Treatment with dopamine antagonist agents should always trigger screening for four cardio-metabolic risk factors (hypertension, central obesity, raised blood glucose and dyslipidaemia). Along with grading of specific recommendations for a strategy or individual treatment, the guideline includes statements, the implications of which should also influence practice. While this will often reflect the natural history of the disorder, it may be increased by monotherapy with antidepressants. Here are some strategies that can help: 1. There is a paucity of evidence to decide between different agents in the treatment of bipolar depression. Effectiveness of medication in preventing psychiatric hospitalization in bipolar disorder—A Swedish register-based study, Reproductive biology and psychotropic treatments in premenopausal women with bipolar disorder, Lithium use and discontinuation in a health maintenance organization, The Northwick Park “functional” psychosis study: Diagnosis and treatment response, Gambling problems in bipolar disorder in the UK: Prevalence and distribution, A randomised controlled trial of time limited CBT informed psychological therapy for anxiety in bipolar disorder, Recovery-focused cognitive-behavioural therapy for recent-onset bipolar disorder: Randomised controlled pilot trial, The long-term natural history of the weekly symptomatic status of bipolar I disorder, Long-term symptomatic status of bipolar I vs. bipolar II disorders, Residual symptom recovery from major affective episodes in bipolar disorders and rapid episode relapse/recurrence, Congenital malformations due to antiepileptic drugs, Impact of axis II comorbidity on the course of bipolar illness in men: A retrospective chart review, Antipsychotics in the treatment of mood disorders and risk of tardive dyskinesia, Aripiprazole monotherapy for maintenance therapy in bipolar I disorder: A 100-week, double-blind study versus placebo, A 6-month, double-blind, maintenance trial of lithium monotherapy versus the combination of lithium and divalproex for rapid-cycling bipolar disorder and co-occurring substance abuse or dependence, Randomised controlled trial of compliance therapy. (, Reinares, M, Colom, F, Sanchez-Moreno, J. Comparison with NICE guidelines: bipolar depression. Affective instability is undoubtedly a component of what troubles many children, but it does not allow ‘early diagnosis’ of true bipolar disorder. However, some of the changes in diagnostic sub-typing with specifiers will have uncertain implications for current treatments. For more information view the SAGE Journals Sharing page. It is a weak inhibitor of dihydrofolate reductase (DHFR). In a recent review and meta-analysis, four small studies support an effect of valproate in bipolar depression (Smith et al., 2010). Bipolar disorder cannot be diagnosed if an episode of (hypo)mania has not yet occurred, and it would be unhelpful to say that a diagnosis has been missed in these circumstances. At a subsequent audit, conducted after provision of a bespoke, patient-held lithium information pack, the respective figures rose to between 54 and 68% (Paton et al., 2013). The long-term value of antidepressants is not sufficiently established. We have not specified doses in this section. The clinical presentation of major depression is similar for unipolar and bipolar patients. Compared with treatment as usual, such enhancement of clinical care appeared to be helpful. short-term treatment with risperidone can help reduce symptoms of mania or mixed mania in children ages 10 and up. The defining feature of bipolar disorder is (hypo)mania, which is not satisfied by identifying simply the anger which is such a strong feature colouring the presentation of borderline patients. Drugs and dosages should be chosen that do not produce extrapyramidal motor side effects (S), which is of particular significance in bipolar patients because of their apparently greater risk of adverse motor reactions compared with schizophrenia (I for haloperidol). Patience may be required to establish that lower doses are effective (IV). Only 13 (about 3%) died by poisoning with prescribed drugs, so the benefit/risk potential appears favourable. Borderline personality disorder is an important diagnosis that may either be confused with or be co-morbid with bipolar disorder. Compared with schizophrenia, there is weaker evidence for presumed environmental aetiologies such as obstetric complications or inner city residence (I, (Bain et al., 2000; Browne et al., 2000; Lloyd and Jones, 2002)). In this manuscript, we will avoid, where possible, the use of generic terms for drugs based on indication and instead prefer to use descriptions of mode of action. Although euphoric mania is the classic type of presentation, a significant number of cases of mania are far from euphoric and may have a mixture of different symptom dimensions. DSM-5 has dropped the category ‘mixed episode’ and introduced a new feature to the diagnosis of a primary manic, hypomanic or depressive episode: the mixed feature specifier. Both lithium and valproate treatment were associated with 90% reduction in completed