The treatment of bipolar disorder in adults, children and adolescents

DRAFT FOR CONSULTATION The treatment of bipolar disorder in adults, children and adolescents The paragraphs in the draft are numbered for the purposes of consultation. The final version will not contain numbered paragraphs. Understanding NICE guidance information for people with bipolar disorder, their families and carers, and the public DRAFT (January 2006) Page 1 of 49

DRAFT FOR CONSULTATION Contents About this information...4 Clinical guidelines...4 What the recommendations cover...4 How guidelines are used in the NHS...5 What is bipolar disorder?...6 What should happen when I am first diagnosed?...7 Questions you could ask healthcare professionals about bipolar disorder...9 What support can I expect from healthcare professionals?...9 Good information, informed consent and mutual support...9 An equal right to care...10 Physical health checks...11 Who can I expect to treat me?...11 Will I have to stay in hospital or have treatment against my will?...12 What treatments are helpful for people with bipolar disorder?...13 Medication...14 Questions you could ask about medication...17 Psychological therapies...18 Other treatments...18 Questions you could ask healthcare professionals about treatment in general...19 What treatments are most likely to help me with mania and depression?...19 Mania or hypomania...19 Depression...21 Episodes of both mania and depression...23 Rapid cycling bipolar disorder...23 What if the treatment I am started on does not help me?...24 What happens if behave in a disturbed or violent way when having an episode?...25 Can I expect treatment in the long-term after I have recovered from a manic episode or symptoms of depression?...26 What are long-term treatments for bipolar disorder?...27 How long is long-term treatment for bipolar disorder?...28 What should I know about long-term treatment with medication?...29 How do I stay healthy?...33 Will I be offered any further support?...34 Special issues for women of child-bearing age...35 If you are planning to become pregnant...37 If you are pregnant but the pregnancy was unplanned...38 If you are pregnant and you become manic...38 If you are pregnant and you have symptoms of depression...39 What should happen during and after giving birth...40 Breastfeeding...40 Looking after your child...40 DRAFT (January 2006) Page 2 of 49

DRAFT FOR CONSULTATION Special issues for children and young people...41 What should happen when I am first told I have bipolar disorder?...41 Can I choose what treatments I get?...41 Will my parents know about and be involved in my treatment?...42 What treatments can help me?...42 Information for families and carers...44 How can I support an adult with bipolar disorder?...44 How can I be involved in the treatment and care of my child?...45 How can I find support for myself?...46 Questions for families and carers to ask healthcare professionals...46 Where you can find more information...47 If you want to read the other versions of this guideline...47 If you want more information about bipolar disorder...48 If you want to know more about NICE...48 DRAFT (January 2006) Page 3 of 49

About this information 1. This information describes the guidance that the National Institute for Health and Clinical Excellence (called NICE for short) has issued to the NHS on bipolar disorder (which used to be called manic depression). It is based on Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care (NICE Clinical Guideline No. [XX]), which is a clinical guideline produced by NICE for doctors, nurses and others working in the NHS in England and Wales (called healthcare professionals in this booklet). Although this information has been written mainly for people with bipolar disorder, it may also be useful for family members, those who care for people with bipolar disorder and anyone interested in bipolar disorder or in healthcare in general. Clinical guidelines 2. Clinical guidelines are recommendations for good practice. The recommendations in NICE guidelines are prepared by groups of healthcare professionals, people representing the views of those who have or care for someone with the condition, and scientists. The groups look at the evidence available on the best way of treating or managing the condition and make recommendations based on this evidence. What the recommendations cover 3. NICE clinical guidelines can look at diagnosis, treatment, care, selfhelp or a combination of these. The areas that a guideline covers depend on the topic. They are laid out in a document called the scope at the start of guideline development. 4. The recommendations in Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care (NICE Clinical Guideline No. [XX]) cover: DRAFT (January 2006) Page 4 of 49

the care you can expect to receive from your healthcare professional what treatment you can expect to be offered, including medication and psychological therapies advice on self-help the services that may help you with bipolar disorder, including psychiatric or specialist mental health services how families and carers may be able to support you, and get support for themselves. 5. Although the guideline is relevant to all people with bipolar disorder, it will only look at the treatment and care of other illnesses or disorders (such as drug and alcohol misuse and personality disorder) if the person also has bipolar disorder. 6. The guideline does not look at treatments that are not normally available within the NHS. 7. This booklet tells you about the NICE guideline on bipolar disorder. It doesn t attempt to explain what causes bipolar disorder or discuss the treatments in detail. If you want to find out more, see page 48. 8. If you have questions about the specific treatments and options covered, you should ask your doctor or nurse, or another healthcare professional. How guidelines are used in the NHS 9. In general, all healthcare professionals in the NHS are expected to follow NICE s clinical guidelines. But there will be times when the recommendations won t be suitable for someone because of a medical condition, general health, wishes or a combination of these. If you think that the treatment or care you receive does not match the treatment or care described on the pages that follow, you should talk to your doctor, nurse or other healthcare professional involved in your treatment. DRAFT (January 2006) Page 5 of 49

