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Transcript of Bipolar disorder mrc psych
Bipolar disorderRajeev KrishnadasClinical LecturerSackler Institute
University of Glasgow
Outline
• Intro/History• Symptomatology and diagnosis• Etiopathogenesis• Course• Treatment
– NICE– Individual more recent evidence
• Post lecture test !!!!!
Bipolar Disorder
• Common illness affecting 2% of the world population (5% if one includes spectrum disorders)
• Lifetime prevalence – 1%• 6th leading cause of medical disability in the
developed nations• Bipolar I – equal in males and females• Bipolar II – more in females
1Cookson J. Br J Psychiatry. 2001;178(suppl. 41): s148–s156.2Strakowski SM, et al. Expert Opin. Pharmacother. 2003;4:751-760.
History – terms for MRCPsych
Symptomatology and Diagnosis
Symptom dimensions in Mood/Psychosis
Classification of Mood Disorders
Bipolar I
Bipolar II
Cyclothymia
Unipolarsingle episode
Dysthymia
Unipolarrecurrent‘Unipolar’
‘Bipolar’
Symptomatology - Mania• Persistently elevated, expansive, or irritable mood, lasting at least 1 week
• Three (or more) of the following symptoms (4/9 in ICD)
– inflated self-esteem or grandiosity
– decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
– Pressure of speech
– flight of ideas or subjective experience that thoughts are racing
– distractibility
– increase in goal-directed activity or psychomotor agitation
– excessive involvement in pleasurable activities that have a high potential for painful consequences
• Marked impairment in occupational functioning or in usual social activities or relationships with
others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic
features.
• Exclude other causes
Symptomatology – Hypomanic episode
• Same symptomatology as mania• Duration – 4 days • Change noticeable by others• No significant socio-occupational disturbance• No Hospitalisation• No psychotic symptoms
Symptomatology – Mixed episode
• The criteria are met both for a manic episode and for a major depressive episode (except for duration) nearly every day during at least a 1-week period.
• Socio - occupational deterioration• The symptoms are not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
Copyright © 2009 Blackwell Publishing Ltd. Published by Munksgaard International Publishers Ltd. 2
Medicating mood with maintenance in mind: bipolar depression pharmacotherapy.Malhi, Gin; Adams, Danielle; Berk, Michael
Bipolar Disorders. 11 Sup 2:55-76, June 2009.DOI: 10.1111/j.1399-5618.2009.00711.x
Symptomatology - Depression
Algorithm for diagnosis
Summary of DSM-IV-TR Classification of Bipolar Disorders
* Symptoms do not meet criteria for manic and depressive episodes.
Bipolar features that do not meet criteria for any specific bipolar disorders
At least 2 years of numerous periods of hypomanic and depressive symptoms*
One or more major depressive episodes accompanied by at least one hypomanic episode
FEMALE>MALE
One or more manic or mixed episodes, usually accompanied by major depressive episodes
MALE=FEMALE
Bipolar DisorderNot OtherwiseSpecified
CyclothymicBipolar IIBipolar I
First, ed. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Rev. Washington, DC: American Psychiatric Association; 2000:345-428.
Bipolar spectrum – Akiskal
Etiopathogenesis!!!!
Genetics of Bipolar disorder
• Population risk – 1 – 2%• MZ concordance – 40 -45%• Heritability – 80 – 85%• Leading linked regions – 6q, 8q, 13q, 22q• Leading candidate genes
– BDNF– DAOA– DISC– TPH2– SLC6A$
• Genes implicated by GWAS – DGKH– CACNA1C– ANK3
J.H. Barnetta, J.W. Smolle. The genetics of bipolar disorder. Neuroscience. Volume 164, Issue 1, 24 November 2009, Pages 331-343
Approximate lifetime rates of mood disorder in various classes of relative of bipolar probands
Degree of relationship to bipolar proband
Risk of bipolar disorder (%)
(Additional) risk of unipolar depression (%)
Monozygotic co-twin 40-70 15-25
First degree relative 5-10 10-20
General population (ie, unrelated)
0.5-1.5 5-10
Owen M. et alJournal of Medical Genetics 1999;36:585-594
Genetics• Strongly genetic
– Heritability estimates approach 0.9
– Concordance in MZ twins of 50-70%
– Early-onset bipolar disorder may be even more genetic
• Multiple genes confer risk (polygenic model) – similar to schizophrenia
• Most recent – Family history of bipolar confers high risk for
development o schizophrenia and vice versa (Lancet 2009)
• Complex gene-environment interactions exist – similar to
schizophrenia
Copyright restrictions may apply.
