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 ..