Tuesda 22.2.

201
y 7

Dr. Anas Ibn Auf

Clinical MD
psych. Assistant
Professor
By the end of session students would
be able to:
⦿ Formulate the management plan
based on Bio Psycho Social Model.
 Management of an acute episode depends
upon the
nature of this episode.
 Often the episode is of a nature and degree
that
hospital admission will be necessary.
 Special consideration should be given to
certain specific issues related to the
clinical presentation, the presence of
concurrent medical problems, and particular
patient groups, both in terms of setting and
choice of treatment.
 Issues of prophylaxis should be
considered, involving both
 First-line
⦿treatment
Lithium is the first-line treatment for acute
mania, with a response rate of around 80%.
Note: Up to 2 weeks of treatment may be
necessary to reach maximal effectiveness for
manic patients. Due to this delayed effect, esp.
for severe mania or psychotic symptoms, with
associated acute behavioral disturbance,
addition of an antipsychotic or a
benzodiazepine is usually required.
⦿ Predictors of good response:
◾ Previous response to lithium
◾ compliance with medication
◾ >3 previous episodes
◾ FHx of mood disorder
◾ Euphoria
◾ lack of psychotic symptoms or suicidal behavior.
⦿ Antipsychotics:
As in acute behavioral disturbance,
antipsychotics (e.g. haloperidol, olanzapine)
are useful in the rapid control of severely
agitated or psychotic patients with bipolar
disorder.
⦿ Benzodiazepines (e.g. lorazepam):
to sedate the acutely agitated manic patient
whilst waiting for the effects of other mood-
stabilising agents. The fact that lorazepam
is well absorbed after intra-muscular
injection (unlike other benzodiazepines) has
made it particularly useful for some very
⦿ ECT has been shown to be one of the
best treatment options in acute
mania.
⦿ Current practice reserves ECT for clinical
situations where pharmacological
treatments may not be possible, such as
pregnancy or severe cardiac disease, or
when the patient's illness is refractory to
drug treatments.
⦿ Carbamazepine may be effective, either
alone or in combination with lithium or
antipsychotics.
Predictors of good response:
◾ Previous response to carbamazepine
◾ poor compliance (due to wide therapeutic
window)
◾ absence of psychotic symptoms
◾ secondary mania (e.g. drug-induced,
neurological disorder, brain injury)
◾ dysphoria, mixed episode
◾ rapid cycling
◾ episode part of schizoaffective disorder.
⦿ Valproate is also effective in the treatment of
acute mania. Valproate is well tolerated and
has very few drug interactions, making it
more suitable for combined treatment
regimes.
Predictors of good response:
 rapid cycling, where some consider it first line,

 dysphoric mania, mixed episodes

 stable or decreasing frequency of manic

episodes
 less severe forms of bipolar spectrum
disorders.

