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CPD 46: BIPOLAR DISORDER IN ADULTS Biography - Aaron Carlyle (MPharm MPSNI MPSI) is the supervising manager pharmacist at Brennan's Pharmacy in Buncrana, Co Donegal. He is a graduate of the University of Manchester, with a Master of Pharmacy degree. He completed his pharmacy training with Boots as a pre-registration pharmacist. Carlyle joined Brennan's in a group support pharmacist role in 2010, and took over management of the Buncrana branch later that year. In addition to his work as a community pharmacist, Carlyle is also involved in pharmacy education. He is a qualified pharmacy assessor and writes pharmacy training courses for clients in both the UK and Ireland. 1. REFLECT - Before reading this module, consider the following: Will this clinical area Educational distance be relevant to my practice. 2. IDENTIFY - If the answer is no, I may still be interested in the area but the article may not contribute towards my continuing professional development (CPD). If the answer is yes, I should identify any knowledge gaps in the clinical area.

Module 1 June 2012

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- will this article satisfy those needs - or will more reading be required? learning needs - and how has my practise changed as a result? Have I identified further learning needs?

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Chronic Pain – assessment and management in primary care

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Bipolar Disorder in Adults Introduction

60 Second Summary Pharmacies are

dispensing Sheehan et al reportedmore in 1996 that the estimated cost of medication than pain for 95 patients to the Irish Health Services when added ever before to Pain is one of the commonest reasons for patients to seek treat to the amount of various Social Welfare payments received and 1 has shown that as many medical attention. A recentIt survey forms of mental was previously referred to as manic the lost earnings INTRODUCTION ofBipolar each patient amounted to 1.9 million illness. depression, and bipolar affective disorder, as 8.3 visits per year to primary care physicians in Ireland disorder is one such6 The recent data from PRIME Pharmacies across Ireland are dispensing pounds at the time of referral. or simply “bipolar”. It is characterised by were due to of pain.2 A large scale survey carried condition and one more medication than ever before to symptoms treat recurrent episodes of mania or hypomania survey showthat thatisthe mean cost considered to per chronic pain patient various forms of mental out illness. However in 15 European countries and to Israel in 2006, screening (a mild moderate level of mania) and is estimated be distressing and across all grades of pain, at very €5,665 per year mood disorders are conditions that shouldn’t depressive episodes with patients reverting 46,394 respondents reported that the prevalence of chronic chronic. In it’s most extreme be considered to be a new affliction. Their which was extrapolated to €5.34 form, it can have harmful billion effects or on 2.86% of Irish to an outwardly normal (i.e. euthymic) state pain ofhave moderate symptoms and characteristics been to severe intensity in adult Europeans was 7 psychological, physical, occupational and social in between. However, for many people the GDP per year. This demonstrates an urgent need for cost 3 recognised for thousands of years. Contrary wellbeing. It is characterised by recurrent episodes 19%. predominant experience is that of low mood. effective strategies manage chronic pain effectively. to early beliefs of demonic or spirituals of maniatoand depressive episodes.