10. You have the right to be fully informed and to share in making decisions about your healthcare, and the care you receive should take account of your individual needs. What is bipolar disorder? 11. Bipolar disorder is the name given to a condition in which a person has periods (or episodes ) of what is called mania and periods of depression. For this reason, the condition was once known as manic depression. It can affect people of any age, from children to older adults (people over 65). 12. During a manic episode, the person usually has feelings of elation (extreme happiness or feeling high ), or irritability, or both. They may also feel over-confident, that they do not need as much sleep as usual, and be driven to take unnecessary risks; their thoughts might race and they may fidget, gesture, or talk a great deal, and have poor concentration. If the episode is severe, the person s speech may become difficult for others to understand and their behaviour may be inappropriate. If the episode is very severe they may also see things that are not really there (hallucinations) and believe things that are not real (delusions). Unfortunately a person having a manic episode may often not realise that there is a problem. 13. Sometimes a person will be more active than normal, but will not usually be elated or overactive as in mania. This is called hypomania and does not usually affect the person s everyday life to the same degree as mania but does change their behaviour. 14. When a person has depression they feel low and lose pleasure in things they used to enjoy and may also have other symptoms such as feeling tired all the time, sleep problems, poor concentration, feelings of worthlessness and/or guilt, thoughts of suicide or harming oneself, and gaining or losing weight. DRAFT (January 2006) Page 6 of 49

15. Episodes of mania and symptoms of depression may alternate with one another, but for many people their main mood is of feeling depressed. Depressed episodes can last for about 6 months. Manic episodes tend to last for 12 weeks but can be as short as 2 weeks. Rarely people may experience both mania and depression almost simultaneously. 16. Some people have no more than one episode of mania or depression per year and feel well otherwise, while others have more episodes and often do not fully recover between episodes. People who have more than four episodes in a year are said to have rapid cycling bipolar disorder; in some people, the change or switch from mania to depression may happen even more quickly, sometimes from week to week or even within a single day (this is called ultra rapid cycling bipolar disorder). 17. People who have episodes of mania and symptoms of depression are said to have bipolar I disorder, while people with hypomania and depression are said to have bipolar II disorder. We know most about the treatment of bipolar I disorder. 18. Sometimes people who have bipolar disorder can have drug and alcohol problems and personality problems. 19. Bipolar disorder can last for a long time, can be very distressing and can affect a person s daily work, schoolwork, social activities and relationships with other people. But many people learn to manage their symptoms with the help of medication and psychological support and continue to lead normal lives despite being ill occasionally. What should happen when I am first diagnosed? 20. Diagnosis of bipolar disorder should usually be made by a psychiatrist or other mental health specialist. If you see your GP about your symptoms, you should usually be offered an appointment with a DRAFT (January 2006) Page 7 of 49

specialist if the GP thinks you may have bipolar disorder. If you have mania or severe symptoms of depression and it is thought you could be a risk to yourself or others, your GP should arrange for you to see a specialist immediately. 21. The specialist should ask you a number of questions which will help him or her to work out what your needs are and what treatments could help you best. You should be asked about: whether any other members of your family had or have bipolar disorder any previous episodes of mania and/or episodes of depression and any symptoms you may have had between episodes events or your feelings leading up to the illness your relationships with other people and your daily life whether you feel anxious (and things that make you anxious) whether you have any other illnesses all prescribed and non-prescribed drugs that you have taken and if you have problems with drugs or alcohol. 22. The healthcare professional may ask a member of your family about these things as well, but you should be asked for your agreement first. 23. Depending on your symptoms you might also be checked to see whether you have a physical problem such as thyroid disease. 24. When you are first diagnosed with bipolar disorder, your healthcare professional should ask you if you have had thoughts of harming yourself or of suicide, or if there is any other risk to your health or wellbeing. 25. If you may be at risk of harming yourself or others, your healthcare professional should develop a plan with you of what should happen if there is a crisis. This should include a list of things that make you feel DRAFT (January 2006) Page 8 of 49

stressed or anxious, and things that you recognise as warning signs leading up to an episode; what to do (such as taking more medicine) if you have manic episodes that develop very quickly and you can recognise the warning signs; and how all your healthcare professionals should work together if you have a crisis. Questions you could ask healthcare professionals about bipolar disorder What makes you think I have bipolar disorder? What do you think causes bipolar disorder? Are all of my symptoms caused by bipolar disorder? How might bipolar disorder affect my everyday life and what might it mean for my physical health? What support can I expect from healthcare professionals? Good information, informed consent and mutual support 26. Your healthcare professionals should build up a good relationship with you and your family members or carers. You should also be given specific information about bipolar disorder, the treatments and any medication you might be offered, how it should be taken, and any side effects you might have while taking it. 27. When explaining things to you, healthcare professionals should use everyday, non-technical language. If you have any additional needs (for example, you have a learning difficulty or a disability), the information and any treatments or care that you receive should be adapted to suit you. If your first language is not English, written material should be provided in your preferred first language and you should have access to an interpreter if needed. You may also be able DRAFT (January 2006) Page 9 of 49

