Bipolar Affective Disorder

Group C
Learning Outcomes
1. Case presentation
2. Unipolar vs Bipolar Illness
3. Define Bipolar Afferent Disorder
4. Disability & Burden of Disease and the Risk to Self, Others and Reputation
5. Classification of Bipolar Afferent Disorder:
a. Bipolar I disorder
b. Bipolar II disorder
c. Cyclothymic disorder
6. Treatment Nonadherence in Bipolar Afferent Disorders
7. Prevention of Bipolar Disorders
Case presentation
A 16-year-old Malay female with good academic background and positive family history of
untreated mood disorder.
She presented to psychiatry clinic with one-week history of increased irritability, excessive
talkativeness and loudness, reduced need for sleep, with demanding and aggressive
behaviour. These symptoms preceded by having worries of her upcoming exam, covid-19
pandemic and her father’s health who was diagnosed with stage 4 colon cancer.
Further questioning revealed presence of hypomanic symptoms since the age of 9, which
lasted for 3 to 4 days and occurred up to 2-3 times per year. One of the hypomanic
symptoms that she experienced was increased goal directed activity in the form of theft
wherein family attributed to behavioural problems.
In ward, her vital signs and systemic physical examination was unremarkable.

Her mental status assessment revealed full-blown manic symptoms with psychotic
features, and the initial Young Mania rating Scale (YMRS) score was 47.

Her routine laboratory test and imaging were normal.

A DSM-5 provisional diagnosis of Bipolar I Disorder severe, most recent episode

manic with mood congruent psychotic features was made.
Because of the severity of the disorder, she required both chemical and physical
restraints, and was put on Epilim, Olanzapine and Lorazepam.

After 2 weeks of unimprovement with pharmacotherapy, electroconvulsive therapy

(ECT) was commenced wherein she responded well, with post ECT YMRS score of
9.

However, she complained of amnesia post ECT, scoring 27/30 on Mini Mental State
Examination (MMSE).

She was able to be discharged home after 8th courses of ECT.

During follow-ups at clinic, her mood was stable, and amnesia improved with full
score on repeated MMSE.
Unipolar vs Bipolar Illness
Bipolar Unipolar

Hx mania /hypomania yes no

personality Cyclothymic and extroverted Dysthymic and introverted

Sex ratio Equal More women than men

Age of onset Teens, 20s, and 30s 30s, 40s, and 50s

Number of episodes Numerous Fewer

Sleep Hypersomnia > insomnia Insomnia > hypersomnia

FHx BD/UD/alcoholism +-BD/UD/alcoholism

Pharmacology Antidepressants Induce hypomania– mania Can be used

with lithium carbonate as prophylaxis
Bipolar Affective Disorders
Bipolar afferent disorders (which previously known as ‘manic depressive illness’) is a chronic episodic mood disorder,
characterised by at least one episode of mania or hypomania and usually occurs with depressive episodes. Either one
can occur first but the term bipolar also includes those who at the same time of diagnosis have only suffered manic
episodes, as most patient will mania eventually develop depression.

Risk factors: age (early 20s), anxiety disorders, post-depression, strong Fhx, substance abuse, stressful life events

Epidemiology

● Globally, an estimated 46 million people had bipolar disorder in 2017 - 52% (female) and 48% (male)
● United States has the highest lifetime rate of bipolar disorder at 4.4%, and India the lowest, with 0.1%
● Malaysia has few or no recorded information on the prevalence of bipolar affective disorders

The mean age of onset is 18-19 years of age.

Male:Female affected ratio is 1:1 for Bipolar Disorder 1. Bipolar Disorder II is more common in females.
Disability and Burden of Bipolar Afferent Disorders
Burden of Disease

Among all the psychiatric disorders, affective disorders including BD are associated with the highest risk of suicide.
This is important to note as suicide-related events contribute substantially to the disease burden.

https://ourworldindata.org/grapher/bipolar-disorder-dalys-age-rate

Disability in patients with Bipolar Afferent Disorders

The ability to continue working with bipolar disorder often depends on the form of the condition Type I or Type II –
and the severity, frequency and duration of the symptoms experienced, including how common and pronounced the
manic and depressive episodes are.