Owen, M. J. et al. Schizophr Bull 2007 0:sbm053v1-1; doi:10.1093/schbul/sbm053
Genetics of Bipolar vs Schizophrenia
Environmental factors
• Early life stress
– Intrauterine, childhood abuse or neglect
• Recent (or chronic) life adversity
• Substance misuse
– Alcohol; cannabis
• Psychosocial deprivation
Imaging findings• The most consistently and frequently observed findings
– Increased white matter hyperintensities– Cortical abnormalities – Amygdala, SGPrefrontal cortex,
Striatum– Cerebellar structural abnormalities– Mild sulcal prominence and ventricular enlargement – Decreased activity of the D/V prefrontal cortex, when
subjects are depressed– Hypo/hyperfrontality (SGPFC) when subjects are manic
• No specific unifying pathophysiologic mechanism • Medications and drug use could account for some
abnormalities
Imaging findings• Structural magnetic resonance imaging (MRI)
– Abnormalities of prefrontal cortical areas (SGPFC), striatum and amygdala exist early in the course of illness - trait
– Abnormalities of cerebellar vermis, lateral ventricles and other prefrontal regions (eg, left inferior), appear to develop with repeated affective episodes, and may represent the effects of illness progression and associated factors - state
• Magnetic resonance spectroscopy (MRS)– Abnormalities of membrane and second messenger metabolism, in striatum
and prefrontal cortex. • Functional imaging studies (fMRI)
– Activation differences between bipolar and healthy controls in these same anterior limibic regions.
• Dysfunction within prefrontal networks and the associated limbic modulating regions (amygdala, midline cerebellum).
• Diminished prefrontal modulation of subcortical and medial temporal structures within the anterior limbic network (eg, amygdala, anterior striatum and thalamus) that results in dysregulation of mood
Circuits implicated
S M Strakowski et al. Molecular Psychiatry 2005
HPA axis abnormalities
Bipolar disorder: neuropsychology – endophenotypes??
• Cognitive impairment is a core feature of the disorder (during depression and mania)
• Cognitive impairment persists on clinical recovery:
– Not simply the result of medications of previous ‘scarring’ effects of past mood episodes
– Seen in unmedicated patients, first degree relatives and high risk individuals
– Heterogeneity among studies
Bipolar neuropsychology (1)
• Bipolar depression:
• Impaired:– Attention (errors of
omission)– Verbal memory– Executive function
• Hypomania and mania:
• Impaired:– Attention (errors of
commission)– Verbal memory– Executive function
Cognitive deficits in euthymic bipolar• Large effect sizes (d≥0.8)
– executive function (category fluency, mental manipulation) – and verbal learning.
• Medium effect sizes (0.5≤db0.8) – immediate and delayed verbal memory – abstraction and set-shifting – sustained attention – response inhibition– psychomotor speed.
• Small effect sizes (0.2≤d b0.5) – verbal fluency by letter– immediate memory– sustained attention
Robinson L et al Journal of Affective disorder - 2006
Neuropsychological function in Schizophrenia vs Bipolar disorder
Schretlen, D.J., et al. Biological Psychiatry. 2007; 62(2): 179–186
Neurochemistry
• Monoamine hypothesis (The usual suspects)– Serotonin– Norepinephrine– Dopamine– Glutamate
• Kindling hypothesis– Multiple sub-threshold stimuli – Mood stabilisers
Causal pathways implicated
Secondary mood disordersMedical disorders
Mania Depression
Secondary mood disordersDrugs
Mania Depression
Comorbidity
Course
• Age of onset - between 15 and 19 years• Mostly starts with depressive episode• Many depressives are hidden bipolars• Annual rate of diagnostic change from
depression to hypomania – 1%• Length of episode of mania – 4 – 6 months• Episodic- relapsing and remitting
Course
Course
• Inter-episodic duration shortens over time• Progressive shortening of cycle length• Average of 10 episodes over life time (2xMDD)• Residual symptoms predict poor prognosis• Lifetime risk of suicide – 15 times general pop• Lithium is antisuicidal• Bipolar II – rapid cycling
Risk of relapse
NICE Guidelines
2006
Treatment
• Acute phase• Maintenance phase
Treat the acute phase
Consider an antipsychotic if:
•manic symptoms are severe
•there is marked behavioural disturbance
Consider valproate or lithium if:
•there has been previous response and good compliance with one of these drugs
Consider lithium if:
•symptoms are less severe
Initiate long-term pharmacological treatment
After a manic episode with significant risk and adverse consequences
Bipolar I: two or more acute episodes
Bipolar II: evidence of significant functional impairment or risk of suicide or frequently recurring episodes
Choose long-term drugs
Base choice of lithium, olanzapine or valproate* on:
•previous response•risk and precipitants of manic versus depressive
relapse •physical risk factors•patient preference and history of adherence•cognitive state assessment if appropriate
