Introduction to bipolar disorder

[SWM]

Introduction to bipolar disorder

Patients may have some periods of depression or mania, or have mixed manic and depressive symptoms, or unusual or abnormal behaviour, with the pattern described below.

Periods of mania with:

* increased energy and activity
* elevated mood or irritability
* rapid speech
* loss of inhibitions, including financial and sexual inhibitions
* decreased need for sleep
* increased importance of self
* delusions, hallucinations, disturbed or illogical thinking.

The patient may be easily distracted.

The patient may also have periods of depression with:

* low or sad mood
* loss of interest or pleasure
* disturbed sleep
* poor concentration or irritability
* guilt or low self-worth
* disturbed appetite
* fatigue or loss of energy
* suicidal thoughts or acts
* delusions, hallucinations, disturbed or illogical thinking.

Either type of episode may predominate. Episodes may alternate frequently or may be separated by periods of normal mood. Psychotic phases include strange or illogical beliefs, or disturbed or illogical thinking.

Mixed states are very common; even if criteria for mixed states are not met, depressive symptoms are very common in manic episodes and associated manic symptoms can occur in bipolar depression.
Lesser degrees of mania and hypomania can be missed on a brief interview and collateral information from relatives is vital.


Essential information for patients and family

* Unexplained changes in mood and behaviour can be symptoms of an illness.
* Effective treatments are available. Long-term treatment can help prevent future episodes.
* If left untreated, manic episodes may become disruptive or dangerous. Manic episodes often lead to loss of job, legal problems, financial problems or high-risk sexual behaviour. When the first, milder symptoms of mania or hypomania occur, referral is often indicated and the patient should be encouraged to see their GP straight away.
* Inform patients who are on lithium of the signs of lithium toxicity
* Manic symptoms can be followed by depressive symptoms; the patient’s GP should be informed of major changes in the patient’s mood and the occurrence of suicidal ideas.


General management and advice to patient and family

* Remain optimistic and emphasize the patient’s strengths and abilities rather than deficits.
* In acute manic or depressive episodes, refer urgently to secondary care.
* During depression, assess risk of suicide. (Has the patient frequently thought of death or dying? Does the patient have a specific suicide plan? Have they made serious suicide attempts in the past? Can the patient be sure not to act on suicidal ideas?) Ask about risk of harm to others.
* During manic periods:
- avoid confrontation unless necessary to prevent harmful or dangerous acts
- advise caution about impulsive or dangerous behaviour
- close observation by family members is often needed
- if agitation or disruptive behaviour are severe, hospitalization may be required
- suicide is not unknown, especially in mixed states. Identify early warning signs with the patient and family
* During depressed periods, consult management guidelines for depression.
* Describe illness and possible future treatments.
* Encourage the family to consult, even if the patient is reluctant.
* Women with bipolar disorder who are planning pregnancy or to become pregnant should seek early advice about control and prevention of the illness and use of medication ante- and postnatally. The risk of relapse is high postnatally. Specialist advice is indicated.
* Work with patient and family to identify early warning symptoms of mood swings, in order to avoid major relapse.
* The treatment plan should include recognition of early warning signs and the agreed management of crises should be clearly recorded in the medical records; a copy of the plan should be given to the patient, and with the patient’s permission, to the family/carers.
* For patients able to identify early symptoms of a forthcoming `high' (sleep disturbance is the most important warning sign for mania), advise:
- planning for a good night's sleep
- avoid taking major decisions
- taking steps to limit capacity to spend money (eg give credit cards to a friend)
- avoiding stimulating or stressful situations (eg parties) (ref 1)
* Therapeutic alliances build on respect and feeling valued; encourage the patient to build relationships with key members of the practice team, eg by seeing the same doctor or nurse at each appointment. Use the relationship to discuss the treatment plan, including medication.
* DVLA must be notified in all cases. Advise patient to inform DVLA: driving should cease during the acute illness (cars and motorbikes) and until patient has been stable and well for at least 3 years with insight into their condition (LGV/PSV driver) (ref 2)
* Cognitive behavioural therapy may be of benefit in relapse prevention of mania and the treatment of depressive episodes.

[Honesty]

Bipolar disorders are one of several medical conditions called depressive disorders. Depressive disorders affect the way a person's brain functions.Bipolar disorder goes by many names: manic depression, manic-depressive disorder, manic-depressive illness, bipolar mood disorder, and bipolar affective disorder are medical terms for the same condition.The mainstay of treatment is a mood stabilizer medication; these comprise several unrelated compounds which have been shown to be effective in preventing relapses of manic, or in the one case, depressive episodes. The first known and "gold standard" mood stabilizer is lithium, while almost as widely used is sodium valproate, originally used as an anticonvulsant. Other anticonvulsants used in bipolar disorder include carbamazepine, reportedly more effective in rapid cycling bipolar disorder, and lamotrigine, which is the first anticonvulsant shown to be of benefit in bipolar depression.

Treatment of the agitation in acute manic episodes has often required the use of antipsychotic medications, such as Quetiapine, Olanzapine and Chlorpromazine. More recently, Olanzapine and Quetiapine have been approved as effective monotherapy for the maintenance of bipolar disorder. A head-to-head randomized control trial in 2005 has also shown olanzapine monotherapy to be as effective and safe as lithium in prophylaxis

[BlueChld]

My husband was diagnosed with bipolar disorder II about two years ago. Prior to his diagnosis, his doctors had always thought he had chronic depression. When we finally found out, it had a huge impact on us. Since then, we have learned a lot about his disorder and it is somewhat manageable with the Lithium and other mood stabilizers. He also goes to his weekly therapy, which seems to help as well.
I must admit though, even with the knowledge I acquired about bipolar disorder, I still find it hard to deal with it at times. I realized that beyond everything else, showing love to him is what helps him the most. Living with a person who has bipolar disorder is a challenge and I can't even pretend to understand how he feels, but I am quite certain it is not half as hard on me than it is on him...