Psychotherapy trials pose difficulties for evidence-based practice that have not been sufficiently recognized. In addition, full disclosure of all analysed data has long been required by the regulatory authorities, and this information is usually accessible if not actually published. ICD-10 hypomania contributes little but confusion to current classification because it tends to encourage the use of the term for frankly manic states (IV, (Goodwin, 2002)). As long as lithium heparin is not used as an anticoagulant, plasma can be used to measure the lithium concentration; plasma and serum lithium concentrations are identical. Read the latest medical research on causes, symptoms and new treatments for bipolar disorder. Just as for drug treatments, more large-scale data with harder outcomes (admission to hospital, offending) would be very welcome, but are not currently available. Although not included in DSM-5 as a course specifier, the majority of patients with bipolar disorder have a tendency to develop more episodes of one pole over the other. Rapid cycling is another specifier. The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. After that, 50 mg/day can be added at weekly intervals as clinically indicated up to doses of 400 mg/day. Most newly introduced treatments for bipolar disorder, whether pharmacological or psycho logical, have been based on an extension of use from another disorder—eg, antipsychotics in mania and antidepressants or cognitive-behavioural therapy for bipolar depression. In addition it is recommended that psychological therapists and those prescribing maintain and active clinical links when working with the same patient. Co-morbidity of bipolar disorder with a range of other psychiatric conditions poses problems of two diametrically different kinds. This risk may not be as widely appreciated as the risk for suicide, but offending is actually a more common outcome and thus associated with a higher absolute risk. The involvement of family members with experience of previous episodes may be helpful (Reinares et al., 2008). (2004) have suggested that mood elevation forms a continuous bridge between unipolar and bipolar disorder. Finally, before the expression of frank (hypo)mania, a significant number of bipolar patients diagnosed with unipolar depression may run into difficulties because of inadequate or inappropriate treatment. The risk/benefit for valproate contraindicates its use in women of child-bearing potential under normal circumstances (I). Diazepam, lorazepam, clonazepam and related agents are useful in the management of acutely agitated manic states (Allen et al., 2001). Severity of mania, presence of psychotic features and mixed features may all influence outcome but are poorly characterized in relation to treatment response. All such therapy recognizes as axiomatic the value of a highly collaborative therapeutic relationship with the patient. This is problematic because failure to follow guidance may have legal implications for doctors. The particular risks to the patient and others will be the result of poor judgement and associated actions in areas of work, personal relationships, alcohol/drug use, spending, driving and sexual activity (I). Any acute episode, regardless of polarity, should receive active treatment. The aim of this study was to provide a descriptive overview of different psychological and pharmacological interventions used in the treatment of patients with bipolar disorder and substance abuse, in order to determine their efficacy. Doctors, patients and carers tend to bring different experiences and beliefs to the therapeutic relationship (II) and make different estimates of future risks. Be aware of the increased potential for a range of adverse reactions and effects, particularly weight gain (S). In general, effect sizes for drug treatment of anxiety disorders appear to be greater than for psychological treatments (Bandelow et al., 2015). Bipolar disorder (BD) is a leading cause of global disability. It is fully accepted that bipolar I disorder can present before puberty and should be diagnosed as such. The STEP-BD study compared paroxetine and bupropion with placebo and the results were certainly negative (Sachs et al., 2007). Want more videos about psychology every Monday and Thursday? Audit data at baseline revealed that the proportion of patients provided with this information at the start of lithium treatment ranged between 42 and 62% (Prescribing Observatory for Mental Health, 2013). Advice on the use of tobacco is also essential because in data from the US, bipolar disorder has the highest rate of current and lifetime use and the lowest quit rate of any other psychiatric disorder (I, (Lasser et al., 2000)). It is unclear whether the common failure to do any monitoring at all in some services is affected by what frequency is actually recommended. A 2006 study found that only half of patients remained well two years after starting treatment. It is an important principle that bipolar patients with significant alcohol or other drug use should have these issues appropriately assessed and treated, and consideration given to involving the specialist addictions service, or dual diagnosis team, if available. Rates of violent crime in male patients were 8% and, for non-violent crime, 18% in one population cohort study, with most of these patients committing their crimes within 5 years of diagnosis (Webb et al., 2014). However, it remains questionable whether this is really a diagnosis that merits classification as a mood disorder, rather than as a particularly severe form or variant of oppositional defiant disorder or ADHD. For whom? 12.5 mg/day