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Bipolar disorder July 2006

Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

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Page 1: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Bipolar disorder

July 2006

Page 2: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Why implement NICE guidance?

NICE guidelines are based on the best available evidence

The Department of Health asks NHS organisations to work towards implementing guidelines

Compliance will be monitored by the Healthcare Commission

Page 3: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Bipolar disorder is complex

Bipolar disorder is an episodic, potentially life-long, disabling disorder that can be difficult to diagnose

Need to improve recognition, reduce sub-optimal care and improve long-term outcomes

There is variation in management of care across healthcare settings

Page 4: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

How to diagnose

Bipolar disorder is a cyclical mood disorder

Abnormally elevated mood or irritability alternates with depressed mood

•bipolar I – at least one manic or mixed episode•bipolar II – at least one major depressive episode

and at least one hypomanic episode

Page 5: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Presentation Key featuresMania Elevated, expansive or irritable mood

With or without psychotic symptoms

Marked impairment in functioning

Hypomania Elevated, expansive or irritable mood

No psychotic symptoms

Less impairment of functioning

Depression Mild, moderate or severe

With or without psychotic symptoms

Rapid cycling At least four episodes in 1 year

Mixed states Manic and depressive features present during same episode

Look for key features

Page 6: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Incidence and prevalenceAnnual incidence

7 per 100,000

Estimated lifetime prevalence – bipolar I 4–16 per 1000

Peak onset between 15 and 19 years of age

Suicidebipolar I – 17% attempt suicidebipolar disorder – 0.4% die annually by suicide

Page 7: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Comorbidity is common

Anxiety 30–50%

Substance misuse disorders (drugs and alcohol) 30–50%

Personality disorders, in particular borderline personality disorder (exercise caution when diagnosing)

Page 8: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

What this guideline coversDiagnosis in adolescents

Pharmacological treatment for:

•acute phase•long term management•rapid cycling•use of antidepressants•women of child bearing potential

Psychological therapy

Weight gain management

Annual physical health check

Page 9: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Diagnosis in adolescents

Diagnosing bipolar I disorder

Use adult criteria, except that:

•mania must be present •euphoria must be present most of the time (for the

past 7 days) •note irritability if it is episodic, severe, results in

impaired function and is not in character or is out of keeping with the context

Page 10: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Supporting diagnosis in adolescents

Increase knowledge and awareness in primary care and community settings

Ensure prompt referrals to secondary care

Use modified adult criteria to diagnose children and adolescents

Consider alternative diagnoses and other possible causes

Page 11: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Treat the acute phase

Consider an antipsychotic if:

•manic symptoms are severe

•there is marked behavioural disturbance

Consider valproate or lithium if:

•there has been previous response and good compliance with one of these drugs

Consider lithium if:

•symptoms are less severe

Page 12: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Initiate long-term pharmacological treatment

After a manic episode with significant risk and adverse consequences

Bipolar I: two or more acute episodes

Bipolar II: evidence of significant functional impairment or risk of suicide or frequently recurring episodes

Page 13: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Choose long-term drugs

Base choice of lithium, olanzapine or valproate* on:

•previous response•risk and precipitants of manic versus depressive

relapse •physical risk factors•patient preference and history of adherence•cognitive state assessment if appropriate

* Valproate should not be prescribed routinely for women of child-bearing potential

Page 14: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Try alternatives if needed

If continuing symptoms or relapse, use alternative monotherapy or add second prophylactic agent:

•lithium and valproate•olanzapine and lithium•valproate and olanzapine

If this proves ineffective:

•consult, or refer to, an expert in pharmacological treatment of bipolar disorder

•prescribe lamotrigine or carbamazepine

Page 15: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Support long-term pharmacological treatment

Ensure prescribing advisers are aware of NICE guidance, and what to consider when choosing treatment

Focus on optimising appropriate long-term treatment

Support service user education and empowerment in pharmacological treatment and management decisions

Make use of early intervention teams, regional mental health trusts and CAMHS teams