Cases of bipolar disorder often remain involvement, the Roman and Greek doctors Diagnosing the condition in adults, particularly unrecognised (mainly due to More recent survey data from another study, carried outmisdiagnosis as were wise enough to believe that depression those presenting to services for the first time unipolar depression), resulting in suboptimal in 2,019 people with chronic pain and 1,472 primary was both a biological and psychological can be diffi cult. This can be for a number of Understanding chronic pain treatment and an increase in the overall total reasons, not least because other conditions and disease. Gymnastics, massage, special diets, care physicians across 15 European countries, have healthcare costs. can mimic the episodes and symptoms Chronic painfactors is defined as pain that outlasts normal healing music, and baths, as well as a concoction of demonstrated that chronic pain affects 12-54% of adult of bipolar disorder. Treatment can be both poppy extract and donkey’s milk were some MANIA AND HYPOMANIA VS. time (usually pharmacological three to six months), and is most frequently and non-pharmacological in and its prevalence in Ireland isPHASE up to 13%.2 The of the remedies used to Europeans, alleviate depressive DEPRESSIVE nature. The managementdisorders of bipolar such disorder associated with musculoskeletal asby low symptoms. HippocratesPRIME (460 -357 BC) referred (Prevalence, Impact and Cost of Chronic Pain) study, pharmacological means can be split into three To bring these terms into context, Maniaback and pain and to an excess of ‘black bile’ and ‘yellow bile’, arthritis. However, it can also be associated phases, namely; treatment of a manic episode, on the other hand, determined the prevalence of chronic Hypomania can be defi ned (and diagnosed) by which he attributed to melancholia (i.e. treatmentsuch of a depressive episodeorand the longwith other disorders as depression metabolic theinconcurrent presence at least three of the depression). Although our term management and prevention of symptom painunderstanding to be as highand as 35.5% Ireland.4 The PRIMEof study disorders or recurrence. neurologicNon conditions such astreatment multipleand pharmacological following symptoms: treatments of such disorders has moved was designed to on, investigate the prevalence of chronic pain advice involves lifestyle changes, structured and many of these early observations of biological sclerosis. • Grandiosity ated self-esteem psychological treatments. In some cases, cognitive into Ireland; and/ infl physical health involvement have proven remaincompare relevant the psychological behavioural therapy and family therapy are also today. profiles of those with and without chronic pain; and explore • Decreased need for sleep Pain (acute or chronic) can be categorised as nociceptive recommended depending on the severity of the

pain-related disability.4 Responses to survey(pressured questionsspeech) were • Talkativeness from 1,204 people. Bipolar disorder is a veryobtained distressing and

presenting symptoms. or neuropathic. Nociceptive pain is caused by an active Pharmacy has a significant role to play and illness, injury and/or processtoassociated can makeinflammatory a positive contribution the lives of with • Flight of ideas (rapidly racing thoughts and chronic condition. In its most extreme form, patientstissue and their carers. i.e. It is Nociceptive essential that good flirting of ideas) actual or potential damage pain Despite the magnitude of the problem, chronic pain is communication exists between all healthcare it can have harmful effects on psychological, results from activity in neural pathways secondary to actual professionals involved in the care of such patients. Marked distractibility physical, occupational and wellbeing. It and• undertreated bothsocial under-recognised in primary care.2,5 In particular, pharmacists are suitably to affects roughly 40,000 people in Ireland, with or potential tissue damage. Nociceptive pain placed is mediated • Increased activity / identify medication non-compliance and respond upwomen. to 38% of patients reported goal-directed being inadequately equal occurrence in bothIndeed, men and by pain receptors skin, Likewise musculoskeletal system, to this located at an earlyinstage. pharmacists are psychomotor agitation It is claimed that approximately 1% the care for their managed inof primary pain symptoms.2 In ideally 8 sited to recognize and advise on possible bone, and joints. Neuropathic pain, on the other hand, population will develop itaddition, in their lifetime. • Excessive involvement in pleasurable activity drug related side-effects and interactions, of people with chronic pain reported waiting up to Generally, it has a peak age of onset in late results from direct injuryaretooften a peripheral or central sensory which there many, communicating without regard for negative consequences 2.2 years between seeking help and diagnosis, and 1.9 adolescence or early adult life, with a further any such advice or findings to the patient, their (examples can include; unrestrained buying nerve; the affected nerves do not produce transduction at 2 representative and any other relevant healthcare small increase in incidence in mid to late years before theirlife. pain was adequately managed. sprees, sexual indiscretions, foolish 8 nociceptors. Pain characteristics and associated conditions professional as appropriate. business ventures) for both types of pain are shown in Table 1.

