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Comparison of BPAD treatment guidelines
- 1. Overview and Comparison of available guidelines for management of BPAD Dr Amit Chail, JR, Dept of Psychiatry
- 2. States in BPAD • Mania / hypomania • Depression • Mixed State • Remission
- 3. Common points • Detailed history • Timeline • Clinical assessment • Establish current polarity and severity • Baselines investigations • Other haematological, biochemical and neuroimaging • Urine – RE, drug screen • D/D • Evaluation- continuous process • Assessment of caregivers and social support
- 4. Treatment setting ? • Indications for in-patient care: – suicidality, – severe agitation and violence, – malnutrition, – catatonia, – patient unable to care for self to the extent that she/he requires constant supervision or support, – comorbid general medical conditions Subject to MHCA-2017
- 5. Treatment plan • Therapeutic alliance • Document your decisions – Pharmacological – Somatic (ECT) – Psycho-social With justifications
- 6. Treatment in various phases
- 7. Acute Mania – NICE guidelines, 2014 • Already taking lithium / Val / SDA, check levels • Optimise / Add anti-psychotic • If not taking an antipsychotic or mood stabiliser, offer haloperidol, olanzapine, quetiapine or risperidone –Stop antidepressants –If first antipsychotic is poorly tolerated/ ineffective • switch • or add Li / Val • Don’t use Lamotrigine • Treat acute phase x 3-6 months; then review
- 8. Acute Mania – IPS guidelines, 2017 .. contd
- 10. Acute Mania – BAP guidelines, 2016 • Not on treatment – haloperidol, olanzapine, risperidone and quetiapine – Valproate • On maintenance treatment • Optimise (check serum levels) • Augment – Li / Val / SDA • If poor adherance – Li is not a good choice • Poor symptom control – Combination - Li / Val / SDA – Consider ECT > Clozapine • Treat • Comorbidity, precipitating biological factors (SUD)
- 11. Acute Mania- CANMAT & ISBD, 2018 • Agitation • Mm • ,,
- 12. Acute Mania- CANMAT & ISBD, 2018 1. Assess medication status • Stop AD • Current mood stabiliser / SDA levels 2. Initiate or optimize therapy and check adherence 3. Add on or switch therapy (alternate first-line agents) 4. Add on or switch therapy (second-line agents)
- 13. Acute Mania- CANMAT & ISBD, 2018
- 17. Acute Bipolar Depression – NICE guidelines, 2014 – Not on treatment –Start OFC / Quetiapine –No response – switch to Lamotrigine – If on Li / Val – check levels / dose •Optimise •Augment – OFC / Q no response, then Li / Val + Lamotrigine
- 18. Acute Bipolar Depression – IPS guidelines, 2017
- 19. NICE vs BAP – Bipolar Depression NICE 2014 BAP 2016 OFC / Quetiapine Quetiapine, lurasidone or olanzapine monotherapy If no response- lamotrigine monotherapy Antidepressant + anti- manic drug in bipolar I patients ECT noticed but not recommended Consider ECT in severe or refractory depression
- 20. Acute Bipolar Depression - CANMAT & ISBD, 2018 1. Assess medication status 2. Initiate or optimize therapy and check adherence 3. Add on or switch therapy (alternate first-line agents) 4. Add on or switch therapy (second-line agents)
- 23. NICE 2014 • Li – first line • If Li is ineffective- add Valproate • If Li - poorly tolerated – switch to Val / Olanzapine • If Quetiapine- in acute phase – continue • Psycho-education • Structured psychotherapy – individual/ group/ family • If planning to stop medication – Discuss and document – Taper – Educate for early signs of relapse – Monitor x 2 years
- 24. IPS 2017 • Goals- – Prevent recurrence and reduce residual symptoms • Lithium and Valproate • Olanzapine and Quetiapine • LAI- Risperidone • Lamotrigine (if predominantly depressive) • Severe cases- Combination – Li / Val / SDA • Maintenance ECT +/-
- 25. NICE vs BAP – Long term treatment NICE 2014 BAP 2016 Lithium lithium as first-line treatment If ineffective, consider adding valproate If ineffective - combination treatment (Depression predominant: add lamotrigine, quetiapine or lurasidone) (Mania predominant: add Val /SDA) Consider lamotrigine as monotherapy in bipolar II disorder when depression is the major burden
- 26. CANMAT & ISBD, 2018
- 27. Indications of ECT (IPS-2017) • Mania/ depression not responding • Catatonic symptoms • Need for rapid control of symptoms • Suicidality • Severe agitation or violence – risk to others • Refusal to eat which puts the life of patient at risk • History of good response in the past • Augmentation of partial response to pharmacotherapy • Not able to tolerate pharmacotherapy • Episodes of severe depression or mania during pregnancy Subject to MHCA 2017
- 29. Risk factors for RCAD • Hypothyroidism • Long term aggressive use of antidepressants • Comorbid substance use • Minor tranquilizer/stimulant or caffeine abuse • Cyclothymic and hyperthymic temperament • Female gender especially during Menopause • Temporal lobe dysrhythmias • Several episodes/stressors as an effect of kindling • Onset of illness as depression • Frequent and more depressive episodes • ? COMT/BDNF gene abnormality • ? Biological rhythm disturbances like wakefulness, light exposure
Editor's Notes
- The lowest doses necessary should be used (S). Do not escalate the dose of dopamine antagonists simply to obtain a sedative effect (S).
- Patient prefernce Past response to treatment
- The primary goal of maintenance treatment is to prevent the recurrence of episode of either polarity, reduce/eliminate the residual symptoms and improve the overall functioning of the patient. In terms of pharmaco-therapeutic agents, best evidence for maintenance treatment is available for lithium and valproate. In recent years evidence has also emerged for use of olanzapine and quetiapine in prevention of recurrence of both depressive and manic episodes. However, these may be avoided because of associated higher risk of metabolic side effects. Long acting risperidone has been shown to be beneficial in prevention of recurrence. Lamotrigine has been shown to be efficacious in prevention of depressive episodes, but not for prevention of manic episodes. Olanzapine, aripiprazole, ziprasidone and asenapine has been shown to be of benefit in prevention of recurrence of manic episodes, but not for depressive episodes. Carbamazepine has also been shown to be effective in prevention of recurrence; however, it is less preferred compared to lithium and valproate because of its side effect profile and drug interactions. Studies have also evaluated the efficacy of lithium and valproate in combination with various antipsychotics. Besides use of pharmacotherapy, there is evidence to suggest the beneficial role of adjunctive psychosocial intervention in the management of BPAD. Maintenance ECT may also be considered in patients who have responded to ECT during their acute episodes. The general principle of management during the maintenance phase of treatment is to continue the medication started during the acute phase of illness. Accordingly, while selecting the agent during the acute episode, clinicians may take into consideration the patient’s preference, clinical factors which may influence the long term outcome, recurrence of episodes and side effects. If the patients have more manic episodes then one may prefer lithium, valproate or carbamazepine while for more depressive episodes one may consider Lithium, lamotrigine or quetiapine. In severe cases, combination of lithium and valproate may be considered. It is important to note that patients with mood disorders are more vulnerable to extrapyramidal side effects like tardive dyskinesia with long term use of antipsychotics, especially typical antipsychotics. Patients who have been treated with a combination of lithium and antipsychotic or valproate and antipsychotic medication, the need for continued use of antipsychotic need to be reassessed on the basis of longitudinal course. Similarly, stoppage of antidepressants needs to be considered once bipolar depression remits