Bipolar disorder

National Institute for Health and Clinical Excellence

Key priorities for implementation

Treating bipolar disorder with drugs

• Valproate should not be prescribed routinely for women of child-bearing potential. If no effective alternative to valproate can be identified, adequate contraception should be used, and the risks of taking valproate during pregnancy should be explained
  
• Lithium, olanzapine or valproate* should be considered for long-term treatment of bipolar disorder. The choice should depend on:
  • response to previous treatments
  • the relative risk, and known precipitants, of manic versus depressive relapse
  • physical risk factors, particularly renal disease, obesity and diabetes
  • the patient's preference and history of adherence
  • gender (valproate should not be prescribed for women of child-bearing potential)
• a brief assessment of cognitive state (such as the Mini-Mental State Examination) if appropriate, for example, for older people
  
• If the patient has frequent relapses, or symptoms continue to cause functional impairment, switching to an alternative monotherapy or adding a second prophylactic agent (lithium, olanzapine, valproate*) should be considered. Clinical state, side effects and, where relevant, blood levels should be monitored closely. Possible combinations are lithium with valproate*, lithium with olanzapine, and valproate* with olanzapine. The reasons for the choice and the discussion with the patient of the potential benefits and risks should be documented
  
• If a trial of a combination of prophylactic agents proves ineffective, the following should be considered:
• consulting with, or referring the patient to, a clinician with expertise in the drug treatment of bipolar disorder
• prescribing lamotrigine* (especially if the patient has bipolar II disorder) or carbamazepine
  
• If a patient is taking an antidepressant at the onset of an acute manic episode, the antidepressant should be stopped. This may be done abruptly or gradually, depending on the patient's current clinical need and previous experience of discontinuation/withdrawal symptoms, and the risk of discontinuation/withdrawal symptoms of the antidepressant in question
  
• After successful treatment for an acute depressive episode, patients should not routinely continue on antidepressant treatment long-term, because there is no evidence that this reduces relapse rates, and it may be associated with increased risk of switching to mania

Monitoring physical health

• People with bipolar disorder should have an annual physical health review, normally in primary care, to ensure that the following are assessed each year:
  • lipid levels, including cholesterol in all patients over 40 even if there is no other indication of risk
  • plasma glucose levels
  • weight
  • smoking status and alcohol use
  • blood pressure

Diagnosis in adolescents

• When diagnosing bipolar I disorder in adolescents the same criteria should be used as for adults except that:
  • mania must be present
  • euphoria must be present most days, most of the time (for at least 7 days)
  • irritability can be helpful in making a diagnosis if it is episodic, severe, results in impaired function and is out of keeping or not in character; however, it should not be a core diagnostic criterion

* Drugs marked with asterisks do not have marketing authorisation for the use in question at the time of publication of this clinical guideline

full guideline available from…
National Institute for Health and Clinical Excellence, MidCity Place, 71 High Holborn, London WC1V 6NA
guidance.nice.org.uk/CG38

National Institute for Health and Clinical Excellence. Bipolar disorder. July 2006