Bipolar Affective Disorder

Background

  • A disorder characterised by two or more episodes in which the patient’s mood and activity levels are significantly disturbed:
    • At least one episode of mania or hypomania
      • A manic episode is a period where the patient is abnormally and persistently elevated, or irritable mood lasting at least 1 week
    • Others may feature depression, although this is not a pre-requisite.  Depressive episode usually lasts at least 2 weeks
    • A mixed episode (mixed affective state) is
      • A mixture or rapid alternation of manic and depressive symptoms or
      • A period of time >1 week where the criteria for both depression and mania are met every day and is sufficiently severe to cause impaired functioning, hospitalisation or psychosis
  • There are two ‘subtypes’ of BAD:
  1. Type 1 is characterised by recurrent episodes of mood disturbance with at least one being mania (or mixed with mania)
  2. Type 2 is characterised by recurrent episodes of mood disturbance with at least one being hypomania (but WITHOUT mania)
  • Type 1 affects around 1% and Type 2 affects around 1.5-5% of the population.  Average age of onset is 19-21 years (<10% over 50).

Aetiology

  • Genetic and familial hereditability is a strong risk factor.
  • The effect of alcoholism, adverse life events, lifestyle and stressors etc, can precipitate and maintain BAD.
  • Commonly, undiagnosed cases will be treated for depression and be ‘pushed’ into a manic episode (iatrogenic).

Presentation

  • The patient may present with features of depression- always ask about previous episodes of mania/hypomania to rule out bipolar which may begin suddenly
  • The patient may present with an episode of mania/hypomania
    • Abnormally elevated mood; extreme irritability; aggression
    • Increased energy or activity, restlessness and decreased sleep
    • Pressure of speech or incomprehensible speech; flight of ideas or racing thought
    • Distractibility, poor concentration
    • Increased sexual drive, disinhibition and sexual behaviour (inappropriate)
    • Extravagant or impractical schemes
      • Ask about money/spending
    • In mania, psychotic features e.g. delusions of grandeur, hallucinations
      • If there are psychotic features, other causes should be ruled out e.g. drug use, Schizophrenia, organic disease etc

Management

  • Acute
    • Manic episode
      • Oral antipsychotic or sodium valproate for immediate control; lithium if non-immediate and if the patient has had a good response in the past
        • Olanzepine, quetiapine (good antidepressant effects too) or risperidone are first line and can be augmented with sodium valproate/lithium if required (e.g. already taking an antipsychotic)
      • Benzodiazepines may also be useful for rapid sedation if required
    • Depressive episode
      • For severe depression, an SSRI in combination with an antimanic drug (lithium, valproate or antipsychotic)
        • Avoid in rapid cycling, recent hypomanic episode
        • Be weary of switch to mania, and initial increase in anxiety/irritability/suicidality etc
        • Consider stopping after symptoms have resolved for at least 8 weeks
      • For mild cases, active monitoring is safer
  • Long-term
    • Antimanic medication (mood stabiliser)
      • Lithium is first choice (SIGN)
      • Antipsychotics are often used (olanzepine/quetiapine are preferred)
      • Valproate occasionally (whilst lamotrigine/carbemazepine are not recommended by NICE, they are occasionally used also and are recommended by SIGN)
    • Psychotherapy can be offered where appropriate, particularly with depressive symptoms

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