to receive psychological treatments and information about medication in your first language. 28. With the right kind of information you can make informed decisions about your care. However, if you have a very severe episode of mania or symptoms of depression, you may no longer be able to make an informed decision or clearly communicate your needs. You might need treatment under the Mental Health Act. This is a law that allows a person with a mental disorder to be treated against their will, or without their agreement, if they are judged to be at serious risk to themselves or others. This is sometimes called being sectioned. So that healthcare professionals can act in your best interests, they might work with you to draw up in advance a set of written instructions (called advance directives) that set out what kind of treatments you do and do not want. A copy of the advance directive should be given to you, the healthcare professional co-ordinating your care and your GP. 29. Your healthcare professional should tell you about self-help groups and support groups and should encourage you to go. Such groups may be able to give you useful information about how to recognise early warning signs of illness, offer you support in times of crisis and give you further information on treatment and how to cope with side effects of medication. Many people with bipolar disorder find it helpful to meet other people with the condition and share their experiences. An equal right to care 30. If you have bipolar disorder and a learning difficulty or personality problems, you should receive the same level of care as other people. Your healthcare professional should take account of any other medication you may be taking. DRAFT (January 2006) Page 10 of 49

Physical health checks 31. Before starting on any medication, your healthcare professional should ask you whether you smoke and how much alcohol you consume. He or she should also make sure that you have blood tests, for example looking at thyroid, liver and kidney functions as well as your blood sugar and cholesterol levels. Your blood pressure, weight and height should also be measured. Depending on your general health, you may be asked to have other tests, such as a chest X-ray and an electrocardiogram (ECG). 32. It is important that while you are receiving treatment for bipolar disorder your healthcare professional offers you a yearly physical health check because some of the medicines can cause weight problems and other difficulties. You should have your blood sugar, blood pressure and weight checked at least once a year and, if you are over 40, your cholesterol levels. 33. Your healthcare professional should talk to you about the results of these checks and write them in your medical notes. Other professionals involved in your care should also be told about the results so that they know about any particular problems when offering you treatments. Who can I expect to treat me? 34. Most people with bipolar disorder receive most of their treatment from a psychiatrist and other specialist mental health professionals, although your GP will continue to pay an important part in your treatment. DRAFT (January 2006) Page 11 of 49

35. If your GP is or has been responsible for your treatment for bipolar disorder: you may be offered an appointment with a specialist mental health professional if you have recently registered with a new practice you should be offered an appointment with a specialist mental health professional if your symptoms become a lot worse (for example if you have a manic episode or if you have severe depression), or if you are thought to be a risk to yourself or others you may be offered an appointment with a specialist mental health professional if treatment has not helped you, if you are finding it difficult to continue treatment, if you have drug or alcohol problems, or if you are considering stopping medication after feeling well again. 36. Whether you are being treated by a GP or a specialist mental health professional or a group of healthcare professionals you should receive the same level of care and where possible you should be able to continue your treatment with the same healthcare professional(s). Your mental health, how the symptoms are affecting your everyday life and your treatment should be regularly reviewed. Will I have to stay in hospital or have treatment against my will? 37. You should receive most of your treatment without having to stay in hospital. However, if your symptoms are very severe, or you are being treated under the Mental Health Act, you can be admitted to hospital. Being in hospital means that you will be in a safe and supportive place and that you should be able to receive more intensive treatment. DRAFT (January 2006) Page 12 of 49

38. As an alternative to staying in hospital, your healthcare professional may offer you treatment in a day hospital, where you spend most of the day but return home at night. 39. Your discharge from hospital should be carefully planned and before you leave hospital, your healthcare professional should ask you if you have had thoughts of harming yourself or of suicide, or if you feel there is any other risk to your health or well-being. What treatments are helpful for people with bipolar disorder? 40. Your treatment may vary depending on whether you are having a manic episode or symptoms of depression, you have rapid cycling bipolar disorder, or you are having long-term treatment. 41. In order to plan your treatment your healthcare professional should discuss with you any treatment you have had before and whether or not it helped you. He or she should also take account of your own preference for treatment. 42. If you are a woman at an age where you could get pregnant (this is often called being of child-bearing age ), your healthcare professional should talk to you about the possible risks involved. For example, you might become ill again, the medication might harm the unborn child, and there might also be risks associated with stopping taking medication during pregnancy. Your healthcare professional should talk to you about suitable contraception. If you plan to have a child you are encouraged to discuss it with your healthcare professional. See also the section on Special issues for women of child-bearing age. 43. At the start of treatment, particularly if you have been manic or had severe depression, your healthcare professional should see you within 1 week. After that they should see you regularly, for example every 2 DRAFT (January 2006) Page 13 of 49