WHAT IS BIPOLAR

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Symptoms must be severe enough to impair functions markedly or require admission to hospital to prevent harm to self or others. The possibility of symptoms being caused by schizophrenia, schizoaffective disorder, or substance abuse must Module be excluded.1With June 2012 comparison to mania, hypomania differs to the extent that symptoms present in a similar fashion but to a lesser severity and without significant disruption to normal functioning.

sionals in Ireland

The depressed phase (or episode) of bipolar disorder can be prolonged and can be the overwhelming experience for many patients. In any case, signs and symptoms can include:

anagement in primary care

• A persistently sad, empty or anxious feeling. • Loss of interest in food, sex, work and other activities. • Tiredness and feeling slowed down, despite rest. • Trouble getting to sleep, wakening too early or over sleeping.

body. I remember it was the year of the World Cup and I became convinced that I was going to be called to play for the Republic of Ireland. The teachers had been watching me and they knew something was wrong. Eventually, my parents were called and asked to take me to a doctor. Three days later I was admitted to a psychiatric hospital. It took me a long time to accept that I w as ill, that I had manic depression and that I had to stay on Lithium. But when I think of the four years or so in my early teens when I was just going up and down, messing in class and getting into trouble, all that time I’d wasted, and to think that others are still going through that – it gets me angry. What did help me to take all of this in were the support groups I attended. I suppose it is only from people who have been down the road before you, and that understand where you’re at, that can really get through to you. HOW IS IT DIAGNOSED?

Diagnosing the condition in adults, particularly those presenting to services for the first time can be particularly difficult. This can be • Reduced or increased appetite and weight for a number of reasons, not least because disturbance. other conditions and factors can mimic the episodes and symptoms of bipolar disorder. A • Poor concentration and indecision. challenge to accurate diagnosis is presented for • Feelings of guilt and worthlessness. instance if patients are only seen when in the depressive state. In this instance, it is essential • Chronic aches and pains without a that patients are asked about a history of physical cause. elated, excited or irritable mood, if an accurate ehan et al reported in 1996 that the estimated cost of diagnosis is to be made. In general, all patients • Thoughts of death or suicide. n for 95 patients to the Irish Health Services when added with depression should be asked about a Current practice sometimes subdivides he amount of Social Welfare payments receivedthe and possible personal history, or family history of illnessofinto twopatient main forms: bipolar I and mania. lost earnings each amounted to 1.9 million bipolar II, whereby6 bipolar I requires episodes nds at the time depression of referral. The from PRIME Diagnosis can also be difficult because those of both and recent mania data for diagnosis affected often have had periods of significant II requiring both vey showand thatbipolar the mean cost perepisodes chronic of pain patient psychological and social disturbances before depression and hypomania, but no evidence stimated at €5,665 per year across all grades of pain, they present to acute services. This can have of mania. Variations include rapid-cycling an influence on the perception of the problem, ch was extrapolated to €5.34 billion 2.86% of Irish disorder, where patients haveor four or more 7 cycles a year. When a patient suffers P per year. Thiswithin demonstrates an urgent need for cost and indeed on the consequent diagnosis and treatment if they are not referred to the most from depressive episodes, without the presence ctive strategies to manage chronic pain effectively. specialist healthcare professional. For instance, of manic episodes, those being either mania or further complexities are introduced with hypomania, then they are said to have unipolar patients’ use of illicit stimulant drugs, which (i.e. clinical) depression rather than bipolar derstanding may mimic manic symptoms. When suspected, disorder.chronic pain differentiation can still be made, as in such onic painEXAMPLES is defined as that outlasts normal healing cases a drug-induced psychosis should wane OFpain PATIENT EXPERIENCE with the clearance of the offending drug. e (usuallyCormac’s three to six months), and is most frequently Story ociated with musculoskeletal disorders such as low Likewise consideration should also be given I was always in trouble, I seemed to need the to the effect of prescribed medications k pain and arthritis. However, can also bethe associated excitement. If someoneit suggested most L-Dopa and corticosteroids are the prescribed outlandish prank, I always seemed to be the h other disorders such as depression or metabolic medications most commonly associated devil. I was thrown out of school at 13 with secondary mania. More often, drug and/ orders ordare neurologic conditions such as multiple when I loosened the wheels of the English or alcohol misuse is comorbid with manic or rosis. teacher’s car. After school it was the same thing depressive mood change. The mood state will – I couldn’t settle down and concentrate – my then significantly outlast the state induced by mind was always over the place. At home I n (acute or chronic) can beallcategorised as nociceptive intoxication or withdrawal and a diagnosis of was arguing with my father. He tried his best to bipolar disorder can be made. europathic. Nociceptive pain is caused by an active get me to study, but I always managed to get ss, injuryout and/or inflammatory process associated with in the evenings. I was never asleep before If first presentation of the condition occurs in 3 in thetissue morning and was 5 am. later life, there tends to be an association with ual or potential damage i.e. wide-awake Nociceptiveatpain At other times, I have felt like a lump of lead other comorbidities, which can cause further ults from –activity in neural pathways secondary to actual I slept around the clock. My parents were complexities. Early specialist intervention is otential convinced tissue damage. is mediated that I Nociceptive was on drugspain – they searched therefore considered key. As an example, my room and quizzed friends. The summer pain receptors located in skin, my musculoskeletal system, anxiety disorders are highly comorbid with I reached 16, it all came to a head. I was in the bipolar disorder from a lifetime perspective, 8 e, and joints. Neuropathic pain,restless on the and othercouldn’t hand, and anxiety symptoms are associated with Gaeltacht and I felt very increased illness burden and poor health related ults from sit direct injuryFor to four a peripheral central sensory in class. nights inor a row I walked the outcomes. Moreover, organic conditions must beachesnerves when Ido couldn’t sleep. Itransduction began to feelata ve; the affected not produce also be excluded. Examples include; thyroid great exhilaration and enormous strength in my 8

