Bipolar Disorder

Question 1

What are the potential factors for Bipolar Disorder?

Answer 1

Genetic factors, environmental factors, biochemical factors, endocrine factors, physical illness or side effects of medication

Question 2

What is Bipolar 1?

Answer 2

Where people have severe manic episodes (often interspersed with episodes of major depression).

Mania last one week

Question 3

What is Bipolar 2?

Answer 3

Where people experience depressive episodes and less severe manic symptoms - classed as hypomanic episodes

Question 4

What are features of a manic episode?

Answer 4

• Inflated self-esteem or grandiosity
• Decreased need for sleep
• More talkative / pressure to keep talking
• Racing thoughts
• Distracted
• Increase in goal-directed activity or psychomotor agitation
• Excessive involvement in activities that have a high potential for painful consequences

Question 5

What are features of depressive episode?

Answer 5

• Suicidal preoccupation
• Negative views
• Feeling of hopelessness
• Fatigue or low energy
• Low appetite
• Previous manic episodes

Question 6

How is Bipolar I and II diagonised?

Answer 6

Bipolar I – At least seven consecutives days of severe mania

Bipolar II – At least four days of hypomania and at least one major depressive episode

Question 7

What does NICE not recommend in primary care of Bipolar Disorder?

Answer 7

The use of questionnaires

Question 8

When should a patient be referred to specialist care from primary care according to NICE?

Answer 8

• When the patient has had overactivity or disinhibited behaviour which has lasted for 4 days or more
• Suspected mania (urgent)
• Suspected severe depression
• When the patient is a danger to themselves or others (urgent)

Question 9

Which is the typical medication for Bipolar Disorder?

Answer 9

Haloperidol

Question 10

When should a patient be referred to secondary care according to NICE?

Answer 10

• Poor or partial response to treatment
• Person’s functioning decline significantly
• Treatment adherence is poor
• Side-effects developed from medications
• Comorbid alcohol n drug misuse suspected
• Person considering stopping medication after a period of relatively stable mood
• Woman with bipolar disorder is pregnant or planning pregnancy

Question 11

What most happen when patients start taking Lithium?

Answer 11

Regular blood test for Lithium levels
- Initally once a week
- Then can go to once a month or 6 weeks.

Question 12

What are the therapies available in secondary care for Bipolar Disorder?

Answer 12

• A psychological intervention
• High-intensity therapy such as cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy

Question 13

What are the main groups of medications used in mania and hypomania - give examples of them?

Answer 13

Antipsychotics such as haloperidol, olanzapine, risperidone and quetiapine

Lithium

Antiepileptics such as Valproate

Question 14

Which medications cannot be initiated in primary care for the management of mania and hypomania?

Answer 14

Lithium cannot be initiated in primary care, in patients that have never taken it before, unless there are shared care arrangements in place

Valproate cannot be initiated in primary care

Question 15

Should a patient with mania or hypomania be given antidepressants?

Answer 15

Ideally no.
If already taking it, it should be considered to stop the antidepressant.

If taking antidepressants in combination with a mood stabiliser, consider stopping the antidepressant too.

Question 16

What should be given if Lithium is ineffective or not suitable?

Answer 16

If lithium is ineffective, give Valproate

If lithium is not suitable, Quetiapine or Olanzapine

Question 17

What would you offer a patient who develops mania or hypomania and is not already taking antipsychotic or mood stabiliser?

Answer 17

They should be offered haloperidol, olanzapine, risperidone or quetiapine.

Question 18

What are the steps to prescribing an antipyschotic or mood stablisier? - for treatment of mania or hypomania

Answer 18

They should be offered haloperidol, olanzapine, risperidone or quetiapine.

If any is ineffective or unacceptable, an alterantive medication out of the list should be tried instead.

If the alternative antipsychotic is not effective at the maximum license dose, lithium could be tried as an ADDITION.

If Lithium is not effective or not suitable, consider adding valporate INSTEAD.

Question 19

Who can valporate not be given to?

Answer 19

Women of childbearing age

Question 20

What should be done if a person is already taking Lithium?

Answer 20

The plasma lithium levels should be checked to optimise treatment.

Depending on patient’s preference, consider adding haloperidol, olanazpine, quietpine or risperidone.

Question 21

What should be done if a person is already taking valporate or mood stabiliser?

Answer 21

Depending on clinical response, consider increasing the dose, up to maximum if necessary.

