Guidelines in the Treatment of Bipolar Disorder ational Center for Mental Health ueve de Febrero St., Mandaluyong City Telephone o.: 53-900 Website: http://www.ncmh.gov.ph
ational Center for Mental Health ueve de Febrero St., Mandaluyong City Telephone o.: 53-900 Website: http://www.ncmh.gov.ph Organizational Structure OIC, Medical Center Chief II Chief, Medical and Professional Staff (Hospital Service) Chief, Medical and Professional Staff (Community Service) Treatment Protocol Committee Beverly A. Azucena, MD, DPBP, FPPA, MMHoA Beverly A. Azucena, MD, DPBP, FPPA, MMHoA Venus S. Arain, MD, DPBP, FPPA (Life), MHA Bernard B. Argamosa, MD, DSBPP Agnes Joy L. Casiño, MD Joeffrey D. Cruzada, MD, DPBP, FPPA Teresa Rosalie D. Del Valle, MD, DPBP, FPPA, MMHoA Victor C. Vinluan Jr., MD, DPBP, FPPA (Life), MHA www.thefilipinodoctor.com l Sign up and open your clinic to the world.
Algorithm for the Treatment of Bipolar Affective Disorder Characteristic symptoms of Bipolar Affective Disorder 2 History, mental status exam, neuro and physical exam 3 4 5 Indication for hospitalization? Commitment Order from the Court? Admit patient 6 Admission for psychosocial reason? 7 Admit patient 8 Baseline lab exams, psychological exam 9 0 High suicide risk? Admit patient Presently disturbed or agitated? Go to B Figure
A Outpatient 2 3 4 Manic? With psychosis? Medicines from Table and Table 2 Follow up after 2-4 weeks 5 6 7 Medicines from Table 2 Re-assessment of patient; monitor adverse event/side effects Depressed? 0 Mixed Go to #2 8 Intolerable side/adverse effects? Continue with present medication Start with individual therapy Psychosocial rehabilitation 2 9 Assess severity of adverse effects Give biperidine HCl or diphenhydramine Go to #2 3 4 Resolution of side effects? Continue medications Go to C Figure 2 www.thefilipinodoctor.com l Sign up and open your clinic to the world.
B Rapid neuroleptization 2 3 4 Improvement of symptoms? Choose medication from Table (Antipsychotic meds) and Table 2 (Mood stabilizers) Intolerable side/ adverse effects? Go to C 5 6 Admit patient Continue medication for 2-4 weeks 7 Baseline lab exams, psychological exam 8 Go to D Figure 3 0
C Choose another medications 2 Intolerable side effects? Go to C 3 Continue medication for 2-4 weeks 4 Go to D Figure 4 D Increase the dose of medication 2 3 Choose another medication 4 5 Combination of different medications Go to E Figure 5 www.thefilipinodoctor.com l Sign up and open your clinic to the world.
E 2 Combination of present medication with the mood stabilizer 3 4 For admission & other treatment modalities Go to B Figure 6 2
CMH Guidelines in the Treatment of Bipolar Disorder I. Definition Bipolar disorder (previously called manic-depressive psychosis) consists of at least one hypomanic, manic, or mixed episode. Mixed episodes represent a simultaneous mixture of depressive and manic or hypomanic manifestations. Although a minority of patients experience only manic episodes, most bipolar disorder (BD) patients experience episodes of both polarity. The classical definition of BD suggests that this disorder is characterized by the presence and alteration of manic and depressive episodes with a return to premorbid level of functioning between the episodes and a favorable outcome in comparison to schizophrenia. However, today this not always the case. There are two types of Bipolar Disorder: Bipolar I disorder and Bipolar II disorder. Bipolar I disorder is defined as having a clinical course of one or more manic episodes and, sometimes, major depressive episodes. A mixed episode is a period of at least week in which both a manic episode and a major depressive episode occur almost daily. A variant of bipolar disorder characterized by episodes of major depression and hypomania rather than mania is known as Bipolar II disorder. A manic episode is a distinct period of an abnormally and persistently elevated, expansive, or irritable mood lasting for at least one week or less if a patient must be hospitalized. A hypomanic episode lasts at least four days and is similar to a manic episode except that it is not sufficiently severe to cause impairment in social or occupational functioning, and no psychotic features are present. II. Epidemiology Bipolar disorder is relatively common with a lifetime prevalence of approximately.3%. BD-I has a lifetime prevalence of 0-2.4%, BD-II has a lifetime prevalence of 0.3-4.8%. Bipolar disorder has an equal prevalence among men and women. Manic episodes are more common in men, and depressive episodes are more common in women. When manic episodes occur in women, they are more likely than men to present a mixed picture. Typically, BD-I starts before