Choice of drug

Consider lithium, olanzapine or valproate* for long-term treatment of bipolar disorder, depending on:

• response to previous treatments

• the relative risk, and precipitants, of manic versus depressive relapse

• physical risk factors, particularly renal disease, obesity and diabetes

• the patient’s preference and history of adherence

• gender (valproate* should not normally be prescribed for women of child-bearing potential)

• a brief assessment of cognitive state if appropriate, for example, for older people.

 

If the patient has frequent relapses, or continuing functional impairment:

• consider switching to a different prophylactic drug (lithium, olanzapine or valproate*)

• adding a second; possible combinations are lithium with valproate*, lithium with olanzapine,valproate* with olanzapine

• discuss with the patient (and document) the potential benefits and risks, and reasons for thechoice

• monitor closely clinical state, side effects and, where relevant, blood levels.

 

If a combination of prophylactic agents proves ineffective, consider:–

• consulting, or referring the patient to, a specialist

• prescribing lamotrigine* (especially if the patient has bipolar II disorder) or carbamazepine.

 

Do not use long-acting intramuscular injections of antipsychotics routinely. But they may beconsidered for people whose mania has responded to oral antipsychotics, but have had a relapsebecause of poor adherence

 

Length of treatment

Normally, long-term pharmacological treatment should last for:

• at least 2 years after an episode of bipolar disorder

• up to 5 years if the person has risk factors for relapse, such as a history of frequent relapses orsevere psychotic episodes, comorbid substance misuse, ongoing stressful life events, or poorsocial support

 

Discuss this with the patient and arrange regular reviews.

Encourage patients to talk to their psychiatrist if they want to stop medication early.l

Offer regular contact and reassessment if, after careful discussion, a patient with bipolar disorderdeclines long-term medication

 

 

After an acute depressive episode

After successful treatment, patients should not normally continue on antidepressant treatment long term – there is no evidence it reduces relapse rates, and it may increase the risk of switching.

 

Chronic and recurrent depressive symptoms

 

For patients who are not taking prophylactic medication and have not had a recent manic orhypomanic episode, consider:

• long-term treatment with SSRIs at the minimum therapeutic dose, and prophylactic medication–

• cognitive behavioural therapy (16–20 sessions) and prophylactic medication

• quetiapine*,

• or– lamotrigine*.

 

Consider lamotrigine* for patients with bipolar II disorder and recurrent depression.

 

Comorbid anxiety disorders

 

For patients with significant comorbid anxiety disorders, consider psychological treatment focused on anxiety, or a drug such as an atypical antipsychotic.

 

Psychological therapy after an acute episode

 

Consider individual structured psychological interventions, such as cognitive behavioural therapy, inaddition to prophylactic medication for people who are relatively stable, but may have mild tomoderate affective symptoms.

 

The therapy should normally be at least 16 sessions over 6–9 months and:

• include psychoeducation, the importance of a regular routine and concordance with medication 

• cover monitoring mood, detecting early warnings and strategies to prevent progression intofull-blown episodes

• enhance general coping strategies

• be delivered by people who have experience of patients with bipolar disorder.

 

Consider a focused family intervention if appropriate. This should last 6–9 months, and coverpsychoeducation, ways to improve communication and problem solving.

 

Psychosocial support 

 

Consider offering befriending to people who would benefit from additional social support, particularlythose with chronic depressive symptoms.l

This should be in addition to pharmacological and psychological treatments, and should be by trainedvolunteers providing, typically, at least weekly contact for between 2 and 6 months.

 

Promoting a healthy lifestyle and relapse prevention

 

• Give patients advice (including written information) on:

- the importance of good sleep hygiene and a regular lifestyle

-the risks of shift work, night flying and flying across time zones, and working long hours 

-ways to monitor their own physical and mental state.

• Provide extra support after life events such as loss of job or a bereavement, and encourage patients totalk to family and friends

• In collaboration with patients, identify the symptoms and indicators of an exacerbation, and make aplan of how to respond (including both psychosocial and pharmacological interventions).

 

Physical care of people with bipolar disorder

Physical monitoring

People with bipolar disorder have higher levels of physical morbidity and mortality than the general population. 

 A schedule for physical monitoring, covering checks to be done as soon as practicable after initialpresentation, at an annual check up, and for monitoring specific drugs.

 

Give results of the annual check up to the patient and healthcare professionals in primary andsecondary care (including whether the person refused any tests). A clear agreement should bemade about responsibility for treating any problems.

 

 

If a person gains weight during treatment:

 Review their medication.

 Consider:

• dietary advice from primary care and mental health services

• advising regular aerobic exercise

• referral to weight management programmes in mental health services

• referral to a dietitian if there are comorbidities, such as coeliac disease.

 

 Drug treatments to promote weight loss are not recommended