Presentation on theme: "2007. Statistics 2-4 new cases per 100,000/year 1 in 200 people will have an episode of hypomania Peak age of onset 25-30 yrs May have had a previous."— Presentation transcript:
Statistics 2-4 new cases per 100,000/year 1 in 200 people will have an episode of hypomania Peak age of onset 25-30 yrs May have had a previous episode of depression in late adolescence 15-20% commit suicide
Bipolar Disorder 1 Life time prevalence 0.4 – 1.6% Characterised by episodes of Depression, mania or mixed states separated by periods of normal moods Mania Features include elevated expansive euphoric mood, irritability, hyperactivity, decreased need for sleep, disorganised behaviour, delusions, hallucinations and functional impairment
Bipolar Disorder 2 Life time prevalence 0.5% No mania but episodes of hypomania, depression or mixed states. Hypomania Characterised by milder elevated mood, over activity, without psychotic features and no functional impairment.
Aetiology Genetic Unipolar depression: risk of severe depression in first degree relatives of a severely depressed patient is 10-15 % (1-2% in the general population) The evidence for a genetic aetiology of bipolar disorder is stronger: the concordance in twin studies is: 70% for monozygotic twins reared together 70% for monozygotic twins reared apart 23% for dizygotic twins in adoption studies, risk for bipolar affective disorder stems more from the genetic rather than the adoptive parent The inheritance is probably non-Mendelian.
Aetiology More common in cyclothymic personalities Depression 6x more common in 6/12 after severe life event
Management New patients Refer urgently Pts with mania or severe depression who are a danger to themselves Refer for assessment Pts with periods of overactive disinhibited behaviour lasting at least 4 dayswith or without periods of depression 3 or more depressive episodes and a history of overactive disinhibited behaviour
Management Existing patients Refer urgently Any acute exacerbation of symptoms An increase in the degree of risk to themselves or others Consider review in secondary care Functioning declines significantly or response to treatment is poor Treatment adherence is poor Patient considering stopping prophylactic medication
Managing acute mania or hypomania STOP antidepressants abruptly or gradually If not on antimanic medication Consider antipsychotic – olanzapine, quetiapine or risperidone. Valproate avoid in women of childbearing age Consider adding short term benzodiazepine Carbamazepine, lamotrigine, gabapentin and topiramate are no recommended for acute mania
Managing acute mania or hypomania STOP antidepressants abruptly or gradually If already on antipsychotic medication Increase dose if possible Consider adding lithium or valproate If taking lithium Check blood levels if low increase dose, if response not adequate consider adding antipsychotic If taking valproate Increase dose till improvement starts or side effects limit dose consider adding antipsychotic
Managing depressive symptoms At risk of switching to mania when antidepressant medication started Therefore if not already on antimanic medication start antimanic drug at same time as antidepressant which should be started at low dose and increased gradually SSRI do not use paroxetine in pregnant women consider adding quetiapine if patient already taking anitmanic drug that is not antipsychotic
Long term management Consider long term treatment in After a manic episode involving considerable risk and adverse consequences A patient with bipolar 1 disorder who has had 2 or more acute episodes A aptient with bipolar 2 disorder who has significant functional impairment, is at risk of suicide or has frequent episodes.
Long term management Choice of drug Lithium Olanzapine Valproate do not use in women of childbearing potential
Long term management Length of treatment At least 2 years Up to 5 years if risk factors for relapse i.e. Frequent relapses, severe psychotic episodes, comorbid substance misuse, ongoing stressful life events or poor social support
Long term management After an acute depressive episode Stop antidepressant as no evidence it prevents relapse rates and may increase risk of switching to mania Chronic and recurrent depressive episodes and have not had a recent manic or hypomanic episode consider Long term treatment with SSRI’s CBT Quetiapine or lamotrigine
Long term management Pregnant women Avoid Valproate Carbamazepine Lithium lamotrigine Long term benzodiazepines paroxetine
Long term management Pregnant women Acute psychotic symptoms Consider atypical or typical antipsychotic Keep dose as low as possible If there is no response and mania severe consider ECT Lithium Rarely valproate if no alternative must explain about risks to fetus and give folic acid 5mg/day
Long term management Depression Mild symptoms Guided self help Brief psychological interventions Antidepressant medication Moderate or severe symptoms consider CBT Combined medication and structured psychological interventions Drugs – quetiapine or SSRI not paroxetine advise re short lived effectsof SSRI on neonate
Long term management Breast feeding Do not breast feed with Lithium Benzodiazepines Lamotrigine Fluoxetine Citalopram Clozapine