4 weeks in the first 3 months and at longer intervals after that if appropriate. 44. If you are over 65, your healthcare professional may consider involving a specialist old-age psychiatric service in your care if you have other illnesses or problems, such as confusion. If you are offered medication, it should be a dose appropriate to your age (usually lower). If you are taking other medicines, your healthcare professional should take extra care because they may react badly with drugs you are being offered for mania. 45. Some people put on weight when taking medication for bipolar disorder. If you gain weight during treatment healthcare professionals should look closely at your medication and may: advise you about diet and arrange for you to have extra support from your GP or from mental health services advise you to take regular exercise arrange for you to see a specialist mental health diet clinic arrange for you to see a dietician, especially if you have a physical illness in addition to bipolar disorder. 46. If you have had thoughts about suicide, medication for mania and antidepressants should only be given to you in small quantities. Medication Medication for mania 47. The main treatments for mania are antipsychotics, lithium or sodium valproate. 48. Antipsychotic medication (which is used to treat other psychosis such as schizophrenia) can be helpful in treating mania particularly if there are psychotic symptoms such as hallucinations and/or delusions. The atypical antipsychotics (such as olanzapine, quetiapine and DRAFT (January 2006) Page 14 of 49

risperidone) are most often used as they tend to have fewer side effects than the older typical antipsychotics (such as haloperidol and chlorpromazine). 49. Lithium is a simple chemical (a type of salt) and is one of the main long-term treatments for bipolar disorder, but it can also be used to treat mania. However as it can have some serious side effects if the blood level is too high, blood tests are needed when you first start it. 50. Valproate and carbamazepine are called anticonvulsants and are also used in the treatment of epilepsy. Of these valproate is most often used in the treatment of bipolar disorder, but pregnant women with bipolar disorder should not usually take as it may cause harm to the unborn child. 51. Lamotrigine is also a fairly new drug in the treatment of bipolar disorder; while you should not usually be offered lamotrigine on its own or as a first treatment, it may help to treat symptoms of depression. 52. A group of drugs called benzodiazepines may sometimes be used in addition to medication for mania to help with anxiety and sleep problems. Antidepressants 53. One of the main treatments for depression in bipolar disorder is an antidepressant. People with bipolar disorder are usually prescribed an antidepressant of a type called selective serotonin reuptake inhibitors (SSRIs). 54. That there is always a risk that a person taking antidepressants for bipolar disorder will switch into a manic episode. For this reason they should also be offered medication for mania to prevent a manic episode. DRAFT (January 2006) Page 15 of 49

What should happen if you start taking antidepressants 55. You may be worried about taking antidepressant medication and your healthcare professional should talk to you about any concerns you may have. For example that this is no risk of being addicted to antidepressants. Nor is there any need to take more of the medication to feel the same effect as time goes on. 56. If you are offered antidepressants, you should be given full information about them. For example that: you could switch into mania or hypomania the medication may take some time to work, and that improvement in your symptoms might be slow and irregular you should take the medication as prescribed and that there may be unpleasant symptoms when stopping the medication your healthcare professional should see you regularly to check for signs of restlessness, thoughts about suicide, and increased anxiety or agitation (particularly when you first start taking an SSRI);if you are under 30 you should usually be seen within 1 week of starting treatment you need to seek help quickly from your healthcare professional if side effects are distressing. 57. If you have feelings of restlessness or agitation that last a long time or are very severe, your healthcare professional should consider whether you should stop taking that medication. 58. If you are offered an SSRI and you are taking other medicines (such as non-steroidal anti-inflammatory drugs), your healthcare professional may offer you another medicine to prevent possible side effects such as bleeding in the digestive system. DRAFT (January 2006) Page 16 of 49

Stopping antidepressants 59. If your symptoms have improved and you feel better, your healthcare professional should give you smaller amounts of the medication over several weeks until stopping, but should advise you to carry on taking medication for mania to avoid the risk of switching. Questions you could ask about medication If you are offered medication, you might want to know more about it, so you could ask one or more of these questions. How will the medication help me? What are the advantages and disadvantages of the different medications available? How long will it take before I start to feel better? Does it matter if I miss a dose? How can I be sure that I am taking the correct dose? Can I stop taking the medication if I feel better? Is there a leaflet or other written material about the medication that I can read? You should be informed about the side effects associated with any medication you are taking. If you are unsure, you might consider asking the following questions. Does this medication have any side effects? What should I do if I get any of these side effects? How long do these side effects last? Are there any long-term side effects of taking this medication? DRAFT (January 2006) Page 17 of 49

