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Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care

Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care

NICE Clinical Guidelines - National Collaborating Centre for Mental Health (UK)

Version: 2006

THE MEDICAL AND PHARMACOLOGICAL MANAGEMENT OF BIPOLAR DISORDER – PART II

Long-term treatment aims to prevent the occurrence of future episodes of bipolar disorder and is important due to the recurrent nature of bipolar disorder. Aspects of long-term treatment include helping patients recognise signs of early relapse, avoiding triggers for episodes and employing pharmacotherapy. The long-term nature of treatment in bipolar disorder makes establishing a positive therapeutic alliance between patient and staff crucial. Patients require long-term medication to prevent a recurrence of both depression and mania. The relative importance of these two aims will be determined by the past history, that is, how many previous depressive and manic episodes have occurred and their severity. Lamotrigine is thought to have a specific effect in reducing the risk of recurrence of bipolar depression. Drugs that are thought predominantly to reduce the occurrence of mania include valproate, lithium and olanzapine, though each of these may also have significant effects in reducing the likelihood of depressive relapse. On average, people with bipolar disorder spend more time suffering from depressive symptoms than from manic symptoms. This is particularly the case in bipolar II disorder in which, in one study (Judd et al., 2003), the ratio of time depressed to hypomanic was 37 to 1 compared with 3 to 1 in bipolar I disorder (Judd et al., 2002). It could therefore be argued that the amelioration of depression is a key aim for most bipolar patients. Tolerability will often be a bigger concern for patients during long-term treatment than during acute treatment.

THE MEDICAL AND PHARMACOLOGICAL MANAGEMENT OF BIPOLAR DISORDER – PART I

Effective pharmacological treatment of bipolar disorder requires treatment of depressive and manic/hypomanic episodes together with long-term treatment to prevent future episodes, both syndromal and sub-syndromal. In recent years the importance of long-term treatment (that is, maintenance treatment) has been emphasised by several guidelines. The need for maintenance treatment is supported by the desire to prevent the costs of future episodes, that is, the intangible suffering to patients and their families and the economic burden of direct and indirect costs. In addition maintenance treatment may reduce long-term impairment associated with the bipolar disorder. There is evidence that functional impairment in patients who have recovered from acute episodes and are asymptomatic is related to the number of previous depressive episodes. The tendency for episodes to become more frequent with time also supports the rationale for maintenance treatment.

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