The treatments require can also affect their ability to work, and may include therapy and medications, many of which
also cause side effects that can further impact their ability to maintain employment.

The episodes of depression and mania can affect their mental capacity (and to an extent their physical ability) to do
their work and lead a relatively normal life.
Risk to Self, Others and Reputation in Bipolar Disorder
Risk to self

Mania brings particular risks of disinhibition, poor judgement, risk taking and sometimes aggression. Depression carries notable risks of
suicidal behaviour, poor self-care and homicide. Both mania and depression bring risks of substance misuse and disrupted relationships.

Risk to others

Depending on the nature of an individual’s illness and how well the illness is managed, the family can be affected in a variety of ways.
When mood swings are mild, family may experience some distress but, over time and with education about mental illness, they can learn
to live with the demands of the illness. Caring for someone with more severe symptoms can be very stressful for the family, especially if
they are not given the opportunity to develop the skills needed to cope with mental illness. It can be exhausting, especially for families
with young children.

In mania, risks are generally related to heightened risk-taking behaviour, but periods of severe depression can arise during a manic
episode (ie, mania may develop into a mixed state) and carry risk of self-injury or injury to others.

Risk to reputation

Due to strong dysphoric manic episodes, patients can exhibit dangerous, aggressive and violent behavious that may have poeple labelling
them as dangerous, crazy people who can’t be trusted,
Classification of Bipolar Affective Disorders
● Bipolar I
● Bipolar II
● Cyclothymic disorder
Bipolar I disorder
Bipolar I disorder involves episodes of mania and of major depression; however,
episodes of major depression are not required for the diagnosis. It is also known as
manic-depression.

Epidemiology

1. In the World Mental Health Survey Initiative involving 11 countries, the

lifetime prevalence of BD I was 0.6%.
2. The mean age of onset for illness is 18.2 years.
3. Women are slightly more affected with prevalence rates of 1.1%, men - 0.8%.
Bipolar I disorder
Etiology

1. Biological, environmental, psychosocial, and genetic factors are all important.

2. First-degree relatives of patients with bipolar disorder are 10 times more likely to develop the illness.
3. Concordance rates for monozygotic twins are 40–70%, and rates for dizygotic twins range from 5 to
25%.
4. Bipolar I has the highest genetic link of all major psychiatric disorderMajor Depressive Episode For at
least two weeks, presenting with five or more of the following symptoms, of which, at least one must be
depressed mood or loss of interest or pleasure. The other symptoms include disruption in appetite with
accompanying weight loss or gain, sleep disturbance, psychomotor agitation or retardation, fatigability,
feeling worthless or guilty, reduced concentration or indecisiveness and recurrent thoughts of death, or
suicidal ideas or actss.
Bipolar I disorder
Clinical presentation
1. Depressive episodes
a. Key symptoms are depressed mood and a loss of interest or pleasure
b. Patients may say that they feel blue, hopeless, in the dumps, or worthless.
2. Manic episodes
a. Hallmarks are an elevated, expansive, or irritable mood.
b. The elevated mood is euphoric and often infectious and can even cause a
countertransferential denial of illness by an inexperienced clinician.
c. Patients often exhibit a change of predominant mood from euphoria early in the course
of the illness to later irritability.
3. Some patients with bipolar I disorder have mixed states with both manic and depressive
features
4. Some seem to experience brief-minutes to a few hours episodes of depression during
manic episodes.
Bipolar I disorder
Diagnosis (DSM 5 criteria)

