Bipolar disorder

Question 1

Bipolar’ is a broad term for a

Answer 1

‘recurrent illness with episodes of either mania or depression

• with return to normal function inbetween

Question 2

DSM-5 criteria for a manic episode

Answer 2

A Distinct period for at least 1 wk of abnormal and persistent elevated, expansive or irritable mood

B Three or more of these unusual features:

1. inflated self-esteem or grandiosity
2. decreased need for sleep
3. talkative/accelerated speech
4. racing thoughts or flights of ideas
5. distractability—as reported or observed
6. increased goal-directed activity or psychomotor agitation
7. excessive activity with ‘painful’ consequences

C Marked impaired social or occupational functioning or need for hospitalisation or psychotic features

D Episode not due to substance abuse or other medical condition

Question 3

Bipolar disorder (manic depression): possible mood swings

Answer 3

Question 4

Management of acute mania / Hospitalisation

Answer 4

For protection of patient and family

Usually involuntary admission necessary

A recent meta-analysis indicates that antipsychotics are the most efficacious drugs.

Question 5

Drugs of choice

Answer 5

First-line:

• olanzapine 5 mg (ο) nocte initially or
• risperidone 0.5–1 mg (ο) nocte initially

Second-line:

• haloperidol or other antipsychotic or
• a mood stabiliser agent: lithium carbonate 750–1000 mg (ο) daily in 2 or 3 divided doses increasing according to serum levels or
• sodium valproate 200–400 mg (ο) bd initially or
• carbamazepine 100–200 mg (ο) bd initially

If parenteral antipsychotic drug required:

• haloperidol 5–10 mg IM or IV
• Repeat in 15–30 mins if necessary (Risk of tardive dyskinesia)
• Change to oral medication as soon as possible.

Oral diazepam will complement haloperidol.

If not responding to medication consider ECT.

Question 6

Maintenance/prophylaxis for recurrent bipolar disorder

Answer 6

Lithium carbonate 125–500 mg (ο) bd then adjusted

• —continue for 6 mths (drug of choice)

or

Second-generation antipsychotics, eg. olanzapine 5 mg (ο) nocte or (if depression prominent)

Lamotrigine or carbamazine or sodium valproate

Lithium + sodium valproate effective for rapid cycling illness (4 or more episodes per yr)

Question 7

Management of bipolar depression

Answer 7

The mood stabilisers may have a bimodal (antidepressant and antimania effect)

• but add an antidepressant (e.g. SSRI, SNRI or MAOI)

Withdraw antidepressant within 1–2 mths because tend to precipitate mania.

ECT is a proven effective treatment.