used, start treatment with an antipsychotic, valproate or lithium Lithium has a slower onset of action than antipsychotics and valproate, so should be used with less severe symptoms
Prescribers should normally consider initiating long-term treatment for bipolar disorder in the following circumstances: − following a manic episode that was associated with significant risk and adverse consequences − when there have been two or more acute episodes in patients with bipolar I disorder − when there is evidence of significant functional impairment, significant risk of suicide or frequently recurring episodes in bipolar II disorder
Key priority for implementation, recommendation in full Lithium, olanzapine or valproate should be considered for long-term treatment of bipolar disorder. The choice should depend on response to previous treatments and: the relative risk, and known precipitants, of manic versus depressive relapse physical risk factors, particularly renal disease, obesity and diabetes the patient’s preference and history of adherence gender (valproate should not be prescribed for women of child-bearing potential) a brief assessment of cognitive state (such as the Mini-Mental State Examination) if appropriate, for example, for older people.
Key priority for implementation, recommendation in full If the patient has frequent relapses, or symptoms continue to cause functional impairment, switching to an alternative monotherapy or adding a second prophylactic agent (lithium, olanzapine, valproate) should be considered. Clinical state, side effects and, where relevant, blood levels should be monitored closely. Possible combinations are lithium with valproate, lithium with olanzapine, and valproate with olanzapine. The reasons for the choice and the discussion with the patient of the potential benefits and risks should be documented. Key priority for implementation, recommendation in full If a trial of a combination of prophylactic agents proves ineffective, the following should be considered: consulting with, or referring the patient to, a clinician with expertise in the drug treatment of bipolar disorder prescribing lamotrigine (especially if the patient has bipolar II disorder) or carbamazepine. When introducing lamotrigine titration should be slower in patients taking concurrent valproate.
Suggested actions that you may want to consider to support long-term pharmacological treatment may include; Raising awareness of NICE recommendations Targeting prescribing advisors and local prescribing leads, emphasising the circumstances for initiating and managing long-term pharmacological treatment and the considerations for deciding on the agent of choice. Updating current prescribing policies and formularies in line with this guidance. Long-term treatment Prescribers should undertake a systematic review of previous treatments and focus on the optimisation of appropriate long-term treatment (with each trial of medication being usually of at least 6 months’ duration) rather than on treating individual episodes and symptoms. Eliminate aggravating factors where possible, for example substance misuse, erratic compliance with medication, or thyroid abnormalities Patient engagement Support patient education in pharmacological management, including recognition of the need for proactive treatment when ‘warning signs’ occur. Consult an expert in pharmacological treatment In long-term management consult with, or refer the patient to, a clinician with expertise in the pharmacological treatment of bipolar disorder. Make use of early intervention teams, regional mental health trusts and CAMHS teams.
Recommendation in full Healthcare professionals should base the treatment of an acute episode in the context of rapid cycling (which should normally be managed in secondary mental health services) on that for the treatment of manic and depressive episodes, but in addition do the following: Undertake a thorough review of previous treatments for bipolar disorder, and consider a further trial of appropriate previous treatments that have been inadequately delivered or adhered to. Focus on the optimisation of appropriate long-term treatment (with each trial of medication being usually of at least 6 months’ duration) rather than on treating individual episodes and symptoms. Encourage patients to keep a regular mood diary (paper or electronic) to monitor changes in severity and frequency of symptoms, and the impact of interventions.
Key priority for implementation, recommendation in full If a patient is taking an antidepressant at the onset of an acute manic episode, the antidepressant should be stopped. This may be done abruptly or gradually, depending on the patient’s current clinical need and previous experience of discontinuation or withdrawal symptoms, and the risk of discontinuation/withdrawal symptoms of the antidepressant in question.
Key priority for implementation, recommendation in full After successful treatment for an acute depressive episode, patients should not routinely continue on antidepressant treatment long-term, because there is no evidence that this reduces relapse rates, and it may be associated with increased risk of switching to mania.