the age of 40. Frequently the correct diagnosis is made after several years because the first episode is psychotic-like or depressive and the diagnosis is only evident after a manic or mixed episode emerges. BD-I is more common in divorced and single persons than among married persons, but this difference may reflect the early onset and the resulting marital discord characteristic of the disorder. A higher than average incidence of BD-I is found among the upper socioeconomic groups. III. Etiology A. Genetic Factors Several family, adoption, and twin studies have documented the heritability of mood disorders. B. Biochemical Factors Studies reported biological abnormalities in patients with mood disorders particularly in the monoamine neurotransmitters--- norepinephrine, dopamine, serotonin, and histamine. C. Psychosocial Factors Life events and environmental stress often precede first episode of mood disorders as it is theorized that stress results in long-lasting changes in the brain's biology. Most psychodynamic theories of mania view manic episodes as a defense against underlying depression. IV. Clinical Features and Symptomatology The onset of mood episodes can be acute or insidious, and emerge from a low-grade, intermittent, and protracted mood substrate which can resemble a dysthymic or cyclothymic state or even personality features. These mood states can also prevail during the inter-episode period and may give rise to low quality of life, interpersonal conflicts and significant global disability. Furthermore, these subthreshold disorders are quite frequent in the families of patients. DSM 5 Criteria Manic Episode A. A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased goal directed activity or energy, lasting at least week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity (three or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behaviour. Inflated self esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hours of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal directed activity (either socially, or at work or school or sexually) or psychomotor www.thefilipinodoctor.com l Sign up and open your clinic to the world. 3
agitation (i.e., purposeless non goal directed activity) 7. Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others or there are psychotic features. D. The episode is not attributable to the psychological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or to another medical condition ote: a full manic episode that emerges during antidepressant treatment (e.g., medication, ECT) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and therefore a bipolar I diagnosis. ote: Criteria A-D constitutes a manic episode. At least I lifetime manic episode is required for the diagnosis of bipolar I disorder. Hypomanic Episode A. A distinct period of abnormally and persistently elevated, expansive or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day B. During the period of mood disturbance and increased energy or activity, three or more of the following symptoms (four if the mood is only irritable) have persisted, represent a noticeable change from usual behaviour and have been present to a significant degree:. Inflated self esteem or grandiosity 2. Decreased need for sleep (e.g., feels rested after only 3 hour of sleep) 3. More talkative than usual or pressure to keep talking 4. Flight of ideas or subjective experience that thoughts are racing 5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed 6. Increase in goal directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non goal oriented activity). 7. Excessive involvement in activities that have a high potential for painfull consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments) C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic D. The disturbance in mood and the change in fuctioning are observable by others E. The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is by definition, manic F. The episode is not attributable to the psychological effects of a substance (e.g., a drug of abuse, a medication, other treatment) ote: A full hypomanic episode that emerges during anti-depressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a hypomanic episode diagnosis. However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess or agitation following anti-depressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis. ote: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar I disorder but are not required for the diagnosis of bipolar I disorder. V. Management A. Assessment Mood disorders should be differentially diagnosed from a number of other morbid conditions, both psychiatric and non-psychiatric. Several