Bipolar Disorder Flashcards
DIAGNOSTIC CRITERIA
- At least 2 episodes, one of which being mania/hypomania with recovery usually complete between episodes
- Criteria for depressive episode same as usual depression criteria
DIAGNOSTIC CRITERIA
Mixed episode
- Occurance of both manic/hypomanic and depressive symptoms in single episode, present every day for at least 2 weeks
PRESENTATION
Mixed episodes
- Typical presentations include
- Depression plus overactivity/pressure of speech
- Mania plus agitation and reduced energy/libido
- Dysphoria plus manic symptoms
- Rapid cycling (fluctuating between mania and depression - 4 or more episodes/year)
ICD-10 CLASSIFICATION
Different classifications of episodes
- Current episode, hypomanic
- Current episode, manic without psychotic symptoms
- Current episod, manic with psychotic symptoms
- Current episode, mild or moderate depression
- Current episode, severe depression without psychotic symptoms
- Current episode, severe depression with psychotic symptoms
- Current episode, mixed
- Currently in remission
EPIDEMIOLOGY
Lifetime prevlalence
0.3-1.5%
EPIDEMIOLOGY
M:F
1:1
EPIDEMIOLOGY
Peak years
15-19 years and 20-24 years
Mean 21 years
PROGNOSIS
Morbidity and mortality
- High in terms of lost work, lost productivity, effect on marriage and family
- Attempted suicide 25-50%
- Complete suicide 10%
DIFFERENTIAL DIAGNOSIS
Depends upon the nature of the presenting episode (mania/hypomania/depression)
PROGNOSIS
Re-occurence within 2 years of 1st episode
40-50% experience another manic episode
PROGNOSIS
Poor prognosis factors
- Poor employment history
- Alcohol abuse
- Psychotic features
- Depressive features between periods of mania and depression
- Male sex
- Treatment non-compliance
PROGNOSIS
Good prognostic factors
- Manic episodes of short duration
- Later age of onset
- Few thoughts of suicide
- Few psychotic symptoms
- Few co-morbid physical problems
- Good treatment response and compliance
AETIOLOGY
- Genetic
- ?Decreased activation and reduced grey matters in areas associated with emotional regulation
- ?Increased activation in ventral limbic brain
- ?Catechoramine hypothesis
- Environmental factors
AETIOLOGY
Environmental factors
- Stressful life events may lead to episodes
- Pregnancy
AETIOLOGY
Cathecholamine hypothesis
- Increase in epinephrine and norepinephrine causes mania
- Whilst decrease causes depression
MANAGEMENT
Acute episodes
- Depends on nature of episode, may require hospitalisation
- Consider issues of prophylaxis
MANAGEMENT
Purpose of outpatient follow up
- Monitor patients psychiatric status
- Monitor medication side effects
- Enhance treatment compliance
- Provide education
- Identifying new episodes early
MANAGEMENT
Relapse prevention
- Help patient identify precipients or early manifestations of illness
- Promote normal sleeping pattern
- Early signs of mania can be treated with short-term use of benzodiazepines or anitpsychotics
MANAGEMENT
When to admit to hospital
- High risk of suicide or homicide
- Illness behaviour endangering relationships, reputation or assets
- Lack of capacity to co-operate with treatment
- Severe psychotic symptoms
- Severe depressive symptoms
- Severe mixed state
- Catatonic symptoms
- Failure of outpatient treatment
MANAGEMENT
Specific clinical features that strongly influence choice of treatment
- Psychotic symptoms
- Catatonic symptoms
- Risk of suicide
- Risk of violence
- Substance related disorders
MANAGEMENT
Specific clinical features - psychotic symptoms
Lithium +/- antipsychotic
MANAGEMENT
Specific clinical features - catatonic symptoms
- Admit
- Exclude medical problem
- Treat with ECT and/or benzodiazepine
MANAGEMENT
Specific clinical features - risk of suicide
- Admit to hospital
- Consider ECT
MANAGEMENT
Specific clinical features - risk of violence
- Assess risk
- Admit to hospital and consider secure setting
MANAGEMENT
Specific clinical features - substance related disorders
- Address issued of misuse
- If detoxification considered, admit to hospital as risk of suicide may be increased
MANAGEMENT
Severe manic episode
- ECT strongly considered as 1st line
MANAGEMENT
Acute manic episode when not currently on treatment
- Antipsychotic therapy 1st line
- Second generation antipsychotics first line
- Lithium or valproic acid 2nd line
MANAGEMENT
Acute manic episode when on antidepressant medication already
- Stop the antideppresant and commence antipsychotic
MANAGEMENT
Depressive episode if already on prophylaxis
- Consider adding SSRI if on antipsychotic
- If not on antipsychotic consider quetiapine
MANAGEMENT
Prophylactic treatment (lines)
- 1st mood stabiliser and/or atypical antipsychotic
- Plus psychosocial intervention
- 2nd switch to or add alternative first line drug
- Plus psychosocial intervention
- 3rd alternative mood stabaliser and/or atypical antipsychotic
- Plus psychosocial intervention/adjunct ECT
