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TREATMENT GUIDELINE FOR BIPOLAR MOOD DISORDER (BMD) |
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MANAGEMENT
OF LEVEL 4 |
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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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POOR FUNCTIONING,
POOR SUPPORT SYSTEMS |
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LEVEL 4 |
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CO-MORBID SERIOUS
MEDICAL CONDITION OR PSYCHIATRIC DISORDER |
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TREAT MEDICAL AND PSYCHIATRIC CO-MORBIDITY |
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SERIOUS SUICIDAL
IDEATION OR SUICIDE ATTEMPT |
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DANGER TO SELF OR
OTHERS |
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DANGER TO SELF OR
OTHERS PROPERTY |
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PSYCHOTIC FEATURES |
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NO RESPONSE TO
TREATMENT |
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ADJUSTMENT TO
MEDICATION |
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ELECTROCONVULSIVE
THERAPY |
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ECT |
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IF PATIENT UNABLE TO OR UNWILLING TO CONSENT TO TREATMENT REFER
TO MENTAL HEALTH CARE ACT |
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ASSISTED USER |
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INVOLUNTARY USER |
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ADMISSION TO HOSPITAL |
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ADMISSION TO HOSPITAL ACCORDING
TO HASA PFF STANDARDS |
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MENTAL HEALTH CARE ACT -
VOLUNTARY, ASSISTED AND INVOLUNTARY USERS |
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MEDICATION
AND PSYCHOTHERAPY |
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CHOOSE EVIDENCE BASED MEDICATION FOR BMD |
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| INITIATE OR REFER FOR PSYCHOTHERAPY |
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EVIDENCE BASED PSYCHOTHERAPY FOR BMD |
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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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CONSIDER
INTRAMUSCULAR OR INTRAVENOUS MEDICATION AS EMERGENCY TREATMENT |
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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 HOURS TO 6 WEEKS AND ASSESS |
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CONSIDER ECT |
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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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CONSIDER ECT |
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CHECK COMPLIANCE, ADHERENCE AND CONCORDANCE |
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RESPONSE BUT
NO REMISSION |
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CONSIDER ECT |
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IN HOSPITAL THE TIME TO REASSES
CAN BE HOURS OR DAYS BEFORE ADJUSTMENT TO MEDICATION OR COMBINATION OF
MEDICATION IS MADE |
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| ADD ONE OF THE OTHER AGENTS |
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| CONTINUE FOR HOURS TO 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 |
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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 |
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| CONTINUE FOR HOURS TO 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 |
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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
HOURS TO 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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CONSIDER ECT |
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RESPONSE BUT
NO REMISSION |
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ADD ONE OF
THE OTHER AGENTS |
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| CONTINUE FOR HOURS TO 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 |
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| CONTINUE FOR HOURS TO 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 |
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| CONTINUE FOR HOURS TO 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 |
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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 HOURS TO 6 WEEKS AND ASSESS |
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CONSIDER ECT |
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REMISSION |
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MAINTENANCE PHASE |
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NO RESPONSE |
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CONSIDER ECT |
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RESPONSE BUT
NO REMISSION |
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CONSIDER ECT |
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| ADD ONE OF THE OTHER AGENTS |
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| CONTINUE FOR HOURS TO 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 |
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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 |
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| CONTINUE FOR HOURS TO 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 |
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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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