disease, multiple sclerosis, HIV or any lesion(s) involving subcortical or cortical areas that can be associated with secondary mania. Such comorbidities as would be expected, become more prevalent and relevant as the age of the patient increases. One of two schemes is often referenced as guidance for diagnosis. These are ICD-10 (International Classification of Diseases, currently in its 10th edition) or DSM-IV (The Diagnostic and Statistical Manual of the American Psychiatric Association). Often, when referencing guidance on bipolar disorder, one of these two systems will be mentioned, and this article will focus on ICD10. Both of these categorical systems however use the presence (or absence) of a number of carefully selected and equivalent clinical features as a template for diagnosing the condition. The diagnostic criteria for bipolar disorder using the ICD-10 criteria outlines that a diagnosis is confirmed after two or more episodes of extreme mood change, one of which must be mania or hypomania, (by contrast, DSM-IV requires only a single manic or mixed episode.) According to ICD-10 criteria, such episodes can include • Mania without psychosis Symptoms must be present for at least one week. Mood is elevated out of keeping with circumstances from joviality to uncontrollable excitement. May include increased energy, resulting in over activity, pressure of speech, and a decreased need for sleep. Attention cannot be sustained, and there is often marked distractibility. Self-esteem is often inflated with grandiose ideas and overconfidence. Loss of normal social inhibitions may result in behaviour that is reckless, out of character or inappropriate to the circumstances. • Mania with psychosis Symptoms as for mania but delusions or hallucinations are usually present. • Hypomania Symptoms must be present for at least four days. A persistent mild elevation of mood, increased energy and activity, and marked feelings of well-being. Increased sociability, talkativeness, over-familiarity, increased sexual energy, and a decreased need for sleep are often present but not to the extent that they lead to severe disruption of work or social rejection. Psychotic symptoms are not present. • Depression As for unipolar depression. With respect to timescales, the duration of episodes can vary markedly. Manic episodes usually begin abruptly and last for between 2 weeks and 4–5 months (median duration about 4 months). Depressions tend to last longer (median duration about 6 months). Recovery may or may not be complete between episodes. The patterns of remission and relapse are very variable, although periods of remission tend to shorten as time goes on, while depressive phases become commoner and longer lasting.

iceptors. Pain characteristics and associated conditions both types of pain are shown in Table 1.

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CPD 46: BIPOLAR DISORDER IN ADULTS

TREATMENT Pharmacological The management of bipolar disorder can be split into three phases: 1. Treatment of a manic or hypomanic episode 2. Treatment of a depressive episode 3. Long-term management and prevention of symptoms returning Educational distance

Module 1 June 2012

Bipolar disorder

learning content for healthcare professionals in Ireland

Manic or hypomanic episodes

Chronic Pain – assessment and management in primary care

Episodes of mania usually require hospital admission to protect patients from behaviour that may place them, or others, at risk of harm. Any drug that might have contributed to the presentation, such as antidepressants, will need to be stopped to prevent prolonged symptoms. Antidepressants are usually stopped abruptly in mania but a gradual tapered withdrawal may be appropriate in those with less severe symptoms to avoid antidepressant discontinuation problems (e.g. influenza-like symptoms, dizziness and insomnia).

an antipsychotic with either lithium or valproate, or valproate with lithium. Depressive episodes

significant risk or adverse consequences, those who have had two or more episodes of mania or depression, or sufferers with significant functional impairment, risk of suicide or frequent episodes.

