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Be vigilant for symptoms of bipolar disorder

Bipolar affective disorder is Characterised by episodes of depression

and at least one lifetime episode of mania or hypomania. The condition is equally common in both genders.

It can be categorised as either bipolar I (at least one manic episode) or bipolar II (at least one hypomanic, but no manic, episode).1 The lifetime prevalence may be as high as five per cent.2

Bipolar disorder is a lifelong condition that can have serious effects on social

and occupational functioning. There is commonly a 10-year delay before diagnosis, and as many as two thirds of patients are misdiagnosed (particularly those with bipolar II disorder) as unipolar depression or borderline personality disorder.3 The delay in diagnosis may have an adverse effect on outcomes.

In bipolar disorder the risk of attempted suicide is increased compared with unipolar disorder.4 Risk to self or others

is a criterion for referral to a specialist

(see table 1, p34).

NICE has recently produced guidelines to help improve the management of bipolar disorder in primary and secondary care.5 The NICE guideline has made a number of recommendations relevant to primary care, including physical health monitoring (see table 2, p35).

Presented here are four cases illustrating different aspects of bipolar disorder.

Case 1

Jean is a 60-year-old woman with a long history of bipolar disorder. She is brought to the accident and emergency department after being found naked preaching to passers-by in the street with delusions that she is Jesus. She gives a two-week history of racing thoughts, poor sleep and overactivity.

Discussion

Mania is the descriptive term for a syndrome of emotional, cognitive and behavioural symptoms where the patient experiences irritability or elation in mood, racing thoughts, grandiosity, overactivity, pressured speech and disinhibition, as well as a decreased need for sleep. In more severe cases, psychotic symptoms may

be present.

Hypomania is a less severe state in which the patient experiences elated mood with symptoms similar to mania but lesser in degree and without significant social and occupational dysfunction.

Medications licensed for mania in the UK include lithium, olanzapine, quetiapine, risperidone and valproate semisodium.

Bipolar disorder requires long-term treatment to minimise the risk of recurrence of acute episodes. Lithium, olanzapine or valproate are currently recommended for long-term treatment

of bipolar disorder, although valproate should not be prescribed in women of childbearing potential. If a patient decides to stop lithium there is a high risk of relapse, especially if it is discontinued rapidly.6

For patients treated with lithium, cards are available from pharmacies. These explain to patients how to take the drug, what to do if they miss a dose, what

side-effects can occur and the need for regular blood tests to check the

plasma level.

Carbamazepine is licensed for use as a long-term prophylactic agent in patients who have failed to respond to lithium. However, NICE recommends that it should only be used on the advice of a specialist because of the risk of toxicity and interactions.5

case 2

A 27-year-old man presents to his GP complaining of low mood with biological symptoms of depression (sleep disturbance, anergia and poor appetite) impacting on his work and relationships. Only when asked specifically does he report periods of hypomania in the past that lasted for weeks at a time.

Discussion

The diagnosis is bipolar depression. It is important to enquire about hypomania in all patients presenting with depression to ensure that bipolar disorder is not missed.

In a longitudinal study of 108 patients attending a primary care setting with depression or anxiety, 22 per cent had bipolar I or II disorder.7

Treatment of bipolar disorder as unipolar depression with antidepressants can destabilise the illness. Patients require an antimanic drug as well as an antidepressant to prevent an antidepressant-induced hypomanic or manic switch. Switching occurs in particular with tricyclic antidepressants such as amitriptyline or dosulepin, as

well as other antidepressants such as venlafaxine. The lowest risk appears to be with SSRIs, such as sertraline.8

NICE recommends that when the depressive episode has resolved, patients do not remain on the antidepressant indefinitely because of the risk of mood switch.5

case 3

A mother brings her 13-year-old son to her GP. For the previous month he has been irritable at home, easily distracted and refusing to go to sleep. His behaviour has been problematic at school, where he has behaved in a sexually inappropriate way with female classmates. He now says he feels wonderful and describes racing thoughts. He has become arrogant and says that he is intellectually gifted.

Discussion

Bipolar disorder can occur in prepubescent children and may be difficult to differentiate from attention deficit hyperactivity disorder, conduct disorder or anxiety disorders. In order to make the diagnosis of bipolar disorder

in children a frank manic episode, not hypomania, should be present. Elation, not simply irritability, must occur most of the time for a seven-day period. Sexual abuse leading to sexual disinhibition, drug and alcohol abuse and organic causes should be considered in the differential diagnosis.

