Bipolar Disorder Management

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Core management
  • Exclude general medical cause
  • For acute mania, manage as per acute psychosis.
  • Reduce risk of relapse with mood stabiliser or antipsychotic. Usually continued for at least 2 years.
  • For depression in bipolar disorder only give antidepressant if also on mood stabiliser or antipsychotic
  • Psychoeducate patient and guardians
Red Flags

Admission usually required if:

  • Evidence of exhaustion, dehydration due to over-activity. IV fluid may be necessary
  • Evidence that the patient is a high risk to themselves (self-harm/ neglect/ vulnerable to exploitation) or a risk to others (agitation/ aggression)
  • No guardian available to monitor adherence to medication

Physical Exam and Investigations

  • Full physical examination to exclude underlying physical causes (delirium)
  • Vital signs: If severely unwell, dehydration/ exhaustion can be potentially fatal
  • FBC and glucose
  • If evidence of hyperthyroidism on examination (weight loss, tremor, exophthalmos, goitre) consider TFTs if available
  • Consider HIV serotesting (HIV can present with secondary mania), U&E, VDRL, and urine drug screen if appropriate.

Psychosocial

  • Psychoeducation – give a photocopy of the information leaflet on bipolar and any other appropriate leaflet
  • Consider referral to local supportive groups (church, women’s groups, MeHUCA)
  • Reduce stress and strengthen social supports
  • Promote functioning in daily living activities
  • Support carers – give information leaflet

Medication

Initial treatment

Commence either a mood stabiliser or an anti-psychotic

  • Give Sodium Valproate 400mg nocte. Increase weekly by 200mg until symptoms improved. Usual effective dose 600- 1000mg. Avoid in women of child-bearing age.

or

  • Give Carbamazepine 200mg nocte. Increase weekly by 200mg until on 400-600mg. Usual dose 400-600mg daily.
  • Use a second-generation antipsychotic (e.g. Risperidone 1 – 2mg) in women of child-bearing age

If psychotic symptoms present also give an anti-psychotic medication such as:

  • Chlorpromazine 100-200mg nocte or Haloperidol 2.5mg nocte.
  • Diazepam 5mg TDS for a maximum of two weeks may help with reducing agitation and increase sleep in the acute management of mania

Medication tips

  • If not improving, ensure that person has been on a typical effective dose of medication for a minimum of four to six weeks before considering switching
  • If switching to another medication, begin that medication first and treat with both medications for 2 weeks before tapering off the first medication.
  • If response is still poor, consult a specialist

Caution: Avoid Sodium Valproate in women of child-bearing age due to teratogenic effects. If no second-generation antipsychotic available, use Carbamazepine but ensure patient using adequate contraception.

Referral and Follow-Up

Referral

  • Ongoing or worsening symptoms despite adequate treatment for 2 – 4 weeks.

Follow-Up

  • For acute mania: Initial follow-up should be as frequent as possible, even daily, until acute symptoms respond to treatment. Once symptoms respond, monthly to quarterly follow-up is recommended.
  • For persons not currently in manic or depressed states, follow-up at least every three months.