BIPOLAR DISORDER

THE SIGNS AND SYMPTOMS OF BIPOLAR DISORDER

SIGN/SYMPTOMS MANIA BIPOLAR DEPRESSION
APPEARANCE Colourful, strange, garish makeup or Disinterest in personal appearance,
dress style grooming and hygiene
MOOD Prolonged elation / euphoria Feelings of sadness suicidal
Excessively optimistic or cheerfull ideation
heightened irritability
SPEECH Talkin fast and loudly difficult to Speech is slowed monosyllabic and
interrupt monotonous

ACTIVITY Risk-taking behavior impulsive Difficultly with initiating tasks

increased psychomotor activity
(restlessness)
SLEEP Decreased need for sleep
COGNITION Difficulties with palnning, reasoning
and decision-making distractible
diminished interest in hobbies
decreased psychomotor activity
Early morning waking with
insomnia OR hypersomnia with
daytime napping
Reduced ability to concentrate
difficulties with memory

SELF PERCEPTION/ Exxagerated self-confidence Reduced self- esteem feelings of

THINGKING grandiose thingking worthlessness and guilt pessimistic
thoughts and sense of
hopelessness
FEATURES OF DEPRESSION THAT SUGGEST A DIAGNOSIS OF BIPOLAR
DEPRESSION RATHER THAN UNIPOLAR (MAJOR) DEPRESSION

Signs and symptoms : Irritability

Melancholia
Psychotic symptoms during depression
Psychomotor changes
Atypical symptoms such as hypersomnia and
hyperphagia
Patern of illness : Early age of onset
Reccurent brief episodes
Multiple episodes
Fsmily history of bipolar disorder
 BASELINE ASSESSMENT FOR PATIENTS WITH BIPOLAR
DISORDER PRIOR TO PHARMACOTHERAPY (BASED ON
DATA FROM Ng et al.,2009)
RECOMMENDATIONS
History Medical history
Substance abuse, cigarette smoking status and alcohol intake
Family history of cardiofascular and cerebrovascular disease,
hypertension, dyslipidaemia and diabetes mellitus
Pregnancy and contraception (for women of Childbearing age)
Examination Physical examination if clinically indicated waist circumference and/or
BMI (weight [kg]/height [m]₵⅔ )
Blood preassure
Investigation Full blood count
Drug screen
Electrolytes, urea, creatinine
Liver function tests
Fasting blood glucose
Fasting lipid profile
Pregnancy test (if clinically indicated)
Treatment of common adverse effects of lithium and anticonvulsants
medication Adverse effect Management options
Lithium, valproate, General Decrease/divide dose.
carbamazepine, Change mood stabilizer.
lamotrigine
Lithium, valproate, Gastrointestinal Give with food
carbamazepine, Change to extended releasenif nausea or
lamotrigine vomiting. Change to suspension or immediate
release if darrhea. Symptomatic relief with
gastrointestinal agents.
Lithium, valproate Weight gain Prior warning; diet; exercise assess thyroid
function.
Add topiramate, zonisamide, or atomoxetine.
Lithium, neurotoxicity Dose at badtime. Gradual initiation to improve
carbamazepine tolerance (wit Li and carama-zepine).
Lithium, valproate Tremor Add proponalol; atenolol; pindolol.
Lithium, valproate Hair loss Add selenium 25-100 mcg/day, zinc 10-50
mg/day.
Lithium Polyuria and Sigle bed time daily dose add amiloride or
polydipsia thiazide diuretic.
 Medication Adverse effect Management options
Lithium hypothyroidism Thyroid replacement or change to a different
mood stabilizer.

Valproate, hepatic Discontinue carbamazepine/ valprate if hepatic

carbamazepine indices >3 X upper limit of normal

Lamotrigine, Rash Gradual initiation.

carbamazdepin Limit other new antigens during initiation.
e Dermatology consultation.
Regrading desensitization.
Discontinue carbamazepine.
Lamotrigine if another explanation for rash is
not evident.

carbamazepine Leukopenia, blood Add lithium.

dyscrasias Discontinue carbamazepine if WBC <3000 or
neutrophils <1000

Valproate thrombocytopeania Reduce the dose or switch to a different agent.

 Medication Adverse effect Management options
Carbamazepine Hyponatremia Decrease dose, dietary sodium
supplementation, add lithium, demeclocycline,
doxycycline
Valproate Poycystic ovary Assessment and consultation, hormonal
syndrome therapy or switch to a different agent.

