By :Gladiar Ayu Pawintri

Advisor :Dr. Iwan Sys, Sp.KJ

BIPOLAR DISORDERIdentifying and Supporting Patients in

Primary Care

IntroductionBipolar disorder first appeared in the medical

literatur in the 1850s when alternating melancholia and mania were paired in a single condition

For a number of years the diagnosis was termed “manic-depressive disorder”, but this was repaced by bipolar disorder in 1980 when the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition (DSM-III) was released

What is bipolar disorder?Bipolar disorder is characterised by

extreme mood swings – from hopeless depression to euphoric or irritable mania - with each episode usually bookended by symptom free period referred to as euthymia.

The severity of Mania Determines the Type of Bipolar DisorderA full Manic EpisodeHypomaniaSubsyndromal (sub-clinical)

A full Manic EpisodeA distinc period of abnormally and persistenly

elevated or iritable mood, accompanied by an abnormally and persistently increased amount of goal-directed activity or energy

Lasting at least one weekPresent most of the day, nearly every day

A person may :Develop grandiose plansCause noticeble social or occupational impairmentDanger to themselves and otherDecrease need for sleep (feature of all forms of mania)

HypomaniaIs characterised by the same features as mania

but the patient’s episode is less severe and does not cause the same degree of social or occupational impairment.

Shorther periods than episode mania

The person may feel :Very positiveHighly productiveFunction well

(But people close to them will have noted the mood sing as being uncharacteristic)

Subsyndromal (sub-clinical)Many people with bipolar disorder will

experience periods of mild depression or mania not pronounced enough to be diagnosed, i.e. Subsyndromal (sub-clinical), between more severe mood swing

Mood Cycle

The Cause of Bipolar DisorderUnknown and likely to be multofactorialA strong inhertitable component (risk of

first degree 5-10%, increase 40-70% for monozygot twins)

Environmental influence

Types of Bipolar DisorderBipolar I disorderBipolar II disorderCyclothymic disorderRapid cyclingMixed episode

Bipolar I and II disorderBipolar I disorder Bipolar II disorder

Is diagnosed when patients have experienced at least one episode of mania

Is diagnosed in people who had at least one episode of depression and one episode of hypomania, but have never experienced an episode of full mania

Onset : 18 years Onset : mid 20’s

30% of people affected are reported to be severely impaired at work

15% of of people are reported to experience dysfunction between episodes

Incidence : similar among females and males

Incidence : more common in females

Cyclothymic DisorderIs diagnosed when adult patient has had

nomerous subsyndromal hypomanic episodes and nomerous depressive disorder over a two year period

Neither of which meet full DSM-V criteria for either mania or depression

Will progress to either bipolar I disorder or bipolar II disorder in 15%-50% of people

Rapid CyclingSpecifies that a patient has had four or

more mood episodes, i.e. Major depressionmania or hypomania

within one yearsAssociated with a reduce response to

treatment and poor outcomes

Mixed EpisodeIs where the patient experiences mania

and depression during the same period, for a week or more

Example : a patient might report feeling sad or hopeless with suicidal thoughts, while feeling highly energised

Identifying patient who may have bipolar disorderPeople with bipolar disorder often have :

A family history of bipolar disorder or “manic depression”

Problems with alcoholDisplayed risk taking behaviour in the past,

e.g sexual, financial or travel relatedA history of complicated and disrupted

circumtances, e.g. Multiple relationship, switching jobs frequently or frequent change of address

Managing patients diagnosed with bipolar disorderGenerally the management is led by a

psychiatristMedicines are mainstay of treatmentGeneral practitioners usually provide repeat

prescription and monitor the patient’s adherence to, and the effectiveness of treatment

Family and friends are an important support network for people with mental illness

Educate patient and their family about bipolar disorder

Patient can reduce the likelihood of experiencing mood swings by maintaining daily routine that include :Regular medicine useHealty sleep patternExerciseAvoidance alcohol

Pharmacological TreatmentThe initial choice of treatment depends on :

whether the patient is manic or depressivethe severity of the symptomspatient preverence the balance of benefit versus risk of adverse effect

Lithium has bee used for over 60 years for the treatment of bipolar disorder

Other medicine, include :Mood stabilisersAntipsychoticAntidepressant

Treatment of episode maniaTappering and then withdrawl of medicines that may

enhance manic episode, e.g antidepresantsLithium (effective treating patient during manic initially in

combination with short-term antipsychotic and benzodiazepines)

Valproat (more rapid response than lithium)

An atypical antipsychotic (may be prescribed alone or in combination with either lithium or valproat)

The typical antipsychotic (effective at controlling acute mania)

Patient with hypomania (the dose may be lower)

ECT(may be effective for patient with treatment resistant and consider if the effect of pharmacological treatment are a serious concern)

Treatment of Episode of DepressionA psychiatrist may prescribe lithium,

valproat, or lamotigrine as a mood stabilising regimen

Antidepressant, e.g SSRI (preferred to trycyclic antidepressant as they are less dangerous if taken in overdose)

Atypical antipsychotics may be used to settle agitation often seen in patients with depression and mania

Treatment of Patient with Rapid Cycling or Mix EpisodesThe medicines may be prescribed for treating

rapid cycling in mood with bipolar disorder :Valproat, lithium, olanzapine, lamotrigine, or

quetiapine as monotherapyLithium with valproat and lithium with carbamazepine

or lamotigrine, in combination

The medicines may be prescribed for treating mix episodes in a patient with bipolar disorder :Olanzapine, quetiapine, and valproat, usually with a

mood stabilizerOlanzapine with fluoxetine or valproat with olanzapine

in combination

Managing Patient during Periods of EuthymiaClinicians can antisipate change in

circumtances that make a relaps symptoms each consultation the clinicican should consider :Are the patient’s symptoms under control?Has there been any change in circumtances that may

cause the patient excess stress, e.g change in occupational, relationship status, social isolation, or finance?

Has the overall health of the patient changed, e.g alcohol compsumption, weight, smoking status or subtance use?

Thank You ..