Most patients with bipolar disorder have far more depressive episodes than manic ones but, Specific drug monitoring considerations until recently, bipolar depression was poorly The treatment of choice for a first episode researched and most of the treatment options Lithium - has a narrow therapeutic range and of mania or hypomania includes an atypical were extrapolated from unipolar depression. so requires close monitoring of plasma levels antipsychotic, a valproate preparation or lithium Bipolar depression often occurs more rapidly, and other physical health parameters, such as if symptoms are less severe. The four atypical more frequently and with more marked renal and thyroid function. Blood levels should antipsychotics currently licensed for treating symptoms than unipolar depression and, for ideally be taken 12 hours after a dose (10–14 mania are aripiprazole, olanzapine, risperidone Sheehan et al reported in aiming 1996 that estimated many, it is a life-long illness rather than one that Introduction hours at most) for athe level betweencost of and quetiapine. These atypical antipsychotics occurs in discrete episodes. pain for 95 0.6–1mmol/L. patients to theLevels Irish Health when added above Services 0.75mmol/L offer are generally preferred because of their more Pain is one of the commonest reasons for patients to seek additional protection manic symptoms to the amount of Social Welfare against payments received and favourable short-term adverse effects. As such, antidepressants have a role in treating 1 surveydepression has shownbut that as many medical attention. A recentbipolar but come with a greater burden of adverse should be used with the lost earnings Valproate is available in as three theyear to primary effects.of each patient amounted to 1.9 million caution because of theinrisk of causing mania or 8.3forms visits in per care physicians Ireland UK: sodium valproate, valproic acid and pounds at the time of referral.6 The recent data from PRIME hypomania (“switching”). They should always due to symptoms of pain.2 A large scale survey carried Lithium toxicity generally occurs above semi-sodium valproate. were In Ireland, only be prescribed in conjunction with an antimanic survey show that the mean per chronic pain patientof 1.5mmol/L and iscost associated with symptoms sodium valproate, valproic licensed.countries outacid in 15are European andtoIsrael in 2006, screening agent reduce this risk. If an antidepressant is estimatednausea, at €5,665 per year across all grades of pain, diarrhoea, course tremor, drowsiness Sodium valproate and semi-sodium valproate is necessary, selective serotonin 46,394 respondents reported that the prevalence of chronicreuptake ataxia. Because lithium almost are metabolised to valproic acid, which is which was and extrapolated to €5.34 billionis or 2.86% of Irish inhibitors (SSRIs) are recommended because pain of moderate toof severe intensity in adult Europeans was exclusively excreted unchanged in urine, any responsible for the pharmacological activity 7 they have a lower risk of switching (3.7 per cent) GDP per year. an urgent need for cost 3 drugThis that demonstrates alters renal handling or electrolyte the drug. Although only 19%. semi-sodium valproate compared with the tricyclic antidepressants effective strategies to manage chronic pain effectively. balance can increase lithium levels and hence is licensed for acute mania, it is generally (11.2 per cent) and, most probably venlafaxine. cause toxicity. This includes angiotensinunclear if there is any effiMore cacy recent or tolerability survey data from another study, carried out converting enzyme inhibitors, thiazide diuretics In rapid cyclers and those with a mixed difference between the preparations. What is 2,019 people with chronic pain and 1,472 primaryare likely to increase Understanding chronicantipain disorder, antidepressants and non-steroidal inflammatory drugs. important is the dose ofin valproate. For rapid the switching rate andhave as such should be Dehydration and a low salt diet can also raise symptom control (i.e. within few days) aacross 15 European careaphysicians countries, Chronic is defined pain and that are outlasts normal healing avoided. In those for whom an antidepressant is pain lithium levelsas rapidly important points loading dose of 20mg/kg/day is occasionally demonstrated that chronic not painappropriate, affects 12-54% of adult quetiapine (at 300mg per day) for consideration. used but at the expense of increased adverse time (usually three to six months), and is most frequently Europeans, and its prevalence in Ireland is up to 13%. The depression, or lamotrigine (unlicensed in2bipolar reactions. associated with musculoskeletal disorders such as low of Erratic compliance or abrupt discontinuation but the usual dose is 50–200mg per day) are PRIME (Prevalence, Impact and Cost of Chronic Pain) study, lithium should be actively discouraged because Lithium is effective in acute mania but its onset back pain and arthritis. However, it can also be associated recommended. In contrast to treatment for on the other determined the prevalence chronic this may increase the risk of a manic relapse. of action is slower than that seen withhand, atypical unipolar depression,of antidepressant treatment with other disorders such as depression or metabolic 4 antipsychotics or valproate. to high this isas 35.5% pain Added to be as Ireland. The PRIME studyshort-term. in in bipolar depression is usually has recently been the as subject of a disorders orLithium neurologic conditions such multiple the need for pre-lithium physical health checks, bipolar management National Patient Safety Agency (NPSA) alert in was designed to investigateSome the prevalence of chronic guidelines pain which may be refused by patients who are recommend that the antidepressant should sclerosis. which, the importance of regular plasma levels, in Ireland; compare the psychological physical health acutely unwell and frequently uncooperative be tapered and off and then withdrawn after eight physical health monitoring and problematic and in a state of treatment decline. weeks of symptom However, Pain this (acuteinteractions profiles of those with and without chronic pain;remission. and explore or chronic) can categorised as nociceptive werebe highlighted. Lithium levels approach is variable and will ultimately depend pain-related disability. should be measured every three months, The short-term use of benzodiazepines, such 4 Responses to survey questions were or neuropathic. Nociceptive pain is caused by an active on the management approach implemented by however in practice they are frequently only as lorazepam or clonazepam, are from also useful obtained 1,204 people. the treating clinician. illness, injury and/or inflammatory process associated with checked following a dose adjustment or during in acute mania for their calming and sedative actual or potential tissue damage i.e. Nociceptive pain an episode of acute illness. effects. Long-term management

