Management of bipolar affective disorder

Assessment (1,2):

• listen to information from friends or relations of the patient because patient may be able to be 'normal' for time of consultation
  
  
• recognising and managing bipolar disorder in adults in primary care
  • recognising bipolar disorder in primary care and referral
    • if adults present in primary care with depression
      • ask about previous periods of overactivity or disinhibited behaviour. If the overactivity or disinhibited behaviour lasted for 4 days or more, consider referral for a specialist mental health assessment
    • refer people urgently for a specialist mental health assessment if mania or severe depression is suspected or they are a danger to themselves or others
    • ask about hypomanic symptoms when assessing a patient with depression and overactive, disinhibited behaviour
      
      
  • managing bipolar disorder in primary care
    • if working with people with bipolar disorder in primary care:
      • engage with and develop an ongoing relationship with them and their carers
      • support them to carry out care plans developed in secondary care and achieve their recovery goals
      • follow crisis plans developed in secondary care and liaise with secondary care specialists if necessary
      • review their treatment and care, including medication, at least annually and more often if the person, carer or healthcare professional has any concerns
        
        
• if bipolar disorder is managed solely in primary care, re-refer to secondary care if any one of the following applies:
  • there is a poor or partial response to treatment
  • the person's functioning declines significantly
  • treatment adherence is poor
  • the person develops intolerable or medically important side effects from medication
  • comorbid alcohol or drug misuse is suspected
  • the person is considering stopping any medication after a period of relatively stable mood
  • a woman with bipolar disorder is pregnant or planning a pregnancy
  • do not start lithium to treat bipolar disorder in primary care for people who have not taken lithium before, except under shared-care arrangements
  • do not start valproate in primary care to treat bipolar disorder

Medication:

• sedatives may be required to calm a wildly excited manic patient
• in the acute episode:
  • requires specialist advice
  • bipolar manic episode - drug treatment options include lithium, semisodium valproate or an atypical antipsychotic e.g. olanzapine
  • bipolar depressive episode - may be treated with antidepressant drug plus anti-manic therapy
• maintenance medication
  • requires specialist advice
  • lithium, olanzapine or valproate should be considered for long-term treatment of bipolar disorder - however lithium remains a first choice for many patients (3)
  • lamotrigine
    • there is consistent evidence that lamotrigine has a beneficial effect on depressive symptoms in the depressed phase of bipolar disorder (4)
    • a systematic review concluded that there is low-moderate level evidence to suggest that lamotrigine might be superior to placebo and similar to lithium in terms of efficacy but better tolerated in the longer term (7)
  • quetiapine alone and the combination of quetiapine– lithium or quetiapine–divalproex have also been shown in a trial to be effective maintenance treatments for bipolar disorder (5)

ECT may have a role in the treatment of mania

• if ECT is used in the treatment of bipolar disorder then within 4 weeks of resolution of symptoms, discuss with the person, and their carers if appropriate, whether to continue treatment for mania or start long-term treatment (1)
• f the person decides to continue treatment for mania, offer it for a further 3-6 months, and then review.

Lithium is a drug that may be used in the treatment of acute manic states or recurrent manic states. Lithium has many toxic effects including anorexia, nausea, vomiting, weakness, tremor, incontinence, dysarthria, retardation, coma and circulatory collapse. Lithium should never be given to a patient with renal impairment. Lithium cuts the relapse rate by about 50% in a 2 year period.

Cognitive therapy:

• there is evidence that, in patients with bipolar I disorder that medication plus cognitive therapy was more effective than medication alone for reducing relapses and number of days in bipolar episodes (5)

Attention to patient nutrition is important.

Notes (1,2):

• managing bipolar depression in adults in secondary care
  • valproate should not be prescribed routinely for women of child-bearing potential
  • lithium, olanzapine or valproate should be considered for long-term treatment of bipolar disorder
  • if a person develops mania or hypomania and is taking an antidepressant (as defined by the British national formulary [BNF]) as monotherapy:
    • consider stopping the antidepressant and
    • offer an antipsychotic, regardless of whether the antidepressant is stopped
  • if a person develops moderate or severe bipolar depression and is not taking a drug to treat their bipolar disorder
    • then offer fluoxetine combined with olanzapine, or quetiapine on its own, depending on the person's preference and previous response to treatment
      • if the person prefers, consider either olanzapine (without fluoxetine) or lamotrigine on its own
      • if there is no response to fluoxetine combined with olanzapine, or quetiapine, consider lamotrigine on its own
  • valproate in women of childbearing potential (1)
    • do not offer valproate to women of childbearing potential for long-term treatment or to treat an acute episode
    • if a woman of childbearing potential is already taking valproate, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure in pregnancy

Reference:

• 1. NICE (April 2018). Bipolar disorder.
• 2. NICE (September 2014). Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care
• 3. Drug and Therapeutics Bulletin 2005; 43(4):28-31.
• 4. Geddes JR et al. Lamotrigine for treatment of bipolar depression: independent meta-analysis and meta-regression of individual patient data from five randomised trials. Br J Psychiatry. 2009 Jan;194(1):4-9.
• 5. Lam DH et al. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. Am J Psychiatry 2005;162:324
• 6. Carvhalo AF et al. Bipolar Disorder. NEJM 2020;383:58-66.
• 7. Hashimoto Y, Kotake K, Watanabe N, Fujiwara T, Sakamoto S. Lamotrigine in the maintenance treatment of bipolar disorder. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD013575. DOI: 10.1002/14651858.CD013575.pub2