If no improvement, consider adding haloperidol, olanzapine, risperidone or quetiapine, depending on paient’s preference and previous response to treatment.

Question 22

What must not be used to treat mania or hypomania?

Answer 22

Lamotrigine

Question 23

What is the first line treatment for Moderate or severe bipolar depression?

Answer 23

If not taking a drug to treat their bipolar disorder - fluoxetine combined with olanzapine OR quetiapine on its own, depending on patient’s preference and previous treatment.

If patient prefers, offer olanzapine (without fluoextine) or lamotrigine on its own.

Question 24

What is the second, third line treatment for moderate or severe bipolar depression?

Answer 24

If no response to fluoextine combined with olanzapine or quetiapine, consider lamotrigine on its own.

Question 25

What should be done to a patient that is taking Lithium for the treatment of bipolar disorder depression?

Answer 25

Plasma lithium levels should be checked. If okay, increase the dose of lithium; if at maximum level, add fluoxetine combined with olanzapine OR add quetiapine, depending on patient's preference or previous treatment. If patient prefers, consider offering olanzapine (without fluoextine) OR lamotrigine to lithium. If no response to adding fluoextine combined with olanzapine or quetiapine, stop addition treatment and consider adding lamotrigine to lithium.

Question 26

What should be done to a patient that is taking Valproate for the treatment of bipolar disorder?

Answer 26

Consider increasing dose of valproate within the therapeutic range. If the maximum dose has been reached and there is limited response to valporate, add fluoxetine combined with olanzapine OR add quetiapine, depending on patient or previous treatment. If patient prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to valporate. If no response to adding fluoxetine combined with olanzapine or adding quetiapine, stop additional treatment and consider adding lamotrigine to valproate.

Question 27

What are the NICE recommendations for the long-term management of Bipolar Disorder?

Answer 27

First take into account previous drugs given to them - which have not been effective and which have. Discuss with patient if they would prefer to continue with that treatment or switch to lithium - explain lithium is the most effective long-term treatment for BD. Offer lithium as first-line, long-term treatment for BD. If not effective, add valporate or olanzapine instead. Or last choice being quetiapine. Disucss benefits and risks of each drug with patient. Before stopping medication, tell them how to recognise early signs of relapse and what to do if symptoms recur. Stop medication gradually and monitor for signs of relapse.

Question 28

What is the NICE recommendation for Bipolar Disorder?

Answer 28

First line - Lithium monotherpay. Second line - Olanzapine, aripiprazole, OR quetiapine in combination with valporate or lithium. Third line - Alternative antipyschotic such as lurasidone, asenapine, ziprasidone OR alternative mood stabiliser (carbamazepine, lamotrigine) in combination. Forth line - Antipsychotic with two mood stabilisers

Question 29

What kind of drug is Lithium?

Answer 29

A mood stabiliser

Question 30

What are the key points to remember when using Lithium?

Answer 30

It should not be started unless continuing for at least 3 years as short term use can worsen the course of illness. It takes at least a week to achieve a response Abrupt discontinuation leads to rebound mania - so decrease risk of relapse by decreasing the dose of lithium gradually over 1 month Individual lithium preparations are not bioequivalent so cannot substituted

Question 31

What are the side effects of Lithium?

Answer 31

The side effects directly relate to plasma levels - >1mmol/L - transient mild GI symptoms, fine hand tremor, thirst, polyuria, hypothyroidism, mental dulling, nephrotoxicity - Toxicity: >1.5mmol/L - anorexia, nausea and vomiting, muscle weakness and twitching, drowsiness, coarse hand tremor - >2mmol/L - disorientation, seizures, coma and death

Question 32

Which drugs cannot be used with Lithium and why?

Answer 32

Diuretics reduce renal clearance of lithium, espcically thiazides - loop diuretics are a little safer. NSAIDs increase serum lithium levels by up to 40% and reduce renal excretion of lithium. High dose Haloperidol taken with Lithium can cause severe neurotoxicity - but is widely prescribed as it is a useful combination SSRIs - can cause SSRI-induced hyponatraemia to occur but is useful combination. Interactions are rare with this. ACEI and A2RAs decrease excretion of lithium, and can precipitate renal failure - extra care and monitoring needed.

Question 33

Patient Counselling for Lithium?

Answer 33

Salt-free diet is contraindicted Maintain adequate fluid balance Vomiting and diarrhoea will lead to sodium depletion, which will increase plasma lithium concentration