Bipolar

Question 1

voluntary patient

Answer 1

patient that is aware of their mental health issues and agrees to be admitted to a hospital

Question 2

sectioned patient

Answer 2

patients that are a danger to themselves or others are are consequently detained as a result- sectioned patients can be treated against their will as they are deemed not to have sufficient capacity

Question 3

for how many days/months can a patient be detained for under;
section 2

section 3

Answer 3

28 days

6 months

Question 4

describe bipolar disorder- used to be called manic depression but not anymore

Answer 4

potentially lifelong and disabling condition characterised by episodes of mania and hypomania, and episodes of depressed mood

Question 5

bipolar types

Answer 5

Bipolar I - Symptoms of mania, Symptoms must last for > 7 days

Bipolar II;
At least one depressive episode
Symptoms of hypomania - must last for at least 4 days

Rapid Cycling- Four or more episodes within a year

Question 6

manic symptoms

Answer 6

psychotic symptoms like delusions and hallucinations
short attention span
inflated sense of self esteem
unusually elevated mood
overactivity-decreased sleep
increased energy-marked distractibility
grandiose ideas-overconfidence

note that hypomanic symptoms are usually similar to manic symptoms but are less disruptive to work and social life. also they do not have delusions and hallucinations

Question 7

the bipolar mood scale

Answer 7

The Bipolar UK Mood Scale is a 0–10 scale that helps people with bipolar disorder track mood fluctuations from low to high.

The Bipolar UK Mood Scale ranges from 0 to 10, with the middle range (4–6) representing typical mood for people without a mood disorder, while people with bipolar disorder may experience a wider range of moods. The high symptoms of bipolar disorder are scored as 7–10, reflecting elevated mood, increased energy, or mania, while the low symptoms are scored as 0–3, reflecting depression or low mood. Each score is associated with specific behaviours and feelings, from balanced mood to extreme highs or lows.

Question 8

hypomania is basically a less severe form of mania true or false

Answer 8

true

Question 9

treatments for bipolar disorder(primary care)

Answer 9

consider hospital admission for all those with acute mania diagnosis.

Refer for urgent mental
health assessment if the person presents with
mania, severe depression, or if they are a
danger to themselves or other people

Question 10

what medications can we not start in primary care(i.e GP, pharmacist…etc) for those with bipolar disorder

Answer 10

don’t start lithium or valproate in
primary care

Question 11

treatments for mania in secondary care

Answer 11

If a person is NOT taking an antipsychotic or mood stabiliser:
 Offer haloperidol, olanzapine, quetiapine or risperidone
 If the first is not effective, try an alternative antipsychotic
 If this is not effective, consider adding lithium
 If lithium ineffective or not suitable, consider adding valproate instead

Question 12

if a person develops mania while taking an antidepressant, what do we do

Answer 12

the antidepressant is tapered and discontinued

Question 13

treatment for bipolar depression , secondary care

Answer 13

Milder cases of bipolar depression can be treated with psychological therapy- like CBT

Antidepressants are not used usually used as monotherapy as they increase the risk
of mania or mood instability

if patient not already taking anything, then offer fluoxetine combined with olanzapine, or quetiapine on its own depending on patients preference or response to previous treatment

we could also consider olanzapine on it’s own or try lamotrigine if patient prefers. we try lamotrigine esp if patient not responding to combination therapy(olanzapine and fluoxetine)

Question 14

the most effective longterm treatment for bipolar disorder

Answer 14

lithium. this is the first line

Question 15

after acute treatment, what needs to be discussed with the patient

Answer 15

Once acute episode has been treated, discuss with patient and their family (or carers)
 Bipolar disorder is a variable and ongoing condition
 There is a risk of relapse after stopping or reducing medication taken during an acute
episode
 Potential benefits and risks of long-term treatments

Question 16

what are the patients options for long term treatment in bipolar disorder

Answer 16

HCp can discuss with patient to continue previous therapy that has worked or to switch to lithium as it is the most effective treatment for bipolar longterm

Question 17

why is it important for patient to adhere to lithium as directed

Answer 17

lithium has a narrow therapeutic index. if levels drop too quickly, it can cause relapse

Question 18

what are the usual monitoring patterns for checking lithium levels-follow up

Answer 18

One week after starting or any dose change
Weekly until levels are stable
3 monthly for first year
After 1st year testing may be 6 monthly for some people.
Additional testing required 6 monthly (U&E, calcium, eGFR, TFT, weight)

Question 19

how long after taking a lithium dose should we do a blood test to monitor levels

Answer 19

12 hours after taking the dose. it is recommended to take it at night so that blood tests can be done in the morning

Question 20

normal initial plasma lithium levels should be between ?

Answer 20

0.6 – 0.8mmol/litre

Levels between 0.8 – 1 mmol/litre may be considered for people who have had previous relapse while taking lithium or persistent symptoms

Question 21

is it important to keep patients on the same brand of lithium if possible

Answer 21

yes it is important to keep patients on the same brand of lithium , to keep levels stable. also great care must be taken when switching between different lithium formulations due to differences in strength

Question 22

above what level do we start seeing toxicity in lithium

Answer 22

approximately 1.5 mmol/litre

Question 23

signs of lithium toxicity

Answer 23

Signs include:
 Increasing GI disturbances (diarrhoea, vomiting)
 Visual disturbances
 Polyuria
 Muscle weakness
 Tremor (fine increasing to coarse)
 CNS disturbances (confusion, drowsiness etc.)
 Abnormal reflexes, myoclonus, incontinence, hypernatremia

Severe toxicity (levels over 2 mmol/litre)
 Can lead to seizures, arrhythmias, BP changes, renal failure, coma, sudden death

Question 24

some counselling points to be given to a patient on lithium

Answer 24

People should be advised to:
 seek medical attention if they develop diarrhoea or vomiting or become acutely ill for any reason.

 ensure they maintain their fluid intake, particularly after sweating (for example, after exercise, in hot climates or if they have a fever), if they are immobile for long periods or if they develop a chest infection or pneumonia

 Dehydration can affect blood levels of lithium – levels may be affected

maintain salt levels in diet – significant changes may affect serum lithium levels

talk to their doctor as soon as possible if they become pregnant or are planning a pregnancy.

Always check if there are any changes to medication – especially if starting any new medicines

Drug interactions include diuretics & ACE inhibitors

Check particularly for medicines bought over the counter. There is a severe interaction with NSAIDs including ibuprofen(Levels of lithium can be increased)

Question 25

what is the most essential thing to give a patient who is on lithium. (not they are advised to always keep this on them )

Answer 25

Patients should be given the purple Lithium therapy booklet and alert card.  They should be encouraged to always show the card to health care professionals when receiving treatment

Question 26

if long term treatment of bipolar disorder with lithium is ineffective/unsuitable, what do we do

Answer 26

If lithium is ineffective, NICE suggests:  Consider adding valproate If lithium is not suitable:  Consider valproate or olanzapine instead Carbamazepine and lamotrigine are other potential options if first line options are not suitable

Question 27

should valproate be taken in pregnancy?

Answer 27

ABSOLUTELY NOT. this is very dangerous. every baby is at risk if the mother takes valporate during pregnancy. the harm that it causes is bigger than what happened with thalidomide

Question 28

what is the most essential thing that can be given to patient taking valproate to take with them

Answer 28

a valproate patient card , to provide key info on the medication, including the risks to unborn babies .

Question 29

can lithium be used in pregnancy

Answer 29

nope