Introduction
Bipolar disorder is a disorder of mood, in which a person has episodes of both elevated and depressed mood. These episodes of major change of mood are associated with distress and disturbance of function. People with bipolar disorder can take control of their illness by working with a multidisciplinary team, and utilising the support of family and friends.
Treatment of bipolar disorder
When people with bipolar disorder experience acute mania, immediate referral to a specialist psychiatric service is usually necessary. Diagnosing bipolar disorder can be very complex and the first assessment may not provide a definitive diagnosis. To confirm the diagnosis, a mental health professional (usually a psychiatrist) should undertake a comprehensive assessment.
1. Hospitalization:
- Abnormal Behaviour ( loss of career, family disintegration)
- Delirious mania.
Comprehensive clinical assessment
Their full medical history will be taken which include:
- a) A 'risk assessment', which assesses a person's potential for experiencing harms associated with mania. These may include aggression, financial harm, risky sexual behaviour or vulnerability to exploitation, and the possibility of contracting communicable diseases (such as HIV, Herpes or Hepatitis C) due to sexual behaviour.
- b) Past episodes of psychiatric problems. If the person has established bipolar disorder, the doctor will also check their compliance with mood stabiliser medications and cease any antidepressants.
- c) Physical examination. Its purpose is to exclude organic causes of the manic behaviour, such as a neurological disorder, systemic disease, the misuse of alcohol or drugs or other substances, or the use of prescription medication.
- d) Also assess any physical consequences of mania (eg, dehydration, emaciation or injuries).
- e) A routine physical investigation (urea and electrolytes, full blood count, liver function tests, thyroid function test, and therapeutic drug monitoring of mood stabiliser serum concentrations).
- f) Finally, other investigations will be carried out if needed. These may include a brain scan, cognitive/dementia screen, and an electroencephalography (EEG).
Once this comprehensive assessment is carried out, a treatment plan is developed with the person to tailor the treatment of bipolar disorder to his or her individual needs.
Phases of treatment:
1. Acute phase: the goal of the acute phase of treatment is symptom reduction and stabilization. Therefore, for the first few weeks of treatment, mood stabilizers may need to be combined with antipsychotics or benzodiazepines, particularly if the patient has psychotic symptoms, agitation or insomnia. If the clinical situation is not an emergency, it is desirable to start patients on a low dose and gradually increase the dose until the maximum therapeutic benefits has been achieved. Once stabilization is achieved, the frequency of serum level monitoring should be 1 to 2 weeks during the first 2 months and every 3 to6 months during the long term maintenance.
2. Continuum phase: the goal of this phase is to prevent relapse of the current episode or cycling into the opposite pole. It lasts about 2 to 9 months after acute symptoms have resolved. The usual pharmacologic procedure in this phase is to continue the mood stabilizer while closely monitoring the patient for signs or symptoms of relapse.
3. Maintenance phase: the goal of this phase is to sustain remission and to prevent new episodes. It is recommended that long term or life time prophylaxis with a mood stabilizer be instituted after two manic episodes or after one manic episode if t is severe or if there is family history of bipolar disorder.
4. Discontinuation: like major depressive disorder, the course of bipolar disorder is typically recurrent and progressive. Therefore, the same issues and principles regarding the decision to continue or discontinue pharmacotherapy apply.
2. Somatic treatment:
Acute treatment of manic episodes
Medications are the main way of managing an acute manic episode. The aim of the medications is to stabilise mood.
Components to the drug management of acute mania
- Commencement of a mood stabiliser (lithium, sodium valproate, carbamazepine or olanzapine). Mood stabilisers act upon the elevated mood but take about one week to start working for most people.
- Concurrent use of an antipsychotic or benzodiazepine (or a combination of these). These medications calm or sedate the person with mania as a temporary procedure, until the mood stabiliser starts to help the person to feel better.
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Mood Stabiliser
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Newer anticonvulsants |
WITH OR WITHOUT Additional Treatments For Other Symptoms
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LITHIUM: Commence with 750 - 1000 mg daily. Determine serum level after 5 to 7 days of steady-dose treatment [Aim for serum concentration of 0.8 - 1.2 mmol/L] OR VALPROATE Commence with 400 - 800 mg daily. Determine serum level after 5 days of steady-dose treatment, OR Use loading dose strategy commencing at 20 - 30 mg/kg [Aim for serum concentration of 300 - 800 ìmol/L] OR CARBAMAZEPINE Commence with 200 - 400 mg daily. Determine serum level after 5 to 7 days of treatment. [Aim for serum concentration of 17 - 50 ìmol/L]. |
LAMOTRIGINE (lamictal) has been shown to have efficacy in the treatment of mania, both as single agent and in combination with lithium or valproate, particularly effective for rapid cycling and in the depressed phase of bipolar illness. GABAPENTIN: gabapentin (neurontin) has been showed efficacious for acute mania and mood stabilization, including rapid cycling. TOPIRAMATE (TOPAMAX): has been used mostly as add- on therapy in mixed patient samples wth refractory mood disorders. A unique characteristic of topiramate is that it is more associated with weight loss than weight gain. OR OLANZAPINES - 20 mg daily |
Treat psychosis Manage sleeping difficulties Oral
Taken by injection (only use if oral administration is not possible, or is ineffective) a)Benzodiazepines (midazolam i.m., diazepam i.v.) b)Antipsychotics olanzapinei.m., haloperidol i.m., zuclopenthixol i.m. |
If the manic episode does not respond to first line treatment
The timing of the decision to change treatment will depend on both clinical urgency and the degree of response, which varies from person to person. It can be
- Increase the dose and/or blood levels of the mood stabiliser
- Add an additional antipsychotic such as Risperidone, olanzapine or haloperidol.
