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Clinical Practice Recommendations for Bp d

Clinical Practice Recommendations for Bp d

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Published by: Nicolás Rodríguez Del Real on Jul 13, 2010
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Clinical overview
Clinical practice recommendations forbipolar disorder
Malhi GS, Adams D, Lampe L, Paton M, O
Connor N, Newton LA,Walter G, Taylor A, Porter R, Mulder RT, Berk M. Clinical practicerecommendations for bipolar disorder.
To provide clinically relevant evidence-based recommen-dations for the management of bipolar disorder in adults that areinformative, easy to assimilate and facilitate clinical decision-making.
A comprehensive literature review of over 500 articles wasundertaken using electronic database search engines (e.g. MEDLINE,PsychINFO and Cochrane reviews). In addition articles, book chaptersand other literature known to the authors were reviewed. The findingswere then formulated into a set of recommendations that weredeveloped by a multidisciplinary team of clinicians who routinely dealwith mood disorders. These preliminary recommendations underwentextensive consultative review by a broader advisory panel that includedexperts in the field, clinical staff and patient representatives.
The clinical practice recommendations for bipolar disorder(bipolar CPR) summarise evidence-based treatments and provide asynopsis of recommendations relating to each phase of the illness.They are designed for clinical use and have therefore been presentedsuccinctly in an innovative and engaging manner that is clear andinformative.
These up-to-date recommendations provide an evidence-based framework that incorporates clinical wisdom and considerationof individual factors in the management of bipolar disorder. Further,the novel style and practical approach should promote their uptakeand implementation.
G. S. Malhi
, D. Adams
,L. Lampe
, M. Paton
,N. O
, L. A. Newton
,G. Walter
, A. Taylor
, R. Porter
,R. T. Mulder
, M. Berk
CADE Clinic, Department of Psychiatry, Royal NorthShore Hospital, St Leonards, NSW, Australia,
NorthernSydney Central Coast Mental Health Drug and Alcohol,Northern Sydney Cental Coast Area Health Service,Sydney, NSW, Australia,
Discipline of PsychologicalMedicine, University of Sydney, Sydney, NSW,Australia,
Sydney South West Area Health Service,Sydney, NSW, Australia,
Child and Adolescent MentalHealth Services, NSCCAHS, Sydney, NSW, Australia,
Department of Psychological Medicine, University ofOtago, Christchurch, New Zealand,
MelbourneUniversity, Barwon Health and the Geelong Clinic,Geelong, Victoria, Australia,
Orygen Research Centre,University of Melbourne, Melbourne, Victoria, Australiaand
Mental Health Research Institute, Melbourne,Victoria, AustraliaKey words: bipolar disorder; treatmentrecommendations; clinical practice guidelines;evidence-based reviewProfessor Gin S Malhi, CADE Clinic, Level 5, Building36, Royal North Shore Hospital, St Leonards, Sydney,NSW 2065, Australia.E-mail: gmalhi@med.usyd.edu.au
Clinical recommendations
The management of bipolar disorder should be based on an integration of evidence-based data andclinical experience.
Once a diagnosis of bipolar disorder is suspected it is important to
promptly. Action involvescareful
so as to provide individual
and effective
The management of bipolar disorder should be based upon a robust therapeutic relationship.
Psychological strategies are effective and should be regarded alongside pharmacological treatmentsas integral to the management of bipolar disorder.
Additional comments
The clinical practice recommendations (CPR) for bipolar disorders should be used in conjunctionwith other recognised sources to guide the management of bipolar disorder.
Practice recommendations or treatment guidelines cannot fully capture the myriad of variablesunique to each individual and thus need to be used flexibly alongside consideration of the person,their sociocultural context and availability of resources.
The bipolar CPR focus on the management of bipolar disorder in adults. Special populations,comorbidities and novel treatments have not been reviewed in detail.
