Bipolar disorders/suicidality Flashcards
Definitions of bipolar disorder
Def: mood disorder categorised by extreme emotional highs and lows and can be further classified into
type 1 and type 2
● type 1- characterized by the presence of a manic episode which may or not be preceded or followed by a
hypomanic or major depressive disorder
● type 2- characterized by the presence of a current/past hypomanic episode as well as a past/current
depressive episode
Epidemiology of BD
● BD affects men and women equally
● It affects 1% of people in South Africa
● The index presentation is usually between 15-25 yrs
Biological factors that could cause BD
● Some studies show an increase in dopamine and glutamate while a decrease in acetylcholine
● There is a genetic component suggesting that it can be hereditary
● Neurobiology shows that people with BD have a decrease in size of their hippocampus, insular,
cingulate cortex and a change to their dorsolateral prefrontal cortex
Psychosocial factors that could cause BD
● Stressors in early life have also been shown to increase risk
● Childhood maltreatment (particularly emotional abuse)
● Substance misuse
Goals of acute management of BD
● Safety of patients and others
● Clinical and functional stabilization
● Minimise adverse reactions
Acute management of BD
- Confirm the diagnosis of mania and or hypomania
- Define patient’s mood state
➢ Therapeutic approach differs for the hypomanic, manic, depressed patient - Detailed assessment and correct Dx
➢ Consider admission
➢ Assess suicide risk
Acute management of Manic or hypomanic episodes
- Withdraw antidepressant
- Antipsychotics (1st line treatment)
➢ Atypical preferred-↓risk of EPSEs
➢ Haloperidol may be used- faster antimanic but ↑risk of
depression and EPSEs - Mood stabilizers- treat episode and prevent
occurance
➢ Lithium- 1st choice
➢ Sodium Valproate- commonly used on the clinical platform
➢ Carbamazepine - Benzodiazepines- sedative
- Supportive psychotherapy
Acute management of a depressive episode
Mild depressive patient: 1. Adjust mood stabilizer 2. If not on mood stabilizer - lithium, lamotrigine or antipsychotic with antidepressant properties. 3. Consider addition of CBT
Type 1 deperessive p.t:
- Antipsychotic w/ antidepressant properties
- OR anti-manic mood stabilizer + SSRI
- NB: Never use antidepressants as monotherapy= ↑risk of mania
Type 2 depressive p.t:
1. Start SSRI- lamotrigine (moderate - severe depression)
2. ↓dose antipsychotics (if psychotic symptoms)
3. Frequent mental state review- provide supportive therapy, consider
ECT in severe depression
Goals of long-term management of BD
● Prevent recurrence of episodes
● Ensure functionality
● Optimise treatment
Long-term management of BD
- Education
➢ Better understanding of illness, medication, early help-seeking ensures a
positive long-term outcome - Medication
➢ NB : Do not stop long-term treatment when illness is controlled ↑risk
of relapse
➢ Consider risk vs benefits in each case
➢ Mood stabilising agents used for prophylaxis and management - Psychotherapy
➢ CBT reduces rate of relapse, particularly in depressive episodes
➢ Improves adherence to meds - Unplanned pregnancy
➢ Medication reviewed
➢ Antipsychotics are the safest and most
effective
➢ Atypicals preferred to minimize risk of extra pyramidal side-effects
NB: Contraindicated: Anticonvulsants Lithium could cause anomalies
Medications used in long-term management of BD
a. Lithium
➢ Start at low dose and titrate up
➢ Do not stop suddenly, 50% of pt.s relapse with a
manic episode
➢ Reduces suicide risk
b. Valproate (1st line in acute mania)
c. Carbamazepine (2nd line)
➢ Sedation
➢ Start on low dose b.d and titrate up, against response and effect
d. Lamotrigine
➢ Main indication: Bipolar depression
➢ Start on low dose for 2 weeks and titrate up according to clinical response
➢ NB: Monitor carefully if used in conjunction w/ another anticonvulsant
e. Antipsychotic agents (1st line agents in acute mania)
Safest in pregnancy
Define suicidality
Suicide: Consciously decided and willful
self-inflicted death.
Parasuicide: Similar to a suicide attempt,
however there is not a true intent to die.
Suicidal ideation: Recurrent and intrusive
thoughts around dying or suicide which may
cause significant distress.
Epidemiology and prevalence of suicide
Around 700’000 people die by suicide every year. It is the 4th most common cause of death for the age
group 15 – 29.
● More females are likely to attempt suicide, but more males are likely to succeed; on average more
males die by suicide than females.