The only requirement for this diagnosis is the occurrence of a manic episode (5% of
patients experience only manic episodes). Between manic episodes, there may be
interspersed euthymia, major depressive episodes, or hypomanic episodes, but none
of these are required for the diagnosis
Manic Episode (DSM 5)
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood
and abnormally and persistently increased goal-directed activity or energy, lasting at
least 1 week and present most of the day, nearly every day (or any duration if hospi
talization is necessary).
B. During the period of mood disturbance and increased energy or activity, three (or
more) of the following symptoms (four if the mood is only irritable) are present to a
significant degree and represent a noticeable change from usual behavior:
1. Inflated self-esteem or grandiosity.
2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
3. More talkative than usual or pressure to keep talking.
4. Flight of ideas or subjective experience that thoughts are racing.
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external
stimuli), as reported or observed.
6. Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation (i.e., puφoseless non-goal-directed activity).
7. Excessive involvement in activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business
investments).
C. The mood disturbance is sufficiently severe to cause marked impairment in social
or occupational functioning or to necessitate hospitalization to prevent harm to self or
others, or there are psychotic features.

D. The episode is not attributable to the physiological effects of a substance (e.g., a

drug of abuse, a medication, other treatment) or to another medical condition.

Note: A full manic episode that emerges during antidepressant treatment (e.g., medi
cation, electroconvulsive therapy) but persists at a fully syndromal level beyond the
physiological effect of that treatment is sufficient evidence for a manic episode and,
therefore, a bipolar I diagnosis.

Note: Criteria A-D constitute a manic episode. At least one lifetime manic episode is
required for the diagnosis of bipolar I disorder.
Bipolar I disorder
Differential diagnosis
1. When a patient with bipolar I disorder has a depressive episode, the differential
diagnosis is the same as that for a patient being considered for a diagnosis of
major depressive disorder.
2. When a patient is manic, however, the differential diagnosis includes bipolar I
disorder, bipolar II disorder, cyclothymic disorder, mood disorder caused by a
general medical condition, and substance-induced mood disorder
Bipolar I disorder
Treatment

1. Pharmacotherapy:
a. Lithium is a mood stabilizer; 50–70% treated with lithium show partial reduction of mania. Long-term
use reduces suicide risk. Acute overdose can be fatal due to its narrower therapeutic index.
b. The anticonvulsants carbamazepine and valproic acid are also mood stabilizers. They are particularly
useful for rapid cycling bipolar disorder and those with mixed features.
c. Atypical antipsychotics (risperidone, olanzapine, quetiapine, ziprasidone) are effective as both
monotherapy and adjunct therapy for acute mania. In fact, many patients (especially with severe mania
and/or with psychotic features) are treated with a combination of a mood stabilizer and antipsychotic;
studies have shown a greater and faster response with combination therapy.
d. Antidepressants are discouraged as monotherapy due to concerns of activating mania or hypomania.
They are occasionally used to treat depressive episodes when patients concurrently take mood
stabilizers.
2. Psychotherapy: Supportive psychotherapy, family therapy, group therapy (may
prolong remission once the acute manic episode has been controlled).

3. ECT:

a. Works well in treatment of manic episodes.

b. Some patients require more treatments (up to 20) than for depression.
c. Especially effective for refractory or life-threatening acute mania or depression.
Bipolar II disorder
Bipolar II, in which hypomania has occurred, but mania has not. However, to make the diagnosis of
bipolar II disorder an episode of major depression must also have occurred.

Epidemiology
● The lifetime risk for bipolar disorder is in the range 0.3–1.5%.
● The 6-month prevalence of bipolar disorder is not much less than the lifetime prevalence, indicating
the chronic nature of the disorder.
● The prevalence in men and women is the same.
● The mean age of onset is about 18 years in community studies.
● Bipolar disorder is highly comorbid with other disorders, particularly anxiety disorders and
substance misuse, as well as general medical conditions such as cardiovascular disease.

Clinical presentation
● Hypomanic episodes
● Depressive episodes
 Bipolar II disorder
Diagnostic Criteria (F31.81)

For a diagnosis of bipolar II disorder, it is necessary to meet the following criteria for a current or past hypomanie
episode and the following criteria for a current or past major depressive episode:

a. Criteria have been met for at least one hypomanie episode (Criteria A-F under“Hypomanic Episode”above) and at
least one major depressive episode (Criteria A-C under “Major Depressive Episode”above).
b. There has never been a manic episode.
c. The occurrence of the hypomanie episode(s) and major depressive episode(s) is not better explained by
schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or
unspecified schizophrenia spectrum and other psychotic disorder.
d. The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression
and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas
of functioning.