Despite the magnitude of the problem, chronic pain is

results fromValproate activity in-neural pathways to actual is a major humansecondary teratogen and If a patient presenting with mania or hypomania andThe goal of long-term treatment both under-recognised undertreated in primary care.2,5is to prevent so should be avoided in pregnancy. As the or potential tissue damage. Nociceptive pain is mediated is already on an appropriate antimanic new mood episodes and to increase the Indeed, up to 38% of patients reported beingbetween inadequately associated fetalinabnormalities occur in early medicine, clinicians should first check period of stability episodes. Targeting by pain receptors located skin, musculoskeletal system, pregnancy, ideally it should be avoided in managed in primary their pain symptoms. In knowing the compliance before considering optimising thecare for predominant symptoms2and 8 bone, and joints. Neuropathic pain, onpotential. the otherIfhand, any woman of child-bearing an treatment by increasing addition, the dose people or indeed course of the illness is essential for effective with chronic pain reported waiting up to pregnancy occursor while a woman is results fromunplanned direct injury to a peripheral central sensory switching the choice of treatment. If the maintenance. NICE recommends long-term 2.2 years between help and should diagnosis, and 1.9 for those response is inadequate then medicines are seekingtreatment taking valproate, she should be advised to seek be considered nerve; the affected nerves do not produce transduction at 2 often combined. Common combinations years before theirinclude pain waswho adequately managed. have suffered a manic episode involving immediate specialist advice. 8

nociceptors. Pain characteristics and associated conditions for both types of pain are shown in Table 1.