or 25 mg every other day for 2 weeks, then 25 mg/day during weeks 3 and 4). Caffeine (in coffee and other drinks) may significantly disturb sleep and exacerbate anxiety symptoms in sensitive individuals (III). Apply now for 2021. This represents a tightening of advice for men particularly, based on new data showing an increased excess of cancers in drinkers (https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489797/CMO_Alcohol_Report.pdf). One final consideration is that when small trials are negative, caution is required in claiming that the trial proves lack of efficacy: under-powered studies by definition run a high risk of type II statistical error. Medicines with putative efficacy against depressive and (hypo)manic relapse are sometimes described as mood stabilizers. People with bipolar disorder (manic depression) often have trouble sleeping. Bipolar patients are at substantially increased risks of self-harm, suicide, victimization, violence and criminality (I). Anecdotally, it is possible that effective treatment with antidepressants is possible without an additional anti-manic drug (Parker et al., 2006). Clinicians should know that NICE2014 recommended monitoring lithium concentrations at 3-monthly intervals for the first year of treatment in otherwise healthy patients, and 6 monthly thereafter (S). Of course, clinically there is an obvious gradient between patients with highly variable mood and those with a much more episodic pattern. An experimental treatment is the intervention of the researcher to alter the conditions of an experiment. Descriptions consistent with bipolar disorder exist since antiquity, but Kraepelin first used the term manic-depressive psychosis to include all cases of affective psychosis. Benzodiazepines may depress neonatal respiration or cause drowsiness, hypotonia or withdrawal symptoms. Second opinions from bipolar specialists are potentially helpful. Thus, declaration of interest should be taken seriously in the publication of psychosocial interventions (Dragioti et al., 2015). In fact, less frequent (annual) but assured monitoring of every patient would probably be more rational and cost effective. The problem for early detection of bipolar disorder. In addition to the lack of focus on bipolar disorder, and certainly contributing to making it worse, is the traditional fault line between child and adolescent services and adult services. As a result serum concentrations may fall and the mother may require higher doses to prevent a relapse. We agree with the NICE guidelines 2014 (p. 304) “it is important to know the form of psychological therapy that can benefit young people with bipolar disorder”. Dopamine agonists a Proposed for bipolar depression Experimental; some evidence Howland Divalproex Mania Not approved for bipolar … Substantial drop-out rates are common even in quite short-term RCTs. These represent most of the patient’s life and may be characterized by a variable sub-syndromal level of mood symptoms. More commonly, alcohol and/or drug use is co-morbid with manic or depressive mood change (I). The Department of Health’s ‘National Service Framework’ in the UK set a template for specialist mental health clinical services to focus on ‘psychosis’; this remains broadly unchanged with a consequent lack of understanding among policymakers of the need for high-quality specialized services for bipolar patients (IV), either in relation to early intervention or to provision of adult services. Dopamine receptor antagonists/partial agonists are anti-manic, not simply sedative. This effect was prevented by co-treatment with lithium. Abrupt withdrawal of sertraline may have caused neonatal withdrawal effects. There are regular reports of adverse outcomes in the development of the children of women treated with antidepressants or other psychotropic drugs. The long-term value of antidepressants is not sufficiently established. There is no cure available for bipolar disorder, which means that patients will require lifelong treatment, even during the times when they feel emotionally stable. There have been few efforts to differentiate the treatment responses along this gradient, except by reference to ‘rapid cycling’, which is an imprecise course specifier. Adverse reactions include tremor, polyuria, polydipsia, weight gain, cognitive problems, sedation or lethargy, impaired coordination, gastrointestinal distress, hair loss, benign leukocytosis, acne, and oedema. Carbamazepine is less effective in maintenance treatment than lithium but may sometimes be used as monotherapy if lithium is ineffective and especially in patients who do not show the classical pattern of episodic euphoric mania (II). The vast majority of UK mental health trusts participate in these traditional audit, intervention, re-audit cycles. Some studies are still interpreted to justify echocardiography to check for cardiac problems in exposed babies (Diav-Citrin et al., 2014). Only lamotrigine, lithium and quetiapine were convincingly shown to prevent depressive relapse. The central problem is that, whatever the intention, adherence to long-term treatment appears to be poor (Kessing et al., 2007). Because effective in the short term, this may lead to their preferential use; active consideration of lithium as a better alternative should be promoted. There is very limited evidence on the treatment of borderline personality disorder especially when co-morbid with bipolar disorder. I’m very interested to see where this one goes. To improve adherence, clinical practice should address the underlying causes of non-adherence within the overall frame work of psychoeducation (Leclerc et al., 2013). In the