Overview

• Chronic mental health disorder characterised by periods of mania/hypomania alongside episodes of depression.
• Bipolar Affective Disorder → at least 2 episodes of mood disturbance, with one being manic/hypomanic.
  • BPAD Type I (most common) → mania and depression.
  • BPAD Type II → hypomania and depression.
  • Rapid Cycling BPAD → ≥4 episodes per year. Respond well to sodium valproate. (Cyclothymia → rapid-cycling BPAD-like disorder where the depression and mania are not severe enough to be diagnosed as BPAD).
• Mania → symptoms must last for >7 days and impair social functioning (or PSYCHOTIC SYMPTOMS - DELUSIONS OR HALLUCINATIONS).
  • Core Symptoms → elevated mood and increased energy.
  • Speech and Thought → increased talkativeness, flight of ideas, increased self esteem.
  • Biological Symptoms → decreased need for sleep, reduced focus, impulsive behaviour, increased sexual drive.
• Hypomania → symptoms must last for >4 days and not disrupt social functioning with no psychotic symptoms.
  • ([1] Impaired social functioning and [2] psychotic symptoms differentiate mania from hypomania)

Making Diagnosis

Clinical Features

• Mania + Hypomania (DIG FAST)
  • D(istractability)
  • I(ndiscretion)/irritability - increased pleasure seeking eg sex, spending, eating etc
  • G(randiosity) - can be as elaborate as thinking you have superpowers, to thinking youre special and will change the world
  • F(light of ideas) → feature of mania rather than schizo.
  • Activity increase (hyperactive seeming, doesnt seem tired even with sleep deficit)
  • S(leep deficit)
  • Talkativeness (pressured speech)
• May be precipitated by SSRI.

Investigations

• Collateral History, Physical Exam, MSE.
• Screen for Organic Causes:
  • Bedside → urine drug screen.
  • Bloods → TFTs, FBC, CRP, U&Es.
  • Imaging → CT/MRI brain.

Management Plan

• Primary Care (BPAD/Mania) → refer to specialist as cannot be diagnosed or treated in primary care.
  • Symptoms of Hypomania → routine referral to CMHT.
  • Symptoms of Mania (psychotic symptoms/functional impairment) but with Insight → urgent referral to CMHT.
  • Risk to self/others/lack of insight → admission to psychiatric ward.
• Acute Pharmacological Management of Mania/Hypopania:
  • Everyone → stop all medications that may cause symptoms (eg. antidepressants). Short course of benzodiazepines (lorazepam) for sedation.
  • If Treatment Free → first line = antipsychotic (olanzapine) to stabilise before starting mood stabiliser. Second line = different antipsychotic (haloperidol, quetiapine, risperidone). Third line = add sodium valproate or lithium (lithium not as effective acutely, need higher dose therefore risks toxicity).
  • If already on Treatment → optimise the medication (stop antidepressants), check lithium levels, add an atypical antipsychotic. Short-term benzodiazapines may help (sedation).
• Long-Term Pharmacological Management of Mania/Hypomania → mood stabilisers (4 weeks after the acute episode).
  • First Line → lithium alone.
    • Lithium → monitor weekly (when starting or when changing dose) until steady therapeutic level is achieved (aim for 0.6-0.8 mmol/L). Then monitor every 3 months, with sample taken 12 hours post-dose. U&Es and TFTs should be monitored every 6 months. Lithium toxicity when level >1.2 mmol/L.
      • Adverse Effects → N&V, diarrhoea, fine tremor, nephrotoxicity (NEPHROGENIC DI), hypothyroidism (weight gain, constipation, bradycardia, muscle weakness), leucocytosis, hyperparathyroidism (and resultant hypercalcaemia = abdominal pain, polyuria, polydipsia).
      • Lithium Toxicity (>1.2 mmol/L):
        • Precipitating Factors (impaired renal function) → dehydration, renal failure, drugs (thiazide diuretics, ACEi/ARB, NSAIDs, metronidazole).
        • Symptoms → coarse tremor (therapeutic levels = fine tremor), nausea, diarrhoea, hyperreflexia, acute confusion, polyuria, seizures, ataxia, coma.
        • Management → mild-moderate: volume resuscitation with normal saline. Severe: haemodialysis.
    • Lithium not effective → lithium + valproate.
    • Lithium poorly tolerated → valproate alone or olanzapine alone.
    • Pregnant (avoid in pregnancy and when breastfeeding) → switch lithium gradually (reduce dose over 4 weeks) to an atypical antipsychotic. Can cause Ebstein’s anomaly (low insertion of the tricuspid valve, resulting in a large atrium and small ventricle - can cause tricuspid regurgitation).