Bipolar
General Overview
General Overview
- Mania
- Distinct period of abnormally persistently elevated, expansive or irritable mood and goal-directed activity/energy >1w (or hospitalization) most of the day nearly every day
- ≥3 (or 4 if mood only irritable)
- Grandiosity (inflated self esteem)
- Sleep (decreased need, eg. rested after 3h of sleep)
- Talkative
- Pleasurable activities that have high potential for Painful consequences
- Activity (goal-directed) or psychomotor Agitation
- Ideas (flight of)
- Distractibility
- Impaired function, not attributable to substance or medical condition
- Hypomania
- Meets criteria but lasts only 4-6 days
- No marked impairment in function
- Absent psychotic features (if present, would be manic)
- Bipolar I
- ≥ one manic or mixed episode
- Bipolar II
- ≥1 MDE + ≥1 hypomanic episode (>4d, not severe enough to affect function, not need hospitalization, no psychotic features)
- Specifiers: with anxious distress, depressed with mixed features, hypo/manic with mixed features, melancholic features, atypical features, mood-congruent or -incongruent psychotic features, catatonia, peripartum onset, seasonal pattern, rapid cycling (4+ mood episodes in a 1 yr)
- Cyclothymia
- Numerous hypomanic and depressive symptoms not meeting criteria ≥2 years (never asymptomatic >2mo)
- Impaired function
DDx
DDx
- Anxiety
- Depression
- Personality (Narcissitic, Borderline, Antisocial)
- Substance use disorders
- Medications
- Medical condition (endocrine)
Labs
Labs
- CBC, electrolytes (Glucose, Cr), lipids, LFT and Bili, INR, TSH, EKG
- bhCG, prolactin
- Urine analysis
- Urine toxicology
- Monitoring
- Lithium:
- Levels weekly until stable then q3-6 months (target 0.6-0.8mmol/L)
- LFT, electrolytes (Urea, Cr, Calcium), TSH q3-6mo
- Divalproex: Levels do not need to be monitored
- LFT, CBC q6mo then yearly
- Lithium:
Acute Management
Acute Management
Acute Mania
Acute Mania
- Assess safety
- If on long-term treatment optimize dose levels, and then consider adjunct antipsychotic
- Monotherapy:
- Mood stabilizers - Lithium, Divalproex
- Lithium more effective in euphoric mania
- Divalproex in Mixed episodes or rapid cycling
- Antipsychotics - Risperidone, quetiapine, olanzapine, aripripazole, asenapine, ziprasidone, paliperidone ER
- Psychosis/agitation
- Mood stabilizers - Lithium, Divalproex
- Adjunctive therapy with lithium or divalproex (20% higher response rate than mood stabilizer alone)
- Risperidone, quetiapine, olanzapine, aripripazole, asenapine
Acute Bipolar I Depression
Acute Bipolar I Depression
- Monotherapy
- Lithium, lamotrigine, quetiapine, quetiapine XR
- Combination therapy
- Lithium or Divalproex AND SSRI or Buproprion
- Olanzapine AND SSRI (fluoxetine)
Acute Bipolar II Depression
Acute Bipolar II Depression
- First line: Quetiapine
- Second line: Lithium, lamotrigine, divalproex or combination as above
Maintenance
Maintenance
- Ensure adherence
- First line for mania and depression: Lithium, divalproex, quetiapine
- Lithium side effects:
- Neuro (ataxia, confusion, agitation, tremor, seizure)
- Cardiac (bradycardia, prolonged QT)
- Renal (nephrogenic diabetes insipidus)
- Thyroid (hypo and hyperthyroidism)
- Consider for the prevention of mania: Risperidone, aripiprazole, olanzapine
- Consider for the prevention of depression: Lamotrogine
- Lithium side effects:
Psychosocial interventions
Psychosocial interventions
- Group psychoeducation, CBT, IPSRT (interpersonal social rhythm therapy) useful adjuncts in acute depressive episodes and maintenance
- Brief psychoeducation
- Family-focused treatment approach (caregivers improve illness management skills and self-care)
- Internet based strategies
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