Patients may be concerned about antidepressant withdrawal and the fear of depression versus mania. Encourage patient empowerment to monitor changes in severity and frequency of symptoms, and the impact of interventions.
Recommendation in full For people with bipolar disorder who are relatively stable (but who may experience mild to moderate affective symptoms), healthcare professionals should consider individual structured psychological therapy (normally at least 16 sessions over 6 to 9 months) in addition to prophylactic medication which should: include psychoeducation about the illness and the promotion of regular daily and routine sleep and of medication adherence include monitoring of mood, detection of early warnings and strategies to prevent early stages from developing into full-blown episodes enhance general coping strategies.
Suggested actions that you may want to consider to support individual psychological therapy may include; Offer individual structured psychological therapy from trained, experienced healthcare professionals Identify key people to support mood monitoring and coping strategies, such as registered mental health nurses, community psychiatric nurses, service users, carers and voluntary sector Identify professionals who require training or updating Review access to services and ensure that it is timely Work collaboratively and engage the client, family or carers
Key priority for implementation, recommendation in full Valproate should not be prescribed routinely for women of child-bearing potential. If no effective alternative to valproate can be identified, adequate contraception should be used, and the risks of taking valproate during pregnancy should be explained. Valproate is teratogenic with an increased risk of neural tube defects and therefore cannot be recommended as a first-line agent in the treatment of mania in women of child-bearing age (unless they are using a highly reliable from of contraception such as an intrauterine device). Prenatal exposure to valproate may also be associated with an increased risk of developmental problems including reduced cognitive performance.
Suggested actions you may want to consider to support the pharmacological management of women of child bearing potential include: Review of care pathways and management. Enable access to experts in pharmacology for support when prescribing for women of child bearing potential. Raising awareness of effect of bipolar illness on: conception - mania can lead to sexual disinhibition and unplanned pregnancy, some medication reduces fertility, whilst carbamazepine reduces the effectiveness of the oral contraceptive effect of pregnancy - there is approximately a 50% chance of an episode of psychosis in the post-partum period child - there is a risk of bipolar disorder in offspring, clinicians often offer to discuss this with patients. Engaging with patients Discuss contraception, and the risks of pregnancy (including the risks of relapse in pregnancy, the possible risks to the unborn child of medication, and the risks associated with stopping medication during the pregnancy) with women of child-bearing potential regardless of whether they are currently planning a pregnancy. Encourage patients to discuss with their doctor any plans to conceive.
Recommendation in full For people who have gained weight during treatment for bipolar disorder, healthcare professionals should review the medication strategy, and consider the following. • Giving dietary advice and support from GP and mental health services. • Advising regular increased aerobic exercise. • Referring to a specialist mental health diet clinic or health delivery group where available. • Referring to a dietician for people with complex comorbidities (such as additional physical problems/dietary difficulties, such as coeliac disease).
Suggested actions you may want to consider to support the risk of weight gain during pharmacological treatment include: reviewing risk of weight gain when prescribing, offer early dietary advice and support when initiating medications that are likely to cause weight gain such as lithium, valproate and antipsychotics - particularly olanzapine review the medication strategy and give dietary advice and support from GP and mental health services. Offer specialist mental health diet clinics where available or health delivery group locally. Review and update local referral and care pathways. Ensure key workers have appropriate training and understanding of recommendations to manage weight gain and actions needed to support them.
Key priority for implementation, recommendation in full People with bipolar disorder should have an annual physical health review, normally in primary care, to ensure that the following are assessed each year: lipid levels, including cholesterol in all patients over 40 even if there is no other indication of risk plasma glucose levels weight smoking status and alcohol use blood pressure.
Agree responsibility for physical health checks locally. Establish local monitoring and early warning systems to identify need for annual review. Develop systems for responsibility and appropriate intervention when health problem detected. Communicate results to client and relevant healthcare professionals. Follow up within 14 days of non attendance in accordance with the Quality Outcomes Framework MH7. This is part of the General Medical Services contract, and awards points to GPs for delivering services for patients with bipolar disorder.
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