Acta Psychiatr Scand 2009: 119 (Suppl. 439): 27–46All rights reserved 
DOI: 10.1111/j.1600-0447.2009.01383.x
2009 John Wiley & Sons A/S 
Bipolar disorder, formerly known as manic-depres-sive illness, is a common, chronic, episodic mooddisorder that is one of the leading causes of disability worldwide (1). In addition to lengthyperiods of illness, it is associated with markedinter-episode dysfunction and consequently, indi-viduals spend a significant proportion of their livesunwell (2). Further, the illness confers a high riskof self-harm and suicide (3) and yet, in practice, thediagnosis is often delayed, resulting in widespreadsuboptimal management of the disorder. Highrates of comorbidity with anxiety disorders and apropensity towards substance misuse further limitdetection and effective treatment.Fortunately, in recent years, there has been amarked increase in the number of studies examin-ing bipolar disorder. Researchers worldwide haveattempted to better define the illness and under-stand its nature, and develop more effective treat-ments and management strategies.
Facts and figures
The aetiology and pathogenesis of bipolar disorderis not known, however, a number of likely factorsincluding psychological, social and biologicaldeterminants have been identified. Environmentalfactors and lifestyle issues are thought to impact onthe severity and trajectory of the illness (4, 5). Inparticular, stressful life events and substancemisuse may adversely affect treatment responseand time to recovery (6, 7). Further, bipolardisorder has been shown to be a strongly heritableillness (8, 9) that results in higher rates of mooddisorder in first-degree relatives (10).The statistics pertaining to bipolar disorder varysomewhat according to its diagnosis and definition;however,somekeyfactsandfiguresaresummarisedin Box 1. Estimates of bipolar disorder differ con-siderably across epidemiological studies of commu-nity samples with recent research suggesting, thattogether,bipolarIandbipolarIIaffectnearly4%of adults(11).However,eventhisfigure,whichistwicethat of other studies (see Box 1), is considered bysome to be conservative because it does not includeindividuals within the bipolar spectrum (12).An early age of onset of bipolar disorder appearsto be associated with greater severity and pooreroutcome (13, 14). However, in practice, there is asignificant delay in the assignment of a correctdiagnosis and institution of appropriate treatment(15).In part, this occurs because bipolar disorder mostoftenbeginswithadepressiveepisodethatnaturallyleads to a diagnosis of depression (16, 17), andusually, several depressive episodes precede the firstepisode of mania or hypomania (18, 19). Further,mania and especially hypomania are routinelyunder-reported and in practice fail to promptclinical consultation (20, 21). In fact, symptoms of hypomania are often not regarded as problematicand can be difficult toidentify if they occur amongstdepressive symptoms as in mixed hypomania (22).Recent research has identified subtle neuropsy-chological deficits even in the euthymic phase of bipolar disorder (23–25), and it is likely that theseimpact upon social and executive functioning.Clinically, bipolar disorder is marked by significantinterpersonal and occupational difficulties (17, 26,27) that perhaps stem from cognitive impairmentand result in functional disability.
Phases and phenomenology
Bipolar disorder is a recurrent episodic illness thatcomprises periods of depression, mania, hypoma-nia and mixed states. The signs and symptoms of bipolar depression are generally similar, but notidentical, to those of unipolar depression. Forinstance, in comparison with unipolar depres-sion, atypical features, particularly hypersomnia,
Box 1. Facts and figures of bipolar disorder
Epidemiological statistics
Lifetime prevalence of bipolar I is 1%; mean reported age of first moodepisode is 18.2 years (28).
Lifetime prevalence of bipolar II is 1.1%; mean reported age of firstmood episode is 20.3 years (28).
Bipolar I affects both genders equally; bipolar II is more common inwomen (29, 30).
Illness characteristics
Age at which first symptoms of bipolar disorder emerge peaks 15–19 years.
First mood episode is most likely to be depression; this is also thepredominant phase of the illness (2, 20).
Bipolar disorder confers a significant risk of suicide (15 times morelikely than in general population); 7–15% of bipolar individuals commitsuicide (30); suicide is most likely to occur during mixed or depressiveepisodes (31).
Treatment responsiveness
A significant number of individuals with bipolar disorder achieve highlevels of functioning; however, many remain chronically ill despiterobust management.
Rapid cycling and psychotic features are associated with greatertreatment resistance.
Medication, especially lithium may significantly reduce the risk ofsuicide (32).