If these strategies have being tried and there is still no relief from symptoms, electroconvulsive therapy (ECT) may be considered.
The benzodiazepine or antipsychotic should be withdrawn once the acute episode has resolved and just the mood stabiliser should be continued.
Management of mixed bipolar disorder
Medication options for the treatment of a mixed episode
The treatment of mixed episodes involves the choice of any of these medications:
- Valproate
- Carbamazepine
- Lithium
- Olanzapine
TREATMENT OF BIPOLAR DEPRESSION
Comprehensive clinical assessment - bipolar depressive episode
Clinical assessment requires patient cooperation and may not be possible if the patient is severely slowed physically and mentally.
It is essential to obtain collaborative information especially in cases where cognitive impairment is suspected:
- Suicide risk assessment
- Exclude organic causes (neurological disorder, systemic disease, substance misuse, drug induced)
- Sophisticated appraisal of possible psychotic symptoms - especially pathological/delusional guilt and hallucinations
- Check compliance with mood stabilisers
- Conduct routine haematological and biochemical investigations (urea and electrolytes, full blood count, thyroid function tests, therapeutic drug monitoring)
- Additional investigations if indicated (eg, brain scan, cognitive/ dementia screen).
Pharmacological intervention - depressive episode
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NEW DEPRESSIVE EPISODE
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BREAKTHROUGH DEPRESSIVE EPISODE ON SINGLE MOOD STABILISER |
FAILURE TO RESPOND
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OR
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Add antidepressant ((SSRIs) and venlafaxine form the first-line choice of treatment.) MAOIs and TCAs should be considered as second-line treatment choices.
OR Add second mood stabiliser ( after blood levels) EG: Lamotrigine, combining of lithium and carbamazepine |
Switch/substitute antidepressants OR Switch/substitute mood stabilisers OR Electroconvulsive therapy
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Continuing failure to respond
- Confirm correct diagnosis
- Re-evaluate psychological/social factors responsible for maintaining depression
- Consider adjunctive psychological therapies
Medications for long-term treatment of bipolar disorder
Long-term treatment is often called the 'maintenance' phase of treatment or 'relapse prevention'. The goal of long-term treatment for bipolar disorder is to maintain a stable mood and to prevent a relapse of mania or a depressive episode.
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LITHIUM (Aim for serum concentration of 0.6 - 0.8 mmol/L) OR VALPROATE(Usual dose range 1000 - 2500 mg; serum concentration 350 - 700 ìmol/L) OR CARBAMAZEPINE(Usual dose range 600 - 1200 mg; serum concentration 17 - 50 ìmol/L) OR LAMOTRIGINE(Usual dose range 50 - 300 mg; serum concentration not useful)
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3. Psychosocial treatments
Learning to live with a continuous illness that is episodic is a major issue for people with bipolar disorder and their families.
- As an adjunct to somatic treatment.
- Repeated episodes of mania and depression tend to lead to increased rates of divorce, family breakdown, and unemployment, a break in social networks and education, and financial difficulties
a) Cognitive Behaviour Therapy: Therapy aims at correcting the depressive negative conditions e.g. Hopelessness, worthlessness and replacing them by new cognitive ideas and behavioral responses. It is used in mild to moderate depression and can be used along with somatic treatment.
b) Interpersonal Therapy: Therapy attempts to recognize and explore interpersonal stressors, role disputes and transitions, social isolation or social skill deficits, which acts as precipitants for depression.
c) Psychoanalytic psychotherapy: Therapy aims at changing the personality itself rather than just ameliorating the symptoms. Their usefulness is uncertain.
d) Behaviour Therapy: This includes the various short term modalities like social skill training, problem solving techniques, assertiveness training, self control therapy, activity scheduling and decision making techniques. It is useful in mild cases of depression.
e) Group Therapy: Group psychotherapy can be useful in mild cases of depression. It is very useful method of psycho education in both recurrent depressive disorder and bipolar disorder.
f) Family and Marital Therapy: The main purpose is to ensure continuity of treatment and to reduce the intrafamilial and interpersonal difficulties and to reduce or modify stressors which may help in a faster and complete recovery.
4. Complementary (non prescribed) medications
- Herbal remedies and other natural supplements have not been well studied and their effects on bipolar disorder are not fully understood.
- Omega-3 fatty acids (found in fish oil) are being studied to determine their usefulness for long-term treatment of bipolar disorder.
- St John's Wort (hypericum perforatum) is a herb which is being studied in regard to depression, but there is some evidence that it can reduce the effectiveness of some medications, can react with some prescribed antidepressants, or may cause a switch into mania.
Conclusion
People who manage their bipolar disorder well provide assurance and hope that living with it and achieving a good lifestyle is now possible. The wider community is now more aware and understanding of bipolar disorder, there is support and there are highly effective treatments now available. While there remains no cure, there is no reason to think that treatments will not improve even further in the future. Future research will aim to reduce the side effects of existing treatments and to develop better ones. With treatment, a person with bipolar disorder can lead a good quality of life.
References:
- Townsend M C Psychiatric mental health nursing- concepts of care. (5 th edn). Philadelphia: F.A Dais company; 2005.
- Kaplan. Comprehensive textbook of psychiatry (9 th edn). Philadelphia: Williams & Wlkins; 2007.
