Harvard Pilgrim/UBH March 2009 1 of 3 Clinical practice summaries are intended to guide treatment for patients with a specific behavioral health disorder. This summary is not meant to substitute for individualized evaluation and treatment specific to the members needs.

Bipolar Disorder

Clinical Practice Guideline Summary for Primary Care DIAGNOSIS AND CLINICAL ASSESSMENT The fundemental problem for persons with Bipolar Disorder is that their typicaly mood cycles are more extreme: they may be euphoric for periods of time and engage in reckless behaviors during periods of mania. This may be followed by a grinding depression that may also be charaterized by self-destructive impulses or behaviors. Bipolar I Disorder requries the history of at least one manic episode, whereas Bipolar II Disorder may carry similiar mood extremes without a history of mania. It is important to distinguish Bipolar Disorder from substance use disorder (e.g. cocaine abuse) or medical conditions (e.g. hyperthyroidism) that may mimic a similar course of mood swings. The medical management of bipolar disorder consists of a broad array of interventions and activities. Regardless of the modalities selected, it is important to provide medical management through all phases of treatment. A diagnostic evaluation includes assessment of: Personal safety and safety of others Level of functional impairment and capacity for self-care Best treatment setting given presenting symptoms Plan for monitoring the mental status and improvement Education for the patient and family/support system about treatment adherence,

promoting regular patterns of activity and of sleep. It is critical to assess suicide risk initially and throughout the course of treatment. The risk of suicide in patients recovering from depression increases transiently as they develop the energy and capacity to act on self-destructive plans made earlier. The risk of suicide in manic patients is high due to agitation and impulsivity, and the risk remains high when the manic episode has ended due to the acute loss of elation. POTENTIAL WARNING SIGNS IN TREATING PATIENTS WITH BIPOLAR DISORDER Any significant or sudden change in mental status, such as a new onset of self

destructive behaviors or violent behaviors, warrents at least consultation with a behavioral health colleague and may require urgent or emergent treatment including hospitalization.

Examples of patients who may require hospitalization include those with comorbid depression who are at risk of suicide, or patients with comorbid substance use disorders requiring detoxification.

Emergence of risky behaviors (excessive spending; hyper sexual impulses, other impulsive acts that put the member at risk), warrants consultation with a behavioral health provider. The extreme points in a persons mood cycle may

Harvard Pilgrim/UBH March 2009 2 of 3 Clinical practice summaries are intended to guide treatment for patients with a specific behavioral health disorder. This summary is not meant to substitute for individualized evaluation and treatment specific to the members needs.

require brief hospitalization in order to assess safety and containment, as well as adjust medication in 24 hours supervised setting.

EFFECTIVE TREATMENT The goal of treatment of Bipolar Disorder is to significantly decrease symptoms and the impairment of the mood cycles. Goals of treatment may include monitoring medication compliance, monitoring the patients mental status for any acute changes, anticipating stressors, identifying new episodes early, and minimizing subsequent functional impairments. A large body of evidence supports the efficacy of psychotherapy in the treatment of unipolar depression. In bipolar depression, interpersonal therapy and cognitive behavior therapy may be useful when added to pharmacotherapy. Electroconvulsive Therapy (ECT) may also be considered for patients with severe or treatment-resistant mania or if preferred by the patient in consultation with the physician. In addition, ECT is a potential treatment for patients experiencing mixed episodes or for patients experiencing severe mania during pregnancy. Medications Acute Treatment Phase Severe Manic or Mixed Episodes -- The first-line pharmacological treatment for

more severe manic or mixed episodes is lithium plus an antipsychotic, or valproate plus an antipsychotic. For less ill patients, monotherapy with lithium, valproate, or an antipyschotic such as olanzapine may be sufficient. Short-term adjunctive treatment with a benzodiazepine may also be helpful. For mixed episodes, valproate may be preferred over lithium. Atypical antipsychotics are prefered over typical antipsychotics because of their more benign side effect profile.

Bipolar Depression -- The first-line treatment for bipolar depression is lithium or

lamotrigine. Antidepressant monotherapy is not recommended. Selective Seritonin Reuptake Inhibitors (SSRIs) are believed to sometimes precipitate manic episodes. Lithium with an antidepressant is an alternative to antidepressant monotherapy.

Rapid Cycling -- Rapid cycling refers to the occurrence of four or more mood

disturbances within a single year that meet criteria for a major depressive, mixed, manic, or hypomanic episode. These episodes are demarcated either by partial or full remission for at least 2 months or a switch to an episode of opposite polarity (e.g., from a major depressive to a manic episode). The initial intervention in patients who experience rapid cycling is to identify and treat any medical conditions, such as hypothyroidism or drug or alcohol use, that may contribute to cycling. Certain medications, particularly antidepressants, may also contribute to cycling and should be tapered or eliminated if possible. The initial treatment for patients who experience

Harvard Pilgrim/UBH March 2009 3 of 3 Clinical practice summaries are intended to guide treatment for patients with a specific behavioral health disorder. This summary is not meant to substitute for individualized evaluation and treatment specific to the members needs.

rapid cycling should include lithium or valproate; an alternative treatment is lamotrigine. For many patients, combinations of medications are required.

Work-up -- When using lithium, valproic acid, or carbamazepine, careful monitoring

is necessary to ensure safe and effective dosing. A pregnancy test should be given prior to initiation and then as clinically indicated. Each agent has serum plasma concentration, complete blood count, blood chemistries, ECG, urinalysis, PT/PTT, and thyroid function test baseline and routine monitoring protocols.

Following remission of an acute episode, patients may remain at particularly high risk of relapse for a period of up to 6 months. Maintenance Phase Maintenance regimens of medication are recommended following a manic episode. The medications with the best empirical evidence to support their use in maintenance treatment include lithium and valproate; possible alternatives include lamotrigine, carbamazepine or oxcarbazepine. If one of these medications was used to achieve remission from the most recent depressive or manic episode, it generally should be continued through the maintenance phase of treatment. Maintenance sessions of ECT may also be considered for patients whose acute episode responded to ECT. For patients treated with an antipsychotic medication during the preceding acute episode, the need for ongoing antipsychotic treatment should be reassessed upon entering maintenance treatment. Psychotherapy Persons with bipolar disorder are likely to benefit from a concomitant psychosocial intervention including psychotherapy that addresses illness management including medication adherence, lifestyle changes, interpersonal difficulties, and early detection of symptoms. Group psychotherapy may also help patients address treatment plan adherence, adaptation to chronic illness, regulation of self-esteem, and management of marital and other psychosocial issues. Support groups provide useful information about bipolar disorder and its treatment. RESOURCES For further information, see the complete version of the American Psychiatric Associations Practice Guideline for the Treatment of Patients with Bipolar Disorder, available at www.psych.org. You can also call the UBH Physician Consultation Service (1-800-292-2922) to discuss treatment concerns with a psychiatrist or contact UBH Customer Service (1-888-777-4742) if you would like to make a referral to a mental health professional.