Psychological therapies 60. Although medication has traditionally been the main treatment for bipolar disorder, psychological therapy combined with medication may also help, particularly with symptoms of depression. 61. Psychological therapy can help if you have moderate symptoms or symptoms that keep coming back. Therapy should address your depressive thoughts and symptoms, any problems you may have and how to address them, and how to improve your relationships. 62. Psychological therapy can also help as a long-term treatment (for at least 16 sessions over 6 9 months) in addition to medication. This should include education about bipolar disorder and advice on how to sleep well and regularly. It should also help you to keep an eye on your mood, recognise early warning signs, and prevent the early stages developing into a full-blown episode. Your healthcare professional should also help you to improve your coping skills. You may also be able to have family based treatment if you live with relatives. Other treatments 63. Very rarely a treatment called electroconvulsive therapy (ECT) may be offered to you if you have very severe symptoms and/or if you have tried lots of other kinds or treatments and your symptoms have not improved. ECT is always given in hospital and it involves passing a small electric current through the brain. 64. You should not usually be offered a treatment called transcranial magnetic stimulation as an alternative to an antidepressant for symptoms of depression. DRAFT (January 2006) Page 18 of 49

Questions you could ask healthcare professionals about treatment in general What treatment will I need? What choices do I have about treatment? How long will I need treatment for? How will having treatment for bipolar disorder affect my daily life/work [for example, driving or working machinery?], etc? What treatments are most likely to help me with mania and depression? Mania or hypomania 65. Healthcare professionals may give you advice to help you cope with your manic feelings. This may include avoiding any situation which may make you over-excited; doing things that help you to feel calm; and getting into a routine (especially sleeping). You may be encouraged to delay making important decisions because you may later regret decisions you have taken when having an episode. 66. If you are taking antidepressant medication at the time that a manic episode starts, your healthcare professional should stop the medication; this may be done suddenly or gradually depending on the severity of your symptoms and whether you have previously experienced symptoms when stopping antidepressants (called withdrawal symptoms). If you are not currently taking medication for mania 67. Your healthcare professional may normally offer you one of the following: DRAFT (January 2006) Page 19 of 49

antipsychotic medication valproate lithium. 68. Lithium does not work as quickly as antipsychotic medication and valproate, so should normally only be offered to you if you have less severe symptoms. Valproate should not usually be offered to women of child-bearing age. Antipsychotics usually work best for people who have severe symptoms or whose behaviour is disturbed. 69. If your healthcare professional offers you an antipsychotic it should be an atypical antipsychotic such as olanzapine, quetiapine or risperidone because they have fewer side effects. However these drugs also have some side effects and your healthcare professional should make sure that you are not put at increased risk by these, for example if you have diabetes. Healthcare professionals may also consider offering pregnant women atypical antipsychotics. If antipsychotic medication does not help improve all the symptoms, your healthcare professional may think about combining the medication with valproate or lithium. 70. If your behaviour is disturbed and/or you have not been able to sleep, your healthcare professional may offer you medication called a benzodiazepine in addition to medication for mania, which will help to calm you down and sleep better. 71. If you are having a manic episode gabapentin, lamotrigine and topiramate should not be offered to you, and carbamazepine should not usually be offered to you. If you are currently taking medication for mania 72. If you are already taking lithium or valproate and you have a manic episode, your healthcare professional should first increase the dose of your medication until you feel that the symptoms start to improve. If you are taking lithium, your healthcare professional should first arrange DRAFT (January 2006) Page 20 of 49

a blood test to check how much of the drug is in your blood. If your symptoms do not improve, then you may be offered olanzapine, quetiapine or risperidone in addition to lithium or valproate. If you have severe mania, your healthcare professional might offer you an antipsychotic straight away in addition to increasing the dose of lithium or valproate; however this depends on your symptoms and how much medication you are taking already. 73. If you are already taking carbamazepine and you have a manic episode, healthcare professionals should not usually increase the dose, but may offer you an antipsychotic in addition to carbamazepine. Because carbamazepine can react badly with other medicines, your healthcare professional should make sure that you are getting the right dose. Depression 74. Healthcare professionals may give you advice about helping to reduce symptoms of depression, particularly if they are not very severe, for example by doing exercise regularly, planning activities, doing things that are pleasurable and give you a sense of achievement, making sure you have a good diet and sleep well, and getting further support to help you in your daily life. 75. If your symptoms of depression have not in the past led to a more severe or long-lasting depression, or your healthcare professional does not think it will become more severe, he or she will not usually offer you treatment right away, but should arrange to see you again, usually within 2 weeks. 76. If you are already taking medication for mania, your healthcare professional should check that you are taking the right amount of medication and change the dose if necessary. 77. Your healthcare professional may then offer you an antidepressant (an SSRI) together with medication for mania if you are not already taking DRAFT (January 2006) Page 21 of 49

