Bipolar disorder Paul Harrison Warneford Hospital Bipolar disorder - - PowerPoint PPT Presentation

Bipolar disorder

Paul Harrison Warneford Hospital

Bipolar disorder guidelines

• NICE (2014)
• British Association for Psychopharmacology (Goodwin et al,

2016, J. Psychopharmacol. 30: 495-553)

– Covers all aspects – Independent – Available free from website: https://www.bap.org.uk/guidelines

• Also BAP guidelines for psychotropic prescribing in

pregnancy/breastfeeding (2017), and off-label prescribing (2017)

Troublesome terms

• Mania vs hypomania

– Mania = mood elevation etc, with functional impairment. – Hypomania = mood elevation (and increased energy) unequivocal, but it does not cause marked functional impairment – Both need to be present for 7 days (though DSM-5 requires

• nly 4 days for hypomania)
• Bipolar I vs Bipolar II

– American (DSM) terms – BD1 = ‘true’ BD, with mania – BD2 = milder BD, with hypomania (and depression).

Majority of BD presents with one or more depressive episodes first, so how to spot BD?

• Screening for undiagnosed past hypomania

– Episode(s) of increased energy/disinhibition/reduced sleep/grandiosity/irritability – Out-of-character/caused problems/regretted – How long? – Was patient on an antidepressant/stimulant at the time?

• Family history of BD

• Differential diagnosis

– Borderline PD (emotionally unstable PD) – Cyclothymia – ‘Organic’ bipolar disorder

• Especially if onset >40, unexpected
• Steroids, L-DOPA, thyroid, cortical lesions

– Schizoaffective disorder – (A ‘degree’ of BD)

• Comorbidities/confounders

– The rule not the exception – Alcohol and drugs – Anxiety disorders

• Often persistent, and not explained by mood

BD vs borderline PD (BPD)

• Distinguishing features of BPD

– Personality not illness – Pervasive efforts to avoid abandonment – Features fluctuate in response to relationships, e.g. ‘acting

• ut’ and anger

– Chronic feeling of emptiness, depressive symptoms, poor self-image – Absence of true hypomanic episodes – (Differences in characteristics of mood instability)

• Comorbid in 20%

– Worse outcomes – BPD ‘blinds clinician to diagnosis of BD’ (and its therapy) – Presence of BPD increases case for psychotherapy

Bipolar depression

• Causes far more morbidity than the manic phase
• SSRIs (and other antidepressants) are largely ineffective

and may precipitate hypomania or rapid cycling

• Hence recognition of bipolarity is important, as leads to

different treatment algorithm

• Clinically similar to unipolar depression, but

– Melancholic, psychotic, or atypical features raise suspicion – Plus family history and past history mentioned earlier

Fluoxetine +

• lanzapine

Quetiapine First line Second line Fluoxetine +

• lanzapine

Lamotrigine Quetiapine Quetiapine + lamotrigine

Drug treatment of bipolar depression

Olanzapine

Bipolar depression (2)

• Quetiapine:

– Strong evidence – (A bit) less weight gain/metabolic syndrome than

• lanzapine

– Anxiety and sedation – Dose varies widely

• Start low, warn about sedation
• Often <300mg/d needed

Bipolar depression (3)

• Lamotrigine

– Reasonable effect as sole agent – Useful adjunct if first-line Rx ineffective – Well tolerated – But slow titration, risk of Stevens-Johnson syndrome – CHC

• Reduces lamotrigine levels (so risks of toxicity in pill-free week)
• Either avoid CHC, or use continuous regimen

Lamotrigine augments quetiapine in bipolar depression

Lancet Psychiatry 2016:3:31-39 Weeks

NB: Lamotrigine response impaired by folic acid Effective over 12 months: 36% in remission, vs 16% in placebo group

Psychosocial aspects of BD

• Psychoeducation

– Identify triggers – Recognise early signs – Early intervention (e.g. sleep hygiene, hypnotics) – Importance of medication, and compliance – Involve family

• Lifestyle advice

– Regular routines, avoid drugs and alcohol

• Other formal psychotherapies

– Little evidence (including for CBT)

Fluoxetine +

• lanzapine

Quetiapine First line Second line Fluoxetine +

• lanzapine

Lamotrigine Quetiapine Quetiapine + lamotrigine

Third line Add valproate Lurasidone (not licensed for BD in UK) ECT

Drug treatment of bipolar depression

Olanzapine

Add lithium

NB: Limited evidence for all compared to unipolar depression

Aripiprazole (resistant cases)

Prophylaxis

• Consider after a single manic episode, and definitely after two
• Lithium – remains first line

– Anti-suicidal effect

• Valproate
• Lithium + valproate
• Quetiapine
• Lamotrigine

– Not good anti-manic

• Carbamazepine – weak evidence, now rarely used
• Stopping prophylaxis: difficult decision, often better to

continue

– Always taper very gradually (especially lithium)

• Naturalistic data interesting…

JAMA Psychiatry AOL 28.2.18

18,000 BD patients followed for 25 years 9,000 admissions

Overall, lithium did best

Quetiapine had only modest benefits – and olanzapine none

Depot antipsychotics did much better than

• ral

…compliance

BD in women of child-bearing age

• Pros and cons of meds vs no meds, and which one
• High risk of relapse during and after pregnancy
• BD itself associated with increased risk of adverse

pregnancy outcomes

• Ideally, discussion and monitoring pre-conception
• Avoid valproate
• Lithium – less risky than thought

– cardiac malformations in 2.4% vs 1.2%

• Lamotrigine, quetiapine, olanzapine – relatively safe

– as is lithium after first trimester

Physical health monitoring

• Same excess mortality and cardiovascular risks as

schizophrenia

• Physical health checks recommended for mood

stabilisers as for antipsychotics

• Lithium monitoring (levels, renal, thyroid, calcium)
• Guidelines and protocols for both are under review

Services for BD

• BD omitted from NSF

– Significance and needs neglected – Refer to AMHT or EIS in usual way

• Specialist BD clinic run at Warneford by academic

psychiatrists

– For research studies, especially clinical trials – Remote mood monitoring – Not an emergency service; not complex or chronic cases – Referrals/queries to oxfordhealth.bipolarclinic@nhs.net – Leaflets

https://oxfordhealth.truecolours.nhs.uk/www/

Questions?

Lester UK adaptation (2014) RCPsych