The document provides an overview of bipolar disorder, including its prevalence, symptoms, diagnosis, course, treatment guidelines, and monitoring recommendations. It discusses the symptomatology and classification of bipolar I and II disorders. It also outlines the etiology, neurobiology, and risk of relapse associated with bipolar disorder. Treatment guidelines from NICE focus on acute stabilization and long-term management using lithium, anticonvulsants, or antipsychotics.
Bipolar depression: Diagnosis and TreatmentScott Eaton
Differentiating Depression in Bipolar Affective Disorder, Unipolar Depression and Borderline Personality Disorder.
How to treat this depression following the new CANMAT 2013 guidelines.
The recognition of bipolar disorder in primary careNick Stafford
Bipolar disorder and the complexities of screening and diagnosis in primary care. How more accurate detection and an integrated care pathway with secondary care can improve the diagnosis and outcome of the treatment of the disorder.
Bipolar depression: Diagnosis and TreatmentScott Eaton
Differentiating Depression in Bipolar Affective Disorder, Unipolar Depression and Borderline Personality Disorder.
How to treat this depression following the new CANMAT 2013 guidelines.
The recognition of bipolar disorder in primary careNick Stafford
Bipolar disorder and the complexities of screening and diagnosis in primary care. How more accurate detection and an integrated care pathway with secondary care can improve the diagnosis and outcome of the treatment of the disorder.
Bipolar disorders in DSM-5: strengths, problems and perspectivesLena Setianingsih
International Journal of Bipolar Disorders
Bipolar disorders in DSM-5: strengths, problems and perspective
Source :http://www.journalbipolardisorders.com/content/1/1/12
Mood disorders:major depressive and bipolar disorderNandu Krishna J
a basic description about mood disorders mainly MDD and bipolar disorder. Can be made useful in presentations and theory exams. Subject was imbibed from different presentations and DSM IV manual. Thanks for viewing.
Bipolar disorders in DSM-5: strengths, problems and perspectivesLena Setianingsih
International Journal of Bipolar Disorders
Bipolar disorders in DSM-5: strengths, problems and perspective
Source :http://www.journalbipolardisorders.com/content/1/1/12
Mood disorders:major depressive and bipolar disorderNandu Krishna J
a basic description about mood disorders mainly MDD and bipolar disorder. Can be made useful in presentations and theory exams. Subject was imbibed from different presentations and DSM IV manual. Thanks for viewing.
Do you have trouble falling asleep, or find yourself constantly waking up throughout the night ? You may have Insomnia. Take a self test @ https://www.sleepmedcenter.com/psychomotor-vigilance-test/
A fun presentation on a very serious issue: systemic lupus. Despite being a widespread disease, there isn't a great deal of awareness surround it - hopefully something SlideShare can help change!
(This presentation was created for general education only. Individuals should consult a qualified healthcare provider for professional medical advice, diagnoses, and treatment of a medical or health condition.)
Depression
Background
Pathophysiology
• The monoamine theory of depression is that it results from a central deficit in the monoamine neurotransmitters serotonin (5-HT) and norepinephrine.
• Other reported physiological features include ↑cortisol and a blunted TSH response.
• However, there is no widely accepted and definitively proven biological model of depression.
Epidemiology
• Time course: for most it is an episodic illness, but for other it follows a more chronic course.
• Incidence: 5% annual risk, 20% lifetime risk.
Presentation
DSM and NICE criteria
These are based on DSM-4, though DSM-5 does not significantly differ.
Major depressive disorder is ≥2 weeks of low mood and/or anhedonia, and at least 4 symptoms out of:
• ↓Energy or fatigue.
• ↓Concentration
• ↓Weight/appetite.
• Disturbed sleep, which commonly includes early waking. Diurnal pattern to symptoms also seen, with symptoms often worse in the morning.
• Slowing of thought and movements (psychomotor slowing) or agitation.
• Ideas of worthlessness or guilt.
• Recurrent thoughts of death or suicide.
• All but the last 2 are considered 'biological' symptoms.