mental disorders including alcohol and substance use disorders, normal bereavement, depression in the frame of schizophrenia, anxiety disorders, personality disorders, dementia and a variety of general medical conditions that cause syndromes similar to depression should be differentiated from mood disorders. Also several drugs used for the treatment for a number of diseases might also cause depression. In general the prevailing opinion is that a missed diagnosis of mood disorder in favor of another mental diagnosis may mean that the patients does not receive proper treatment, which has serious consequences. B. Treatment Bipolar patients need a core treatment with the so-called mood stabilizers and depending on the episode and the state of the clinical picture additional agents can be used. Treatment is artificially separated into acute phase treatment and maintenance. During the acute-phase the therapist should decide where the patient should be treated (e.g., outpatient, inpatient, day hospital etc). The decision is based on the assessment of issues like the risk of suicide, the patient's insight, comorbidity, severity of impairment and the psychosocial support available. As a general rule, patients who respond to acute-phase treatment receive a similar treatment during the maintenance phase. During that phase, medication should be kept at the same dosage if possible. The first kind of available treatment for mood disorders was psychotherapy. Some kind of psychosocial, moral or psychotherapeutic intervention was available since antiquity; however only during the 20th century psychotherapy was systematically developed as a formal treatment. 4
A variety of psychoterapies are today available and to some extend have a proven efficacy in the treatment of mood disorders. Although there are still psychoanalytical and psychodynamicoriented approaches, today most professionals prefer the more pragmatic, short term and focused approaches of behavioral or cognitive therapy or utilize an electric approach. Table A: Conventional/typical antipsychotics Acute dose Maintenance dose Haloperidol 20-60 5-20 Chlorpromazine 300-000 50-400 Table B: Atypical antipsychotics Acute dose Maintenance dose Risperidone 4-6 - 4 Olanzapine 0-5 2.5-0 Clozapine 00-900 25-200 Quetiapine 300-800 200-400 Amisulpride 400-800 200-400 Aripiprazole 0-30 5 Table 2: Mood stabilizers Acute dose Maintenance dose Lamotrigine* Week & 2: 25 mg PO 00-200 mg/day in 24 hrly divided doses Week 3 & 4: 50 mg PO 24 hrly Week 5: 00 mg PO 24 hrly or divided doses Lithium carbonate 400 mg - 2 g PO in divided doses for st 5-7 days.2 g PO 6-8 hrly Carbamazepine 400 mg/day in divided 400-600 mg/day PO doses in divided doses Max dose: 600 mg/day Valproic acid 600-000 mg/day 500-2000 mg/day (valproate, Max dose: 2.5 g/day Max dose: 3000 sodium valproate) mg/day Valproate 750 mg/day 250-500 mg/day semisodium Max dose: 60 mg/kg/day (divalproex a) * Recommended for Bipolar Depression only www.thefilipinodoctor.com l Sign up and open your clinic to the world. 5
Index of Drugs Related to the Guideline This index lists the products of interest and/or their therapeutic classifications related to the guideline. This index is not part of the guideline. For the doctor's convenience, brands available in the PPD references are listed under each of the classes. For drug information, refer to the PPD references (PPD, PPD Pocket Version, PPD Text, PPD Tabs, and www.thefilipinodoctor.com). ATIPSCHOTICS Atypical Antipsychotics Asenapine Saphris Aripiprazole Abdin Abilify Clozapine Clopax Clopixene Leponex irva Olanzapine Epilanz-0 Olavex 5/ Olavex 0 Olazin Olzadin Zyprexa Zyprexa Zydis Paliperidone Invega Invega Sustenna Quetiapine Quekline Queppin Seroquel Seroquel XR Risperidone Renuvie Residon Respixl Riscare Risdin Risperdal Risperdal Consta Risperdal Quicklet Zysda Benzamides Amisulpride Amiabel Solian Butyrophenones Haloperidol Haldol Haldol Decanoas Serenace Zuredel Phenothiazines Fluphenazine Sydepres Chlorpromazine Zycloran Thioxanthenes Flupentixol Fluanxol Fluanxol Depot Other Antipsychotics Lithium carbonate Litcab Quilonium - R ATIDEPRESSATS Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine Adep Drafzin Motivest Prodinl Sertraline Deperin Exulten Zolodin Zoloft Escitalopram Escinal Escivex 5/ Escivex 0 Jovia Lexapro Mentumir Zescita Dapoxetine Priligy Paroxetine Seroxat orepinephrine- Reuptake Inhibitors Duloxetine Cymbalta Benzodiazepines Midazolam Midazolex Sedacum Clorazepate Tranxene Anticonvulsants Carbamazepine Carbilepp Tegretol Zynaps Divalproex Depakote ER / Depakote Sprinkle Epival Zystal Lamotrigine Lamictal Motrigine Zyglia Valproic acid Depacon Depakene Syrup Valpros 6