Bipolar Treatment Plans

Notes for Otago Academic Training ProgrammeJune 2017

Chris Gale

Aims

● Relieve symptoms,

● Reduce the morbidity associated with the mooddisorder

● Limit the disability

● Limit self-harm risk or potential risk of fatality.

● The end goal is achieving recovery topremorbid level of functioning with improvedhealth awareness and quality of life.

Phases care

● Acute: from relapse or first presentation untilresponse.

● Continuation: from response until symptomscompletely abate or remit.

● Maintenance: from remission until recovery orrelapse.

(Relapse is more frequent than oftenacknowledged).

Formulate

● Formulation builds on diagnosis, which has reliability butlacks the validity of formulation because the lattercontextualises the problems of the individual andprovides a richer understanding as to why he or she isunwell now.

● Formulation is also necessary because both treatmentsand diagnoses have been derived from studies of groupswhereas management of mood disorders is an individual(personalised) endeavour; therefore it is important tounderstand the person in the context of their uniquecircumstances

Case formulation descriptions is that the latter recognises the resilienceand strengths of a patient

Resilience refers to the ability to adapt to and recover from stress (and isnot simply the absence of vulnerability:

Resilience mechanisms can also be the target of clinical work,particularly in the maintenance phase of mood disorder treatment

For instance, resilience to mood disorders can be strengthened

biologically e.g., using lithium as a neuroprotective agent

psychologically e.g., teaching cognitive reappraisal skills

socially e.g., improving social support

through lifestyle change e.g., building exercise habits (Hare et al.,2014).

Improved resilience is a transdiagnostic treatment goal in recovery-oriented mental health services

Personalisation.

● In acute phase, primarily biological,

● In continuation, shared– Formulation

– Treatment goals

– Monitoring methods

– Consideration advance directive acute relapse.

● In maintenance, self monitoring and knowingwhen to seek help.

Chronic Disease model

● There is growing recognition that mood disorders are in many caseschronic illnesses with a waxing and waning course.

● They are therefore best managed using a chronic illness model,which elevates the person’s active engagement in the managementof their condition.

● Unlike acute illnesses, where the clinician’s expert tools are theprimary lever for change, chronic illness management centres on theperson withthe disorder.

● Consequently, while current classification systems and the treatmentscience that depends on them emphasise objective features of thecase, clinicians must be equally attentive to the patient’s subjectiveexperience of the disorder and the management they are receiving

Optimal Treatment

● requires not only the involvement of severalhealth care professionals including a generalpractitioner (GP), mental health nurse,psychiatrist and psychological counsellors

● And active partnership of family, carers andsupport groups as part of an integrated careteam.

● Rapid and seamless transitions are extremelyimportant.

Acute managementRanking of antimanic drugsaccording to primary outcomesderived from multiple treatmentmeta-analysis

Efficacy is shown as a continuousoutcome against the dropout rate.Treatments toward the red sectioncombine the worst efficacy andtolerability profiles and treatmentstowards the green section combinethe best profiles.

ARI=aripiprazole. ASE=asenapine.CBZ=carbamazepine.VAL=valproate. GBT=gabapentin.HAL=haloperidol. LAM=lamotrigine.LIT=lithium. OLZ=olanzapine.PBO=placebo. QTP=quetiapine.RIS=risperidone. TOP=topiramate.ZIP=ziprasidone.

Guidelines for Acute Mania.

DOI 10.1111/acps.12717

Guidelines Bipolar Depression.

Problems data.

● Variation in guidelines.

● Some variation in evidence.

● Known risks medicines.– Lithium lower risk than Valproate/Carbamazepine to

fetus.

– Renal impairment (Li)

– Metabolic syndrome.

– Hypothyroidism.

Patient preference.

● Idiosyncratic tolerance.– Side effects such as sedation.

– Engagement in psychotherapies.

● Priorities (stage of life)

● Risks and benefits (particularly preventionrelapse).

● Service Limitations.– Advance directives may not work.

Tools.

● Recovery plan

● Relapse plan

● Mood monitoring.– Bipolar UK scales

● Outcome scales.– Young Mania Rating Scale

– Quick Inventory Depressive Symptoms.

● Sleep Diary– Electronic? Fitbit, smartwatch.

Administration and structure.

● Rapid assessment in crisis.– Hours to days, not days to weeks.

– No threshold referrals.

● Monitoring metabolic side effects– GP visits paid.

– Diet, exercise, green prescriptions.

● Team meetings, family included, aboutmanagement.

Hard outcomes

YMRS, QIDS, etc are proxy measures.

● Suicide rate in people with bipolar.

● Self harm rate.

● Disability– Proportion of people on invalid's benefit.

– Number of relationships destroyed.

– Number of bankruptcies

– Number of cardiovascular events.

– Life expectancy.

Swedish data all cause mortality.

Crump C, Sundquist K, Winkleby MA, Sundquist J. Comorbidities and Mortality in Bipolar DisorderA Swedish National Cohort Study. JAMA Psychiatry. 2013;70(9):931-939.doi:10.1001/jamapsychiatry.2013.1394

Life expectancy Bipolar, Sweden

● Women with bipolar disorder died 9.0 years earlier thanother women (mean age, 73.4 vs 82.4 years),

● Men with bipolar disorder died 8.5 years earlier thanother men (mean age, 68.9 vs 77.4 years)

● Among all people who died of natural causes, womenwith bipolar disorder died 7.5 years earlier than otherwomen (mean age, 75.1 vs 82.6 years), and men withbipolar disorder died 6.6 years earlier than other men(mean age, 71.6 vs 78.2 years).

Mortality and medications, Sweden.

Crump C, Sundquist K, Winkleby MA, Sundquist J. Comorbidities and Mortality in Bipolar DisorderA Swedish National Cohort Study. JAMA Psychiatry. 2013;70(9):931-939.doi:10.1001/jamapsychiatry.2013.1394

Paradigm shift?

● The idea of episodic illness with full recovery isinaccurate.

Mood disorders, like anxiety disorders, arechronic and relapsing.

● Secondary care may find itself taking a primaryrole with disabling mood disorders, but mustsupport primary care with the less disabled.

Thank you.