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18th January 2024

Mood disorders

Depression

It is defined as at least 2 weeks of low mood in conjunction with varied emotional, physical, behavioural, and cognitive symptoms. It can be classified as mild, moderate, or severe according to the nature and number of the associated symptoms, duration and the degree of functional and social impairment caused.

Depressive illness reduces the quality of life for those afflicted as well as their families and carers, in addition to increasing the morbidity and mortality of comorbid conditions such as diabetes mellitus and coronary heart disease. Depression also increases rates of self-injurious behaviour, substance misuse and social problems.

Suicide is the main cause of increased mortality in those affected.

More than 50% of those affected will recover within 6 months; however, recurrence rates are high and chronic depressive illness develops in up to 27% of patients.

Pathophysiology

The cause is unknown, but depression evolves from a complex interaction of biological, social, and psychological factors.

Factors that increase risk include:

  • Chronic comorbidities (e.g., COPD, thyroid disorders)
  • Medicines (e.g., corticosteroids, ß-blockers)
  • Female sex
  • Older age
  • Recent childbirth
  • Psychosocial issues (e.g., unemployment, bereavement, poverty, divorce)
  • Personal or family history of depression
  • Adverse early experiences (e.g., childhood physical abuse)
  • Past head injury

Symptoms

The following have all been described as symptoms of depression:

Core symptoms Additional symptoms Somatic symptoms
  • Low mood (that varies little from day to day and is unresponsive to circumstances)
  • Anhedonia (reduced interest in previously enjoyed activities)
  • Poor concentration and memory
  • Low self-esteem and self-confidence
  • Feelings of guilt, hopelessness, and worthlessness
  • Diurnal variation (symptoms worse in the morning)
  • Deliberate self-harm
  • Suicidal thoughts or acts
  • Early morning awakening / disturbed sleep
  • Anorexia/weight loss
  • Loss of libido
  • Psychomotor agitation (restlessness, pacing, fidgeting)
  • Psychomotor depression (appear slowed down, slow walking, slow or monotonous speech, blunted affect)
  • Anergia (increased fatigability, even on limited exertion)

Source: NICE. (2021). Depression | CKS | NICE. Retrieved July 6, 2022, from https://cks.nice.org.uk/topics/depression/

WHO. (2019). ICD-10 Version: 2019. In ICD-10 Version: 2019. Retrieved from https://icd.who.int/browse10/2019/en#/V

Definitions

  • Subthreshold depressive symptoms: When a patient has some of the core symptoms, but their number or severity is insufficient to meet the criteria for full diagnosis
  • Persistent subthreshold depressive symptoms: previously known as dysthymia, the persistence of subthreshold symptoms for more than 2 years.
  • Recurrent depressive disorder: repeated episodes of depression without a history of episodes of elation and increased energy (mania).
  • Cyclothymia: a persistent instability of mood in which the patient experiences periods of mild depression and mild elation, which are not severe enough to be classed as bipolar affective disorder or recurrent depressive disorder.
  • Atypical depression: involves abnormal symptoms such as weight gain, hyperphagia, hypersomnia, mood reactivity (improved mood upon exposure to positive stimuli), leaden paralysis (an unusually heavy feeling in the arms or legs), rejection sensitivity (feeling anxious and hyper-reactive to rejection or perceived rejection)

Severity grading

  • Mild depression: at least 2 symptoms present; the patient is distressed by their symptoms but usually able to continue with activities
  • Moderate depression: at least 4 symptoms present; the patient will have considerable difficulty continuing with activities
  • Severe depression without psychotic symptoms: several marked, distressing symptoms present, often with somatic symptoms and/or suicidal ideation, without psychotic symptoms. The patient is often unable to continue normal activities
  • Severe depression with psychotic symptoms: also termed psychotic depression; an episode of severe depression with symptoms of psychosis such as hallucinations, delusions, psychomotor retardation, or stupor

Diagnosis

Depression is diagnosed using the Diagnostic and Statistical Manual of Mental Disorders 5ᵗʰ edition (DSM-5) or International Classification of Diseases 10ᵗʰ revision (ICD-10) criteria.

In order to make a diagnosis, patients must have at least 1 core symptom that has been present most of the time, on most days of the week, for at least 2 weeks.

There are various validated measures to assess patients presenting with depressive symptoms; these include:

Investigations are not routinely indicated but may be necessary to exclude other causes of depression or conditions that are known to be associated with depression. Any of these may co-exist with depression, and the presence of one does not exclude the possibility of another.