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CPD 46: BIPOLAR DISORDER IN ADULTS

Lamotrigine - although useful in treating and preventing bipolar depression, it must be titrated slowly to reduce the risk of blood dyscrasias and a serious rash developing. A rash develops in 10 per cent of patients and in 1 per cent can become serious or potentially life threatening, with rare reports of Stevens– Module 1 Johnson syndrome and toxic epidermal June 2012 necrolysis. It is usually maculopapular and generally appears within eight weeks of starting treatment. Anyone patient who develops a rash, for which there is no other obvious cause and sionals which in Ireland appears to be spreading or worsening should be advised to stop their lamotrigine and seek immediate medical attention. A rash is more likely if lamotrigine is co-prescribed with valproate (which prolongs the half life and reduces the clearance of lamotrigine).

anagement in primary care

Carbamazepine - is a potent inducer of cytochrome P450 hepatic enzymes and so can increase the clearance of many other drugs and potentially cause treatment failure. Medicines affected include most antidepressants, antipsychotics, benzodiazepines, methadone, theophylline and oestrogens.

Electroconvulsive therapy (ECT) is also occasionally used for severe manic or depressive episodes, if other treatments have failed or the condition is potentially lifethreatening. PHARMACY INVOLVEMENT Treatment Points It is essential that good communication exists between all healthcare professionals involved in the management of bipolar disorder patients, to ensure that treatment plans are clear and carefully executed. So too, effective communication with patients or their carers is an essential element. When speaking to patients or their carers, everyday jargon-free language should be used to give a full and clear explanation of the condition and its treatment. Written, evidence-based information about the condition and its treatment should also be provided as appropriate.

Pharmacists are suitably placed to identify medication non-compliance and respond to this at an early stage, either by consulting with the patient directly or highlighting the Monitoring issue to their carer/GP/community mental Individuals with bipolar disorder have higher health team member. So too, pharmacists levels of physical morbidity and mortality than can help identify medication related sidethe general population. As such, they are effects and offer solutions where possible, recommended to have an extensive physical e.g. antipsychotic related constipation may be health check soon after initial presentation and treated with the use of a bulk-forming laxative. this should be repeated annually. The initial Similarly, pharmacists can refer patients to their checkinshould include fasting blood ehan et health al reported 1996 that the aestimated cost of prescribing clinician for the management of glucose, blood pressure, full blood counts, liver n for 95 patients the Irish lipid Health Services when added side-effects such as nausea or hypersalivation, and renaltofunction, profi le, thyroid function where a prescription only supportive medication he amount Social In Welfare payments and andofweight. addition, many ofreceived the medicines therapy may be required. used of in the treatment of bipolar disorder lost earnings each patient amounted to 1.9 million have specific physical health monitoring Pharmacists that have a good rapport with nds at the time of referral.6 The recent data from PRIME their patients may identify deterioration in recommendations. vey show that the mean cost per chronic pain patient their clinical condition and encourage early e.g. antipsychotic medication monitoring intervention, while those that seek to effectively stimatedrequirements: at €5,665 per year across all grades of pain, counsel patients on their medicines can offer ch was extrapolated to €5.34 billion or 2.86% of Irish advice and guidance on their monitoring • Fasting blood glucose – baseline and every 7 P per year.3months This demonstrates urgentolanzapine) need for cost requirements and perform follow-up checks to (at 1 month an if taking ensure that these have been undertaken at the ctive strategies effectively.risk • ECG to – amanage baselinechronic if there pain are underlying appropriate frequency. factors Another area where pharmacy plays an • Lipid profi le – baseline derstanding chronic pain and repeated after important role is in advising on the use of non – 3months prescribed medications and supplements. Over onic pain is defined as pain that outlasts normal healing the counter medicines and internet purchases • Prolactin – baseline and repeated if e (usually three to six months), and isonly) most frequently of medicines can interact significantly with symptomatic (risperidone prescribed medicines and have the ability to ociated with musculoskeletal disorders such as low • Weight – baseline, then every 3 months for contribute to Adverse Drug Reactions (ADR’s). k pain andthe arthritis. However, it can also be associated Patients may choose to self medicate for first year and annually thereafter h other disorders such as depression or metabolic a number of reasons. In the case of some NON PHARMACOLOGICAL psychiatric patients, it can be the deliberate orders or neurologic conditions such as multiple Drug treatment remains the principal intention to over medicate for the purpose of rosis. therapeutic intervention in bipolar disorder, inducing perceived pleasurable feelings. In but a few alternative approaches can help in other cases it is because of an unquestioning n (acute or canmanagement. be categorised as nociceptive thechronic) long-term Teaching patients belief in the power and efficacy of nature’s to recognise earlypain warning signs by ofan an active acute healing remedies and processes. Other reasons europathic. Nociceptive is caused episode can enable them to actively seek help referenced by patients; the disappointment and ss, injuryatand/or inflammatory process associated with an early stage in their decline and possibly dissatisfaction with conventional medicines, reducetissue the associated likelihood of hospital ual or potential damage i.e. Nociceptive pain the outright rejection of orthodox treatments, ults from admission. activity in neural pathways secondary to actual uncritical journalism, desperation for a ‘cure’, and anecdotal case studies or surveys lifestyle changes, such as is reducing otential Making tissue damage. Nociceptive pain mediated masquerading as research. stress, practising good sleep hygiene, keeping