it. Quetiapine may be offered if you have moderate or severe depression so long as you are not already taking an antipsychotic. 78. If you are taking an antidepressant, it is best to also take medication for mania because there is a risk that antidepressants can start a manic episode. However if you decide not to take medication for mania, your healthcare professional should warn you about this risk. He or she should see you regularly if you take an antidepressant on its own and you should first be given a small amount of medication, which can be increased if necessary. 79. If you have symptoms of depression (and have not had rapid cycling symptoms recently), you may be offered a psychological treatment in addition to medication. But you may also be offered it if you have decided not to take an antidepressant or the medication has not helped you after 2 4 weeks. The therapy should address your depressive thoughts and symptoms, any problems you may have and how to address them, and how to improve your relationships. 80. If you have depression and your mood has recently been up and down, your healthcare professional should not offer you antidepressants, but may increase the dose of your medication for mania, or offer you another medicine for mania or a medicine called lamotrigine in addition to your current medication. Although lamotrigine is not recommended for manic episodes alone, it can help if you have symptoms of depression. 81. If you have had repeated periods of depression or you have had symptoms of depression for a long time that make it difficult to carry on with daily life, healthcare professionals may offer you the following treatments in this order: psychological therapy long-term treatment with a small amount of an antidepressant (an SSRI) together with medication for mania DRAFT (January 2006) Page 22 of 49

quetiapine (as long as the medication for mania is not an antipsychotic) lamotrigine (if you have bipolar II disorder you may be offered lamotrigine on its own). 82. If you have a severe depression and you also have symptoms of psychosis (including hallucinations and delusions), your healthcare professional may offer you antipsychotic medication (such as olanzapine, quetiapine or risperidone) in addition to any other treatment you are having. Episodes of both mania and depression 83. If you have an episode of both mania and depression (the symptoms can be mixed or can alternate very quickly, usually within a few hours), you may be offered medication for mania, but not usually an antidepressant. If you are already taking medication for mania, your healthcare professional may increase the dose and/or offer you an antipsychotic depending on what you are already taking. 84. Your healthcare professional should arrange to see you at least weekly so that they can make sure that you are beginning to get better. They should ask you if you have had thoughts about suicide. Rapid cycling bipolar disorder 85. Your treatment should be the same as above but your healthcare professional should also: Look at all the treatments you have had so far for bipolar disorder; he or she may then offer you an effective treatment that you may have had before. Look at treating your illness as a whole (the wider pattern of ups and downs) rather than treating one particular episode or symptom. DRAFT (January 2006) Page 23 of 49

Encourage you to keep a diary of your moods and feelings to help the healthcare professional look at changes in your symptoms and how helpful treatments have been. What if the treatment I am started on does not help me? 86. In general if the treatment you are started on does not help you, healthcare professionals will look at your treatment again and may make changes to it or offer you other treatments. 87. If you have symptoms of depression and antidepressants do not help, your healthcare professional should offer you another assessment. He or she may then increase the dose of the antidepressant, offer you a different kind of antidepressant (such as mirtazapine or venlafaxine), or offer you quetiapine, olanzapine or lithium in addition to the antidepressant if you are not taking any of these medications already. 88. If you have tried three different treatments but these have not helped you, your healthcare professional may offer you a referral to a consultant psychiatrist who is an expert in bipolar disorder. 89. Your healthcare professional should only offer you electroconvulsive therapy (ECT) if other treatments have not helped you and/or your healthcare professional thinks your life may be at risk, for example, if you have severe depression, a long or severe manic episode or catatonia (a severe condition which can lead to extreme excitement and activity or to a loss of movement in the muscles and extreme feelings of disinterest in the world). 90. If you are offered ECT it should only be after all the disadvantages and advantages of the treatment have been assessed. This would include the risk of having an anaesthetic, the risk of having ECT if you have any other illnesses or problems, the risk of having problems (such as loss of memory) after the treatment, and also the risks of not having the treatment, for example your symptoms becoming worse. DRAFT (January 2006) Page 24 of 49

91. If you have ECT, healthcare professionals may stop or reduce the amount of lithium or benzodiazepines you may be taking, take extra care during treatment if you are taking anticonvulsants, and carefully check on how you are feeling. Questions you could ask healthcare professionals if you do not feel better after treatment I had expected to feel differently from how I am feeling now. Can we discuss how I am getting on? I feel worse, not better. Can we discuss my treatment? Do we need to look at different types of treatment? What happens if behave in a disturbed or violent way when having an episode? 92. If you show signs of behaving violently or in a way that might seriously disturb others, your healthcare professional should start by looking at your lifestyle and surroundings and anything else that might help to reduce your stress. Healthcare professionals should only try and restrain you or use medication to control the behaviour if these approaches have not worked. 93. If you do behave in a way that seriously disturbs others or you are a risk to yourself, or it is thought that you could behave in this way, your healthcare professional should make sure that you are in a place where you are safe and feel supported, check on your physical health, and may help you to do activities that do not make you feel agitated. 94. If you are given medication to control the behaviour it should usually be medication that can be swallowed (such as lorazepam or an antipsychotic, or a combination of an antipsychotic and DRAFT (January 2006) Page 25 of 49

