mania_bipolar_disorders_management

Question 1

What are mood stabilisers used for?

Answer 1

Stabilise the extreme highs of mania and profound lows of depression; More effective against mania; Three main drugs: Lithium, Sodium valproate, Carbamazepine

Question 2

What is the therapeutic range of Lithium?

Answer 2

0.6-1.0 mmol/L; 0.6-0.8 is suitable for patients who are lithium-naïve; 0.8-1.0 is suitable for patients with chronic/long-term lithium use or who have had a relapse in symptoms

Question 3

What should be checked before starting Lithium?

Answer 3

Measure BMI, check FBC, U&Es, and TFTs

Question 4

How often should Plasma lithium levels be monitored?

Answer 4

Checked 1 week after starting or changing dose and weekly until a steady therapeutic level is achieved; Blood sample should be taken 12 hours after taking the dose of lithium; Monitored every 3 months thereafter; U&Es and TFTs monitored every 6 months

Question 5

What are the signs and symptoms of Lithium toxicity (>1.5mmol/L)?

Answer 5

GI disturbance, Polyuria/polydipsia, Sluggishness or giddiness, Ataxia, Gross tremor, Seizures, Renal failure

Question 6

What triggers Lithium toxicity?

Answer 6

Salt balance and electrolyte changes (e.g. D&V, dehydration); Drugs interfering with lithium excretion (e.g. diuretics, NSAIDs); Accidental or deliberate overdose

Question 7

How should Lithium toxicity be managed?

Answer 7

Check lithium level; Stop lithium dose; Transfer for medical care (rehydration, osmotic diuresis); If overdose is severe, the patient may need gastric lavage or dialysis

Question 8

What are the key points about Sodium Valproate?

Answer 8

Anticonvulsant; Treats acute mania; Prophylaxis in BPAD; Given as sodium valproate because of reduced side effects; Plasma levels do not need monitoring; No widely accepted therapeutic range; Dose-related toxicity is not usually an issue; Check BMI, FBC and LFTs before starting

Question 9

What should be monitored with Carbamazepine?

Answer 9

Anticonvulsant; Can cause toxicity at high doses; Induces liver enzymes; Close monitoring of carbamazepine levels is essential; Check for drug interactions before prescribing

Question 10

What are the risks of mood stabilisers during pregnancy?

Answer 10

Mood stabilisers are teratogenic; Risk of harm to fetus should be weighed against harm of manic relapse; Lithium - Ebstein’s anomaly; Valproate and carbamazepine - spina bifida; Women of childbearing age should be given contraceptive advice and prescribed a folate supplement if using valproate; Closely monitor the fetus if mood stabilisers are used in pregnancy

Question 11

What other drugs can be used for BPAD?

Answer 11

Antipsychotics (e.g. olanzapine); Usually atypical (e.g. olanzapine, risperidone, quetiapine) because of fewer side-effects; Check BMI, pulse, BP, fasting blood glucose or HbA1c, lipid profile before starting; Anticonvulsants like Lamotrigine (2nd line for prophylaxis in BPAD type II); Check FBC, U&Es, and LFTs before starting

Question 12

How is acute mania or hypomania treated?

Answer 12

Stop all medications that may induce symptoms (e.g. anti-depressants, recreational drugs, steroids and dopamine agonists); Monitor food and fluid intake to prevent dehydration; If not currently on treatment: Give an antipsychotic and a short course of benzodiazepines; If already on treatment: Optimise the medication, Check compliance, Adjust doses, Consider adding another medication (e.g. antipsychotic added to mood stabiliser); Short-term benzodiazepines may help; ECT may be used if patients are unresponsive to medication

Question 13

What is the long-term treatment for BPAD?

Answer 13

Mood stabilisers are the mainstay; Other medications may be added when new symptoms arise or when facing stress that could precipitate relapse (e.g. antipsychotics or benzodiazepines); Depression in BPAD: Antidepressants should only be given with a mood stabiliser or antipsychotic; 1st line: fluoxetine + olanzapine/quetiapine; 2nd line: lamotrigine; Monitor closely for signs of mania and immediately stop antidepressants if signs are present; Medication can be cautiously withdrawn if the patient is symptom-free for a sustained period

Question 14

What psychological treatments are available for BPAD?

Answer 14

CBT: Identify relapse indicators; Helps patients to test out their excessively positive thoughts to gain a sense of perspective; Relapse prevention strategies: Developing routine, Ensuring good quality sleep, Promoting a healthy lifestyle, Avoiding excessive stimulation/stress, Addressing substance misuse, Ensuring drug compliance; Psychodynamic Psychotherapy: Useful if mood stabilised

Question 15

What social interventions can help in BPAD?

Answer 15

Family support and therapy; Aiding return to education or work

Question 16

What should be summarised for BPAD management?

Answer 16

Psychological interventions designed for BPAD may be helpful; Lithium is the mood stabiliser of choice; Alternative: sodium valproate; During an acute manic episode, may need to stop antidepressant; Consider antipsychotic therapy (e.g. olanzapine); Management of concomitant depression: talking therapies, fluoxetine (given with olanzapine or quetiapine); Address comorbidities: diabetes mellitus, cardiovascular disease and COPD; Primary Care Referral: Symptoms of hypomania → routine referral to CMHT; Symptoms of mania or severe depression → urgent referral to CMHT

Question 17

PACES TIPS

Answer 17

Consider admission and section if at risk; Explain the diagnosis (condition where patients tend to experience the extremes of emotion for variable lengths of time); Explain the importance of controlling it (both extremes can lead to making certain decisions and taking risks that you would otherwise regret); Explain that there are medications available (helps balance the chemicals in the brain); Advise about crisis resolution team and Samaritans