pain receptors located in skin, musculoskeletal system, regular work patterns and reducing alcohol and An example of some of relevant interactions 8 e, and joints. Neuropathic pain, onuseful the other hand, substance misuse, are also interventions. and ADR’s include: treatments, ults from Structured direct injurypsychological to a peripheral or centralsuch sensory • a mild serotonin syndrome in patients who as cognitive behavioural therapy and family ve; the affected dorecommended not produce transduction mix St John’s wort (Hypericum perforatum) therapy,nerves are also in patients at 8 iceptors.exhibiting Pain characteristics and associated mild to moderate symptoms.conditions with serotonin-reuptake inhibitors. both types of pain are shown in Table 1.

• decreased bioavailability of digoxin when combined with St John’s wort, • induction of mania in depressed patients who mix antidepressants and ginseng • the interaction when warfarin is combined with ginkgo (Ginkgo biloba) causing bleeding, • exacerbation of extrapyramidal effects with neuroleptic drugs and betel nut (Areca catechu); • increased risk of hypertension when tricyclic antidepressants are combined with yohimbine. • Disulfiram which inhibits aldehyde dehydrogenase inhibits the metabolism of warfarin. Metronidazole causes an unpleasant disulfiram-like reaction when mixed with alcohol. • Consumption of 6-8 glasses of grapefruit per day may raise levels of carbamazepine and pimozide. Grapefruit juice is thought to the metabolism of many drugs and inhibition can last a number of hours. • Diphenhydramine in therapeutic doses inhibits CYP45 2D6-mediated metabolism of venlafaxine in humans. • dextromethorphan above therapeutic doses can cause loss of coordination, dizziness and, nausea. It should also be avoided when an MAO inhibitor is concomitantly given. Ultimately, pharmacists have the potential to play an incremental role in the effective management of patients with bipolar disorder and should be alert to any of the small yet significant contributions that can help make this happen. REFERENCES 1. Scottish Intercollegiate Guidelines Network 82 Bipolar affective disorder. A national clinical guideline. 2005 2. NICE clinical guideline no. 38 Bipolar disorder the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. July 2006. 3. British Association for Psychopharmacology guidelines. Evidence-based guidelines for treating bipolar disorder: revised second edition -recommendations from the British Association for Psychopharmacology. 2009. 4. http://www.aware.ie/help/information/ literature-2/bipolar-disorder/ 5. Goodwin GM (2009) Evidence-based guidelines for treating bipolar disorder. Revised second edition. Recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology 23: 346–88. 6. Fraser K, Martin M, Pharmaceutical Care (13)Mood Disorders: Bipolar Conditions. Pharmaceutical Journal 2001; 266:824-832 7. Bleakley S, Henry R, Understanding Bipolar Disorder. Pharmaceutical Journal 2010; 8. Hunter R, Fraser K et al, Bipolar Disorder – aetiology and pathophysiology. Hospital Pharmacist 2004; 11:129-132 9. Dunne F, Omar M, Over-the-counter and purchase-on-internet medications - Implications for psychiatry, BJMP 2012; 5(4): a535

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Cpd 46 bipolar disorder in adults  
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