Diagnosis
- Make accurate diagnoses of hypomania, mania and depression:
- consider identifying core symptoms using:
- a check list as in DSM-5
- a patient-completed screening instrument
- use term 'hypomania' as defined in DSM-5
- do not dismiss or minimise mood elevation when the cause of disturbed behaviour:
- personality problems or situational disturbance should be invoked only if mania (or hypomania) is absent
- in all patients with depression, ask about distinct periods of elated, excited or irritable mood of any duration and a family history of mania
- diagnosis is only reliable after a clear-cut episode of (hypo)mania
- consider identifying core symptoms using:
- Possible co-morbidities:
- assess, monitor and treat:
- alcohol and/or substance use disorder
- anxiety disorders
- borderline personality disorder
- assess, monitor and treat:
- Possible differential diagnoses
- stimulant drugs (e.g. levodopa and corticosteroids)
- borderline personality disorder
- organic conditions, e.g. thyroid disease, multiple sclerosis, or any lesion(s) involving right-sided sub-cortical or cortical areas
- Borderline personality disorder:
- should not be confused with episodes of mania or depression
- may be co-morbid with an episodic mood disorder
Pre-pubertal children
- Defining characteristics: unequivocal euphoria and an episodic course:
- do not make the diagnosis in children or young people unless there has been a period of prospective longitudinal monitoring by appropriately experienced clinicians taking into account the child or young person’s educational and social functioning
- Possible differential diagnosis:
- disruptive mood dysregulation disorder (DMDD)
Management
- When mania is diagnosed:
- always consider admission to hospital or intensive community management
- offer assessment by a trained psychiatrist
- Risks to the patient and others are from poor judgement and associated actions
- always try to obtain third party information if in doubt when making a risk assessment
- If in a mixed state or depressed ask about suicidal ideation and plans/means/preparation for suicide
- Assess risk of exploitation, violence and offending
- Carefully document decisions in formulating a care plan
- Establish and maintain a therapeutic alliance:
- take responsibility for diagnosis, physical examination, investigations and explanation of management plan
- communicate clearly and honestly
- listen to what is bothering the patient
- very disorganised psychotic patients will require assertive management of social needs
- Educate the patient and their family about:
- the disorder
- the potential benefits and risks of medication and need to continue it long term
- Enhance treatment adherence:
- use known tolerability and safety to guide prescribing
- inform patients about possible side-effects and monitor for emergence
- prioritise reducing adverse reactions: use different scheduling, alternative formulations or lower doses
- Promote awareness of stressors, sleep disturbance, early signs of relapse, and regular patterns of activity:
- promote regular patterns of daily activities
- identify and modify habitual, very irregular patterns
- consider using diaries or apps to self-monitor mood or activities
- assess and treat alcohol/drug use and offer advice
- help the patient and significant others recognise emerging symptoms of manic or depressive episodes
- promote regular patterns of daily activities
- Evaluate and manage functional impairments:
- full functional recovery usually takes ≥12 weeks
- advise patient about withdrawal from work or other responsibilities when necessary
- discourage major life decisions while in a depressive or manic state
- manage patient expectations of capacity to work
- consider needs of patients’ carers and children: provide information about local or national support groups
- full functional recovery usually takes ≥12 weeks
- Consider physical health in clinical assessment and treatment planning:
- monitor weight and other relevant risk factors at least annually and offer treatment
- consult BAP guidelines on management of weight gain and metabolic disturbances associated with psychosis and antipsychotic drug treatment
- Consider the use of alcohol and drugs (including caffeine, tobacco):
- assess and treat established addictive problems
- Consider risks for adverse outcomes including self-harm, suicide, victimisation, violence and criminality:
- modifiable risk factors include co-morbid drug and alcohol use disorders and illness severity
- Increase the focus of care planning in women of childbearing potential:
- address contraception and pregnancy prospectively
- valproate and carbamazepine are teratogenic
