Clinical Guideline for the Management of Bipolar Disorder in Adults Goal: To improve the quality of life of adults with bipolar disorder Identification and Treatment of Bipolar Disorder Criteria for Diagnosis: Bipolar disorder is a mental illness characterized by the occurrence of one or more of the following: Manic episodes Mixed episodes Hypomanic episodes in the presence (or history) of one or more depressive episodes Subtypes of Bipolar Disorder Bipolar I Disorder One manic or mixed episode (lasting for at least a week). A depressive episode is not required in order to warrant a diagnosis of bipolar I, although most people usually have multiple depressive episodes. Psychosis may also be present in some cases. Bipolar II Disorder One hypomanic episode and at least one depressive episode. The patient must never have had a manic episode. Cyclothymic Disorder Over a period of two years, numerous periods of time with hypomanic symptoms as well as periods of depressive symptoms that does not meet the criteria of a major depressive episode. More than half of the days need to be either high to low, and all periods of wellness need to last for less than two months. The patient must have never had a manic, mixed or major depressive episode during the first two years of the disturbance. Bipolar Disorder NOS Displays of bipolar features that do not meet the criteria for any specific form of bipolar disorder. page 1 of 8
Assessment: Assessment should include evaluation for: Laboratory: Psychotic features Cognitive impairment Risk of suicide Risk of violence to persons or properties Risk-taking behavior Sexually inappropriate behavior Substance abuse Number of prior episodes Average length of episodes Average interepisode duration Interval since the last episode Level of psychosocial and symptomatic functioning between episodes of illness Laboratory and other diagnostic studies should be guided by the psychiatrist s evaluation of the individual s condition and by the choice of pharmacologic treatment Thyroid function should be assessed in mood disordered patients Goals of Treatment: The goals of treatment for bipolar disorder are: Goals of Psychiatric Management: Achieve control of acute manic and depressive symptoms Reduce the number of times that mood cycling and mood instability occur Help people with bipolar disorder function at the highest level possible Minimize lesser bipolar symptoms that still could have an impact Minimize side effects of treatment Help people with bipolar disorder adhere to their management plan Establish and maintain a therapeutic alliance Monitor psychiatric status Provide patient and family education regarding bipolar disorder Promote understanding of and adaptation to the psychosocial effects of bipolar disorder Enhance treatment compliance Promote regular patterns of activity and wakefulness Reduce the morbidity and sequela of the disorder page 2 of 8
Psychotherapeutic Treatments: Pharmacotherapy: Treatment of Episodes: Inpatient family intervention Behavioral family management Family therapy Psychosocial rehabilitation Psychoeducation Cognitive behavioral treatment Support groups Interpersonal and social rhythm therapy Mood stabilizers are primary for mania, but second generation antipsychotics can also be considered Lamotrigine with or without a mood stabilizer is primary for depression Antidepressants should be used only in conjunction with mood stabilizers Atypical antipsychotics and benzodiazepines may also be useful adjunctive medications Manic: The choice of a target serum level for primary agents may involve a compromise between maximizing efficacy and minimizing side effects The individual s general medical condition, including thyroid function, should be checked and any abnormalities treated The use of antidepressant medications should be checked and should preferably be discontinued or avoided Agitation, psychosis and other dangerous behaviors: Benzodiazepines or neuroleptics may be used as adjuncts to manage these symptoms while awaiting the full effects of a primary mood stabilizer or to augment the effects of a mood stabilizer Risk versus benefit needs to be considered with either class of medication If the individual has not significantly improved within two to three weeks: A second mood stabilizer should be added to the treatment regimen Pharmacokinetic interactions among medications must be kept in mind Alternatively, Electroconvulsive Therapy (ECT) may be considered based on judgments about safety, efficacy and service recipient preference as long as the patient has the capacity to give informed consent page 3 of 8
Treatment of Episodes: (cont.) Other Treatment Considerations: Depressive: Intensified psychiatric management Continued use of mood-stabilizing medication, preferably using lamotrigine, at an adequate dosage Specific psychotherapy Antidepressant medication decisions regarding the use of antidepressant medication require assessment of risk versus benefit, prior response, presence of atypical features and service recipient preference ECT for the patient who has the capacity to give informed consent Psychotically depressed individuals: Treatment decisions are similar to those for severely depressed individuals Many individuals with psychotic depression may respond to the combination of a mood stabilizer and an antipsychotic in addition to lamotrigine ECT is also a possible treatment for these individuals Individuals with a severe depressive episode may require other adjunctive agents Mixed or Rapid Cycling: Individuals with mixed episodes: Treatment is guided by the same principles underlying the treatment of manic individuals The use of antidepressants should be avoided if possible Individuals who cycle rapidly between depressive and manic states: Acute phase: Treatment of general medical conditions, including optimization of thyroid functioning, may not be effective Some individuals may respond to the elimination of antidepressants from their treatment regimen May often require hospitalization to obtain control over active symptoms and for the protection of the patient; this is usually of brief duration and allows the initiation of a medication regimen sufficient to control symptoms and allow transfer to outpatient treatment An outpatient visit with a behavioral health practitioner should take place within seven calendar days of discharge from acute care page 4 of 8