● Suicides are more prevalent in low and middle SES countries which accounts for 77% of all suicides.
● Vulnerable or marginalized groups who face social ostracization, including refugees, migrants,
indigenous people of colonized nations, prisoners, and transgender or LGBTQI individuals.
● There are far more suicide attempts and parasuicides than true suicides.
● Ingestion of pesticides or poisons, hanging, or firearms are some of the most common means of
suicide.
● A previous suicide attempt is the best predictor for future suicidal behaviour or suicide attempts.
*Particularly in South Africa, suicide accounts for approximately 10% of all non-natural deaths, with
an increased prevalence of suicidal behaviour amongst African youth
Name Emile Durkheims four types of suicide, and rate each of them according to social integration and regulation
Altruistic - High social integration
Egoistic - low social integration
Altruistic and egoistic has the same level of social regulation
Anomic - low social regulation
Fatalistic - high social regulation
Anomic and fatalistic has the same level of social integration
Risk factors of suicidality
• Sex (M:F = 3:1)
• Demographics (age, social engagement, profession)
• Social factors (SES and social fragmentation)
• Family history and biology (reduced activity in serotonin pathways)
- Suicidal behaviour clusters in families: genetic vs non-genetic
- Evidence of reduced serotonin in the brainstem and CSF (also associated with increased risk of aggression and impulsivity)
o Evidence of reduced serum cholesterol in the middle-aged
• Physical illness
• Mental illness (mood disorders, especially in mixed states, personality disorders, schizophrenia, eating disorders)
• Substance abuse (opioids, alcohol, and prescription meds)
Protective factors in suicidality
- Religion or cultural customs
- Family and friends
- Children or pregnancy
- Personality
- Influence over the external environment
What are the outcomes of risk assessment of suicidal patients
- What is the likely risk of further self-harm or risk of completed suicide?
- Is there a treatable mental illness?
- What psycho-social problems need to be addressed?
- What intervention, support or care is required?
What should you consider in the management of suicidality
● The severity and intensity of suicidal intention
● Other risk factors for suicide
● Presence and severity of any mental disorders
● Availability of care & support at home / in community
Approach to management of suicidality
- Medical Stabilisation
- Determine level of care depending on risk of suicide
- Alleviate distress by treating underlying causes, identify psychosocial stressors, consider
psychotherapy - Monitor & Follow-Up
Discuss medical stabilization in suicidality
One should remove/reduce the immediate risk to the patient then manage the trauma or
decontaminate the patient.
Discuss the level of care needed according to the patients risk (to commit suicide) status
High risk patients should be admitted and low risk patients should be treated as
outpatients.
Involuntary admission should take place under MHCA if necessary for high risk patients.
If the patient is awaiting transfer, ensure a safe space with no sources of harm and
provide constant observation.
Discuss how you would alleviate stress in a suicidal patient
● Treat underlying physical / mental illnesses, or substance misuse
● Identify psychosocial stressors such as precipitating events, ongoing difficulties
○ Precipitating events e.g. deaths, loss of job, breakup, school, sexual identity, trauma
○ Ongoing difficulties e.g. abusive relationships, occupational stress, chronic isolation
○ Mental illness e.g. depression, bipolar, borderline personality
● Pharmacotherapy
○ Medication should have minimal side effects, minimal risk in overdose and dispensed in small
quantities.
○ Preferably dispensed to carer for safekeeping and supervision of administration
● Psychotherapy
○ CBT / problem-solving therapies
○ Psychodynamic Therapy - Building insight on unconscious behaviour and solving conflicts in the
patient’s life, whether they be inter-or intrapersonal
○ Social services to alleviate crisis such as debt, homelessness, unemployment
Discuss the protocol regarding the monitoring and follow-up visits of suicidal patients
● Contact weekly for at least the first 2 months, and then as long as risk persists
● Review suicidal risk and mental state at every visit
● Refer to mental health services / community resources
● Engage carers to ensure supervision,
support and care (encourage their
own support too)
Pharmacotherapy and suicide - what can be used and what should be avoided or only used in short term treatment
SSRIs can increase risk of suicide (energising drugs). This risk is reduced in tricyclics as these are sedative drugs. Thus, they are to be
considered in patients with prominent insomnia. However, they are cardiotoxic and lethal in overdose. The preferred drug is still SSRI’s with close monitoring of pt.
Benzodiazepines may be used to treat severe insomnia, agitation, panic attacks or anxiety. Due to their addictive potential, they should only be used on a short term basis.