Coding and Recording Procedures

- Diagnostic code for bipolar disorder in DSM 5: 296.89 (F31.81).

- Example of Recording procedure: 296.89 [F31.81] bipolar II disorder, current episode depressed, moderate
severity, with mixed features; 296.89 [F31.81] bipolar II disorder, most recent episode depressed, in partial
remission).
Hypomania Disorder
A. Distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and
persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly
every day.

B. During the period of mood disturbance and increased energy and activity, three (or more) of the following
symptoms have persisted (four if the mood is only irritable), represent a noticeable change from usual behavior,
and have been present to a significant degree:

1. Inflated self-esteem or grandiosity.

2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).

3. More talkative than usual or pressure to keep talking.

4. Flight of ideas or subjective experience that thoughts are racing.

5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor

agitation.

7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging
in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
C. The episode is associated with an unequivocal change in functioning that is
uncharacteristic of the individual when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupa
tional functioning or to necessitate hospitalization. If there are psychotic features,
the episode is, by definition, manic.
F. The episode is not attributable to the physiological effects of a substance(e.g a
drug of abuse, a medication or other treatment).
Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous
functioning; at least one of the symptoms is either (1 ) depressed mood or (2) loss of interest or pleasure.

1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, or hopeless) or
observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
2. Anhedonia (Markedly diminished interest or pleasure in all), or almost all, activities most of the day, nearly every day (as
indicated by either subjective account or observation).
3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease
or increase in appetite nearly every day.
4. Insomnia or hypersomnia nearly every day.
5. Psychomotor agitation or retardation nearly every day (observable by others; not merely subjective feelings of restlessness or
being slowed down).
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by
others).
9. Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation with out a specific plan, a suicide attempt, or a
specific plan for committing suicide.

B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The episode is not attributable to the physiological effects of a substance or another medical condition.
Differential Diagnosis

❏ Major depressive disorder. Perhaps the most challenging differential diagnosis to consider is major depressive
disorder, which may be accompanied by hypomanic or manic symptoms that do not meet full criteria (i.e., either fewer
symptoms or a shorter duration than required for a hypomanic episode).
❏ Cyclothymic disorder. In cyclothymic disorder, there are numerous periods of hypomanic symptoms and numerous
periods of depressive symptoms that do not meet symptom or duration criteria for a major depressive episode. Bipolar
II disorder is distinguished from cyclothymic disorder by the presence of one or more major depressive episodes. If a
major depressive episode occurs after the first 2 years of cyclothymic disorder, the additional diagnosis of bipolar II
disorder is given.
❏ Schizophrenia spectrum and other related psychotic disorders. Bipolar II disorder must be distinguished from
psychotic disorders (e.g., schizoaffective disorder, schizophrenia, and delusional disorder). Schizophrenia,
schizoaffective disorder, and delusional disorder are all characterized by periods of psychotic symptoms that occur in
the absence of prominent mood symptoms. Other helpful considerations include the accompanying symptoms,
previous course, and family history.
❏ Panic disorder or other anxiety disorders. Anxiety disorders need to be considered in the differential diagnosis and
may frequently be present as co-occurring disorders.
❏ Substance use disorders.
❏ Attention-deficit/hyperactivity disorder. Attention-deficit/hyperactivity disorder (ADHD) may be misdiagnosed as
bipolar II disorder, especially in adolescents and children.
 Treatment
We can divide the pharmacologic treatment of bipolar disorders into acute and maintenance phases.

