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Bipolar disorder Key slides. What is bipolar disorder? NICE Bipolar disorder guidelines 2006 www.nice.org.uk. 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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what is bipolar disorder nice bipolar disorder guidelines 2006 www nice org uk
What is bipolar disorder?NICE Bipolar disorder guidelines 2006 www.nice.org.uk
  • 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
  • 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
some background information nice bipolar disorder guidelines 2006 www nice org uk
Some background informationNICE Bipolar disorder guidelines 2006 www.nice.org.uk
  • 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
  • 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
long term management nice bipolar disorder guidelines 2006 www nice org uk
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
slide5
Support long-term pharmacological treatmentwww.nice.org.uk/nicemedia/pdf/implementation_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
slide6
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

Overview of the drug treatment of bipolar disorderNICE Bipolar disorder guidelines 2006 www.nice.org.uk
slide7
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

Overview of the drug treatment of bipolar disorderNICE Bipolar disorder guidelines 2006 www.nice.org.uk
other considerations nice bipolar disorder guidelines 2006 www nice org uk
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
slide9
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
slide10
Carry out regular health reviews/monitoringwww.nice.org.uk/nicemedia/pdf/implementation_tools/CG38presenterslides.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)
summary key service issues
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