Malhi et al.
melancholia, psychotic symptoms and psycho-motor changes are more likely to feature in bipolardepression (19, 21). In contrast, the signs andsymptoms of mania are quite markedly differentand often completely reversed (Table 1).Admixtures of symptoms of varying severity andduration produce a variety of symptom profiles thatconstitute differing mood episodes. The latter,along with course specifiers, are described inTable 2. Clinically, mania, hypomania and mixedstates characterise bipolar disorder and differenti-ate it from unipolar depression. Bipolar disorder isfurther categorised into subtypes that includebipolar I and bipolar II (see Table 3). However,the thresholds for defining mood episodes, andhence these subtypes, remain under discussion (35).Consequently, in addition to a categoricalapproach,someresearchershaveproposedadimen-sional perspective in which bipolar illness is viewedas a spectrum of disorders (bipolar spectrum disor-der) (12, 36). However, to date, the majority of findings stem from research conducted in bipolar Idisorder and therefore these recommendations dealpredominantly with the subtypes defined in DSM-IV-TR (33) (see Table 3). The management of bipolar I disorder is considered according to itsphases of illness; however, the recommendationsalso comment upon complex presentations such asrapid cycling, mixed states and partial or notreatment response.Specific terminology has been used in the bipolarclinical practice recommendations (CPR) tocategorise the pharmacological agents available forthe treatment of bipolar disorder. The terms havebeen chosen on the basis of the intended
rather than the traditional
of themedication (see Fig. 1). For example,
Table 1. Common signs and symptoms associated with mania and bipolar depressionSigns
symptoms* Mania Bipolar depressionAppearance Unusual, garish or strange attire Diminished attention to physical appearance,grooming or personal hygieneBehaviour Increased sociabilitySustained goal-directed activity (although often ineffective)Increased impulsivity and risk-taking behaviours and increasedsexual driveReduced interest or pleasure in most activitiesLess likely to initiate activitiesReduced appetite
weight lossCognition Distractible or heightened focus on irrelevant detailsDifficulties with planning and reasoningDiminished capacity to make decisionsDiminished concentrationProblems with short-term memoryDifficulty in decision-makingEnergy Marked increase in energy Diminished energy, lethargyMood Abnormal and sustained elation
euphoria or irritability Depressed mood, sadness or flatness, feelings ofworthlessness, diurnal variation in moodPsychomotor changes Restlessness, agitation Retardation (slowed speech, thoughts, movements)Sleep Reduced need for sleep Impaired sleep: insomnia, early morning awakeningor hypersomnia with daytime nappingSpeech Loud, accelerated, pressuredTalkative and difficult to interruptSlowed, decreased volumeReduced variation in toneReduced contentThought content Inflated self-esteemGrandiose ideation (may be delusional)Diminished self-esteem.Ideas of hopelessness and helplessnessRecurrent thoughts of death or suicidal ideation (with plans or attempts)Excessive or inappropriate guilt, self-blame (may become delusional)Thought form Flight of ideas, racing thoughtsCircumstantiality
tangentialityImpoverished, slowed thinkingNegative ruminationsSource: adapted from Malhi and Berk (34).*Refer to DSM-IV-TR (33) for detailed descriptions and additional criteria and specifiers.Table 2. DSM-IV-TR phenomenology of bipolar episodesBipolar disorder episodesManic episode A distinct period of abnormally and persistentlyelevated, expansive or irritable mood, lastingat least 1 week duration (or any duration ifhospitalised) that causes significant functionalimpairmentMajor depressiveepisodeIncludes at least five of the depressive symptomcriteria (see Table 2 in Malhi et al. (37)) overa 2-week period causing impairment in functioningMixed episode Criteria for both a manic and major depressiveepisode (except for duration) are satisfied nearlyevery day during a period of 1 week or moreHypomanic episode A distinct period of persistently elevated, expansiveor irritable mood, lasting throughout at least4 days. There are no psychotic features and theepisode does not cause marked impairment insocial or occupational functioning, or necessitatehospitalisationRapid cycling The occurrence of four or more mood episodesduring a period of 12 months. Episodes can occurin any combination and order, but are demarcatedby partial or full remission for at least 2 months orby a switch to an episode of opposite polaritySource: for detailed diagnostic criteria consult DSM-IV-TR (33).
Bipolar CPR

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