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TREATMENT GUIDELINE FOR BIPOLAR MOOD DISORDER (BMD) |
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MANAGEMENT
OF LEVEL 3 |
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LEVEL
1 |
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GO TO ALGORITHM BMD MANAGEMENT |
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LEVEL
2 |
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LEVEL 3 |
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MANIA, MODERATE OR SEVERE
DEPRESSION, RAPID CYCLING, FIRST EPISODE MANIA OR HYPOMANIA, CO-MORBIDITY ON
AXIS 1, 2 OR 3, POOR RESPONSE TO TREATMENT. |
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LEVEL
4 |
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MANAGE AND TREAT CO-MORBIDITY |
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NO DEFINITION FOR TREATMENT RESISTANCE |
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POOR RESPONSE TO TREATMENT DEFINED AS RESPONSE BUT NO REMISSION |
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MEDICATION
AND PSYCHOTHERAPY |
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MEDICATION FOR BIPOLAR MOOD DISORDER |
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| INITIATE OR REFER FOR PSYCHOTHERAPY |
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EVIDENCE BASED PSYCHOTHERAPY FOR BMD |
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EVIDENCE SUGGEST THAT THE
COMBINATION OF MEDICATION AND PSYCHOTHERAPY SEEMS TO HAVE THE BEST OUTCOME
AND IS THEREFOR ALWAYS RECOMMENDED IN ALL PATIENTS WHERE POSSIBLE |
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SUPPORTIVE
PSYCHOTHERAPY UNTIL ABLE TO COMPREHEND |
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BEHAVIOUR
THERAPY UNTIL ABLE TO COMPREHEND FULLY |
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EVIDENCE
BASED PSYCHOTHERAPY FOR BMD |
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| ALWAYS IN COMBINATION WITH MEDICATION |
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CONTINUE
UNTIL PATIENT IS IN REMISSION |
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REMISSION |
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CBT OR
PSYCHO-EDUCATION IF PATIENT IN FULL REMISSION |
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CONTINUE FOR
AT LEAST 21 SESSIONS |
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MEDICATION FOR BIPOLAR MOOD DISORDER |
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MONITOR COMPLIANCE, ADHERENCE AND CONCORDANCE CONTINUOUSLY |
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MANIA OR HYPOMANIA WITH EUPHORIC
MOOD |
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RAPID CYCLING |
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MIXED OR DYSPHORIC MOOD |
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MANIA WITH PSYCHOSIS |
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| LITHIUM
AND/OR VALPROATE AND/OR TYPICAL AND/OR SECOND GENERATION ANTI-PSYCHOTIC (IF
IMI SGA GIVEN, NO BENZODIAZAPINE WITHIN 2 HOURS) ALWAYS COMBINATION IF
SEVERE |
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VALPROATE AND/OR
CARBAMAZEPINE/OXCARBAZEPINE AND/OR
LAMOTRIGINE AND/OR SECOND GENERATION ANTI-PSYCHOTIC (DISCONTINUE
ANTI-DEPRESSANT) (IF IMI SGA GIVEN, NO BENZODIAZAPINE WITHIN 2 HOURS) |
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VALPROATE AND/OR LITHIUM AND/OR
CARBAMAZEPINE/OXCARBAZEPINE AND/OR SECOND GENERATION ANTI-PSYCHOTIC (IF IMI
SGA GIVEN, NO BENZODIAZAPINE WITHIN 2 HOURS) |
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TYPICAL OR ATYPICAL
ANTI-PSYCHOTIC AND/OR LITHIUM AND/OR VALPROATE AND/OR
CARBAMAZEPINE/OXCARBAZEPINE AND/OR BENZODIAZEPINE (LORAZEPAM/ CLONAZEPAM) (IF
IMI SGA GIVEN, NO BENZODIAZAPINE WITHIN 2 HOURS) |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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PRINCIPLES: |
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COMBINATIONS OF MEDICATION IS THE
NORM |
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REMISSION |
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MAINTENANCE PHASE |
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GO THE FULL DOSE AS PER EVIDENCE
AND PER BLOOD LEVEL AND TOLERATED DOSE |
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NO RESPONSE |
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GO TO LEVEL 4 |
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CHECK COMPLIANCE, ADHERENCE AND
CONCORDANCE |
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RESPONSE BUT
NO REMISSION |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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| ADD ONE OF THE OTHER AGENTS |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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GO TO LEVEL 4 |
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RECONSIDER TREATMENT AND
DIAGNOSIS |
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ENSURE ADEQUATE PSYCHOTHERAPY |
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RE-ASSESS AND USE DIFFERENT
COMBINATIONS OF MEDICATION AND PSYCHOTHERAPY |
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| LITHIUM
AND/OR VALPROATE AND/OR LAMOTRIGINE |
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CONTINUE FOR
4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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NO RESPONSE |
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GO TO LEVEL 4 |
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RESPONSE BUT
NO REMISSION |
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ADD ONE OF
THE OTHER AGENTS |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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GO TO LEVEL 4 |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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GO TO LEVEL 4 |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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GO TO LEVEL 4 |
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RECONSIDER TREATMENT AND
DIAGNOSIS |
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ENSURE ADEQUATE PSYCHOTHERAPY |
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RE-ASSESS AND USE DIFFERENT
COMBINATIONS OF MEDICATION AND PSYCHOTHERAPY |
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| LAMOTRIGINE
AND/OR LITHIUM AND/OR VALPROATE AND/OR ANTIDEPRESSANT AND/OR MOOD
STABILIZER (DO NOT GIVE ANTI-DEPRESSANT WITHOUT MOOD STABILISER) |
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LAMOTRIGINE AND/OR LITHIUM AND/OR
VALPROATE AND/OR ANTIDEPRESSANT AND/OR CARBAMAZEPINE/OXCARBAZEPINE (DO NOT GIVE ANTI-DEPRESSANT WITHOUT MOOD
STABILISER) IF SUICIDE RISK: CONSIDER ECT |
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LAMOTRIGINE AND/OR LITHIUM AND/OR
VALPROATE AND/OR WITH TYPICAL OR ATYPICAL ANTI-PSYCHOTIC AND/OR
ANTIDEPRESSANT (DO NOT GIVE ANTI-DEPRESSANT WITHOUT MOOD STABILISER) MAY CONSIDER ECT AS FIRST LINE TREATMENT |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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REMISSION |
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MAINTENANCE PHASE |
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NO RESPONSE |
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GO TO LEVEL 4 |
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RESPONSE BUT
NO REMISSION |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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| ADD ONE OF THE OTHER AGENTS |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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CONSIDER
ECT AND GO TO LEVEL 4 |
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| CONTINUE FOR 4-6 WEEKS AND ASSESS |
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REMISSION |
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MAINTENANCE PHASE |
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RESPONSE BUT
NO REMISSION |
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GO TO LEVEL 4 |
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RECONSIDER TREATMENT AND
DIAGNOSIS |
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ENSURE ADEQUATE PSYCHOTHERAPY |
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RE-ASSESS AND USE DIFFERENT
COMBINATIONS OF MEDICATION AND PSYCHOTHERAPY |
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