Investigations

  • Blood glucose
    • Hyperglycaemia suggesting diabetes mellitus
  • Urea, electrolytes & creatinine
    • Normal values suggesting electrolyte imbalances
    • Low eGFR, high creatinine suggesting renal dysfunction
  • ESR & CPR
    • Raised suggesting infection or inflammation
  • Liver function
    • LFTs suggestive of hepatic dysfunction
    • High GGT suggesting high alcohol intake
  • Thyroid function
    • High T4 / low TSH indicating hyperthyroidism
    • Low T4 / high TSH indicating hypothyroidism
  • Calcium Levels
    • Abnormal values indicative of hyper or  hypocalcaemia
  • Full blood count
    • Low Hb indicating anaemia
  • Urine drug screen
    • Suggesting substance use/misuse

Differential diagnosis

  • Anxiety disorders
    • Can present with a wide range of physical and affective abnormalities, including fatigability, sleep disturbance, cognitive dysfunction, and unwanted thoughts.
    • These may present with physical symptoms not seen in depression, such as panic attacks, cognitive distortions, and muscle tension.
  • Neurological conditions (such as Parkinson’s disease, Multiple Sclerosis, dementia)
    • Neurodegenerative and neurological diseases can be associated with affective symptoms, changes to behaviour and cognitive function, such as memory and attention. However, depression does not cause focal neurological signs, and the presence of these should alert to the possibility of other pathology.
  • Substance misuse
    • Pharmacologic agents can have physiological effects on mood and behaviour
    • Substance abuse can often produce similar symptoms to depression, such as feelings of guilt or worthlessness, appetite changes, psychosis, and suicidal ideation
    • The substance use should pre-date the depressive symptoms in order to diagnose substance-induced depression
  • Diabetes mellitus
    • Depression and diabetes share symptoms such as weight loss, fatigue, and low mood. However, the key difference is the blood glucose dysregulation defining diabetes.
  • Chronic Obstructive Pulmonary Disorder
    • Physiological abnormalities such as hypoxaemia and hypercapnia can present with similar symptoms to depression, such as lethargy, impaired concentration, and irritability.
    • The presence of physiological changes in COPD, such as alterations to lung function, can help set the diagnoses apart.
  • Hypothyroidism or hyperthyroidism
    • Endocrine disorders can produce changes similar to depressive disorders, such as lethargy, weight changes, and mood disturbance. However, endocrine diseases have distinct laboratory abnormalities to help identify them.
  • Obstructive Sleep Apnoea Syndrome
    • Often produces feelings of fatigue, insomnia, cognitive deficits and decreased libido.
    • This is more common among patients with obesity and can be diagnosed using the aid of polysomnography.
  • Infectious and inflammatory disorders
    • Many infectious and inflammatory disorders can produce neuropsychiatric signs and symptoms; however, they usually have other associated pathology that can be used to help identify them, such as sensory loss or biomarkers in the form of antibodies.

Always consider suicide and self-harm risk in patients with suspected depressive disorders.

Management

All patients should be provided information about the nature and course of their illness.

Important principles in the management of depressive illness include recognising that people have a right to decline treatment and that the most appropriate, least intrusive, and resource-intensive treatment should be tried first.

If capacious patients do not want an intervention, use a watchful waiting approach, offering a follow-up in 2 weeks.

The image below outlines the NICE recommendations for patients who want treatment based on illness severity. They are listed in order of the Committee’s interpretation of clinical and cost-effectiveness.

MRCP Part 1 - Summary of depression management by severity

Source: Adapted from (NICE, 2022c)(NICE, 2022a)(NICE, 2022b)

CBT: Cognitive Behavioural Therapy

BA: Behavioural Activation

IPT: Interpersonal Psychotherapy

STPP: Short-term Psychodynamic Psychotherapy

For a full explanation of these therapies, see https://www.nice.org.uk/guidance/ng222/chapter/recommendations#more-severe-depression

References: 

Anti-depressant medication

No antidepressant is recommended above all others, and drugs should be chosen judicially based on patient factors (such as comorbidities, suicide risk, current medications) and side-effect profiles. SSRIs are often first-line as they are often safer in overdose and better tolerated than other classes.

In general:

Scenario Consider
First episode depression SSRI
Recurrent episode An antidepressant with a previous good response
Aged ≤ 16 years Fluoxetine
Recent MI Sertraline

Below is a list of common antidepressants and key considerations in their use. This list is not exhaustive.

