28th January 2024

Management

BPD is best managed through a combination of treatment modalities, the choice of which should consider suicide risk, disease polarity, treatment adherence and pharmacokinetics.

Mania

The treatment aims for a manic patient are to reduce the core symptoms, reduce psychotic symptoms, minimise abnormal behaviour, and minimise the side effects of treatment.

Dopamine antagonists are the first line choice, typically one of Haloperidol, Olanzapine, Quetiapine, or Risperidone.

• If this is not effective or tolerated, an alternative from the above may be tried
• Following this, Lithium or Sodium valproate may be added

If the patient is already on an antidepressant medication, this should be tapered and discontinued.

Mixed episodes

Usually treated in the same way as manic episodes.

Depression

One of the difficulties in pharmacological management of bipolar depression is the risk of (hypo-)manic or mixed switch resulting from antidepressant treatment. For this reason, antidepressants may be judiciously used as long as antidepressant monotherapy is avoided and they are co-prescribed with an anti-manic agent.

Options are:

• Quetiapine alone
• Fluoxetine + olanzapine
• Olanzapine alone
• Lamotrigine alone

Maintenance

Maintenance therapy aims to prevent new (hypo)manic, mixed, and depressive episodes, as well as to improve residual symptoms.

Long-term management is typically commenced 4 weeks after the acute episode has resolved. The options for maintenance include:

• Continuing current anti-manic agent
• Starting long-term therapy with Lithium (or, failing this valproate* or olanzapine alone or in combination with lithium)

Lithium

Lithium is highly effective in reducing relapse risk and is the only drug to meet the stringent criteria of being a true mood stabiliser. It works in acute mania, depression and as a maintenance therapy.

It can be combined with other drugs, commonly anticonvulsants and dopamine antagonists. Most patients will respond to one of these drugs.

The exact pharmacological mechanism by which lithium benefits mood disorders is unknown.

Monitoring

All patients on lithium therapy must be routinely monitored via blood tests.

• Lithium levels are measured 12 hours post-dose
• The first level should be taken 1 week after initiation
• Subsequent measurements should occur 1 week after every dose change and weekly until levels stabilise
• After levels have stabilised, they can be measured every 3 months

Individual serum lithium targets will be prescribed. Typically 0.6-0.8 mmol/L is suitable for those prescribed lithium for the first time, with higher levels suggested for those who have relapsed on lithium treatment previously.

Adverse effects

• Nausea, diarrhoea
• Muscle weakness
• Fine tremors
• Polyuria, polydipsia, diabetes insipidus
• Hypo- or hyperthyroidism
• Hyperparathyroidism
• Nephrotoxicity
• Rhabdomyolysis

Toxicity

Toxicity occurs at concentrations greater than 1.5 mmol/L.

Severe toxicity occurs when levels exceed 2 mmol/L.

Signs of toxicity include:

• Diarrhoea
• Vomiting
• Anorexia
• Muscle weakness
• Lethargy
• Ataxia
• Tinnitus
• Blurred vision
• Coarse tremor
• Choreoathetoid movements
• Dysarthria
• Drowsiness
• Hyperreflexia
• Psychosis
• Seizures
• Coma
• Renal failure

Note: there is a list of conditions in which lithium is contraindicated, including patients who refuse regular blood tests.

Women of childbearing potential should be advised to use reliable contraception.

* Note on Sodium valproate:

• There is significant risk of fetal malformations and adverse neurodevelopmental outcomes due to Valproate exposure during pregnancy. It is not recommended for women of childbearing potential unless all other alternatives are inappropriate, ineffective, or not tolerated.
• If prescribed to females of childbearing potential, they should be placed on a pregnancy prevention plan.

Electroconvulsive Therapy

As in unipolar major depression, ECT can be used in cases of bipolar major depression, as well as mixed episodes and occasionally mania. The indications for its use include failure to respond to multiple medication trials, acute life-threatening illness (such as suicidality or severe neglect), severe psychosis and catatonia.

There is a risk of precipitating hypo-/mania with the use of ECT, but is lower than that posed by antidepressant medications.

• In patients who develop mania during their ECT treatment course, ECT is often continued alongside an antipsychotic as ECT is effective for mania.

It is used in mania less commonly than in depression, as manic patients often respond to pharmacological therapy.

Psychotherapy

It is recommended that targeted psychotherapy is provided alongside pharmacotherapy.

Psychoeducational approaches are considered best as these allow patients to develop skills to recognise and manage their moods, stressors and maximise their quality of life. These approaches may include:

• Structured group psychoeducation
• Family interventions
• Cognitive behavioural therapy
• Interpersonal therapy

Other advice for preventing relapse should be given to patients, for example:

• Encouraging treatment compliance
• Maintaining good sleep hygiene and adequate sleep duration
• Avoiding shift work, night flying and routinely working excessive hours
• Structuring their day with activities and social contact
• Self-monitoring symptoms, triggers, and early warning signs
• Coping strategies
• Reduction or cessation of smoking (nicotine is a stimulant)
• Avoiding misuse of alcohol and drugs
• Avoiding excessive caffeine