benzodiazepine) rather than one that has to be injected into a muscle. If this medication does not calm you down, then healthcare professionals may give you olanzapine or lorazepam (and sometimes haloperidol) that will be injected into the muscle (this might be more than once a day). This should calm you down quite quickly (it is called rapid tranquillisation ). If you are given olanzapine and benzodiazepine as an injection, they should not be given to you less than an hour apart. Can I expect treatment in the long-term after I have recovered from a manic episode or symptoms of depression? 95. Your healthcare professional may offer you long-term treatment to help to reduce the risk of symptoms coming back and improve the quality of your daily life. 96. You will normally be offered long-term treatment in the following circumstances: after a severe manic episode if you have bipolar I disorder and you have had two or more episodes if you have bipolar II disorder and your daily life is severely affected by your symptoms, you have had thoughts of suicide, or you are likely to have further episodes. 97. Before offering you medication as long-term treatment, and to make sure you receive the treatment that most suits your needs, your healthcare professional should look carefully at whether previous treatments have helped you, and how your mood changes as a result of events in your life; look at your medical history and any risks to your health and take into account your own choice for medication. DRAFT (January 2006) Page 26 of 49

What are long-term treatments for bipolar disorder? 98. Such treatments are mainly medication but you may also be offered psychological and other treatments. 99. Healthcare professionals may first offer you an atypical antipsychotic (usually one that you took during an episode) or olanzapine; if this does not suit you or does not help you may then be offered lithium or valproate (especially if you have more symptoms of depression than mania, but not usually if you are a woman of child-bearing age), or lithium. 100. If these do not help you within at least 6 months, then you may be offered two of the medicines together. If a combination of the medicines does not help you, then your healthcare professional may offer you an appointment with a professional who is an expert in bipolar disorder, or may offer you lamotrigine (especially if you have bipolar II disorder) and possibly carbamazepine. 101. When you have recovered from depression, you should not usually carry on taking the antidepressants because there is no evidence that doing so helps to stop the symptoms coming back and there might also be a risk that people might develop mania while carrying on taking antidepressants. 102. However if you are not taking medication for mania and you have not had an episode of mania for 5 years, but you do have symptoms of depression that have lasted for a long time, you may be offered long-term treatment with an antidepressant (SSRIs) together with medication for mania or cognitive behavioural therapy (with medication for mania). 103. If you are relatively stable but with some continuing symptoms, you may be offered psychological therapy (for at least 16 sessions over 6 9 months) in addition to medication. This should include DRAFT (January 2006) Page 27 of 49

education about the illness, advice on coping skills, on how to sleep well and regularly, and on taking medication as prescribed. It should also help you to keep an eye on your mood, recognise early warning signs, and prevent the early stages developing into a full-blown episode. Healthcare professionals should make sure that psychological treatments are given by appropriately trained people. 104. If you live with your family or see them regularly, and if it is thought that it could help you, your healthcare professional may offer you a psychological therapy that involves you and your family. This should involve education about the illness, improving communication skills and helping you and your family to solve problems. 105. If you have symptoms of depression that have lasted a long time, and your healthcare professional thinks that further support would help you, he or she may offer you what is called a befriending service in addition to any medication or psychological treatments you are having. Befriending involves a trained volunteer visiting you once a week for between 2 and 6 months to talk and listen to you, and offer practical advice and support. 106. If you have problems with alcohol or drugs, your healthcare professional may offer you psychological treatment to help you cope with the problem, such as education about alcohol and drugs and encouraging you to develop a plan for changing your behaviour that suits your needs. How long is long-term treatment for bipolar disorder? 107. This varies from person to person, but long-term treatment usually lasts for at least 5 years. Your healthcare professional should discuss this with you and make sure that he or she sees you regularly. If you wish to stop taking medication within this time, you should discuss this with your healthcare professional. DRAFT (January 2006) Page 28 of 49

