Bipolar and Mania

Bipolar 1 vs Bipolar 2

Bipolar 1 → At least one manic episode which has lasted longer than a week. Patients may only experience mania but some may experience deep depression after an episode of mania. Manic episodes last 3-6 months if untreated.

Bipolar 2 → More than one episode of severe depression. One or more episode of hypomania which have lasted at least 4 days. No episodes of mania.

First line and second line options to treat bipolar

• Lithium 1st

• Valporate 2nd

Management of acute mania / hypomania

• If prescribed antidepressants - STOP

Treat with anti-psychotics:

• Haloperidol

• Olanzapine

• Quetiapine

• Risperidone 

If the first choice of antipsychotics isnt appropriate try a second. If the alternative isnt effective try lithium or valproate (Valproate should NOT be offered to women of child bearing age).

Lamotrigine should NOT be used in mania

Bipolar depression management

Psychological interventions → CBT

Anti-depressant treatment options:

• Fluoxetine (chosen for bipolar due to good evidence) + olanzapine

• Quetiapine (requires frequent ECG monitoring due to QT prolongation) 

• Olanzapine only

• Lamotrigine if not responded to any of the above

Lamotrigine

Lamotrigine is last line in bipolar depression due to weak evidence. Main thing to look out for with lamotrigine is a skin rash.

Lithium ranges

Narrow therapeutic window 0.4-1.0mmol/l

• 0.8-1.0mmol/l is aim in acute mania

• 0.6-0.8mmol/l is therapeutic range for maintenance 

• 0.4-0.6mmol/l for elderly

Lithium monitoring

Lithium levels should be taken 12 hours after first dose.

Then weekly after initiation and each dose change

Then 3 monthly for the first year, then 6 monthly

Physical health monitoring with lithium

• Renal function - lithium is renally excreted

• ECG prior to treatment initiation

• Thyroid function

• BMI/ body weight

• U&Es

• FBC

Contraindications with lithium 

• Arrhymias

• Severe renal impairment

• Untreated thyroid disorders

• Low sodium levels 

• Dehydration

• Addison’s disease

Cautions with lithium

• Cardiac disease

• Diuretics - reduce lithium levels as your excreting more

• Elderly

• Epilepsy

• QT prolongation

• Diarrhoea & vomiting

• Post surgery

When is lithium steady state level achieved

4-6 days

Common side effects of lithium 

• GI disturbances

• Fine tremor 

• Polyuria - increased urine

• Polydipsia - increased thirst 

• Ankle oedema 

• Weight gain 

• Muscle weakness

Lithium long term adverse effects

• Hypo/hyperthyroidism

• Hyperparathyroidism

• Nephrotoxicity

• Renal tumours

• Rhabdomyolysis - damage to muscle tissue breakdown

Signs of lithium toxicity

Levels >1.5mmol/l:

• Diarrhoea

• Vomiting

• Anorexia

• Muscle weakness, lethargy and dizziness

• Impaired coordination

• Coarse tremor

Levels >2mmol/l STOP-

• Seizures

• Hyperreflexia

• Hyperextension of limbs

• Toxic psychosis

• Renal failure

• Circulatory failure

• Coma

• DEATH