NICE recommends that the diagnosis should only be made by a clinician with specialist training in child and adolescent psychiatry.5

The only drug licensed for use in bipolar disorder in children aged 12 and over is lithium. Unlicensed medications may

be prescribed by specialist services. Medication should be used in lower doses than in adults and requires closer monitoring because children may be more prone to adverse effects such as sedation, extrapyramidal symptoms and obesity. In the long-term management of bipolar disorder in children, an atypical antipsychotic is the drug of choice. The child should attend a specialist service.

case 4

A 35-year-old woman has a history of bipolar disorder since the age of 17 and has had previous hospitalisations with both mania and depression. She has been maintained on a combination of lithium and valproate and has been well for five years. She now wishes to become pregnant and attends her GP for advice.

Discussion

There are two main issues regarding pregnancy – risk of teratogenicity and increased risk of relapse in the postnatal period.

Teratogenicity

In pregnancy, lithium leads to an increased risk of a congenital cardiac anomaly (Ebstein's anomaly) in the fetus, which occurs in one to two babies in every 1,000.

Current concern centres on the use of valproate in women. It is associated with neural tube defects in 5 to 9 per cent of pregnancies,9 and in utero exposure can lead to neuropsychological deficits in later life. Further, there is a risk of polycystic ovary disease with valproate.10

Consequently, NICE recommends that valproate should not be used in women of childbearing potential unless absolutely necessary.5 If used it is imperative that patients take adequate contraceptive measures.

The postnatal period

The risk of postnatal illness is increased

in bipolar disorder. Puerperal psychosis occurs in 25 to 50 per cent of women with bipolar disorder, compared with around 0.1 per cent of the general population.11 Because of the risk that this poses to the health of the mother and child, close liaison is required between GP, midwife, obstetrician, health visitor and psychiatrist during pregnancy, delivery and the postpartum period. The patient's mental state should be monitored closely in the puerperium because of the high risk of relapse.

General discussion

Bipolar patients have significant medical comorbidity, in particular cardiovascular disease, diabetes, obesity and thyroid disease.12

Drugs such as olanzapine, lithium and valproate are associated with weight gain.

Steps taken to improve general lifestyle can reduce a number of the risk factors associated with cardiovascular disease, including smoking and weight gain. NICE recommends that physical health should be reviewed yearly.5

Patients on lithium should have levels monitored every three months, and urea, creatinine and thyroid function every six months. The quality and outcomes framework of the new GMS?contract for GPs (QOF2) includes indicators for monitoring patients on lithium therapy and carrying out an annual review in patients with bipolar disorder (see table 3, above).

There should be liaison between primary and secondary care to ascertain where the responsibility for physical

care lies.

Conclusion

Bipolar disorder can be easily missed,

and without antimanic drug cover antidepressant treatment can lead to a switch to mania or hypomania. Clinicians therefore need to be vigilant to the presence of unreported hypomanic symptoms.

The care of female bipolar patients

of childbearing potential needs special attention because of the risk of teratogenicity with valproate and lithium, and risk of polycystic ovaries with valproate. The risk of relapse in the postpartum period is high, and

multi-agency communication is essential during pregnancy and the puerperium.

Finally, it is important not to forget the need for regular physical monitoring in all bipolar patients.

References

1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Association, 1994

2 Kessler RC, Berglund P, Demler O et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005:62;593–602

3 Calabrese JR, Hirschfeld RM, Reed M, et al. Impact of bipolar disorder on a US community sample. J Clin Psychiatry 2003:64;425–32

4 Chen YW, Dilsaver SC. Lifetime rates of suicide attempts among subjects with bipolar and unipolar disorders relative to subjects with other Axis I disorders.

Biol Psychiatry 1996:39;896–9

5 National Institute for Health and Clinical Excellence. The Management of bipolar disorder in adults, children and adolescents, in primary and secondary care. Clinical Guideline number 38. London: NICE, 2006

6 Cavanagh J, Smyth R, Goodwin GM. Relapse into mania or depression following lithium discontinuation: a 7-year follow-up. Acta Psychiatr Scand 2004:109;91–5

7 Manning JS, Haykal RF, Connor PD, et al. On the nature of depressive and anxious states in a family practice setting: the high prevalence of bipolar II and related disorders in a cohort followed longitudinally. Compr Psychiatry 1997:38;102–8

8 Post RM, Altshuler LL, Leverich GS, et al. Mood switch in bipolar depression: comparison of adjunctive venlafaxine, bupropion and sertraline. Br J Psychiatry 2006:189;124–31

9 Yonkers KA, Wisner KL, Stowe Z, et al. Management of bipolar disorder during pregnancy and the postpartum period. Am J Psychiatry 2004:161;608–20

10 O'Donovan C, Kusumakar V, Graves GR, et al. Menstrual abnormalities and polycystic ovary syndrome in women taking valproate for bipolar mood disorder.

J Clin Psychiatry 2002:63;322–30

11 Jones I, Craddock N. Bipolar disorder and childbirth: the importance of recognising risk. Br J Psychiatry 2005:186:453–4

12 Kupfer DJ. The increasing medical burden in bipolar disorder. JAMA 2005:293;2528–30

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