Class Examples Considerations
SSRIs

(Selective Serotonin Reuptake Inhibitors)
  • Fluoxetine, Sertraline, Citalopram, Paroxetine
  • Consider gastroprotection in those at increased risk of GI bleeding
  • Can be alerting
  • Small risk of overdose
  • Citalopram and escitalopram can cause dose-dependent QT interval prolongation
  • Do not offer to patients taking warfarin or heparin
SNRIs

(Serotonin & Noradrenaline Reuptake Inhibitors)
  • Venlafaxine, Duloxetine
  • Do not offer to patients taking warfarin or heparin
NaSSAs

(Noradrenergic & Specific Serotonergic Antidepressants)
  • Mirtazapine
  • Has a sedative effect
  • Does not cause sexual side effects
  • Commonly causes weight gain
TCAs

(Tricyclic Antidepressants)
  • Amitriptyline, Imipramine, Clomipramine
  • Very dangerous in overdose
  • Sedative and anticholinergic effects
  • Contraindicated in recent MI
  • Do not offer to patients taking warfarin
MAOIs

(Monoamine Oxidase Inhibitors)
  • Phenelzine, Selegiline
  • May precipitate a hypertensive crisis
  • Higher risk of serotonin syndrome
  • Interact with foods containing tyramine

References

Follow-up and treatment cessation

Initial review should occur 2 weeks after commencing medication unless there is an increased risk of self-harm or the patient is aged < 30 years, in which case they should be reviewed after 1 week. This is due to disturbances that may occur on initiation, such as over-stimulation, agitation, anxiety, psychosis, and increased impulsivity.

Regular reviews should then be scheduled every 2-4 weeks. To reduce the risk of relapse, the minimum recommended treatment duration is 6 months, but patients may safely continue treatment beyond this.

If no benefit is seen after 2 weeks, check adherence and consider increasing the dose, switching class of antidepressant, or adding psychological therapies.

Caution must be exercised when switching between antidepressants – specific guidance can be found in The Maudsley prescribing guidelines in psychiatry (authored by Taylor and Barnes, 2018).

Antidepressants should be reduced slowly over an average of 4 weeks to minimise discontinuation symptoms.

Discontinuation symptoms may include:

  • Restlessness
  • Problems sleeping
  • Diaphoresis
  • Abdominal symptoms
  • Altered sensations (paraesthesia, electric shock feelings)
  • Altered mood (irritability, anxiety, confusion)
  • Headache

Discontinuation symptoms tend to start within a few days of treatment cessation and are self-limiting, resolving within 2 weeks in most cases.

If depression is treatment-resistant, Electroconvulsive Therapy (ECT) or lithium augmentation may be considered.

Electroconvulsive Therapy

ECT is a therapy in which generalised seizure activity is induced by an electric current passed through the patient’s brain via scalp electrodes. The patient is placed under general anaesthesia and is given muscle relaxants to prevent muscle spasms.

Risks include retrograde and anterograde amnesia, status epilepticus, laryngospasm, and headache.

Most patients will undertake a course of twice-weekly sessions for 6 weeks.

ECT should only be used to achieve rapid improvement in severe symptoms after other treatment options have failed or when the condition is considered life-threatening.

Situations in which ECT may be used:

  • Treatment-resistant depression
  • Life-threatening depression
  • Catatonia
  • Prolonged or severe manic episodes
  • Psychotic depression

References

Self-harm and suicide

Deliberate self-harm (DSH) and suicide are manifestations of emotional distress and illness. Their incidence is rising over the years and is common in patients of all ages and social groups.

Unfortunately, there is relatively poor provision of resources and treatment available to help those who self-harm, and unhelpful attitudes from health and care staff, as well as the wider public, are commonplace.

Rates of self-harm are higher among females than males; however, completed suicide is more prevalent among males.

The majority of self-poisonings involve over-the-counter or prescribed medications, and the majority of self-injury incidents involve cutting.

Definitions

  • Self-harm: an intentional act of self-injury or self-poisoning, regardless of the motivation or the degree of suicidal intent. It is a wide spectrum of behaviour with harmful physical effects.
    • A person who repeatedly self-harms is at higher risk of committing suicide. It is important to note that an act of self-harm is not always an attempt at suicide; for some patients, it can be an act of self-preservation, for example, to reduce internal tension. In most cases, the motivation for DSH is complicated, involving a number of biological, social, and psychological factors.
  • Suicide: an intentional self-inflicted death
  • Suicide attempt: an act that is potentially self-injurious, that is committed with an intent to die
  • Suicidal intent: the intensity of the individual’s wishes to die. Suicidal thoughts can be present without suicidal intent (known as passive suicidal ideation)

Factors influencing suicide risk

Risk factors for DSH include:

