Psychiatry - Bipolar Affective Disorder (2)

Question 1

Bipolar Affective Disorder?

Answer 1

• One of the most common, severe and persistent psychiatric illnesses
• Public mind: Notions of ‘creative madness’
• Periods of prolonged and profound depression alternate with periods of excessively elevated and/or irritable mood, known as mania

Question 2

Bipolar Affective Disorder?

Types of Bipolar?

Answer 2

• Chronic episodic illness associated with behavioural disturbance
• Old term: manic depression
• Episodes of mania (or hypomania) and depression. Either one can occur first and one may be more dominant than the other but all cases of mania eventually develop depression

Types of bipolar disorderf bipolar disorder:

• Bipolar I: Manic episodes (most commonly interspersed with major depressive episodes). The manic episodes are severe and result in impaired functioning and frequent hospital admissions
• Bipolar II: Criteria not met for full mania = hypomanic. Hypomania = no psychotic symptoms and results in less associated dysfunction. Often interspersed with depressive episodes

Question 3

Bipolar Affective Disorder?

Epidemiology?

Answer 3

• Bipolar I rates are higher in males
• Bipolar II rates are higher in females
• Family history: Five to ten times more likely to have bipolar disorder themselves
• Anxiety and substance misuse are commonly associated

Question 4

Bipolar Affective Disorder?

Presentation?

Answer 4

Manic phase:

• Grandiose ideas
• Pressure of speech
• Excessive amounts of energy
• Racing thoughts and flight of ideas
• Overactivity
• Needing little sleep, or an altered sleep pattern
• Easily distracted
• Bright clothes or unkempt
• Increased appetite
• Sexual disinhibition
• Recklessness with money
• Severe cases: Grandiose delusions, auditory hallucinations, delusions of persecution and lack of insight

Question 5

Bipolar Affective Disorder?

Diagnosis?

Answer 5

ICD-10:

• At least two episodes of disturbance in mood – one of which must be mania / hypomania

DSM-5:

• Only one episode of mania without depression or one episode of hypomania with a single episode of major depression and divides bipolar disorder into types I and II

ICD-10 further divides bipolar disorder into:

• Currently hypomanic
• Currently manic
• Currently depressed
• Mixed disorder
• In remission

Question 6

Bipolar Affective Disorder?

Clinical Course?

Answer 6

• Frequency and duration of episodes are variable
• The symptoms of mania (or hypomania) and the presence of depressive symptoms may vary from day to day and also within the day
• Between episodes patients may lead a normal work life and a normal lifestyle
• 10-20% have rapid cycling - defined as four or more cycles of depression and mania a year, with no intervening asymptomatic episodes

Question 7

Bipolar Affective Disorder?

Differential Diagnosis?

Answer 7

• Other psychiatric disorders
• Hyper/ hypothyroidism
• Anorexia nervosa
• Cerebrovascular event / cerebral neoplasm
• Dementia
• CKD
• Acute drug withdrawal or illicit drug ingestion

Question 8

Bipolar Affective Disorder?

Management?

Answer 8

• Knowing when to refer
• Management for bipolar type I
• Non-pharmacological
• Psychological therapies
• Other Tx: ECT (NICE), transcranial magnetic stimulation (not recommended by NICE)

Question 9

Bipolar Affetive Disorder?

Pharmacological Management?

Answer 9

Follow up for acute episode: once/week for 6 weeks and then every 4 weeks for the first 3 months

Management of a first manic episode:

• Urgent control
• Reduce symptoms rapidly
• Refer urgently (Mental Health Act (MHA))
• Oral therapy / IM
• Rapid tranquilisation (refuses – use Common Law – allows Tx in emergency / MHA)

Question 10

Bipolar Affective Disorder?

Management of Acute Manic Episode (1)?

Answer 10

• If already on antipsychotic and develop a further manic episode: Increase dose to maximum licensed dose or maximum tolerated dose e.g. haloperidol, olanzapine, quetiapine and risperidone
• If a second antipsychotic is ineffective at maximum licensed or tolerated dose, consider adding lithium. If lithium is inappropriate (e.g. the patient refuses regular monitoring) consider adding valproate
• Rarely rapid tranquilisation: Antipsychotics, benzodiazepines or antihistamines given orally, IM or in exceptional circumstances intravenously (IV)

Question 11

Bipolar Affective Disorder?

Management of Acute Depressive Episode (1)?

Answer 11

• Antidepressants may be less effective in bipolar disorder, even if depression is the main feature. Use carefully in bipolar disorder
• Mild depression may not require any specific therapy and patients should be reviewed initially on a 1- to 2-week basis
• If depression develops rapidly in a patient with a previous manic episode who is not on treatment then an anti-manic drug should be started (as above)
• Patients with moderate-to-severe depression should be offered fluoxetine combined with olanzapine or quetiapine on its own
• If there is no response, lamotrigine on its own can be tried

Question 12

Bipolar Affective Disorder?

Management of Acute Depressive Episode (2)?

Answer 12

• If already taking lithium – check level and increase. If fails, fluoxetine combined with olanzapine or quetiapine can be added
• If already on valproate, a similar approach as if was on lithium
• Psychological therapy
• Review psychological and pharmacological treatments within four weeks of the acute episode
• Options include long-term treatment (in which case review in 3-6 months) or stopping treatment
• If treatment is stopped, the patient should be counselled about reporting early symptoms of recurrence.
• Long-term pharmaceutical options - lithium with or without valproate or various combinations or sole use of valproate, quetiapine and olanzapine

Question 13

Bipolar Affective Disorder?

