Bipolar Disorders

Introduction

Bipolar Disorders is a type of mood disorder in which there is (typically) alternation of a depressive phase
and a manic or hypomanic phase.
It experienced by about 1% of the adult
population at some point in their lifetime.
About equal incidence between males and females.
It may be precipitated by psychosocial stress; strong genetic vulnerability often present

Clinical features

Depressive phase:

  • Low mood
  • Impaired appetite and sleep
  • Ideas of worthlessness or hopelessness
  • Suicidal ideation
  • Other depressive symptoms and signs

Manic or hypomanic phase:

  • Elation
  • Euphoria
  • Irritability
  • Expansive mood
  • Disturbed sleep
  • Grandiosity
  • Disinhibition

Differential diagnoses

  • Schizo-affective disorder
  • Schizophrenia
  • Organic mood/affective disorder (including effects of drug abuse)

Complications

  • Social and personal consequences of inappropriate behaviour (e.g. unplanned pregnancy, sexually-transmitted infections, etc)
  • Suicide
  • Increased risk of morbidity (reduce life expectancy) (e.g. trauma and accidents)
  • Increased mortality

Investigations

  • Investigations as indicated to rule out organic/medical causes
  • Full Blood Count and renal function tests (to determine suitability of mood stabilizers)

Treatment objectives

  • Reduce risk to self and others
  • Normalize mood
  • Return to full functional status
  • Prevent recurrence

Non-drug treatment

Cognitive-behavioural therapy as sole treatment in mild cases, and adjunct in all others Electroconvulsive therapy (ECT)

  • An effective and essentially safe treatment for severe and acuteb presentations
  • A course of 8-12 treatments are usually needed

Drug treatment

A. Management of the manic patient

Risperidone, oral,
Adults: 1-4 mg 12-24 hourly, to a max. of 8 mg daily
Children

  • >12 years; 500 micrograms stat. then adjust daily in steps of 500 micrograms – 1 mg daily to a max. of 6 mg daily
  • < 12 years; Not recommended

Or

Olanzapine, oral,
Adults: 5-15 mg 12-24 hourly to max. 20 mg daily
Children

  • 12-18 years; 2.5 mg daily, up to max. of 20mg daily
  • <12 years: Not recommended

Or

Haloperidol, oral,
Adults: 5-10 mg 12 hourly up to a max. of 20 mg daily

Or

Chlorpromazine, oral,
Adults: 25 mg 8 houly or 75 mg at night, Then increase by 25 mg daily to 50-100 mg 8 hourly

Or

Sodium valproate, oral,
Adults 250-750 mg 12 hourly (controlled release preferable)
Children < 18 years; Not recommended

Or

Carbamazepine, oral,
Adults: 200-800 mg 12 hourly (controlled release preferable)
Children < 18 years; Not recommended

C. Management of significantly aggressive patient

(See  ‘The Acutely Disturbed Patient‘).
Management of the depressive phase
Lamotrigine, oral,
Adults: 25 mg daily for 2 weeks then increase by 25 mg every 2 weeks to a max. of 200 mg daily as required
Children: < 18 years; Not recommended

And

Lorazepam, oral,
Adults: 2-3 mg 8-12 hourly, max. 10 mg daily
Children

  • 2-18 years; 0.05 mg/kg 8 hourly, max. 2 mg daily

Or

Diazepam, oral,
Adults: 5-10 mg 6-12 hourly
Children

  • 12-18 years; 10 mg 12 hourly
  • 5-12 years; 5 mg 12 hourly

Note

The benzodiazepines are withdrawn as soon as the patient is calm, but this should be done by slowly tapering the dose.

D. Maintenance management after control of the acute phase

Lithium, oral,
Adults: 200-600 mg 6-8 hourly (max. 2400 mg daily)
Children

  • 12-18 years; 200-600 mg 8 hourly (max. 2400 mg daily)
  • 6-12 years; 5-20 mg/kg 8 hourly
  • < 6 years; Not recommended

Note

Lithium levels should be monitored 12 hours after dose, twice weekly until condition stabilises, then once every month.

Or

Sodium valproate, oral,
Adults: 250-750 mg 12 hourly (controlled release preferable)
Children < 18 years; Not recommended

Or

Carbamazepine, oral,
Adults: 200-800 mg 12 hourly (controlled release preferable)
Children < 18 years; Not recommended

Supportive measures

  • Psychotherapy and social intervention for patient and relatives/caregivers

Notable adverse drug reactions

  • More likely with doses above
    recommended upper limits

Lithium

  • Gastrointestinal disturbances
  • Tremors
  • Confusion
  • Myoclonic twitches

Carbamazepine:

  • hypersensitivity reactions
  • Transient memory impairment is common following ECT

Prevention

  • No primary preventive measures are clearly delineated
  • Adherence to therapy with mood stabilizers until discontinuation is considered prudent (this is individually determined)

Referral Criteria

Refer all patients suffering a first episode, not responding to treatment after one month and all children to a psychiatrist.