suicide. The mechanisms linking bipolar states to self-harm or other violent acts (for example, impulsivity, disinhibition, inducing or exacerbating low mood via alcohol/drugs) are poorly understood. Treatment follows the same principles as for other patient groups, although few studies have been directed specifically at the elderly. This can be concluded from the findings in several small studies of lithium responders. It is unclear whether the common failure to do any monitoring at all in some services is affected by what frequency is actually recommended. In a meta-analysis of the data from bipolar patients, rates of the metabolic syndrome were elevated about two-fold compared with controls (Vancampfort et al., 2013). Specifically. We have sometimes reached different conclusions. By contrast, in treatment-resistant unipolar patients, two trials of adjunctive aripiprazole suggested antidepressant efficacy (Thase et al., 2008b). For newer medicines, clinicians may wish to consult Summaries of Product Characteristics (SmPCs). It also blocks L-, N-, and P-type calcium channels and is a weak 5-HT3 receptor antagonist. Facilitated use of a five-session psychoeducational package increased comprehension of the principles and practice of self-management compared with self-instruction (Miklowitz et al., 2012). CBC, platelet count, and liver function tests may be performed during the first 2 months of treatment. Overview. Failure to find a difference between groups is associated with higher proportions of patients with more previous episodes (Scott et al., 2007). 400 mg (as lithium carbonate) if normal renal function. Most patients with mania will require short-term treatment with medicine(s) in an appropriate clinical setting (I). There are no specific treatments for rapid cycling. Severity of mania, presence of psychotic features and the admixture of depressive symptoms may all influence outcome but are also poorly characterized in relation to treatment response. However, to call such cases bipolar would increase the temptation for treatment choices to be extrapolated from bipolar I/II data. Such findings have strongly influenced the NICE recommendations for the treatment of mania and depression. Aripiprazole, other dopamine antagonists and partial agonists, carbamazepine and lithium are also options. A retrospective naturalistic study, Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: A response to the National Institute for Clinical Excellence report, The initial field trials of DSM-5: New blooms and old thorns, The comorbidity of bipolar and anxiety disorders: Prevalence, psychobiology, and treatment issues, A placebo-controlled study of lamotrigine and gabapentin monotherapy in refractory mood disorders, Antipsychotic-induced extrapyramidal side effects in bipolar disorder and schizophrenia: A systematic review, Lamotrigine for treatment of bipolar depression: Independent meta-analysis and metaregression of individual patient data from five randomized trials, Relapse prevention with antidepressant drug treatment in depressive disorders, Comparative evaluation of quetiapine plus lamotrigine combination versus quetiapine monotherapy (and folic acid versus placebo) in bipolar depression (CEQUEL): A 2 x 2 factorial randomised trial, Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): A randomised open-label trial, Complex and rapid-cycling in bipolar children and adolescents: A preliminary study, The comorbidity of bipolar disorder and axis II personality disorders: Prevalence and clinical correlates, A family study of schizoaffective, bipolar-i, bipolar-ii, unipolar, and normal control probands, Effectiveness and safety of long-term antidepressant treatment in bipolar disorder, Antidepressant treatment and suicide attempts and self-inflicted injury in children and adolescents, Long-acting injectable antipsychotics for the maintenance treatment of bipolar disorder, Antidepressants for bipolar depression: A systematic review of randomized, controlled trials, PET-measured D2, 5HT2A, and NET occupancy by quetiapine and n-desalkyl-quetiapine (norquetiapine) in non-human primates, Recurrence of mania after lithium withdrawal. Practice may also be made more comprehensive with a patient-completed screening instrument (Category IV evidence, (IV)). Acute extrapyramidal symptoms are still regarded as a predictor of subsequent TD, and are probably more common in bipolar patients (Gao et al., 2008). For adequate assessment, anxiety should be regularly monitored (in addition to the usual focus on depression and mania). Also, in Swedish database studies, the impact of long-term combination treatment on violence was only seen when dopamine antagonists were added to mood stabilizers and not vice versa (Fazel et al., 2014). There also needs to be a shared and consistent approach across mental health disciplines. Breastfeeding requires an understanding by patients of the potential risks of toxicity to the neonate and the need for vigilance in their care. Maternal physiological changes during pregnancy may necessitate dosage adjustments. 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