Bipolar disorder

Question 1

Symptoms of mania

Answer 1

Abnormally elevated mood
Extreme irritability 
Aggression 
Increased energy 
Pressure of speech 
Flight of ideas 
Psychotic symptoms

Question 2

What does a diagnosis of a manic episode require

Answer 2

Requires symptoms of mania lasting for at least 7 days which usually begin abruptly

Question 3

Symptoms of hypomania

Answer 3

Mild elevation of mood, irritability
Increased energy
Feelings of well-being, or physical and mental efficiency
Increased sociability

Question 4

Hypomania vs mania

Answer 4

Hypomania is suggested by symptoms of mania that are not severe enough to cause marked impairment in social or occupational functioning, and the absence of psychotic features

Question 5

What suggests a mixed episode

Answer 5

Mixture, or rapid alternation(usually within a few hours), of manic/hypomanic and depressive symptoms

Question 6

Symptoms and signs that may help distinguish bipolar disorder from unipolar depression

Answer 6

Hypersomnia, lability and weight instability
Earlier age of onset
More frequent episodes of shorter duration
Co-morbid substance misuse
Higher post-partum risk
Psychosis
Lower likelihood of somatic symptoms

Question 7

What are the minimum diagnostic criteria for bipolar disorder in children and young people

Answer 7

Mania must be present
Euphoria must be present on most days and for most of the time, for at least 7 days
Irritability is not a core diagnostic criterion

Question 8

Age limit for referral of children to CAMHS

Answer 8

Children aged under 14 years of age

Young people aged 14-18 years may be referred to a specialist early intervention in psychosis service or to a CAMHS team

Question 9

Which factors suggest cyclothymia as opposed to depression or bipolar disorder

Answer 9

Suggested by chronic disturbance of mood, consisting of periods of depression and hypomania, where the depressive symptoms do not meet the criteria for a depressive episode

Question 10

Most common comorbidities in people with bipolar disorder

Answer 10

Anxiety disorders

Alchol and substance misuse

Question 11

Assessment of bipolar disorder in primary care

Answer 11

Refer to a specialist mental health service

Determine risks of harm to others and self

Question 12

How can you determine the risks of harm to others

Answer 12

Assess:

Risk of neglect of people dependent on them for care, in particular family, children, and any other dependents(follow local safeguarding procedures)

Any risk to the public, especially if there is a risk of aggression or previous history of violence

Question 13

When should an urgent referral to a mental health service be made

Answer 13

Mania
Severe depression
Danger to themselves or other people
Risk of exploitation or violence

Question 14

What can be done for a person with bipolar disorder in primary care while awaiting specialist assessment

Answer 14

Do not start antipsychotic medication unless on the advice from a consultant psychiatrist

Consider tapering antidepressant medication on specialist advice if mania develops

Advise person to stop driving during acute illness

Question 15

What should be screened for in children presenting with symptoms of bipolar disorder

Answer 15

Assess for abuse

Question 16

Useful support links for people with bipolar disorder

Answer 16

Bipolar UK
MIND
Base-uk(for people wanting to return to work)
DVLA

Question 17

If a person with bipolar disorder is being managed solely in primary care, when should they be re-referred to secondary care

Answer 17

Poor or partial response to treatment
Significant decline in person’s functioning
Development of intolerance or side effects of medication
Comorbid alcohol or drug misuse
Pregnancy

Question 18

Treatment of acute mania in secondary care

Answer 18

Oral antipsychotic(haloperidol, olanzapine)
Second antipsychotic if above not effective
Lithium as third line or sodium valproate if lithium not suitable
Antidepressant medication is usually tapered and discontinued if person develops mania

Question 19

How are mixed episodes treated in secondary care

Answer 19

Usually treated in the same way as episodes of mania

Question 20

Options for treatment of depression in secondary care

Answer 20

Quetiapine alone
Fluoxetine + olanzapine
Olanzapine alone
Lamotrigine alone

Question 21

Management of mania after acute episode has resolved

Answer 21

Continue current treatment for mania, or

Start long-term treatment with lithium to prevent relapses or,

Sodium valproate addition to lithium

Psychological therapies

Question 22

What actions will secondary care undertake for long term management of an individual with bipolar disorder

Answer 22

Monitor physical, mental health and effects of meds for at least first 12 months

Encourage person to make a lasting power of attorney

Write a care plan with the person and/or their carer that defines roles of primary and secondary care

Question 23

Why should a person with bipolar disorder be advised to make a lasting power of attorney

Answer 23

So that a trusted person or an advocate can express the person’s point of view as expressed in the advanced statement or statement of wishes and feelings, especially if there are financial consequences resulting from mania or hypomania episodes

Question 24

What should a care plan consist of

Answer 24

Individualised social and emotional recovery goals
Assessment of person’s mental state
Medication plan
Advance statement
Statement of wishes and feelings regarding treatment in future
Key clinical contacts in emergencies

Question 25

What is an advance statement

Answer 25

A written statement, drawn up and signed when the person is well, which sets out there are treatments that the person does not wish to receive if they lose their capacity to make decisions for themselves through illness

Question 26

What routine health reviews are required for people with bipolar disorder

Answer 26

For adults being managed in primary care, assess person’s mental and physical health at least annually

Question 27

When should an individual with bipolar disorder be reviewed more regularly

Answer 27

If the person of their carer expresses any concerns

If there is sleep disturbance

After significant life events, such as loss of a job or bereavement

Question 28

What advice should be given regarding prevention of a relapse

Answer 28

Encourage compliance with treatment 
Sleep advice 
Avoidance of shift work, night flying and across time zones 
Regular routine in morning 
Self-monitoring of symptoms 
Avoidance of caffeinated drinks 
Avoidance of alcohol, drugs and smoking

Question 29

What is bipolar disorder type I

Answer 29

presents with manic episodes (most commonly interspersed with major depressive episodes). The manic episodes are severe and result in impaired functioning and frequent hospital admissions.

Question 30

What is bipolar disorder type II

Answer 30

patients do not meet the criteria for full mania and are described as hypomanic. Hypomania in comparison to mania has no psychotic symptoms and results in less associated dysfunction. This type is often interspersed with depressive episodes.

Question 31

ICD-10 requirement for diagnosis of bipolar disorder

Answer 31

At least two episodes in which a person’s mood and activity levels are significantly disturbed (one of which must be mania or hypomania)

Question 32

Which side effect is lamotrigine commonly associated with

Answer 32

Rashes