Bipolar Affective Disorder

Question 1

Presentation and diagnosis of mania

Answer 1

Mania - acute abnormally elevated mood/irritability for min 1wk

• decreased sleep
• flight of ideas
• poor concentration
• increased libido, disinhibition, sex drive, reckless behaviour
• psychosis - grandiose delusions, hallucinations

Question 2

Presentation and diagnosis of hypomania
Differentiating between depression and bipolar depression

Diagnosis of bipolar disorder

Answer 2

Hypomania - less severe, no impact of ADLs or psychosis for min 4 days

Early, abrupt onset
Frequent shorter episodes

1 episode of each or 2 episodes of mania

• Bipolar 1 - M+D
• Bipolar 2 - H+D
• Rapid cycling - 4+ episodes of mood disturbance in 1 year

Question 3

Management of suspected bipolar disorder

-primary care

Answer 3

Refer to specialist MH to confirm diagnosis, treat acute episode and establish care plan
-RISK ASSESS
Once mood stable, compliant => discharge to local CMHT or GP

May need to detain if attempting to self discharge/refuse admission or treatment
-can change mind very rapidly

Question 4

Risk factors for bipolar disorder

Epidemiology (age, sex)

Answer 4

Past psych history - past episodes of mania => needed for diagnosis

Drug, alcohol - stimulants (cocaine, ecstacy, amphetamines) => manic

FHx - 1st degree relatives, high concordance in MZ

Age and sex - 20s, equal prevalence in both sexes

Question 5

Medication

• acute manic episodes in secondary care
• long term management to prevent relapse

Answer 5

1st line - atypical antipsychotic (risperidone, olanzepine, quietapine)
-act faster than mood stabilisers
-taper and discontinue antidepressants
If sedation needed - IM lorazepam

Long term plan - lithium
-can add valproate is lithium not enough
-or continue on current treatment
Establish care plan in cases of relapse
-immediate harm => local crisis resolution, HTT
-signs of relapse but not immediate risk => CMHT assessment

Question 6

Contraindications to valproate, lithium

Monitoring

Answer 6

Pregnant - valproate only used if there is no other effective option/bipolar is severe

Breastfeeding - avoid lithium

Monitor physical health
-weight, BMI, smoking, glucose, cholesterol annually

Question 7

Describe how and what you would monitor in lithium use

• SE
• Toxicity signs and management

Answer 7

V narrow therapeutic window

• new dose - bloods 7-10 days later
• stable dose - 3 monthly (kidney, LFTs, TFTs, Ca)

SE

• fine tremor
• nausea, GI upset
• metallic taste

Toxicity => saline or hemodialysis

• coarse tremor
• hyperreflexia
• polyuria
• seizure, coma