Bipolar

Question 1

Basic info

Answer 1

Lifelong condition
HYPOMANIA/MANIA + DEPRESSION

Manic ep = elevated moods/irritability last at least 1 week with at least 3 more symptoms and severe enough to cause impairment in social or occupational functioning or needs hospitalisation or includes psychotic features.

Hypomanic ep = Not severe enough to cause what manic ep does.

Depressive ep = Lasts at least 2 weeks there’s either depressed mood or loss of interest/pleasure in nearly all activities, with 4 extra depressive symptoms.

Mixed ep = - Mix or rapid alteration between manic and depressive symptoms OR
- at least 1 week where manic or hypomanic ep criteria met + at least 3 depression symptoms in most days OR
- At least 2 weeks where major depressive ep criteria met and at least 3 manic/hypomanic symptoms in most days.

Rapid cycling bipolar = at least 4 of the above eps within 1 year

Often comes with other diseases like anxiety disorders, substance misuse, personality disorders and ADHD.

Question 2

Aetiology, pathophysiology and diagnosis

Answer 2

Mania -
Diagnosis: needs symptoms for at least 1 week and begin abruptly.

Symptoms:
- Abnormally elevated mood, extreme irritability, sometimes aggression,
- Increased energy/activity, restlessness, decreased need for sleep,
- Incomprehensible speech,
- Racing thoughts,
- Distractibility, poor concentration, - Increased libido, disinhibition, sexual indiscretions,
- Impractical plans
- Psychotic symptoms: delusions, hallucinations (usually voices).

Hypomania-
Diagnosis: needs to be for at least 4 days.
Symptoms:
NOT severe enough to cause impairment in functioning and no Psychotic features. CAN HAVE -
- Mild elevation of mood, or irritability,
- Increased energy/activity, increased performance at work/socially,
- Feelings of well-being, physical and mental efficiency,
- Increased sociability, talkativeness, and over-familiarity.

Depression -
Symptoms:
- Persistent sadness or low mood,
- Loss of interest or pleasure, low energy.

Diagnosis criteria for young:
- Mania must be present.
- Euphoria must be present on most days and for most of the time, for min 1 week.
- For confirmation need to refer to specialist mental health assessment. use Judgment to figure out urgency. Young = CAMHS

Question 3

Treatment

Answer 3

NON PHARMACOLOGICAL:
GP needs to do risk assessment for harm, suicide
Depression = psychological intervention

Pharmacological:
Acute mania/hypomania
- 1st line = Antipsychotics (haloperidol, olanzapine, quetiapine, risperidone)
ALT + Lithium or valproate

Moderate to severe manic EP - Asenapine (2ND GEN)

Long term management
Olanzapine (if responded to this drug b4) or Lithium
- Lithium full prophylactic effect may take 6 to 12 months to occur.
ALT to lithium - + or alone Valproate.
Carbamazepine IF UNRESPONSOVE TO LITHIUM

• When discontinuing antipsychotic need to be gradually reduced over minimum 4 weeks to reduce reoccurrence risk

Short term initial - Benzodiazepines (eg lorazepam) Not for long because of dependence risk.

Antidepressants
Can be used for coexisting bipolar depression BUT AVOID in mani or hypomania (causes them to be more manic as more happier mood)
- Can stop if hypomania/mania develops.

AVOID IF pt has rapid-cycling bipolar disorder, a recent Hx of mania/ hypomania, or rapid mood fluctuations.