BIPOLAR DISORDER

Identifying and Supporting Patients in

Primary Care
By :
Gladiar Ayu Pawintri
Advisor :
Dr. Iwan Sys, Sp.KJ

Introduction
Bipolar disorder first appeared in the medical

literatur in the 1850s when alternating

melancholia and mania were paired in a single
condition
For a number of years the diagnosis was
termed manic-depressive disorder, but this
was repaced by bipolar disorder in 1980
when the Diagnostic and Statistical Manual of
Mental Disorders, 3rd Edition (DSM-III) was
released

What is bipolar disorder?

Bipolar disorder is characterised by

extreme mood swings from hopeless

depression to euphoric or irritable mania with each episode usually bookended by
symptom free period referred to as
euthymia.

The severity of Mania

Determines the Type of Bipolar

A full Manic Episode

Disorder
Hypomania
Subsyndromal (sub-clinical)

A full Manic Episode

A distinc period of abnormally and persistenly

elevated or iritable mood, accompanied by an

abnormally and persistently increased amount of
goal-directed activity or energy
Lasting at least one week
Present most of the day, nearly every day
A person may :
Develop grandiose plans
Cause noticeble social or occupational impairment
Danger to themselves and other
Decrease need for sleep (feature of all forms of mania)

Hypomania
Is characterised by the same features as mania

but the patients episode is less severe and

does not cause the same degree of social or
occupational impairment.
Shorther periods than episode mania
The person may feel :
Very positive
Highly productive
Function well
(But people close to them will have noted the mood
sing as being uncharacteristic)

Subsyndromal (sub-clinical)
Many people with bipolar disorder will

experience periods of mild depression or mania

not pronounced enough to be diagnosed, i.e.
Subsyndromal (sub-clinical), between more
severe mood swing

Mood Cycle

The Cause of Bipolar Disorder

Unknown and likely to be multofactorial
A strong inhertitable component (risk of

first degree 5-10%, increase 40-70% for

monozygot twins)
Environmental influence

Types of Bipolar Disorder

Bipolar I disorder
Bipolar II disorder
Cyclothymic disorder
Rapid cycling
Mixed episode

Bipolar I and II disorder

Bipolar I disorder

Bipolar II disorder

Is diagnosed when patients

have experienced at least one
episode of mania

Is diagnosed in people who had

at least one episode of
depression and one episode of
hypomania, but have never
experienced an episode of full
mania

Onset : 18 years

Onset : mid 20s

30% of people affected are

reported to be severely
impaired at work

15% of of people are reported

to experience dysfunction
between episodes

Incidence : similar among

females and males

Incidence : more common in

females

Cyclothymic Disorder
Is diagnosed when adult patient has had

nomerous subsyndromal hypomanic

episodes and nomerous depressive
disorder over a two year period
Neither of which meet full DSM-V criteria
for either mania or depression
Will progress to either bipolar I disorder
or bipolar II disorder in 15%-50% of
people

Rapid Cycling
Specifies that a patient has had four or

more mood episodes, i.e.

Major depression
mania or hypomania

within one years

Associated with a reduce response to

treatment and poor outcomes

Mixed Episode
Is where the patient experiences mania

and depression during the same

period, for a week or more
Example : a patient might report feeling
sad or hopeless with suicidal thoughts,
while feeling highly energised

Identifying patient who may

have bipolar disorder

People with bipolar disorder often have :

A family history of bipolar disorder or manic
depression
Problems with alcohol
Displayed risk taking behaviour in the past,
e.g sexual, financial or travel related
A history of complicated and disrupted
circumtances, e.g. Multiple relationship,
switching jobs frequently or frequent change
of address

Managing patients diagnosed

with bipolar disorder
Generally the management is led by a

psychiatrist
Medicines are mainstay of treatment
General practitioners usually provide repeat
prescription and monitor the patients
adherence to, and the effectiveness of
treatment
Family and friends are an important support
network for people with mental illness
Educate patient and their family about bipolar
disorder

Patient can reduce the likelihood of

experiencing mood swings by maintaining

daily routine that include :
Regular medicine use
Healty sleep pattern
Exercise
Avoidance alcohol

Pharmacological Treatment
The initial choice of treatment depends on :
whether the patient is manic or depressive
the severity of the symptoms
patient preverence
the balance of benefit versus risk of adverse effect
Lithium has bee used for over 60 years for the

treatment of bipolar disorder

Other medicine, include :
Mood stabilisers
Antipsychotic
Antidepressant

Treatment of episode mania

Tappering and then withdrawl of medicines that may

enhance manic episode, e.g antidepresants

Lithium (effective treating patient during manic initially in
combination with short-term antipsychotic and benzodiazepines)

Valproat (more rapid response than lithium)

An atypical antipsychotic (may be prescribed alone or in
combination with either lithium or valproat)
The typical antipsychotic (effective at controlling acute
mania)
Patient with hypomania (the dose may be lower)
ECT(may be effective for patient with treatment resistant and
consider if the effect of pharmacological treatment are a serious
concern)

Treatment of Episode of
Depression
A psychiatrist may prescribe lithium,

valproat, or lamotigrine as a mood

stabilising regimen
Antidepressant, e.g SSRI (preferred to trycyclic
antidepressant as they are less dangerous if taken in
overdose)

Atypical antipsychotics may be used to settle

agitation often seen in patients with depression and
mania

Treatment of Patient with Rapid

Cycling
or
Mix
Episodes
The
medicines
may be prescribed for treating
rapid cycling in mood with bipolar disorder :
Valproat, lithium, olanzapine, lamotrigine, or quetiapine

as monotherapy
Lithium with valproat and lithium with carbamazepine
or lamotigrine, in combination

The medicines may be prescribed for treating

mix episodes in a patient with bipolar disorder :

Olanzapine, quetiapine, and valproat, usually with a

mood stabilizer
Olanzapine with fluoxetine or valproat with olanzapine
in combination

Managing Patient during Periods

of Euthymia
Clinicians can antisipate change in

circumtances that make a relaps symptoms

each consultation the clinicican should
consider :
Are the patients symptoms under control?
Has there been any change in circumtances that may

cause the patient excess stress, e.g change in

occupational, relationship status, social isolation, or
finance?
Has the overall health of the patient changed, e.g
alcohol compsumption, weight, smoking status or
subtance use?

Thank You ..