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23.4 Bipolar Mood Disorder

Table of Contents

It is a lifelong illness, which may have an episodic, variable course. The presenting episode may be manic, hypo manic, depressive or mixed. By definition, a diagnosis of bipolar disorder requires either a current or previous episode of mania or hypomania. Bipolar disorder causes substantial psychosocial morbidity, frequently affecting patients’ relationships within the family as well as their occupation and other aspects of their lives

Diagnostic Criteria

An episode of mania is typically characterised by:

  • Elevated mood /extreme happiness
  • Irritability
  • Increased energy/activity
  • Talkativeness
  • Reduction in the need for sleep
  • Grandiose and/or religious delusions

Non-Pharmacological Treatment

  • Hospitalisation may be required during acute mania
  • Psychotherapy, usually after the manic episode has been controlled with medication
  • Family therapy and psycho-education of patient and family to increase compliance and knowledge of the condition
  • In severe cases, psychiatrist directed electroconvulsive therapy may be required.

Pharmacological Treatment

For Manic or Mixed Episodes

For agitated and acutely disturbed patient: See section on aggressive disruptive behaviour.

Maintenance therapy

C: Sodium valproate 20 mg/kg/day (PO) in 2–3 divided doses

OR

A: Carbamazepine 600mg (PO) daily, increase by 200mg at three day interval up to a maximum of 2000mg

OR

S: Lithium carbonate 400–1000mg (PO) as a single dose or in 2 divided doses. Elderly 400mg daily

Note: Consider oral haloperidol with adjunctive benzodiazepines in patients who are difficult to manage, i.e. not settling with mood stabiliser monotherapy, and especially where there are features of psychosis.

Treatment for Severe Depressive Episodes in Bipolar Patients

Give antidepressant in combination with mood stabilizer and antipsychotic if there is psychosis:

Drug of choice:

A: Amitriptyline 50mg nocte daily

AND

A: Carbamazepine 300mg twice a day

AND

B: Haloperidol 3–4.5 mg 12 hourly (if there is psychosis)

Note: Do not use monotherapy antidepressants in bipolar patients.

Referral

Refer to the next level in the following situations:

  • Mixed or rapid cycling biplolar disorder
  • Depressive episodes in bipolar patients not responding to treatment

Manic episodes not responding to treatment

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