Bipolar Affective Disorder

Question 1

AETIOLOGY:

Answer 1

1. Genetic
   - FHx of bipolar affective disorder/schizophrenia/schizoaffective disorder
   - first-degree relatives of patients with bipolar have 7x increased risk of bipolar disorder(10%), 2-3 increased risk of unipolar depression(20-30%), higher risk of schizophrenia/schizoaffective disorder
2. Environmental
   - Childbirth( in previous 6/12)
   - 50% untreated bipolar patients experience mania postnatally.
   - Recent negative life events

Question 2

MANAGEMENT:

1. Tx. setting
2. Tx. acute mania/hypomania
3. Tx. acute depression in context of bipolar disorder
4. Maintenance tx.

Answer 2

1. • may need detention under MHA
     - admit if reckless behaviour endangering self/others; impaired judgement; thoughts of self-harm/hurting others/suicide; significant psychotic symptoms; excessive psychomotor agitation with risk of self-injury/dehydration/exhaustion
2. a) If on antidepressant, discontinue gradually.
   b) Start antipsychotic(quetiapine/haloperidol/risperidone/olanzapine)
   - if not tolerated/ineffective, offer alternative antipsychotic.
   - if still not adequate response, consider adding lithium/valproate
   - avoid lithium if poorly concordant.
   c) if already on mood stabilizers, optimise treatment
   - consider adding antipsychotic
3. a) Pharmacological tx if moderate-severe depression
   b) Offer fluoxetine+olanzapine/quetiapine
   - if no response/preferred by patient, consider lamotrigine by itself
   c) If already on lithium/valproate, consider optimising dose before adding fluoxetine+olanzapine/add quetiapine
   - if preferred, can consider adding olanzapine(without fluoxetine) OR lamotrigine.
   - if unresponsive, stop additional treatment and add lamotrigine
4. a) in those with serious adverse risks/repeated hypomanic or depressive eipsode with significant functional impairment.
   b) Lithium as first-line. Olanzapine/valproate as alternatives.
   - all teratogenic
   - lamotrigine considered if majority of episodes depressive
   - when started on valproate, liver and haematological function assessed at 6/12
   - Lithium levels measured every 3/12. Net benefit after ≥2y
   c) Psychological interventions
   - consider family intervention
   - tailored group or individual psychological intervention
   d) ECT
   - can precipitate manic episode in bipolar disorder
   - useful antimanic agent when severe mania and mixed states.

Question 3

COURSE AND PROGNOSIS:

Answer 3

1. > 90% with single manic episode have future episodes
   - about average 4 mood episodes in 10y
2. 5-15% have ≥4 mood episodes within 1y
   - rapid cycling
   - poor prognosis
   - respond poorly to lithium
3. 10-15% completed suicide

Question 4

DYSTHYMIA AND CYCLOTHYMIA:

1. Epidemiology and course
2. Management

Answer 4

1. Insidious onset with chronic course, often from childhood/adolescence
   - significant number go on to develop more severe mood disorders
2. Same drugs as in depression and bipolar.
   - antidepressants in mild depression can precipitate hypomania
   - consider psychological therapies

Question 5

LITHIUM THERAPY:

1. Indications
2. Adverse effects
3. Monitoring
4. Lithium toxicity

Answer 5

1. Prophylaxis in bipolar affective disorder, adjunct in refractory depression
2. very narrow therapeutic range(0.4-1.0 mmol/L)
   - nausea, vomiting, diarrhoea
   weight gain
   - nephrotoxicity
   - thyroid enlargement, hypothyroidism
   - T wave flattening/inversion n on ECG
   - idiopathic intracranial hypertension
   - fine tremor
3. • Monitor every 3 months. Take reading 12h post-dose
     - Monitor renal and thyroid function every 6/12.
     - issue patients alert card, information booklet and record book.
4. > 1.5 mmol/L
   - Precipitated by dehydration, diuretics(especially thiazide ones), metronidazole, ACE-inhibitors, NSAIDS, renal failure
   - features: coarse tremor, hyperreflexia, acute confusion, seizure, coma
   - Mx: Volume resus for mild-moderate toxicity; haemodialysis if severe toxicity; sodium bicarbonate although limited evidence for this.