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1
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|
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2
|
- He had a period of depression when in the sixth form, but did not seek
treatment though had to retake the year.
- In first year diagnosed as depressed by GP and given fluoxetine, took
for about three months and recovered.
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3
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- His mother suffered from post natal depression after both
childbirths. She was admitted
after his sister’s birth, but well since. Maternal aunt ‘hospitalised with a
breakdown’.
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4
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5
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- He is talking non stop, won’t let others get a word in. Excitable,
irritable & overcheerful. Has
needed little sleep in the past week, been up singing and making
‘amazing recordings’. Arrested
after trying to get on the stage at a music pub. Says everyone wanted to hear him
sing. Does also think that
people have been breaking into his house to record him as he heard his
song on the radio.
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6
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- More family history (& more bipolar)
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7
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8
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- B. with at least 3 of:
- Grandiosity
- Decreased need for sleep
- Increased talkativeness
- Flight of ideas (or racing thoughts)
- Distractibility
- Increased energy
- Loss of inhibitions
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9
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- A. Elevated, or irritable mood
- B. with at least 3 of:
- Grandiosity
- Decreased need for sleep
- Increased talkativeness
- Flight of ideas (or racing thoughts)
- Distractibility
- Increased energy
- Loss of inhibitions
- C. Marked impairment of social or occupational functioning
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10
|
- Consider an antipsychotic if:
- manic symptoms are severe
- there is marked behavioural disturbance
- Consider valproate or lithium if:
- there has been previous response and good compliance with one of these
drugs
- Consider lithium if:
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11
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|
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12
|
|
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13
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|
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14
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|
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15
|
|
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16
|
|
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17
|
|
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18
|
- 21 patients
- 15 female : 6 male
- (including 5 females post partum)
- Average age : 29 years (range 19-47)
|
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19
|
- 10 relapsed (8 manic & 7
depressive episodes)
- 9 remained well
- 1 died (murder)
- 1 not traced
|
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20
|
- More common than in depressive disorder
- single manic episodes occurred in ? out of 393 patients in Angst et al
1973
|
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21
|
- More common than in depressive disorder
- single manic episodes occurred in 2 out of 393 patients in Angst et al
1973
|
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22
|
- 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
|
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23
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- Base choice of lithium, olanzapine or valproate* on:
- previous response
- risk and precipitants of manic versus depressive relapse
- physical risk factors
- patient preference and history of adherence
- cognitive state assessment if appropriate
- * Valproate should not be prescribed routinely for women of
child-bearing potential
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24
|
- Valproate should not be used routinely for women who may become
pregnant. It may:
- cause foetal abnormalities
- affect the child’s cognitive development
- If prescribed, ensure adequate contraception. Explain risks during
pregnancy and to the health of the unborn child
- An antipsychotic may be used with caution
|
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25
|
- Psychoeducation which includes:
- Understanding of the diagnosis and recurrent nature of the illness
- Monitoring of mood and recognition of early warning signs
- Promotion of medication adherence
- Minimise alcohol and drug misuse
|
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26
|
|
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27
|
- Over the course of the year an annual review
should include:
- lipid levels, including
cholesterol, in patients over 40
- plasma glucose levels
- weight
- smoking status and alcohol use
- blood pressure
|
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28
|
|
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29
|
|
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30
|
- Recovered 16%
- Remitted 25%
- (no episode in last 5 yrs)
- Incomplete remission 35%
- (chronic impaired function)
- Chronic 16%
- (current episode >2yrs)
- Suicide 8%
|
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31
|
- Lifetime risk of 15-20%
- Most have been recently (or are) depressed with a severe illness course
- Often late in the course of illness (15 years) particularly females
- High rates of alcoholism and divorce
- Inadequate (or non compliant) treatment
- Only 30% on lithium
|
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32
|
- Mortality by suicide for bipolars is 10-20 times higher than the general population
- The rates of suicide on lithium are consistently lower than when off lithium
- Combined reports: 67 suicides /
5120 versus 74/ 1439 patient years
- 0.2 versus 1.0 per 100 patient
years
- (General population: 0.016)
- Also Suicide attempts x10 lower in bipolars when on lithium compared to when not on lithium
|
|
33
|
|
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34
|
|
|
35
|
|
|
36
|
|
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37
|
- 32 Patients with bipolar disorder
|
|
38
|
- 39 had a recurrence
- 17 (44%) were related to discontinuation of lithium
- Only one patient discontinued lithium and did not have a recurrence
before the end of the study
- Of those that continued with lithium at therapeutic levels 22(56%) had a
recurrence
|
|
39
|
- Following discontinuation of treatment the risk of recurrence is temporarily higher than
that of the natural history of the condition
|
|
40
|
|
|
41
|
|
|
42
|
- Base choice of lithium, olanzapine or valproate* on:
- previous response
- risk and precipitants of manic versus depressive relapse
- physical risk factors
- patient preference and history of adherence
- cognitive state assessment if appropriate
- * Valproate should not be prescribed routinely for women of
child-bearing potential
|
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43
|
|
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44
|
|
|
45
|
|
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46
|
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Notes
