Bipolar Disorder

Bipolar 1 Disorder – lifetime history of at least one clear-cut manic episode, with or without episodes of hypomania or depression
Bipolar II Disorder– History of hypomanic episode and major depressive episodes, with no history of a full manic episode
Cyclothymic Disorder – Recurrent episodes of hypomania and mild (subthreshold) depressive symptoms

Acute Mania in Bipolar Disorder

Non-pharmacologic:

Assess safety and functioning
Establish treatment setting
Discontinue antidepressant
Discontinue caffeine, alcohol stimulants and illicit drugs
Rule out medical causes
Psycho-education
Relapse drill to train patient to promptly recognize warning signs
Behavioral strategies/rhythms

Pharmacologic:

Lithium 900-2100mg/day (divided q6 to 8 hourly) guided by serum level (1-1.2 mmol/L)

SE: NVD, hypothyroidism, renal impairment, fine tremors, weight gain, acne, hair loss, cognitive problems.

Toxic effects, serum level >2 mmol/L : Coarse tremor, poor appetite, dehydration, restlessness, muscle fasciculation, ↑muscle tone, ataxia, dysarthria. Hypotension, arrhythmias, circulatory collapse, seizures, coma.

Check lithium level Q3 months; Monitor Kidney and thyroid function at least Q6 months

Valproic acid 750-2000 mg/day guided by serum level. SE: weight gain, PCOS, teratogenic, thrombocytopenia, hepatotoxicity

Antipsychotics: Risperidone 3-6mg, olanzapine 5-20mg

Second line: Carbamazepine SE: Agranulocytosis, sedation

Third line: Haloperidol, chlorpromazine

Depressive Episodes in Bipolar Disorder

Non-pharmacologic:

· Assess safety and functioning including suicidal risk, comorbid medical problems or substance abuse

· Behavioral strategies/rhythm

· Psycho-education

Pharmacologic:

- Strategy depends on whether patient is already on medication and had breakthrough episode of major depression or whether they are medication free. If an unmedicated patient, therapy begins with lithium, lamotrigine or quetiapine. If severe initiate treatment with two therapies.

- If already on medication for bipolar disorder, do a dose adjustment near to the upper level of therapeutic range of lithium.

- Lithium 600-1800 mg/day po, adjusted according to serum levels (target 1-1.2mmol/L, 0.5-0.8mmol/L in elderly patients). Watch out for signs of toxicity: ataxia, tremor, sedation or agitation, diarhea, vomiting

- Quetiapine: 300mg/day po: SE; weight gain, sedation, orthostasis, metabolic disturbances

- Lamotrigine 100-300mg/day po. SE: rash.

Maintenance Treatment

After 2 months of recovery, patients are said to be in maintenance phase. Continue medication with adjustments based on serum blood levels.

Other interventions that prevent relapse include psychosocial strategies such as

1. Psychoeducation,

2. Cognitive behavioural therapy,

3. Family therapy

4. Interpersonal and social rhythm therapy.

Effective psychotherapies improve adherence by

i. Education about the disorder, including likelihood of relapse

ii. Training in self-monitoring,

iii. Education about managing side effects

iv. Strategies to manage stressors

v. Attention to patient’s own beliefs and altitude toward the illness

vi. Brief version of psychoeducation periodically also facilitates longer-term adherence.