- risk/benefit of other medicines in pregnancy and breast feeding must reflect risks of relapse as well as their adverse effects
- very high risk for relapse of bipolar disorder postpartum:
- consider effective prophylactic treatment
Acute manic episodes
- Patients not already taking long-term treatment:
- severe manic episodes: oral dopamine antagonist (haloperidol, olanzapine, risperidone or quetiapine). Other options:
- valproate (not for women of childbearing potential)
- aripiprazole
- other dopamine antagonists and partial agonists
- carbamazepine
- lithium
- where parenteral treatment required without full patient consent:
- dopamine antagonists/partial agonists and GABA modulators (benzodiazepines): follow established protocols and use lowest doses necessary
- less ill, non-psychotic manic patients/hypomania:
- extrapolate treatment from practice in mania
- patient preference should guide treatment selection where possible
- taper and discontinue antidepressants (drugs approved for the treatment of unipolar depression)
- if initial treatment is successful, consider long-term treatment
- severe manic episodes: oral dopamine antagonist (haloperidol, olanzapine, risperidone or quetiapine). Other options:
- Patients who suffer a manic episode while taking long-term treatment:
- inadequate symptom control: ensure that highest well-tolerated dose is offered
- lithium: check serum levels; consider establishing a higher level within the therapeutic range; consider adding dopamine antagonist or partial agonist, or valproate
- in general, follow the same principles as for a first episode or episode occurring off long-term treatment
- poor adherence: if associated with adverse reaction, consider dose reduction or more tolerable alternative regimen
- lithium: may not be indicated long-term if adherence poor
- If symptoms are inadequately controlled with optimised doses of the first-line medicine and/or mania is very severe, add another medicine:
- lithium or valproate with a dopamine antagonist/partial agonist
- clozapine in more refractory illness
- electroconvulsive therapy (ECT) if mania particularly severe/treatment resistant, patient's preference or severe mania during pregnancy
- Mixed features in a manic or hypomanic episode:
- identify as mixed features rather than a 'mixed episode' (DSM-5)
- treat as for mania
- Assess contribution of substance use and consider if medically assisted withdrawal is required
- Discontinuation of short-term treatments:
- plan drug discontinuation in relation to the need for long-term maintenance treatment
- medicines used only for acute treatment of mania: after full remission of symptoms (≥8 weeks of euthymia), taper dose of over >4 weeks
- adjunctive medication for symptomatic effect to promote sleep or sedation: discontinue gradually as soon as symptoms improve
Acute depressive episode
- Patients not already taking long-term treatment:
- consider quetiapine, lurasidone, or olanzapine
- consider initial treatment with lamotrigine in combination with agents preventing recurrence of mania
- if considering antidepressants (i.e. drugs for major depressive episode in unipolar illness), co-prescribe with a drug for mania (e.g. dopamine antagonists, lithium, valproate) in patients with a history of mania (e.g. fluoxetine with olanzapine)
- consider ECT if high suicidal risk, treatment resistance, psychosis, severe depression during pregnancy or life-threatening inanition
- where depressive symptoms less severe: lithium
- additionally: family-focused, cognitive behaviour therapy or interpersonal rhythm therapy
- Patients who suffer a depressive episode while taking long-term treatment:
- ensure current choice of long-term treatments is likely to protect from manic relapse (e.g. lithium, valproate, dopamine receptor antagonist/partial agonist drugs)
- ensure adequate doses of medicines, serum lithium levels within therapeutic range
- address current stressors
- if patient fails to respond to optimisation of long-term treatment, initiate treatment as above (or as for treatment-resistant depression, below)
- Choice of drug for a depressive episode:
- monotherapy with antidepressants may increase risk of switch to mania or mood instability during treatment
- dual-action monoamine re-uptake inhibitors (venlafaxine, duloxetine, amitriptyline and imipramine) carry a greater risk of precipitating a switch to mania than single action drugs (especially selective serotonin re-uptake inhibitors)
- antidepressant drugs appear unlikely to induce mania when used in combination with a drug for mania
- antidepressant as monotherapy in bipolar II disorder: any increase in dose should be gradual; be vigilant for early management of any adverse reactions (e.g. hypomania, mixed states or agitation)