absence of independent evidence of benefit and from appropriate trials in such children, the extrapolation could not be encouraged. Recently there has been a double-blind comparison of venlafaxine with lithium in bipolar II depression suggesting an important advantage to venlafaxine in continuation treatment (Amsterdam et al., 2015). Knowing that there will be a risk of relapse is useful and informs clinical practice. Carefully document your decisions in formulating a care plan (S). Mental Health Providers: Making the Right Choice, Bipolar Help: Self-Help For Bipolar and How to Help a Bipolar Loved One, Help for Bipolar Depression: Where to Find It, Rape Victim Stories: Real Stories of Being Raped, Depression Quotes & Sayings That Capture Life with Depression, Positive Inspirational Quotes for People with Depression, Quotes on Mental Health and Mental Illness, HONcode standard for Anxiety symptoms are often persistent between episodes and may contribute to mood instability (I). The provision of greatly increased levels of psychotherapy to vulnerable patients is not without its risks, most notably of sexual or financial exploitation by the therapist (Nutt and Sharpe, 2008). DSM-5 has dropped the category ‘mixed episode’ and introduced a new feature to the diagnosis of a primary manic, hypomanic or depressive episode: the mixed feature specifier. Beliefs about ECT in the general population appear to remain influenced by unfavourable media portrayal (Lebensohn, 1999) and this has not diminished (IV). However, despite their widespread use by an earlier generation of psychiatrists, placebo-controlled data to show that the older dopamine antagonists (‘first generation’ antipsychotics) were effective in mania were very limited before the turn of the century (e.g. Here are some strategies that can help: 1. However, it is recognized that much of the difference between active treatment arms and placebo are due to early events, and drop-out rates tend to be very high. At a subsequent audit, conducted after provision of a bespoke, patient-held lithium information pack, the respective figures rose to between 54 and 68% (Paton et al., 2013). However, it is dogmatic about the use of medication: 18.104.22.168 Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (for example, repeated self-harm, marked emotional instability, risk-taking behaviour and transient psychotic symptoms). Folate supplementation is advised for all pregnant women, but it is unclear whether this reduces the increased risk of neural tube defects associated with carbamazepine and valproate. The early diagnosis of bipolar disorder may not be easy. However, the greatest challenge is the early adoption of a long-term treatment strategy acceptable to patient and family. Magnetic Therapy. The use of alcohol or drugs may be excessive. The group noted that quetiapine has an unusual weight of evidence to support its use in adults with bipolar depression and may have a unique combination of pharmacological actions which account for this. In fact, the effect for depressive relapse was higher than for mania in this study (Cipriani et al., 2013c). Sleep disturbance is perhaps the most commonly described final common pathway to mania (II, (Wehr et al., 1987)). The following general principles are important. Among nonpharmacological treatments, acute bipolar depression is responsive to ECT (Itagaki et al. The term bipolar disorder or manic depression was given no special consideration (and entirely omitted from the glossary of key terms) in the National Service Framework for mental disorders in the United Kingdom (Department of Health, 1999). The neglect of the specific needs of bipolar patients in UK government policy (Morriss et al., 2002) justifies our restating the obvious in the previous paragraphs. The further role of structured psychotherapy will be considered in relation to relapse prevention. Make use of evidence to address poor insight, the seriousness of the illness, reluctance to give up the experience of hypomania or mania, the risk of relapse and the benefit of therapeutic engagement (II). This is particularly the case in relatively treatment-resistant cases. It can also influence how results are analysed, if statistical methods are not pre-specified. In DSM-IV, a mixed episode was defined as requiring the full syndrome of mania and major depression to be present simultaneously for at least 1 week. Acute extrapyramidal symptoms are still regarded as a predictor of subsequent TD, and are probably more common in bipolar patients (Gao et al., 2008). In a national POMH audit conducted in 2012 (Prescribing Observatory for Mental Health, 2013), 22% of patients with an affective disorder who were prescribed antipsychotic medication had been screened for all four of these measures in the previous year, 54% for up to three measures, and 24% had received no screening. Although the place of pharmacotherapy for borderline symptoms is based on limited evidence, the shared symptom of mood instability may be appropriately treated by medicines (e.g. Lean Library can solve it. Characteristics, evaluation and treatment, Multivariate Meta-analysis of the discriminative validity of caregiver, youth, and teacher rating scales for pediatric bipolar disorder: Mother knows best about mania, The state of assessment for pediatric bipolar disorder: It is time to throw away the old textbook, Psychotherapy of borderline personality disorder, Pramipexole for bipolar II depression: A placebo-controlled proof of concept study, Double-blind comparison of the continued use of antipsychotic treatment versus its discontinuation in remitted manic patients, Dose-response and