- Lithium and its augmentation by antidepressants, antipsychotics, and benzodiazepines have been the
principal approach to the illness. However, the acute use of lithium has been limited in recent years by
its unpredictable efficacy, problematic side effects, and the need for frequent laboratory tests.
- Three anticonvulsant mood stabilizers—carbamazepine, valproate, and lamotrigine—are commonly
used options. Unlike lithium, valproate is only indicated for acute mania, although most experts agree
it also has prophylactic effects. Carbamazepine has been used worldwide for decades as a first-line
treatment for acute mania.
- Antipsychotics. The FDA approved many of the atypical antipsychotics for use in bipolar disorder (eg:
olanzapine, risperidone)
Treatment for acute bipolar depression
1. Lithium. There is limited evidence for lithium in bipolar depression. Early studies were promising,
but later placebo-controlled studies did not confirm lithium’s efficacy.
2. Anticonvulsants. The most promising anticonvulsant has been lamotrigine, which has several
reasonable studies showing efficacy for bipolar depression. Its major limitation is that it must be
titrated gradually to prevent a severe skin rash.
3. Antipsychotics. Several of the atypical antipsychotics have shown efficacy for bipolar depression.
Quetiapine has the best evidence.
4. Antidepressants. It remains controversial whether antidepressants are useful for the depressive phase
of bipolar disorder. They seem to be less effective than for major depressive disorder and may induce
cycling, mania, or hypomania. Most experts agree that antidepressants are not appropriate as
monotherapy for patients with bipolar disorder.
5. Electroconvulsive Therapy. Electroconvulsive therapy may also be useful for patients with bipolar
depression who do not respond to lithium or other mood stabilizers and their adjuncts
Maintenance Treatment

- Preventing recurrences of mood episodes is the greatest challenge facing clinicians. Not only
must the chosen regimen achieve its primary goal—sustained euthymia—but the medications
should not produce unwanted side effects that affect functioning. Sedation, cognitive
impairment, tremor, weight gain, and rash are some side effects that lead to treatment
discontinuation.
- Lithium, carbamazepine, and valproic acid, alone or in combination, are the most widely used
agents for the long-term treatment of patients with bipolar disorder. For patients treated with
long-term lithium, thyroid supplementation is often necessary to treat lithium-induced
hypothyroidism.
- Lamotrigine has prophylactic antidepressant and, potentially, mood- stabilizing properties.
Lamotrigine appears to be superior at the acute and prophylactic treatment of the depressive
phase of illness compared to the manic.
Psychosocial Therapy
Psychotherapy can be a crucial
adjunct for patients. The goals of
this therapy include helping
treatment adherence, promoting
stability, and avoiding risk
factors for the disorder.
Cognitive-behavioral therapy,
interpersonal and social rhythm
therapy, and family focused
therapy are all reasonable
therapies to use. Table 6-8
summarizes psychotherapeutic
treatments for bipolar disorder,
including the presumed
underlying mechanism and
sample interventions.
Cyclothymic disorder
- Symptomatically a mild form of bipolar II disorder, characterised by episodes of
hypomania and mild depression.
- DSM-5: A chronic, fluctuating mood disturbance with many periods of
hypomania and of depression.
- 3-5% of all psychiatric outpatients; lifetime prevalence ~1%
- Frequently coexists with borderline personality disorder.
- Female:male = 3:2
- Onset between 15-25 y/o.
Cyclothymic disorder: Etiology
Biological factors
- 30% positive family histories for bipolar I disorder (prevalence in bipolar I
disorder families >> other mental disorders/ mentally healthy)
- Mild/attenuated form of bipolar II disorder - evidences to support

Psychosocial factors
- Trauma and fixations during the oral stage of infant (birth-18 months old)
development
- Patients defend themselves against underlying depressive themes with their
euphoric or hypomanic periods by means of denial
- Hypomania is frequently triggered by a profound interpersonal loss
Cyclothymic disorder: Diagnosis and Clinical features
DSM-5: Patient has never met the criteria for a major depressive episode and did not meet
the criteria for a manic episode during the first 2 years of the disturbance; require the more
or less constant presence of symptoms for 2 years (1 year for children and adolescents)

Signs and symptoms: identical to bipolar II but generally less severe/of shorter duration

