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BIPOLAR DISORDER - Coggle Diagram
BIPOLAR DISORDER
Differential Diagnosis
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In children /adolescents consider symptoms e.g. sexual/emotional/physical abuse /undiagnosed learning difficulties. Organic causes e.g. epilepsy due to neuroleptic medication
Management
Primary care - Refer suspected bipolar disorder to specialist mental health service for diagnosis. Refer urgently if presents with mania/depression/danger to themselves or others. Consider vulnerability to exploitation/violence when in an abnormal mental state. If admission required, every attempt to persuade person to go voluntarily. If refuses hospital, compulsory admission may be necessary if requires assessment/treatment in hospital and admission in the in the interest of their own health /safety or protection of other people. Compulsory admission under sections 2,3,4 of mental health act
Determine risk of harm to others by assessing risk of neglect- family/children/dependents. follow safeguarding procedures. Any risk to public if aggression or previous history of violence
Ask about particular substances used /quantity/frequency/pattern of use/route of administration/duration of current level of use
Primary care: Do not start antipsychotic medication while waiting for specialist assessment unless advised by consultant psychiatrist. If mania develops consider tapering antidepressant on specialist advice,
Primary care: Abuse might be contributing factor to cause of bipolar disorder in children.
People with confirmed bipolar disorder whose responded effectively and remain stable following secondary care treatment, may be offered option to return to primary care ongoing management : people under age 55, only initiate valproate if two independent specialists have agreed there is no suitable alternative treatment. Females of child bearing age should be enrolled on pregnancy prevention programme and males to use contraception if taking sodium valproate.
Primary care: Monitoring person's mood/if necessary following crisis plans.
Review physical/mental health and medication at least annually.
Signpost to Bipolar UK, MIND and Rethink websites for local self help groups.
Refer back to secondary care if poor or partial response to treatment/adherence, functioning declines significantly, develops intolerable side medication side effects, comorbid alcohol or drug misuse is suspected, female reproductive potential is taking sodium valproate without two specialist independent consideration to same. Or if a woman is pregnant or planning a pregnancy
Secondary care: treating acute episode and establishing long term management. For treatment of Mania - therapeutic trail of oral antipsychotic e.g. haloperidol, olanzapine, quetiapine or risperidone. If first line not effective , second line to be offered. If not effective, lithium/sodium valproate unless premenopausal female. Antidepressant tapered /discontinued if develops mania.
Secondary Care: Mixed Episodes treated same way as episodes of mania.
For treatment of Depression - Quetiapine alone or Fluoxetine combined with Olanzapine or Olanzapine alone or Lamotrigine alone
Four weeks after acute episode resolved- Secondary care team to discuss long term management plan to prevent relapses - Continue current treatment or mania or start long term treatment with lithium or valproate added to lithium if treatment ineffective. If lithium poorly tolerated, valproate alone or Olanzapine alone may be considered.
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Secondary Care - Encourage to make lasting POA or an advocate to express person's point of view as expressed in advanced statement of wishes and feelings particularly if mania or hypomania episodes as a result of financial issues.
Write a care plan with person/carer
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