Bipolar disorder Key slides

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Bipolar disorderKey slides
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What is bipolar disorder? NICE Bipolar disorder
guidelines 2006 www.nice.org.uk

• Bipolar I one or more manic or mixed episode,
  often accompanied by one or more major depressive
  episode
• Bipolar II one or more major depressive
  episode, accompanied by one or more hypomanic
  episode

• A chronic relapsing and remitting disorder
• Abnormally elevated mood or irritability
  alternates with depressed mood
• In most cases depressive episodes are more
  frequent than manic ones

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Some background informationNICE Bipolar disorder
guidelines 2006 www.nice.org.uk

• Early onset
• usually before 30 years (peak in late teens)
• Cause unclear
• although there is a genetic component there is
  no cure
• Co-morbidity common
• e.g. anxiety, personality disorder, drug/alcohol
  abuse
• High risk of suicide

• Correct diagnosis difficult
• but is essential for effective treatment
• often misdiagnosed as depression initially
• frequently only recognised only after several
  periods of psychological or social disturbance
• Recognition needs improving
• to enable early diagnosis/referral and
  appropriate treatment
• GPs have important role to play in this

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Long-term management NICE Bipolar disorder
guidelines 2006 www.nice.org.uk

• Long-term treatment and support are required to
  minimise the risk of recurrence of manic and
  depressive episodes and optimise quality of life,
  social and personal functioning
• Important
• collaborative relationship with patients and
  families
• continuity of care
• crisis support
• an integrated (primary and secondary) care plan
  are all important

• The primary long-term treatments are drugs, but
  psychological/psychosocial therapy/support are
  also important
• Initiate long-term drugs
• after a manic episode with significant risk and
  adverse consequences
• bipolar I two or more acute episodes
• bipolar II evidence of significant functional
  impairment or risk of suicide or frequently
  recurring episodes

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Support long-term pharmacological
treatmentwww.nice.org.uk/nicemedia/pdf/implementa
tion_tools/CG38presenterslides.ppt

• Prescribing advisers should be aware of NICE
  guidance, and what to consider when choosing
  treatment (update prescribing policies and
  formularies accordingly)
• Focus on optimising appropriate long-term
  treatment
• Support patient education and empowerment in
  pharmacological treatment and management
  decisions
• Make use of early intervention teams, regional
  mental health trusts and CAMHS teams
• Raise awareness of effective antidepressant
  prescribing
• Support patient fears about antidepressant
  withdrawal

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Overview of the drug treatment of bipolar
disorderNICE Bipolar disorder guidelines 2006
www.nice.org.uk

• Antimanic agents (mood stabilisers)
• Consider lithium, olanzapine or valproate for
  long-term treatment
• If frequent relapses, or functional impairment,
  switch to alternative monotherapy or add a second
  drug (e.g. olanzapine plus lithium or valproate)
• If trial of a combination of agents is
  ineffective, consider consulting or referring to
  a bipolar disorder specialist, or prescribing
  lamotrigine (esp. if bipolar II disorder) or
  carbamazepine
• Be aware of side-effects, drug interactions and
  requirements for monitoring

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Overview of the drug treatment of bipolar
disorderNICE Bipolar disorder guidelines 2006
www.nice.org.uk

• Antidepressants
• Can be used to control depressive episodes (with
  antimanic medications) e.g. SSRIs
• After successful treatment of an acute depressive
  episode, do not continue long-term
  antidepressants routinely
• Stop antidepressant at the onset of an acute
  episode of mania (abruptly or slowly)
• NOTE. Patients with bipolar disorder who are
  prescribed an antidepressant should always be
  prescribed an antimanic drug

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Other considerationsNICE Bipolar disorder
guidelines 2006 www.nice.org.uk

• Do not prescribe valproate routinely for women
  with childbearing potential
• For women planning a pregnancy, valproate,
  carbamazepine, lithium or lamotrigine should be
  stopped. A low dose antipsychotic may be used
  with caution
• Normally continue prophylactic medication (not
  antidepressants) for at least 2 years after an
  episode
• Provide regular reviews
• If long-term medication declined, offer regular
  contact and reassessment with primary or
  secondary care services
• Long-acting IM antipsychotics (depots) are not
  recommended for routine use

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Consider psychological therapy and psychosocial
supportNICE Bipolar disorder guidelines 2006
www.nice.org.uk

• For those who are relatively stable, individual
  structured psychological therapy (CBT, family
  therapy) should include
• at least 16 sessions over 6 to 9 months
• psychoeducation
• promotion of medication adherence
• monitoring of mood, detection of early warnings
  and prevention strategies
• coping strategies
• Consider offering befriending to people who would
  benefit from additional social support,
  particularly those with chronic depressive
  symptoms

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Carry out regular health reviews/monitoringwww.ni
ce.org.uk/nicemedia/pdf/implementation_tools/CG38p
resenterslides.ppt

• An annual review should include a review of
  mental and physical health and social functioning
  
• Monitor the following (as a minimum)
• lipid levels, including cholesterol, in patients
  over 40 years
• plasma glucose levels
• weight
• smoking status and alcohol use
• blood pressure
• Support patients in controlling weight
• review risk of weight gain when prescribing
• offer early dietary advice and support
• advise to take exercise
• Careful monitoring of weight is needed with all
  antipsychotics, lithium, valproate and
  carbamazepine
• Note see NICE guideline for more details and
  recommendations for monitoring for specific drugs
  (additional checks and serum levels)

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Summary key service issues

• Improve recognition and diagnosis of bipolar
  disorder, particularly in adolescents
• Improve education of health professionals and
  patients, and involve patients (and
  families/carers) more in the management of their
  disorder
• Support long-term pharmacological management,
  alongside psychological therapies, according to
  NICE guidelines
• Review care pathways and management of bipolar
  disorder in women of child-bearing potential
• Provide regular (at least annual reviews) of
  physical, mental and social status
• Monitor and support patients in controlling
  weight