BIPOLAR DISORDER

 (Mania)

A disorder of mood control characterized by episodes in which the person’s mood and activity level are significantly
disturbed: in some occasions, there is an elevation of mood and increased energy and activity (mania) and in other
occasions, there is a lowering of mood and decreased energy  and activity (depression). Characteristically, recovery is
complete in between the episodes.

Causes

  • Biological, genetic, environmental factors

Clinical features

Patient can present in an acute manic episode, in a depressive episode or in between the episodes.

Mania

  • Elevated, expansive or irritable moods
  • Speech is increased with flight of ideas (increased talkativeness)
  • Increased self image, restlessness, over-activity
  • Decreased need for sleep
  • Delusions of grandeur, increased libido
  • Increased appetite but weight loss occurs due to overactivity
  • Auditory and visual hallucinations may be present

Depression

  • As for depression described above, but with a history of manic episode

Differential diagnosis

  • Organic mental states e.g. drug or alcohol intoxication, delirium
  • Chronic Psychosis

Investigations

  • Good medical, social and personal history
  • Assess for acute state of mania
  • If depressive symptoms, investigate for previous manic episodes
  • Assess for other medical or mental conditions (alcohol or subtance abuse, dementia, suicide/self harm)

Management

Patients with suspected bipolar disorder should be referred for specialist assessment.

Manic episode

Multiple symptoms as above for > 1 week and severe enough to interfere with work/social
activities and/or requiring hospitalization

  • Discontinue antidepressant if any
  • Provide counseling and education
  • Chlorpromazine initially 100-200 mg every 8 hours, then adjust according to response
    • Daily doses of up to 300 mg may be given as a single dose at night
    • Gradually reduce the dose when symptoms of mania resolve and maintain on doses as indicated
      in section on Chronic psychosis
  • Or haloperidol initially 5-10 mg every 12 hours then adjust according to response
    • Up to 30-40 mg daily may be required in severe or resistant cases
  • Or trifluoperazine initially 5-10 mg every 12hours then adjust according to response
    • Up to 40 mg or more daily may be required in severe or resistant cases

If under specialist supervision: initiate a mood stabilizer

  • Carbamazepine initial dose 200 mg at night, increase slowly to 600-1000 mg/day in divided
    doses
  • Or Valproate initial dose of 500 mg/day. Usual maintenance dose 1000-2000 mg

If agitation/restlessness, add a benzodiazepine for short period (until symptoms improve)

  • Diazepam 5-10 mg evey 12 hours
Note
  • If extrapyramidal side-effects (muscle rigidity, dripping of saliva, tongue protrusion, tremors) are
    present while on antipsychotic drugs

    • Add an anticholinergic: Benzhexol initially 2 mg every 12 hours then reduce gradually to once daily
      and eventually give 2 mg only when required

Bipolar depression

Depressive symptoms but with history of manic episode/diagnosis of bipolar disorder

  • Counsel about bipolar disorder
  • Begin treatment with a mood stabilizer (carbamazepine or valproate, see above)
  • Psychoeducation and psychotherapy if available
  • If moderate/severe depression, consider treatment with antidepressant in addition to
    mood stabilizer BUT under specialist supervision (there is risk of triggering a manic episode)

In between episodes

Indication for use of mood stabilizers to prevent both manic and depressive episodes

    • 2 or more episodes (2 manic or 1 manic and 1 depressive)
    • 1 severe manic episode involving significant risk and consequences
  • Valproate (or carbamazepine) as above
Caution
  • Avoid mood stabilizers in pregnant women. Use low dose haloperidol if necessary
  • Use lower doses in elderly
  • Refer adolescents for specialist management

Prevention

  • Good psychosocial support