Page 16: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations
Page 17: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Modify treatment for rapid cycling

For an acute episode base treatment on that for manic and depressive episodes and:

•review previous treatments; if inadequately delivered or adhered to, consider a further trial of previous treatments

•optimise long-term treatment; each trial of medication should usually last at least 6 months

•encourage patients to keep a mood diary

Page 18: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Use antidepressants with care

Acute manic phase

Stop antidepressants at onset of acute manic phase and decide if discontinuation is abrupt or gradual based on:

•current clinical need•previous experience of discontinuation/withdrawal

symptoms•the risk of discontinuation/withdrawal symptoms

Page 19: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Consider need for treatment

Is long-term antidepressant treatment needed after an acute depressive episode?

No evidence for reduced relapse rates

May be associated with increased risk of mania

Page 20: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Educate staff and service users

Raise awareness of effective antidepressant prescribing

Highlight the importance of a thorough review of pharmacological history

Support patient fears about antidepressant withdrawal

Review prescribing policies and formularies, update as appropriate

Page 21: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Consider psychological therapy

For those who are stable, individual structured psychological therapy should include:

•at least 16 sessions over 6 to 9 months•psychoeducation •promotion of medication adherence •monitoring of mood, detection of early warnings

and prevention strategies •coping strategies

Page 22: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Implement psychological therapy

Offer individual structured psychological therapy

Identify key people to support mood monitoring and coping strategies

Identify training needs

Review access to services

Work collaboratively and engage the client, family or carers

Page 23: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Take possible pregnancy into account

Valproate should not be used routinely for women who may become pregnant. It may:

•cause foetal abnormalities•affect the child’s cognitive development

If prescribed, ensure adequate contraception. Explain risks during pregnancy and to the health of the unborn child

An antipsychotic may be used with caution

Page 24: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Provide care for women of child-bearing potential

Review care pathways and management of bipolar disorder in women of child-bearing potential

Raise awareness of the effects of bipolar disorder and treatment on:

•conception •pregnancy •child

Engage with patients, discuss contraception and family planning

Page 25: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Mitigate drug-related weight gain

Review medication strategy and consider:

•dietary advice and support •advising regular increased aerobic exercise•referring to a specialist mental health diet clinic or

health delivery group•referring to a dietitian if needed for people with

complex comorbidities

Page 26: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Support patients in controlling weight

Review risk of weight gain when prescribing, offer early dietary advice and support

Offer diet clinics or health delivery groups locally

Identify a named key worker with appropriate training, use the care programme approach (CPA)

Document in clinical notes/individualised care plan

Page 27: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Review annually

Over the course of the year an annual review should include:

• lipid levels, including cholesterol, in patients over 40• plasma glucose levels• weight• smoking status and alcohol use• blood pressure

Page 28: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Establish review systems

Agree responsibility locally

Establish monitoring and early warning systems

Develop systems for responsibility and intervention

Communicate results

Follow up non attendance

Page 29: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Target resources

Recommendations considered to have greatest impact on resources are:

•pharmacological management of women of child-bearing potential

•psychological management•weight management •annual review of physical health

Page 30: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Costs and savings

Recommendation Cost £m

Pharmacological management of women of child-bearing potential

3.6

Psychological management 20.8

Weight management 3.6

Annual review of physical health 3.4

Estimated saving achieved through increased psychological management

-11.4

National cost impact 20.1

Page 31: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Access tools online

Costing tools

•costing report•costing template

Implementation advice

Available from: www.nice.org.uk/CG038

Page 32: Bipolar disorder July 2006. Why implement NICE guidance? NICE guidelines are based on the best available evidence The Department of Health asks NHS organisations

Access the guideline online

Quick reference guide – a summary www.nice.org.uk/CG038quickrefguide

NICE guideline – all of the recommendations www.nice.org.uk/CG038niceguideline

Full guideline – all of the evidence and rationale www.nice.org.uk/CG038fullguideline

Information for the public – a plain English version www.nice.org.uk/CG038publicinfo