  • Age:
    • DSH rates peak between 16-35 years
    • Suicide rates peak between 45-49 years
  • Socio-economic problems or disadvantage
  • Social isolation
  • Mental health problems, especially depressive, psychotic and personality disorders
  • Chronic physical health problems/illness
  • Stressful life events such as relationship breakdown, abuse, neglect, domestic violence
  • Exposure to suicide, e.g., through bereavement
  • Early adversity, e.g., childhood abuse
  • Drug and/or alcohol misuse
  • Involvement with the criminal justice system
  • High-risk occupations (e.g., healthcare professionals, farmers, construction workers)

Protective factors that may reduce the risk of suicide include:

  • Effective coping strategies
  • Supportive relationships
  • Dependents (e.g., children, pets, other family members)
  • Religious beliefs

Symptoms and diagnosis

The assessment and management of persons presenting with DSH should utilise a bio-psycho-social approach to consider the person’s problems, needs and future risk.

It is impossible to precisely predict suicidal risk, and various assessment tools can be used, such as the Columbia Suicide Severity Rating Scale (C-SSRS Screener) and the Patient Safety Screener 3 (PSS-3).

These scales are designed to measure the severity and intensity of suicidal ideation, the suicidal behaviour and the lethality of any attempts.

All psychiatric assessments should include screening for suicidal ideation and self-harm. 

The SAD PERSONS scale was developed to help screen suicide risk in adults. Although the scale has been found to have poor predictive validity in real-world studies, it can provide a useful memory aid for some of the risk factors for suicide rather than being an official risk-calculation tool.

 
S male Sex
A Age < 19 or > 45 years
D Depression
P Previous attempt
E Excess alcohol or substance use
R Rational thinking loss
S Social supports lacking
O Organised plan
N No spouse
S Sickness

Source: MD App. (n.d.). SAD PERSONS Scale Calculator. Retrieved July 12, 2022, from https://www.mdapp.co/sad-persons-scale-calculator-411/

It is scored with 1 point for each factor, with the final score reflecting risk:

0 – 4: low risk

5 – 6: medium risk

7 – 10: high risk

Management

Acute management

Patients who present with self-harm should be met with a sensitive, compassionate attitude to help minimise their distress.

If possible and appropriate:

  • See the individual alone for the initial psychosocial interview
  • Allow family members, friends, or advocates to be present if requested
  • Assess the individual’s emotional and mental state
  • Ask the individual to explain their feelings and understanding of the episode in their own words
  • Make treatment decisions jointly with the individual
    • If there is doubt regarding the person’s capacity to make informed decisions, the opinion of a psychiatrist with experience in this area should be sought
  • Examine physical injuries

Patients who are found to be at acute risk of suicide will require immediate and intensive management; the exact nature of this depends on the presentation and mental state; for example, some patients will need treatment under the Mental Health Act.

MRCP Part 1 - Treatment algorithm for patients presenting with self-harm

Adapted from (BMJ Best Practice, 2020). BMJ Best Practice. (2020). Suicide risk mitigation. Retrieved July 11, 2022, from https://bestpractice.bmj.com/topics/en-gb/3000095/treatment-algorithm#patientGroup-0-0

In episodes of self-poisoning, it may be useful to access the TOXBASE® website (http://www.toxbase.org/) or telephone the UK National Poisons Information Service (NPIS) on 0344 8920111 for a patient-specific risk assessment.

Any person who presents with DSH who does not necessitate referral to an emergency department or mental health crisis team should still be fully assessed and risk evaluated.

Particular points to take note of include:

  • Features of depressive illness
  • Presence of mental health disorders
  • Feelings of hopelessness, impulsivity, or futility
  • Features suggesting suicidal intent
    • Perceived lethality of the method
    • Use of violent methods
    • History and frequency of DSH
      • Risk is increased by more frequent, recent, or lethal attempts
    • Evidence of planning (e.g., a written suicide note, changes to will, closure of bank accounts, plans for care of dependents/pets)
  • Misuse of drugs and/or alcohol
  • Safeguarding concerns of young persons or vulnerable adults
  • Seriousness of physical injuries
  • Access to methods of further self-harm and future intent

Immediate interventions that may be used to reduce harm include:

  • Psychiatric admission
  • Providing reassurance and reducing tension
  • Acute sedation
  • Making family, carers, and friends aware of the risk
  • Removing access to means of harm (e.g., disposing of stockpiled medication)

Complications from DSH depend on the method employed, for example, acute liver failure after paracetamol overdose, permanent scarring or damage to nerves following cutting.