Other Treatment Considerations: (cont.) Patient Education: Breakthrough/Relapse: Psychiatric management should help the individual to identify precipitants or early manifestations of breakthrough episodes so that treatment can be initiated promptly Early signs of breakthrough episodes should be treated according to the guidelines for the treatment of acute episodes Insomnia may be either a precipitant or an early indicator of mania or depression Education about the importance of regular sleep habits and the occasional use of benzodiazepines to promote normal sleep patterns may be useful in preventing the development of a manic episode Other early or subtle signs of mania may be treated with the short-term use of benzodiazepines or neuroleptics Maintenance Phase: All patients with bipolar disorder should be informed of the recommendation for maintenance treatment based on the marked decrease in the probability of recurrence with long-term treatment; if the patient insists on discontinuation of medications, a slow taper is assessed to provide less acute destabilization Decisions regarding maintenance treatment should be reviewed at times of clinical change and approximately annually in stable individuals Patients and families must be informed about the potential metabolic side effects of the atypical antipsychotics, particularly clozapine, olanzapine and quetiapine, including weight gain, hyperglycemia, dyslipidemia and increased risk of diabetes mellitus A decision to initiate maintenance medication depends on: Probability of a recurrence with and without medication Likely consequences of a recurrence Risks and other burdens associated with taking a maintenance medication Some individuals will also benefit from a specific psychotherapeutic treatment The following themes should be communicated: Bipolar disorder is a no-fault illness Bipolar disorder is responsive to medication Medication may take time to become effective Continue medications even when you are feeling better Talk to your doctor about any side effects Talk to your doctor before stopping medications or if you have any questions page 5 of 8
Referral: Referrals may be considered for: Case management In-home services Family support School-based services Community treatment programs Sources: American Psychiatric Association: Practice Guidelines for the Treatment of Psychiatric Disorders Compendium 2006, APA 2006 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. APA 2000 Tennessee Department of Mental Health and Developmental Disabilities, July 2002. Texas Implementation of Medication Algorithms: Update to thealgorithms for Treatment of Bipolar I Disorder, J Clin Psychiatry 66: 7, July 2005 National Committee for Quality Assurance. HEDIS 2010, Volume 2, Technical Specifications, Washington, DC: NCQA 2009. page 6 of 8
ALGORITHM FOR TREATMENT OF BDI Currently Hypomaniac/Maniac Copyright 2005, Texas Department of State Health Services, all rights reserved. EUPHORIC MIXED STAGE 1 Monotherapy* Li, VPA, ARP, QTP, RIS, ZIP VPA, ARP, RIS, ZIP Nonresponse: Try alternate monotherapy 1b. OLZ** or CBZ** 1b. OLZ** or CBZ** Nonresponse: Try alternate monotherapy STAGE 2 Two-Drug Combination* Li, VPA, AAP Choose 2 (not 2 AAPs, not ARP or CLOZ) Partial STAGE 3 Two-Drug Combination* Li, VPA, AAPs, CBZ, OXC, TAP Choose 2 (not 2 AAPs, not CLOZ) Partial STAGE 4 = Continuation Li = lithium mmcbz = carbamazepine mmltg = lamotrigine mmoxc = oxcarbazepine mmtpm = topiramate mmvpa = valproate AAP = atypical antipsychotic mmarp = aripiprazole mmcloz = clozapine mmolz = olanzapine mmris = risperidone mmqtp = quetiapine mmzip = ziprasidone TAP = typical antipsychotic ECT = electronconvulsive therapy ECT or Add CLOZ or Li + VPA or + AAP CBZ or OXC *Use targeted adjunctive treatment as necessary before moving to next stage: mmagitation/aggression-clonidine, sedatives mminsomnnia-hypnotics mmanxiety-benzodiazepines, gabapentin **Safety and other concerns led to placement of OLZ and CBZ as alternate 1 st stage choices. It is appropriate to try >1 combination at a given level. New trials from each stage can be labeled Stage 2 (1), Stage 2 (2), etc. page 7 of 8
ALGORITHM FOR TREATMENT OF BDI Currently Depressed Copyright 2005, Texas Department of State Health Services, all rights reserved. *Note safety issue described in text. ** LTG has limited antimanic efficacy and in combination with an antidepressant may require the addition of an antimanic. On Li Increase to.8 On other antimanic (continue) On no antimanic, with history of severe and/or recent mania On no antimanic, without history of severe and/or recent mania = Continuation AAP = atypical antipsychotic BUP = Bupropion CBZ = Carbamazepine ECT = electronconvulsive MAOI = manoamine oxidase inhibitor Li = Lithium LTG = lamotrigine OFC = olanzapine/fluozetine combination QTP = quetiapine SSRI = citalopram, excitalopram, fluoxetine, paroxetine, sertraline, fluvoxamine VEN = Venlafaxine VPA = valproate STAGE 1 Antimanic + LTG Partial LTG QTP* or OFC* STAGE 2 Partial STAGE 3 Combination from Li, LTG, QTP, or OFC Partial STAGE 4 Li, LTG**, QTP, OFC, VPA, or CBZ + SSRI, BUP, or VEN or ECT Partial STAGE 5 MAOIs, Tricyclics, Pramipexole, other AAPs*, OXC, Other Combinations of Drugs at Stages, Inositol, Stimulants, Thyroid page 8 of 8