Bipolar affective disorder Flashcards
Define bipolar affective disorder
Serious long-term mental illness, which is usually characterized by episodic depressed and elated moods, and increased activity (hypomania or mania).
Define mania
Abnormally and persistently elevated, expansive, or irritable mood:
○ Lasts at least 1 week
○ Accompanied by at least three additional symptoms
○ Severe enough to cause marked impairment in social or occupational functioning OR necessitate hospitalisation OR includes psychotic features
What are the risk factors for bipolar affective disorder
Previous episodes of mania/hypomania
Family history of bipolar disorder
Onset of mood disorder prior to 20 years of age
Stressful life events
Previous Hx of depression
Lifetime substance misuse disorder Hx
Pre-existing anxiety disorder
What are the manic symptoms of bipolar affective disorder
- Abnormally elevated mood, extreme irritability, aggression
- Increased energy/activity
- Reduced need for sleep, restlessness
- Distractibility, poor concentration
- Increased libido, disinhibition, sexual indiscretions
- Extravagant or impractical plans
- Psychotic symptoms: delusions (usually grandiose) or hallucinations (voices)
What complications of bipolar affective disorder may be evident in the history
- Financial difficulties from overspending.
- Traumatic injuries and accidents.
- Sexually transmitted infections and unplanned pregnancy from disinhibition and increased libido.
- Damage to reputation, income and occupation, and relationships.
- Self-neglect, exhaustion, and dehydration.
- Exploitation by others.
- Alcohol and substance misuse
- Harm to others.
What are the differentials for bipolar affective disorder
Unipolar depression
Cyclomythia
Schizophrenia
Substance misuse
Mood disorder due to thyroid dysfunction, stroke
Organic brain disease e.g. frontal lobe dementia, CVD
What investigations are done for suspected bipolar affect disorder
Confirmation requires a specialist mental health assessment
Bedside
○ Full history + collateral
○ Urine dip
○ Urine toxicology
Bloods
○ FBC | Vit D | Toxicology screen | TFTs
○ Fasting lipid profile | fasting glucose | MRI brain | actigraphy
Other
○ Consider questionnaires
Primary evaluation of mental disorders (PRIME-MD)
Patient health questionnaire (PHQ-9)
Mood disorder questionnaire (MDQ)
Composite international diagnostic interview (CIDI)
Bipolarity index
Young mania rating scale (YMRS)
What are the referral pathways for bipolar affective disorder in primary care
Mania → Urgent referral to CMHT for specialist mental health assessment
Hypomania → routine referral to CMHT for specialist mental health assessment
<14yo → CAMHS
14-18yo → specialist early intervention in psychosis service or CAMHS
Advise to stop driving during acute illness until seen by a psychiatrist
What is the biological management for mania in bipolar affective disorder in secondary care
Mania: PO Antipsychotic (Haloperidol, Olanzapine, Quetiapine, risperidone)
Agitation/insomnia → Short-term Benzodiazepine use (e.g. Lorazepam)
Second line: Alternative antipsychotic- if first antipsychotic is not tolerated or ineffective
Third line: Addition of Lithium
Fourth line: Sodium valproate
All attempts unsuccessful → ECT
What is the psychological management for a depressive episode of bipolar affective disorder in secondary care
Psychological intervention for bipolar depression
CBT for bipolar
Interpersonal therapy
Behavioural couples therapy
What is done in the following situations for acute bipolar affective disorder management:
If on antidepressants as monotherapy
If on antidepressant + antipsychotic
If already on lithium
If already on mood stabilisers
If on antidepressants as monotherapy → STOP antidepressant, ADD antipsychotic
If on antidepressant + antipsychotic → STOP antidepressant
If already on lithium → CHECK plasma lithium levels + CONSIDER antipsychotic
If already on mood stabilisers → CHECK levels + CONSIDER increasing dose + CONSIDER antipsychotic
What is the long-term management for bipolar affective disorder
Discussed 4 weeks after episode has resolved
Bio
First line: Lithium (mood stabiliser)
Second line: Sodium Valproate OR Olanzapine OR Quetiapine
Sodium valproate should NOT be prescribed to female children, adolescents and women of childbearing potential or pregnant women
Social
Education
Family support and therapy
Information on work, education, housing, benefits, driving (must inform DVLA)
Encourage lasting power of attorney
Write a care plan together
Resources: Bipolar UK, MIND
What is the psychological long-term treatment for bipolar affective disorder
Structured psychological intervention (individual, group, family) designed for BPAD e.g. CBT for BPAD
Psychoeducation (identify relapse indicators)
High-intensity psychological intervention e.g. CBT, IPT/IPSRT, behavioural couples therapy
(FOR DEPRESSIVE PHASE, NOT MANIA)
What monitoring is required for lithium treatment
Prior to commencing lithium, the following should be checked:
○ BMI
○ U&Es (inc. calcium + GFR)
○ TFTs
○ FBC
○ ECG- if CVD or CV risk factors
Measure plasma lithium levels 1 week after starting or changing dose and monitor weekly until stable levels reached. It should then be measured at least every 3 months thereafter in the first year (aim 0.6-0.8)
Every 6 months: U&Es (Calcium + GFR) and TFTs
What are the side effects of lithium use
Nephrotoxicity
Hypothyroidism,
Lithium toxicity (N&V, polyuria, polydipsia, arrhythmia, weight gain, renal failure)
Neurological adverse effects (extrapyramidal)
Benign leukocytosis
What are the complications of bipolar affective disorder
Suicide and deliberate self-harm
Anti-psychotic therapy-related sudden cardiac death
Weight gain
Disability
Parkinson’s
Cognitive dysfunction
Consequences of disinhibition and impaired social functioning
What is the prognosis for bipolar affective disorder
Likelihood of recurrence is almost certain
Episodes may become more frequent
With treatment, episodes of mania, depression, or mixed states last for approximately 3 to 4 months
Overall long-term outcome is not good - treatments are effective at reducing symptoms but only a minority of patients are substantially well over long-term follow-up
Mortality is higher in patients with bipolar disorder than in the general population - due to CVD and suicide
What are the two types of BPAD
type I disorder: mania and depression (most common)
type II disorder: hypomania and depression
Define hypomania
Abnormally and persistently elevated, expansive, or irritable mood that lasts for 4 days WITHOUT additional symptoms etc.
Define a depressive episode in BPAD
Period of at least 2 weeks during which there is either depressed mood or loss of interest or pleasure in nearly all activities (or irritability in children and adolescents), accompanied by at least four additional depressive symptoms.
What are the hypomanic symptoms of BPAD
- Mild elevation of mood, irritability
- Increased sociability, talkativeness
- Increased energy and activity
What are the depressive symptoms of BPAD
- Feelings of persistent sadness or low mood
- Loss of interest or pleasure
- Low energy
What is the social management for bipolar disorder
Contact family/carers and inform on diagnosis
Offer needs assessment
Education, employment, housing, benefits, driving
Resources: bipolaruk, mind, rethink
Encourage lasting power of attorney
Create a care plan - Wellness Recovery Action Plan (WRAP)
What is the biological treatment for a depressive episode in bipolar affect disorder
First line: Fluoxetine + olanzapine OR quetiapine
Second line: lamotrigine