Psychiatric Disorders in Chemically Dependent Individuals - October 2012Dawn Farm
This program provides an overview of co-occurring addiction and psychiatric illness, including standard diagnostic criteria, individual considerations for determining the appropriate course of treatment, available treatment interventions, and the perspectives of both the addict and the treatment provider on addiction and psychiatric illness. It is presented by Dr. Patrick Gibbons, LMSW, DO; Adjunct Clinical Instructor in Psychiatry at the University of Michigan; Medical Director of the WCHO Community Crisis Response Team; consultant with Pain Management Solutions in Ann Arbor; Medical Director of the Michigan Health Professionals Recovery Program, and Medical Director of Dawn Farm. This program is part of the Dawn Farm Education Series, a FREE, annual workshop series developed to provide accurate, helpful, hopeful, practical, current information about chemical dependency, recovery, family and related issues. The Education Series is organized by Dawn Farm, a non-profit community of programs providing a continuum of chemical dependency services. For information, please see http://www.dawnfarm.org/programs/education-series.
Discussion 1
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C.Z. Case Discussion
C.Z. presents with delusion, hallucination, trouble focusing, thought disorders, and speech difficulties. These symptoms suggest C.Z. has schizophrenia, as defined by the American Psychological Association (APA; 2020). Also, DSM-V include 2 or more criteria present for a significant portion of time during 1 month period, C.Z. has delusion, hallucination This paper describes schizophrenia’s etiology, course, associated abnormalities, and management.
Etiology
Schizophrenia’s etiology includes several possible causes. Potential causes include heredity, stressful events, alcohol, and substances use, especially amphetamine and cannabis, and perinatal, neuroanatomic, and neurodevelopmental factors (Rosenthal & Burchum, 2021; Hany et al., 2022). Social isolation, childhood trauma, family history, and urbanization also heighten risk (Hany et al., 2022). However, the specific cause is unknown.
Course
The course of schizophrenia is varied. Some patients may show subtle, gradual changes before schizophrenia symptoms manifest (Rosenthal & Burchum, 2021). Once the illness develops, acute episodes feature delusions and hallucinations symptoms (Rosenthal & Burchum, 2021). Patients may have less vivid residual symptoms after the acute episode, including suspiciousness, diminished judgment, reduced self-care capacity, and poor anxiety management (Rosenthal & Burchum, 2021). The condition’s long-term course features episodic acute exacerbations with partial remission intervals with progressive decline in social functioning and mental status becoming evident with time (Rosenthal & Burchum, 2021). Others may have continuous symptoms. Appropriate treatment can prevent long-term deterioration and reduce acute relapse risk.
Structural/Functional Abnormalities
Notably, schizophrenia is linked to structural and functional abnormalities. Imaging tests have shown structural abnormalities, including disrupted white matter integrity and reduced gray matter volume in parietal and temporal regions (Zhao et al., 2018). Functional abnormalities are present since schizophrenia is linked to a dysregulation of dopaminergic signaling and increased striatal activity (Zhao et al., 2018). Other functional abnormalities include abnormal neural activity and emotional and cognitive dysfunction (Zhao et al., 2018). Notably, the abnormalities occur over the disease’s course, with Zhao et al. (2018) observing abnormalities before symptoms emerge and becoming more evident with the onset of the illness.
Treatment
Pharmacotherapy is recommended for schizophrenia for symptom management to enhance and maintain recovery. APA (2020) guidelines recommend antipsychotics for patients with schizophrenia (Keepers et al., 2020). Medications for this disorder could be classified typical and atypicals, the first one also by binding affinity with D2 receptor: low, medium, and high. ...
What is Depression?
(1)Major depressive disorder: Combination of symptoms interfering with person’s ability to work, sleep, study, eat, & enjoy once-pleasurable activities. Disabling & prevents person from functioning normally. Often recurs in persons life.
(2)Dysthymic disorder: Long-term (> 2 years) but less severe symptoms that may not disable a person but can prevent one from functioning normally or feeling well.
(3)Psychotic depression: Severe depressive illness accompanied by some form of psychosis, such as break with reality, hallucinations, & delusions.
(4)Postpartum depression: When new mother develops major depressive episode within one month after delivery. Estimated that 10-15% women with postpartum depression after giving birth.
(5)Seasonal affective disorder (SAD): Depression during winter months, when less natural sunlight, that lifts during spring and summer. Half of these cases do not respond to light therapy alone but responsive to combo antidepressants, light, and psychotherapy.
(6)Bipolar disorder: Aka manic-depression. Cycling mood changes from extreme highs (mania) to extreme lows (depression).
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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
19.
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
62.
63.
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.