Management of Acute Mixed Episode?

Answer 13

During an acute mixed episode antidepressants should be avoided and the aim should be to try to stabilise patients on anti-manic medication

Question 14

Bipolar Affective Disorder?

Prophylaxis?

Answer 14

• First-line: Lithium +/- valproate if ineffective
• Intolerant to lithium valproate or olanzapine should be considered
• Second-line: Valporate, carbamazepine, lamotrigine
• Long-term therapy usually continues for two years but may be needed for as long as five years.
• If medication is stopped – aware of early warn symptoms
• Gradually decrease (unless acute toxicity develops)
• Mood should be monitored for two years after treatment is stopped
• Cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy may be appropriate

Question 15

Bipolar Affective Disorder?

Rapid Cycling?

Answer 15

• 4 or more episodes of mania or depression in 1 year
• It is associated with a longer course of illness, an earlier age at onset, more illegal drug and alcohol abuse and increased suicidality
• Do TFTs
• Stop antidepressants
• Anti-manic therapy should be optimised and compliance checked
• First-line therapy is a combination of lithium and valproate and, if this fails, lithium alone
• Lithium withdrawal or toxicity may also cause rapid cycling and levels should be checked

Question 16

Bipolar Affective Disorder?

Rapid Cycling?

Monitoring?

Answer 16

• Weekly initially
• Annually once stable
• Monitoring lipid profile, plasma glucose, weight, use of tobacco, alcohol and other illicit drugs and monitoring of blood pressure
• Regular questioning about side-effects and suicidal ideation should occur

Question 17

Bipolar Affective Disorder?

Rapid Cycling?

Prognosis?

Answer 17

• Chronic, lifelong illness
• On average, 10 episodes are experienced in a lifetime
• The risk of recurrence is high: 12 months after a mood episode, the recurrence rate is 50% at one year, 75% at four years and 10% thereafter
• The pattern of remissions and relapses is very variable
• There is a high lifetime suicide risk in patients with bipolar disorder. 25-56% present at least one suicide attempt during their lifetime and 15-19% die from the attempt
• Lithium has been shown to reduce the risk of suicide and the number of suicide attempts in bipolar disorder

Question 18

Bipolar affective Disorder?

Extra Information?

Answer 18

• Be aware of medications that can cause mania/hypomania e.g. steroids, anti-TB medication, some CVD drugs, anti-parkinsonian drugs etc
• Manic stupor : Unusual disorder patients are mute and immobile
• 1 in 100 diagnosed at some point with bipolar
• Can occur at any age, often between 15 - 19 and rarely > 40.
• Equally affects men and women from all backgrounds
• Family Hx: Increases likelihood up to 7x
• Hyperthymic personality

Question 19

Bipolar affective Disorder?

Extra Information?

Answer 19

Chemical imbalance in the brain:

• Some evidence there is an imbalance of one or more neurotransmitters: noradrenaline, serotonin and dopamine.
• Mania - ?NA too high, depression - ?NA too low

Genetics:

• But no single gene is responsible for bipolar disorder.
• Instead, a number of genetic and environmental factors are thought to act as triggers

Triggers:

• A stressful circumstance or situation often triggers the symptoms of bipolar disorder Physical, sexual or emotional abuse
• Death of a loved one

Question 20

Bipolar affective Disorder?

Cyclothymia?

Answer 20

• Previously regarded as a disorder of personality (cyclothymic temperament), mainly because of its early age of onset and relative stability throughout adult life
• Cyclothymia is now considered to be a mood disorder

Clinical features:

• Persistent instability of mood with numerous periods of mild depression and mild elation, not sufficiently severe or prolonged to fulfil the criteria for BPAD or recurrent depressive disorder.
• The mood swings are usually perceived by the individual as being unrelated to life events
• Early onset – teens/early 20s. More common if relative has BPAD

Management:

• If contemplated then lithium as mood stabiliser

Question 21

Bipolar Spectrum Disorder:

Answer 21

One view of affective disorders is that they consist of a continuum with bipolar affective spectrum disorder sitting uneasily between cyclothymia and bipolar II:

Affective continuum:

• Dysthymia
• Unipolar depression
• Atypical depress
• Psychotic depression
• Cyclothymia
• Bipolar spectrum
• Bipolar II
• Bipolar I

·

Question 22

Bipolar Spectrum Disorder?

Answer 22

Bipolar spectrum disorder is characterised by:

• At least one major depressive episode
• No spontaneous hypomanic or manic episodes

The history will include some of the following:

• A family history of bipolar disorder in a first-degree relative
• Antidepressant-induced mania or hypomania
• Hyperthymic personality (at baseline, non-depressed state)
• Recurrent major depressive episodes (>3)
• Brief major depressive episodes (on average, <3mths)
• Atypical depressive symptoms (DSM-IV criteria)
• Psychotic major depressive episodes
• Early age of onset of major depressive episode
• Post-partum depression
• Antidepressant ‘wear-off’ (acute but not prophylactic response
• Lack of response to up to 3 antidepressant treatment trials

Question 23

Bipolar Spectrum Disorder?

Answer 23

Patients with features of bipolar spectrum disorder may represent a subset of patients who do not respond well to antidepressants (often precipitating a switch to a hypomanic or manic episode) and for whom a mood stabilizer may be the drug of choice (e.g. valproate)