Psychiatry Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

July 10, 2018

In This Article

Bipolar Disorder

British Psychological Society and Royal College of Psychiatrists

Offer carers of people with bipolar disorder an assessment (provided by mental health services) of their own needs and discuss with them their strengths and views. Develop a care plan to address any identified needs, give a copy to the carer and their GP, and ensure it is reviewed annually.

As early as possible, negotiate with the person with bipolar disorder and their carers about how information about the person will be shared. When discussing rights to confidentiality, emphasize the importance of sharing information about risks and the need for carers to understand the person’s perspective. Foster a collaborative approach that supports both people with bipolar disorder and their carers and respects their individual needs and interdependence.

Identify children, young people, and adults at risk of abuse or neglect who are dependent on, living with, or caring for a person with bipolar disorder and review the need for an assessment according to local safeguarding procedures for children or adults as appropriate, and offer psychological and social support as needed.

When adults present in primary care with depression, ask about previous periods of overactivity or disinhibited behavior. If the overactivity or disinhibited behavior 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.

Do not use questionnaires in primary care to identify bipolar disorder in adults.

When assessing suspected bipolar disorder, undertake a full psychiatric assessment, documenting a detailed history of mood, episodes of overactivity and disinhibition or other episodic and sustained changes in behavior, symptoms between episodes, triggers to previous episodes and patterns of relapse, and family history; assess the development and changing nature of the mood disorder and associated clinical problems throughout the person's life (eg, early childhood trauma, developmental disorder, or cognitive dysfunction in later life); assess social and personal functioning and current psychosocial stressors; assess for potential mental and physical comorbidities; assess the person’s physical health and review medication and side effects, including weight gain; discuss treatment history and identify interventions that have been effective or ineffective in the past; encourage people to invite a family member or carer to give a corroborative history; discuss possible factors associated with changes in mood, including relationships, psychosocial factors, and lifestyle changes; and identify personal recovery goals.

Take into account the possibility of differential diagnoses, including schizophrenia spectrum disorders, personality disorders, drug misuse, alcohol-use disorders, attention deficit hyperactivity disorder, and underlying physical disorders such as hypo- or hyperthyroidism.

When diagnosing bipolar disorder in children or young people take account of the following: mania must be present; euphoria must be present on most days and for most of the time, for at least 7 days; irritability is not a core diagnostic criterion.

If a person develops mania or hypomania and is not taking an antipsychotic or mood stabilizer, offer haloperidol, olanzapine, quetiapine, or risperidone, taking into account any advance statements, the person’s preference, and clinical context (including physical comorbidity, previous response to treatment, and side effects).

If an alternative antipsychotic is not sufficiently effective at the maximum licensed dose, consider adding lithium. If adding lithium is ineffective, or if lithium is not suitable (for example, because the person does not agree to routine blood monitoring), consider adding valproate instead.

If the person is already taking lithium, check plasma lithium levels to optimize treatment. Consider adding haloperidol, olanzapine, quetiapine, or risperidone, depending on the person’s preference and previous response to treatment.

If the person is already taking valproate or another mood stabilizer as prophylactic treatment, consider increasing the dose, up to the maximum level if necessary, depending on clinical response. If there is no improvement, consider adding haloperidol, olanzapine, quetiapine, or risperidone, depending on the person’s preference and previous response to treatment.

If a person develops moderate or severe bipolar depression and is not taking a drug to treat their bipolar disorder, 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.

If a person develops moderate or severe bipolar depression and is already taking lithium, check their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum level, add either fluoxetine combined with olanzapine or add quetiapine, depending on the person’s preference and previous response to treatment. If the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to lithium.

If there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to lithium.

If a person develops moderate or severe bipolar depression and is already taking valproate, consider increasing the dose within the therapeutic range. If the maximum tolerated dose, or the top of the therapeutic range, has been reached and there is a limited response to valproate, add fluoxetine combined with olanzapine or add quetiapine, depending on the person’s preference and previous response to treatment.

If the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to valproate. If there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to valproate.

Offer lithium as a first-line, long-term pharmacologic treatment for bipolar disorder and, if lithium is ineffective, consider adding valproate; if lithium is poorly tolerated, or is not suitable (eg, because the person does not agree to routine blood monitoring), consider valproate or olanzapine instead or, if it has been effective during an episode of mania or bipolar depression, quetiapine.

Before starting antipsychotic medication, measure and record the person’s weight or BMI, pulse, blood pressure, fasting blood glucose or HbA1c, and blood lipid profile.

Monitor and record the following during dose titration and then regularly and systematically throughout treatment: pulse and blood pressure after each dose change; weight or BMI weekly for the first 6 weeks, then at 12 weeks; blood glucose or HbA1c and blood lipid profile at 12 weeks; response to treatment, including changes in symptoms and behavior; side effects and their impact on physical health and functioning; the emergence of movement disorders; adherence.

If stopping an antipsychotic drug, reduce the dose gradually over at least 4 weeks to minimize the risk of relapse.

Measure plasma lithium levels 1 week after starting lithium and 1 week after every dose change, and weekly until the levels are stable. Aim to maintain plasma lithium level between 0.6 and 0.8 mmol per liter in people being prescribed lithium for the first time.

Consider maintaining plasma lithium levels at 0.8-1.0 mmol per liter for a trial period of at least 6 months for people who have had a relapse while taking lithium in the past or are taking lithium and have subthreshold symptoms with functional Impairment.

Measure the person’s plasma lithium level every 3 months for the first year. After the first year, measure plasma lithium levels every 6 months, or every 3 months for people in any of the following groups: older people; people taking drugs that interact with lithium; people who are at risk of impaired renal or thyroid function, raised calcium levels, or other complications; people who have poor symptom control; people with poor adherence; and people whose last plasma lithium level was 0.8 mmol per liter or higher.

Reference

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as:

processing....