- ~50% have depression as their major symptom

- Almost all patients have periods of mixed symptoms with marked irritability.
- Usually face marital and interpersonal difficulties
- Irregular and abrupt changes in mood, sometimes occur within hrs - unpredictable
- Patients often feel that their moods are out of control.
- Substance abuse (5-10% have substance dependence)
Cyclothymic disorder: Differentials
- All possible medical and substance related causes of depression and mania, eg.
seizures, cocaine, amphetamine, steroids
- Borderline, antisocial, histrionic and narcissistic personality disorders
- Attention Deficit/Hyperactivity disorder in children and adolescents - use of
stimulants to differentiate
- Bipolar II disorder - major depressive and hypomanic episodes
Cyclothymic disorder: Treatment
1. Biological therapy
- Mood stabilisers and antimanic drugs: lithium, carbamazepine and valproate as
first lines; dosage and plasma concentration=those in bipolar I
- Antidepressants should be given with caution because of increased
susceptibility to antidepressant induced hypomanic or manic episodes.

2. Psychosocial therapy
- Goal: increase patient’s awareness of condition and help patients develop coping
mechanisms for mood swings
Management (Mild) short term : First-line management should involve
low-intensity psychosocial interventions:

● Computerised cognitive-behavioural therapy (CCBT)

● Individualised CBT or individual guided self-help
based on CBT principles
● Structured group physical activity programme

(Mild) long term : Risk assessment

● Ongoing review: response to low-intensity

psychosocial intervention, compliance and
symptoms
● Measurement scales to assess response to
treatment and quality of life
● Relapse prevention plan
● Assess for social support and previous issues
flagged up during consultations
● If they are on antidepressant therapy review
compliance, use, side effects and adjust doses if
appropriate
Moderate/severe (short term) : First-line management involves a combination of antidepressant therapy (biological
treatment) and high-intensity psychosocial interventions which will depend on if they have/do not have a chronic physical
health problem (see below).

If they are presenting with a severe depressive episode with psychotic symptoms, then augmenting treatment with an
antipsychotic (aripiprazole, risperidone, quetiapine or olanzapine)

Moderate/severe (long term) : Risk assessment

● Review their response to high-intensity psychosocial intervention compliance and symptoms

● Review their response to antidepressant therapy, compliance, side effects and adjust doses if appropriate.
● Measurement scales to assess response to treatment and quality of life
● Relapse prevention plan
● Assess social support and previous issues flagged up during the consultation
Treatment NonAdherence in Bipolar Afferent Disorders
Risk factors for treatment non-adherence in bipolar disorder should be identified and addressed to
improve the clinical outcomes. Recent studies have reported 19 - 69% treatment non-adherence
rates among people with BD. Significant risk factors for non-adherence are:
1. side effects of the medications
2. difficulties with medication routines
3. negative attitudes towards drugs in general
4. depressive polarity of the last acute episode
5. presence of subsyndromal symptoms
6. comorbid obsessive-compulsive disorder
7. current acute episode
8. substance abuse/dependence
9. younger age
Prevention of Mood Disorder
Bipolar disorder is often a lifelong, disruptive illness which carries a substantial morbidity. There
are several areas of psychosocial function where problems may arise:

● adjustment to the diagnosis, and the need for lifestyle limitations;

● interpersonal and relationship difficulties, and occupational problems;
● misuse of both illegal and legal substances;
● problems relating to concordance with medication.
Prevention of Bipolar Disorder
For patients who have had two or more episodes of illness in less than 5 years, particularly where
the illnesses have proved personally disruptive or hazardous, longer-term maintenance treatment
should be considered.

With carefully supervised follow-up, the likelihood of relapse can be substantially reduced by
maintenance treatment, although lesser degrees of mood change often continue. These mood
changes may require adjunctive antidepressant or antipsychotic drug treatment.
Prevention of Bipolar Disorder
Continuation therapy:

● Prevention of relapse in the first few weeks and months following recovery from mania or
depression
● Following resolution of mania, the acute-phase treatment is usually continued for several
weeks or months and then gradually discontinued (unless relapse prevention with the same
agent is being considered)
● Following resolution of bipolar depressive disorders, it is uncertain whether antidepressants
should be continued, because prolonged use of antidepressants could precipitate a manic
episode
Prevention of Bipolar Disorder
Continuation therapy:

● Long-term drug treatment:

Choice depends on the adverse effects and previous response to treatment. Combinations of
drugs are frequently used in practice.

