Bipolar affective disorder

See NICE guidance on ‘Bipolar Disorder’ (www.nice.org.uk). For advice on antidepressant drug use in bipolar disorder refer to Antidepressant drugs.

Lithium, antipsychotics and antiepileptics are used in bipolar disorder to control acute attacks and to prevent their recurrence. In the long-term treatment of bipolar disorder the choice of drug depends upon:
• 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 – see note below regarding use in women of child-bearing age
• a brief assessment of cognitive state (such as the Mini-Mental State Examination) if appropriate, for example, for older people.

For monitoring requirements for lithium, antipsychotics and antiepileptics refer to:

Withdraw all prophylactic drugs gradually over at least 4 weeks. In particular, abrupt withdrawal of lithium may cause mania; withdraw over a 3-month period.

Reproductive health issues: see SIGN 127 (www.sign.ac.uk).
• Discuss pregnancy planning and the role of contraception.
• Discuss specific risks in relation to postnatal relapse of illness for women with bipolar disorder.
• When planning a pregnancy, discuss the risks and benefits of changing or stopping medication and emphasise the need to continue contraception where appropriate.

Valproate medicines are contraindicated in women and girls of childbearing potential unless conditions of Pregnancy Prevention Programme are met (MHRA advice April 2018)

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