108. If, after carefully discussing the advantages and disadvantages with your healthcare professional, you decide not to take medication long-term, you should still be offered regular appointments with professionals. What should I know about long-term treatment with medication? If you are offered an antipsychotic as long-term treatment 109. Before offering you an antipsychotic, your healthcare professional should discuss with you risks of taking the medicine (which may include weight gain) as well as the benefits. If you decide to begin treatment with an antipsychotic, he or she should measure your weight and height. Your healthcare professional should also check the amount of glucose and cholesterol in your blood and, if you have heart problems, arrange for you to have an ECG. 110. You should not usually be offered antipsychotics by injection, unless you find it difficult to take antipsychotics in tablet form. 111. Once you start taking the medication, your healthcare professional should measure your weight regularly, especially if you have put on a lot of weight. He or she should also arrange for you to have your cholesterol and glucose levels in your blood tested regularly after starting the medication, especially if you are taking olanzapine, and more often if your glucose or cholesterol blood levels are raised. If you are offered lithium as long-term treatment 112. Before you start taking lithium, your healthcare professional should talk to you about taking the medication as prescribed and not missing doses or stopping the drug suddenly; you should also be advised to drink water regularly. Your height and weight should be measured and your healthcare professional should arrange for your blood, urine, thyroid and kidneys to be checked before you start the DRAFT (January 2006) Page 29 of 49

treatment, and your heart should be checked using an electrocardiogram (ECG) if you are a risk of heart disease. 113. Your healthcare professional should check your blood within 1 week of starting lithium or any change in dose and regularly until a beneficial level is reached. Your blood should then be checked regularly (more often if there is a problem) and your healthcare professional should take extra care if you are over 65. The side effects of lithium, particularly if the blood level is too high include: tingling sensations, problems with co-ordination, unintentional movements of the muscles and problems with memory and concentration. Your weight should be monitored regularly and you may need additional thyroid and kidney tests 114. If you are taking lithium your healthcare professional should not usually offer you non-steroidal anti-inflammatory drugs (you should also be warned not to buy these drugs over-the-counter). If you are offered this medication your healthcare professional should arrange to see you more regularly. 115. If you start vomiting or you have diarrhoea when taking lithium, you should be advised to seek medical help and to drink water if you have these symptoms after exercising, when in hot climates, or if you have a high temperature, especially if you are over 65 and have chest infections or pneumonia, or are immobile for long periods. If you are over 65, your healthcare professional should also be very careful when prescribing diuretics (a type of medicine that helps people to pass more urine). Your healthcare professional may advise you to stop taking lithium for up to 7 days if you become severely ill. 116. If for some reason you stop taking lithium very suddenly (for instance if you feel that it is not working), your healthcare professional should talk to you about taking an atypical antipsychotic or valproate as well as lithium to try to improve your symptoms. Alternatively your healthcare professional may offer you one of these drugs on its own. DRAFT (January 2006) Page 30 of 49

Your healthcare professional should arrange to see you regularly to check for signs of mania and depression. If you are offered valproate as long-term treatment 117. If you are a woman of child-bearing age you should not usually be offered valproate, but if it is prescribed, your healthcare professional should make sure that you are using adequate contraception because there may be risks to the unborn child with valproate. These risks should be fully explained to you. See also the section, Special issues for women of child-bearing age. 118. Before you start treatment with valproate, your healthcare professional should measure your height and weight and check your blood and your liver. Your healthcare professional should arrange for you to have your liver and blood tested 6 months after starting treatment and check your weight if you are putting on a lot of weight. However you will not usually need to have regular blood tests unless the medication is not helping you or there is a problem. 119. Your healthcare professional should be careful if you are also taking an anticonvulsant, and see you more frequently if you are over 65. 120. Your healthcare professional should talk with you about how to spot signs of problems with your blood or liver and to seek urgent medical help if symptoms develop. If there are such problems, your healthcare professional should advise you to stop taking the medication immediately. If you are offered lamotrigine as long-term treatment 121. Your healthcare professional should start you on small amounts of the medication which should be increased gradually, especially if you are also taking valproate. DRAFT (January 2006) Page 31 of 49

122. If you a woman taking the contraceptive Pill, your healthcare professional should talk with you about using another kind of contraception, and/or increasing the dose of lamotrigine if you are taking it. 123. Your healthcare professional should advise you to seek medical help urgently if you develop a rash. If it is caused by the medication, your healthcare professional should advise you to stop taking it. If you are offered carbamazepine as long-term treatment 124. You should only start treatment with carbamazepine after an expert in bipolar disorder has been consulted. When starting treatment you should have your liver and blood tested. 125. Once you have started the treatment the amount of medication should be increased gradually to reduce the risk of you having problems with physical co-ordination. 126. Your healthcare professional should arrange for you to have your liver and blood tested 6 months after starting treatment and check your weight if you have put on a lot of weight. He or she should also check your blood and urine every 6 months and also make sure that the medication is not reacting badly with other drugs (including the contraceptive Pill), particularly if you start taking a new drug. Your healthcare professional should also take extra care if you are over 65 and/or you have physical problems and you are taking other drugs. If you are advised to stop taking the medication 127. If you are advised to stop taking an antipsychotic, lithium, valproate, lamotrigine or carbamazepine, usually the amount of the medication should be reduced gradually over at least 4 weeks. 128. If you are stopping taking an antipsychotic and you are not continuing with other medication, or you have had a few manic DRAFT (January 2006) Page 32 of 49