⦿ Other: lamotrigine, used specially in depressive

episodes, not mania or hypomania. Topiramate
is also used in both depressed and manic
Specific clinical features:
⦿ Psychotic symptoms: It is not uncommon for patients
to experience delusions and/or hallucinations during
episodes of mania or depression. Management:
Mood stabilizer with/without an antipsychotic,
consider ECT, if severe consider admission to
hospital.
⦿ Catatonic symptoms: During a manic episode (manic
stupor). Management: Admit to hospital, exclude
medical problem, clarify psychiatric diagnosis, if
diagnosis clear treat with ECT and/or
benzodiazepine.
⦿ Risk
of suicide: Assess nature of risk, note association
with rapid cycling mood. If significant risk, or
unacceptable uncertainty, admit to hospital (or if in
hospital, increase level of observation), consider
⦿ Risk of violence: Assess nature of risk. Note
increased risk with rapid mood cycling,
paranoid delusions, agitation, and
dysphoria. Admit to hospital, consider
need for secure setting.
⦿ Substance-related disorders: Comorbidity is
high, often confusing the clinical picture.
Substance misuse may lead to relapse
both directly and indirectly (by reducing
compliance). Equally, alcohol consumption
may increase when on lithium.
Management: Address issues of misuse, if
detoxification considered, admit to hospital
as risk of suicide may be increased.
⦿ Other comorbidities Personality
disorders, anxiety disorder, ADHD,
conduct disorder.
⦿ Frequently acute episodes of bipolar disorder
are severe enough to require hospital
admission (often on a compulsory basis).
Points to note:
⦿ Patients with symptoms of
mania/hypomania or depression often
have impaired judgement (sometimes
related to psychotic symptoms), which
may interfere with their ability to make
reasoned decisions about the need for
treatment.
⦿ Risk assessment includes not only behaviors
that may cause direct harm (e.g. suicide
attempts or homicidal behavior), but also
those that may be indirectly harmful (e.g.
overspending, inappropriate sexual
activities, excessive use of drugs/alcohol,
driving whilst unwell).
⦿ High risk of suicide or homicide.
⦿ Illness-related behavior that
endangers relationships,
reputation, or assets.
⦿ Lack of capacity to cooperate with
treatment.
⦿ Lack (or loss) of psychosocial
supports.
⦿ Severe psychotic symptoms.
⦿ Severe depressive symptoms.
⦿ Severe mixed states or rapid
cycling (days/hours).
⦿ Catatonic symptoms.
⦿ Failure of outpatient treatment.
⦿ A need to address comorbid conditions (e.g.
Once the diagnosis has been clearly established,
possible physical causes excluded, and the
presenting episode effectively treated, follow-up
has a number of key aims:
⦿ Establishing and maintaining a therapeutic
alliance.
⦿ Monitoring the patient's psychiatric status.
⦿ Providing education regarding bipolar disorder.
⦿ Enhancing treatment compliance.
⦿ Monitoring side-effects of medication and
ensuring
therapeutic levels of any mood stabilizer.
⦿ Identifying and addressing any significant
comorbid conditions.
⦿ Promoting understanding of and adaption to
the
psychosocial effects of bipolar disorder.
⦿ Identifying new episodes early.
⦿A key part of psychiatric management
helping patients to identify
precipitants or early manifestations
of illness, so that treatment can be
initiated early.
⦿ This may be done as part of the usual
psychiatric follow-up, or
psychotherapeutic intervention.
⦿ Primary aim: Prevention of recurrent episodes (either
mania or depression.)
⦿ Indications: Any patient who has had at least 2
episodes in 5 years (APA Guidelines 1994).
First-line treatment:
⦿ Lithium: except for mixed mania (i.e. depressive
symptoms during manic episodes) and patients
with rapid cycling mania.
Second-line treatments
⦿ Carbamazepine: more effective in the
treatment of bipolar spectrum than classical
bipolar disorder.
⦿ Sodium valproate/divalproex: more effective
in rapid
cycling.
◾ Other anticonvulsants: used sometimes:
Most patients will struggle with some of the following
issues:
⦿ Emotional consequences of significant periods of
illness and receiving the diagnosis of a chronic
psychiatric disorder.
⦿ Developmental deviations and delays caused by past
episodes.
⦿ Problems associated with stigmatization.

⦿ Problems related to self-esteem.

⦿ Fear of recurrence and the consequent inhibition of

normal
psychosocial
functioning.
⦿ Interpersonal
difficulties.
⦿ CBT:
Time-limited, with specific aims:
 educate the patient about bipolar
disorder and its treatment
 teach cognitive behavioral skills for
coping with psychosocial stressors
and associated problems
 facilitate compliance with treatment
 monitor the occurrence and
severity of symptoms.
⦿ Interpersonal and social rhythm
therapy: To reduce lability of mood by
maintaining a regular pattern of daily
activities (e.g. sleeping, eating,
physical activity, and emotional
stimulation).
⦿ Family therapies:
Usually brief, include psychoeducation (of
patient and family members) with specific
aims:
 accepting the reality of the illness
 identifying precipitating stresses and
likely future stresses inside and
outside the family
 planning strategies for managing
and/or minimizing future stresses
 bringing about the patient's family's
acceptance of the need for continued
treatment.
⦿ Support groups:
 These may provide useful information
about bipolar disorder and its
treatment.
 Patients may benefit from hearing the
experiences of others, struggling with
similar issues.
 This may help them to see their problems
as not being unique.
 understand the need for medication.
 access advice and assistance with other
practical issues.