Lithium Acne Dermatolgycal consultation, topical or systemic

antibiotics.
Lithium Lethargy, cognitive Reduce dose if possible, assess thyroid status
dulling
 Atypical antipsychotics in bipolar
disorder: efficacy summary
Acute treatment Maintenance/ continuation
treatment
Mania Depression Mania Depression
Olanzapine ++ = ++ +
Risperidone ++ ? ++ +?
Quetiapine ++ ++ ++ ++
Ziprasidone ++ ? + (as adjunct) ?
Aripiprazole ++ - + -
Asenapine (not ++ ? ? ?
licensed in UK)
Paliperidone ++ ? ? ?
++ = at least one good randomized controlled trial (RCT) showing clinically significant
effect; + = at least one RCT showing some effect; - = RCT evidence of a lack of cinically
significant effects; ? = uncertain or no controlled data available.
 Tabel 5.4 Atypical antiphsycotics: dosing
and adverse events
Drug (range ½ Wt gain Glucose Cardiac Pro- EPS Sedation
, mg/day) life + lipids effects lactin
Quetiapine 6 ++ ++ - O O ++
(150-800)
Resperidone 6 – + + - ++ ++ +
(2-6) 24
Olanzapine 30 +++ +++ - + + ++
(5-20)
Ziprasidone 7 O O QT O + O
(40-160) Prolon-
gation
Aripiprazole 72 O O - O + O
(10-30)
Paliperidone 23 + + - + ++ +
(6-12)
O = none;
Tabel 7.2 Recommendations for the pharmacological treatment
of acute bipolar I depressionᵃ
First Line Lithium, lamotrigine, quetiapine, lithium or divalproex + SSRI,
olanzapine + SSRI, lithium + divalproex, lithium or divalproex +
bupropion
Second line Quetiapine + SSRI, divalproex, lithium or divalproex + lamotrigine,
adjunctive modafinil
Third line Carbamazepine, olanzapine, lithium + carbamazepine, lithium +
pramipexole, lithium or divalproex + venlavaxine, lithium + MAOI,
ECT, lithium or divalproex or AAP + TCA, lithium or divalproex or
carbamazepine + SSRI + lamatrigine, ajunctive EPA, adjunctive
riluzole, adjunctive topiramate
Not Gabapentin monotherapy, aripiprazole monotherapy
recommended
ᵃthe manaement of a bipolar depressive episode with antidepressants remains
complex.
The clinician must balance the desired effect of remission with the undesired effect of
switching.
AAP, atypical antiphsycotic; ECT, electroconvulsive therapy; EPA, eichosapentanoic
acid; SSRI, selective serotonin reuptake inhibitor; ZIP, ziprasidone.
 Treatment algorithm for bipolar depression
Step 1
Review general
Asses svety/functioning behavioural
principals strategies/rhythms psychoeducation
&
Assess On On OLZ, RIZ, On On OLZ, RIZ,
medication status DVP ARI or ZIP DVP ARI or ZIP

+
Step 2 Add SSRI/BUP Add SSRI, Li
Initiate/optimize, or add or LAM or
Check compliance /switch to Li, switch to Li, LAM LI QUE OLZ Li or DVP
LAM or QUE LAM or QUE Li,+DVP
+SSRI +SSRI/ BUP
No
response
Step 3
Add Add SSRI Add SSRI,
Add-on or switch switch to Switch to
/BUP or Li or LAM Switch Li or Add SSRI/BUP
therapy Li or QUE QUE,
add/switc or switch DVP to QUE or or switch Li or
QUE+SSRI,
No h to LAM to Li, LAM
Li, Li+SSRI/
OLZ or switch DVP to LAM
response or QUE or SSRI/BUP to or QUE
BUP
OLZ+SSRI LAM
Step 4
Add-on or switch
therapy
No Replaceone or both agents with
response alternate fisrt or second
Step 5
add-on or switch Consider ECT, trhird line agrnt and
therapy novel or experimental options
ARI, arpipizole; BUP, bupropion; DVP, divaproex; ECT, electroconvulsive therapy; LAM, lamotrigine; OLZ, olanzapine; QUE, quetiapine; RIS,
risperidone; SSRI, selective serotonin reuptake inhibitor; ZIP, ziprasidone.
 Tabel 7.3 recommendation for maintenance
pharmacotherapy of bipolar disorder
First line Lithium, lamotrigine monotherapy (limited efficacy in preventing
mania), divalproex , olanzapine, quetiapine, lithium or divalproex+
quetiapine, risperidone LAI, adjunctive risperidone LAI,
aripiprazole (mainly for preventing mania), adjunctive ziprasidone.
Second line Carbamazepine, lithium + divalproex, lithium + carbamazepine,
lithium or divalproex + olanzapine, lithium + reperidone, lithium +
lamotrigine, olanzapine + fluoxetine.
Third line Adjunctive phenytoin, adjunctive clozapine, adjunctive ECT,
adjunctive topiramate, adjunctive omega-3-fatty acids, adjunctive
oxcarbazepine, or adjunctive gabapentin.
Not Adjunctive flupentixol, monotherapy with gabapentin, topiramate
recommended or antidepressants.
ECT= electroconvulsive therapy, LAI= long acting injection, SSRI= selestive serotonin
reuptake inhibitor
tabel 7.4 issues to consider for maintenance
treatment

1. Use for maintenance the same medication that worked for an

acute episode
2. Consider predominant polarity
a) Depressive polarity (more depressions than manias) –
lamotrigine, quetiapine, lithium but not aripiprazole
b) Manic polarity (more manias than depressions) – any first
line except lamotrigine.
3. Past history of maintenance response
4. Family history of maintenance response
5. Consider combination maintenance if previous history of
partial response to monotherapy.
TERIMAKASIH