○ Lithium
■ Reduces the risk of relapse, more effective at preventing manic than depressive
episodes
■ Benefit outweighs the risks of adverse events for most patients who are at least at
moderate risk of relapse
■ Plasma levels should be monitored regularly
Prevention of Bipolar Disorder
Continuation therapy:

● Long-term drug treatment:

Choice depends on the adverse effects and previous response to treatment. Combinations of
drugs are frequently used in practice.

○ Anti-epileptic drugs
■ Valproate: reduced risk of relapse, uncertain how it compares to lithium
■ Carbamazepine: less effective than lithium
■ Lamotrigine: effective at preventing depressive relapses
○ Antipsychotic drugs
■ Long-term treatment usually reserved for patients with recurrent psychotic
symptoms or for when alternative treatments have not proven effective
Prevention of Bipolar Disorder
Continuation therapy:

● Long-term drug treatment:

Choice depends on the adverse effects and previous response to treatment. Combinations of
drugs are frequently used in practice.

○ Education to recognize early signs of relapse

■ Many patients develop characteristic prodromal symptoms before a relapse:
● Reduced need for sleep
● Increased physical activity
● Racing thoughts
● Elated mood
● Irritability or rage if plans or wishes are not satisfied
● Unrealistic plans
● Overspending
Prevention of Bipolar Disorder
Continuation therapy:

● Long-term drug treatment:

Choice depends on the adverse effects and previous response to treatment. Combinations of
drugs are frequently used in practice.

○ Psychological treatments
■ Family therapy
■ Cognitive therapy
Pharmacotherapy and non-pharmacotherapy for bipolar
disorder
Treatment of acute mania

1. Lithium carbonate
- Considered as ‘mood stabilizer’
- Slow onset of antimanic action, usually used in combination with other antimanic drugs
2. Valproate (valproic acid)
3. Carbamazepine and Oxcarbazepine
- First line treatment for acute mania
4. Clonazepam and Lorazepam
- High-potency benzodiazepine anticonvulsants
- Alternate usage in insomnia, aggression, dysphoria and panic
5. Atypical and Typical Antipsychotics
- Olanzapine, risperidone, quetiapine, ziprasidone, aripiprazole
Pharmacotherapy and non-pharmacotherapy for bipolar
disorder
Treatment of acute bipolar depression

1. Antidepressants
- Often enhanced by a mood stabilizer in the first line treatment for first or isolated episode of bipolar
depression.
2. Combination of olanzapine and fluoxetine
3. Lamotrigine or Ziprasidone
4. Electroconvulsive therapy (ECT)
Pharmacotherapy and non-pharmacotherapy for bipolar
disorder
Maintenance treatment of bipolar disorder

Lithium, carbamazepine, and valproic acid, alone or in combination, are the most widely used agents in the
long-term treatment of patients with bipolar disorder. Lamotrigine has prophylactic antidepressant and, potentially,
mood-stabilizing properties. Lamotrigine appears to have superior acute and prophylactic antidepressant properties
compared with antimanic properties. Given that breakthrough depressions are a diϫcult problem during prophylaxis,
lamotrigine has a unique therapeutic role.
Pharmacotherapy and non-pharmacotherapy for bipolar
disorder
Psychological approach.
Psychotherapy in conjunction with antimanic drugs (e.g., lithium) is more effective than
either treatment alone. Psychotherapy is not indicated when a patient is experiencing a
manic episode. In this situation, the safety of the patient and others must be
paramount, and pharmacologic and physical steps must be taken to protect and calm
the patient.
a. Cognitive
b. Behavioral
c. Psychoanalytically oriented
d. Supportive
e. Family
f. Group