Maintenance treatment in BD Flashcards
What is meant by bipolar disorder being ‘multidimensional’?
There are multiple episodes in which can be clinically different
The symptoms can be mixed or opposite
Can people with BD have MDE diagnosis?
Yes, people can get a diagnosis of a Major Depressive Episode which doesn’t exclude their bipolar diagnosis, it can be a part of it and most often is
Comorbidities in BD
many both physical and mental
some issues with them: e.g. substance misuse disorder - alcohol induces mania or depression in BD
What are the 3 phases of treatment in BD? What characterizes them?
1) Acute treatment - until symptomatic remission (clinical response)
2) Continuous phase- from clinical response to recovery (could include treating post-mania depression)
3) Maintenance phase- trying to prevent mood episodes, can still be addressing some symptoms on the way
Types of treatment for BD?
FGA good for treating bipolar
Psychoeducation (preferably in group) is one of the most effective in preventing future episodes
Family therapy requires everyone in the family for success
CBT works for certain groups but not all people with bipolar
What are the goals of maintenance treatment?
- Prevent syndrome and sub-syndrome episodes of illness (taking control over the symptoms)
- Reduce morbidity and mortality (Prevent suffering Enhance functioning and QOL Prevent suicide)
3 Prevention of relapse
Main questions to ask for maintenance treatment?
When should maintenance treatment be considered?
How long should it be continued?
What agents should be used?
How long should it be continued?
Once maintenance treatment is started, it should continue indefinitely unless the risk: benefit ratio of maintenance medication alters
What are the guidelines on stopping medication?
BAP (2016)
⇒Once maintenance treatment is started, it should continue indefinitely unless the risk: benefit ratio of maintenance medication alters
⇒ If treatment is stopped, ensure there is a management plan to recognize and treat early warning signs of mania and depression
⇒ NICE (2014) Discontinue over minimum of 4 weeks and with Li preferably over 3 months+ Monitor mental state for 2 years after medication has stopped entirely
What happens if you discontinue Lithium rapidly?
Relapse
Suppes et al 1991
What drugs are offered in BD?
NICE 2014
Lithium = 1st line maintenance agent
If ineffective, add valproate
If lithium is poorly tolerated, or is not suitable, consider valproate, olanzapine or quetiapine (antipsychotics)
BUT
No mention of aripiprazole or lamotrigine as long term treatments
More effective in preventing mania than depression
Li reduces risk of suicide (by 60% versus placebo)
Require monitoring of levels in pee
What does Carbamazepine do?
Induces metabolism of other drugs (e.g. anitipsychotics blood concentration dropping by 75%)
Medication for those who are not responsive to Li
Teratogenic
Adverse effects: nausea and vomiting, hepatotoxicity, drowsiness and diplopia
What is Lamotrigine?
Aniticolvulsant, to treat epilepsy, very well tolerated but has a highest risk for Steven Johnon’s syndome (all anticonvulsants have but this one has the highest)
It is arguable if it is antimanic
Good combination with Lythium
What med combo are best for which symptoms?
- Olanzapine & aripiprazole: prevention of mania
- Lamotrigine: prevention of depression
- Lithium and Quetiapine: at both poles
Indirect evidence supports maintenance effect of valproate (no placebo-controlled data
No proven benefit for long-term antidepressants