- lamotrigine: effective in bipolar I and suitable for bipolar II disorder
- if any treatment successful for depressive episode, consider long-term treatment
- Consider tapered discontinuation of antidepressant drugs after as little as 12 weeks' full remission of symptoms:
- longer treatment justified if patients relapse on withdrawal
- Treatment of resistant depression:
- consider ECT
- manage augmentation strategies as in unipolar patients; ensure adequate anti-manic cover with lithium, valproate, or a dopamine antagonist/partial agonist
Long-term treatment
- Prevention of new episodes:
- consider long-term treatment following a single severe manic episode
- consider a wider package of treatment with enhanced psychoeducation, motivational, and family support, especially in early stages of illness
- patient has accepted treatment for several years and remains very well: advise continuing indefinitely, as high risk of relapse
- Options for long-term treatment:
- continuous rather than intermittent treatment with oral medicines preferred
- optimum long-term treatment strategy is not established
- acute stressor imminent or present, early symptoms of relapse, or anxiety prominent: short-term add-ons (e.g. GABA modulators or dopamine antagonists/partial agonists):
- consider supplying prospectively to patients
- higher doses of long-term treatments may be effective instead of add-ons
- Choice of long-term medicines:
- consider lithium as initial monotherapy
- if lithium ineffective, poorly tolerated or poor adherence: valproate, dopamine antagonists/partial agonists
- if a medicine led to prompt remission from the most recent depressive or manic episode, consider its long-term use:
- consider lithium as a better alternative to dopamine agonists
- alternative against manic relapse: carbamazepine (or oxcarbazepine)
- if prophylaxis against recurrence of mania is required and adherence to oral medication is erratic or injection preferred:
- consider long-acting (‘depot’) formulations
- consider lamotrigine and quetiapine as monotherapy in bipolar II disorder:
- in bipolar I disorder, lamotrigine usually requires combination with an anti-manic long-term
- Failure to respond to monotherapy, continuing sub-threshold depressive symptoms/relapses:
- consider long-term combination treatment:
- predominantly manic: combine predominantly anti-manic agents (e.g. lithium, valproate, dopamine antagonist or dopamine partial agonist)
- predominantly depressive: combine lithium, lamotrigine, quetiapine, lurasidone, or olanzapine
- refractory mania: consider continuation of clozapine if effective
- responsive to ECT during an acute episode, but poor on oral agents: consider maintenance ECT
- consider adjunctive psychotherapy
- consider long-term combination treatment:
- Rapid cycling:
- identify and treat contributing conditions (e.g. hypothyroidism or alcohol/drug use)
- taper and discontinue antidepressants
- combinations of medicines may be required
- discontinue treatments ineffective after evaluation ≥6 months
- Discontinuation of long-term treatment:
- risk of relapse remains, even after years of sustained remission
- make an informed assessment of the potential dangers
- taper over ≥4 weeks
- discontinuation of medicines does not imply withdrawal of services to patients
- Specific psychosocial interventions:
- may enhance care and reduce risk of relapse
- structured psychoeducation appears to be key ingredient
- more successful with patients early in illness course
- user groups can provide useful support and information
Treatment of alcohol use disorder
- Offer naltrexone or nalmefene as part of a behavioural programme
- Offer acamprosate if naltrexone has not been effective to help patients remain abstinent
Treatment in special situations
- Children and young people:
- for mania:
- consider aripiprazole or refer to adult recommendations
- other options: olanzapine, quetiapine and risperidone
- for moderate to severe bipolar depression:
- consider medicines and psychological treatments as recommended for adults
- refer to BNF for Children to modify doses and be aware of increased potential for adverse reactions and effects
- for mania:
- Elderly
- consider lower treatment doses and titrate carefully
- Women and pregnancy
- see management section
full guideline available from...
The British Association for Psychopharmacology,
36 Cambridge Place, Hills Road, Cambridge, CB2 1N0S Tel – 01223 358395
www.bap.org.uk/pdfs/BAP_Guidelines-Bipolar.pdf
GM Goodwin, PM Haddad, IN Ferrier, et al. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 2016; (epub ahead of print).
First included: October 04. Updated February 2010, May 2016.
Credit:
Lead image: Elnur/stock.adobe.com
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