comparative efficacy and tolerability of quetiapine across psychiatric disorders: A systematic review of the placebo-controlled monotherapy and add-on trials, British Association for Psychopharmacology, Strengths of evidence and recommendations for guidelines, Treatment of different phases of bipolar illness, Treatment of different phases of bipolar disorder, Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology, http://handbook.cochrane.org/chapter_12/12_2.htm, https://www.ecnp.eu/projects-initiatives/nomenclature.aspx, http://pathways.nice.org.uk/pathways/antenatal-and-postnatal-mental-health, Cross-Disorder Group of the Psychiatric Genomics et al., 2013, http://www.joinmq.org/pages/mental-health-research-funding-landscape-report, https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/489797/CMO_Alcohol_Report.pdf, Prescribing Observatory for Mental Health, 2013, https://www.gov.uk/drug-safety-update/medicines-related-to-valproate-risk-of-abnormal-pregnancy-outcomes, http://medicine.iupui.edu/flockhart/table.htm, http://www.nimh.nih.gov/health/publications/bipolar-disorder-in-children-and-adolescents/index.shtml#pub7, American Academy of Paediatrics Committee on Drugs, 2000, http://www.bap.org.uk/bipolardeclarations. After birth these changes reverse and there is a risk that higher serum concentrations will results in adverse reactions, unless doses are reduced. Site last updated January 17, 2021, The Impact of Antidepressant Discontinuation on Relapse, Remission, and Mood Episode Cycling in Bipolar Disorder, Comprehensive Management of Mania in the Elderly. At present there is little to guide practice other than safety concerns and pragmatic outcomes in individual cases. As already indicated, we recommend psychoeducation as the preferred or first-line psychological intervention. In practice, patients may already be taking lithium or valproate when mania occurs as a breakthrough during long-term treatment. Comparison with other alternatives, notably cognitive behaviour therapy (CBT) (see also below), has also illustrated the economy of a more educational approach (Parikh et al., 2012). (, Van Meter, AR, Moreira, AL, Youngstrom, EA (, Vancampfort, D, Vansteelandt, K, Correll, CU. In fact, it is unusual for ECT to be used without a patient’s consent, and under mental health legislation, even in services with a high utilization rate; even then, outcomes appear reassuring (Wheeldon et al., 1999). Other efforts to improve adherence such as user-friendly packaging, monitoring of pill taking, delivery of supplies of medicine may contribute to successful treatment in certain individuals. Issues in the efficacy and safety of psychotherapy, Drug harms in the UK: A multicriteria decision analysis, Comparing the risk of tardive dyskinesia in older adults with first-generation and second-generation antipsychotics: A systematic review and meta-analysis, Suicide: The leading cause of maternal death, Mood stabilizers and antipsychotics for acute mania: A systematic review and meta-analysis of combination/augmentation therapy versus monotherapy, A history of investigation on the mood stabilizing effect of carbamazepine in Japan, The risk of spina bifida aperta after first-trimester exposure to valproate in a prenatal cohort, Rates of lifetime suicide attempt and rates of lifetime major depression in different ethnic groups in the United States, Suicidal behavior in bipolar mood disorder: Clinical characteristics of attempters and nonattempters, Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom’s General Practice Research Database, The International Society for Bipolar Disorders (ISBD) task force report on antidepressant use in bipolar disorders, Hyperprolactinemia and medications for bipolar disorder: Systematic review of a neglected issue in clinical practice, Gabapentin in bipolar disorder: A placebo-controlled trial of adjunctive therapy. In such studies patients can act as their own controls before, during and after treatment, patient numbers can be very large and observation periods can be long. All such studies are associated with high drop-out rates, so that interpretation of drug/placebo differences over the longer term (the prevention of new episodes) will be problematic. Carbamazepine and valproate are associated with a range of congenital abnormalities, including neural tube defects (incidence 1% with carbamazepine and 1–2% with valproate (Omtzigt et al., 1992)) and the foetal hydantoin syndrome (facial dysmorphophobia, cleft lip and palate, cardiac defects, digital hypoplasia, and nail dysplasia), which was originally described with phenytoin. We recommend the corresponding BAP guidelines for attention deficit hyperactivity disorder (Bolea-Alamanac et al., 2014), anxiety disorders (Baldwin et al., 2014) or substance misuse (Lingford-Hughes et al., 2012). It is not established that early rashes “progress” to Stevens–Johnson syndrome and toxic epidermal necrolysis, even when the early rash is erythema multiforme. The group noted that the ISBD international task force, in trying to balance the same opposite opinions, did not broadly endorse antidepressant use, but acknowledged the experience that individual bipolar patients may benefit nevertheless. In contrast, we accept them for what they are while recognizing their limitations. The evidence from network meta-analysis of many RCTs is coherent and supports efficacy of a range of different medicines (I). DSM-5 retains borderline, obsessive–compulsive, avoidant, schizotypal, antisocial and narcissistic personality disorders, but also recognizes dependent, histrionic, paranoid and schizotypal. 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