Longer term care

Upon discharge, persons who have self-harmed should be followed up in primary care within 48 hours. They should be offered risk management and psychosocial support where appropriate.

In most cases, patients are discharged to the care of their GP with no further specialist intervention; thus, prompt and clear communication with the GP is vital.

Identified mental health problems should be suitably managed. 

Patients should be offered written and verbal information about sources of support (see table, right)

Management looks different in every patient; for example, if stopping DSH completely is unrealistic, patients may be given harm-minimisation advice (e.g., advice on less dangerous methods, carer advice), producing a crisis plan with contact numbers or treatment for substance misuse.

Examples of long-term interventions include:

  • Effective treatment of psychiatric disorders
  • Alleviating psychosocial stress
  • Enhancing positive coping strategies
  • Developing crisis management plans

References

Bipolar Affective Disorder (BPD)

A long-term mental disorder featuring 2 or more episodes of significantly disturbed mood and activity levels. On some occasions, their mood is elevated, and in some, it is depressed.

Incidence and impact

Patients will experience periods of relapse and remission, especially in the presence of poor treatment adherence. Recovery may not be complete between episodes, and episodes may become more frequent over time.

Around 2% of the UK population screen positive for BPD, rates are similar between males and females. It is more common between the ages of 16 and 24.

BPD has the highest risk for suicide attempts and completion of all psychiatric conditions. Up to 56% of patients will make at least 1 suicide attempt in their lifetime, and up to 59% have suicidal ideation.

Other consequences of BPD include those resulting from impaired disinhibition and functioning, for example, damage to reputation, occupation and relationships, financial difficulties due to overspending, injuries, accidents, unplanned pregnancy, self-neglect, substance misuse and exploitation by others.

BPD is often comorbid with anxiety disorders, substance misuse disorders, ADHD, and personality disorders. Additionally, mortality from cardiovascular disease is twice that of the general population.

Definitions

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) subtypes BPD into Bipolar I disorder and Bipolar II disorder:

Bipolar I disorder Bipolar II disorder
At least 1 manic episode, with or without a history of major depressive episodes At least 1 major depressive episode with at least 1 hypomanic episode, with no evidence of mania
  • Manic episode: a period of at least 1 week of an abnormally and persistently elevated or irritable mood, plus at least 3 additional symptoms which are severe enough to cause significant impairment in social or occupational functioning, or which requires hospitalisation, or which includes psychotic features.
  • Hypomanic episode: a period of at least 4 days of a mildly elevated or irritable mood, which is not severe enough to cause a significant impairment in social or occupational functioning or necessitate hospitalisation without psychotic features.
  • Depressive episode: a period of at least 2 weeks of depressed mood or anhedonia, with additional symptoms.
  • Mixed episode: A period of rapid alteration between manic and depressive symptoms OR a period of at least 1 week in which symptoms meet the criteria for a manic/hypomanic episode, and at least 3 symptoms of depression are present on most days OR a period of at least 1 week in which symptoms meet the criteria for a depressive episode, and at least 3 symptoms of mania/hypomania are present on most days.
  • Rapid-cycling bipolar disorder: when at least 4 mood (depressive, manic, hypomanic, or mixed) episodes are experienced within a 12-month period.

Pathophysiology

BPD is considered one of the most heritable psychiatric disorders, with 1st degree relatives having a 5x increased risk compared to the general population. A number of risk alleles have been identified by genomic studies as having a small effect.

Environmental factors such as early life stress, maternal death before age 5, childhood trauma or abuse, emotional neglect, cannabis use, cocaine exposure and Toxoplasma Gonddi exposure have all been associated with onset or relapse of BPD.

Symptoms and diagnosis

A diagnosis of BPD can be suspected in primary care, but a specialist psychiatric assessment must be carried out in order to confirm diagnosis.

Use clinical judgement to determine the urgency of referral or admission.

Symptoms of mania may include:

  • Increased energy and activity
  • Marked feelings of wellbeing
  • Feelings of physical and mental efficiency
  • Increased sociability, talkativeness, over-familiarity
  • Increased sexual energy
  • Decreased need for sleep
  • Irritability
  • Conceit
  • Impolite behaviour and loss of social inhibitions
  • Inattention and distractibility
  • Elation
  • Pressured speech
  • Inflated self-esteem and grandiose ideas
  • Overconfidence

In episodes of mania with psychotic features, the following may be seen:

  • Delusions
  • Hallucinations
  • Flight of ideas
  • Manic stupor

Symptoms may be mood-congruent or mood-incongruent

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

References

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