* Valproate should not be prescribed routinely for women of child-bearing potential
Try alternatives if needed
If continuing symptoms or relapse, use alternative monotherapy or add second prophylactic agent:
•lithium and valproate•olanzapine and lithium•valproate and olanzapine
If this proves ineffective:
•consult, or refer to, an expert in pharmacological treatment of bipolar disorder
•prescribe lamotrigine or carbamazepine
Support long-term pharmacological treatment
Ensure prescribing advisers are aware of NICE guidance, and what to consider when choosing treatment
Focus on optimising appropriate long-term treatment
Support service user education and empowerment in pharmacological treatment and management decisions
Make use of early intervention teams, regional mental health trusts and CAMHS teams
Modify treatment for rapid cycling
For an acute episode base treatment on that for manic and depressive episodes and:
•review previous treatments; if inadequately delivered or adhered to, consider a further trial of previous treatments
•optimise long-term treatment; each trial of medication should usually last at least 6 months
•encourage patients to keep a mood diary
Use antidepressants with care
Acute manic phase
Stop antidepressants at onset of acute manic phase and decide if discontinuation is abrupt or gradual based on:
•current clinical need•previous experience of discontinuation/withdrawal
symptoms•the risk of discontinuation/withdrawal symptoms
Consider need for treatment
Is long-term antidepressant treatment needed after an acute depressive episode?
No evidence for reduced relapse rates
May be associated with increased risk of mania
Educate staff and service users
Raise awareness of effective antidepressant prescribing
Highlight the importance of a thorough review of pharmacological history
Support patient fears about antidepressant withdrawal
Review prescribing policies and formularies, update as appropriate
Consider psychological therapy
For those who are stable, individual structured psychological therapy should include:
•at least 16 sessions over 6 to 9 months•psychoeducation •promotion of medication adherence •monitoring of mood, detection of early warnings
and prevention strategies •coping strategies
Implement psychological therapy
Offer individual structured psychological therapy
Identify key people to support mood monitoring and coping strategies
Identify training needs
Review access to services
Work collaboratively and engage the client, family or carers
Take possible pregnancy into account
Valproate should not be used routinely for women who may become pregnant. It may:
•cause foetal abnormalities•affect the child’s cognitive development
If prescribed, ensure adequate contraception. Explain risks during pregnancy and to the health of the unborn child
An antipsychotic may be used with caution
Provide care for women of child-bearing potential
Review care pathways and management of bipolar disorder in women of child-bearing potential
Raise awareness of the effects of bipolar disorder and treatment on:
•conception •pregnancy •child
Engage with patients, discuss contraception and family planning
Mitigate drug-related weight gain
Review medication strategy and consider:
•dietary advice and support •advising regular increased aerobic exercise•referring to a specialist mental health diet clinic or
health delivery group•referring to a dietitian if needed for people with
complex comorbidities
Support patients in controlling weight
Review risk of weight gain when prescribing, offer early dietary advice and support
Offer diet clinics or health delivery groups locally
Identify a named key worker with appropriate training, use the care programme approach (CPA)
Document in clinical notes/individualised care plan
Review annually
Over the course of the year an annual review should include:
• lipid levels, including cholesterol, in patients over 40• plasma glucose levels• weight• smoking status and alcohol use• blood pressure
Establish review systems
Agree responsibility locally
Establish monitoring and early warning systems
Develop systems for responsibility and intervention
Communicate results
Follow up non attendance
Lithium – Gold standard
Geddes J, Burgess S, Hawton K, Jamison K, Goodwin G. American Journal of Psychiatry 2004 217-222
Efficacy of lithium – all relapseEfficacy of lithium – all relapse
Efficacy of lithium – ManiaEfficacy of lithium – Mania
Geddes J, Burgess S, Hawton K, Jamison K, Goodwin G. American Journal of Psychiatry 2004 217-222
Efficacy of Lithium – Depression?
Geddes J, Burgess S, Hawton K, Jamison K, Goodwin G. American Journal of Psychiatry 2004 217-222
Lithium - summary• Mania – Acute treatment
– Strong evidence in the treatment of moderate to severe manic episodes.
• Depression – Acute treatment– Controversial, but recognized as a therapeutic option.
• Maintenance therapy– lithium prevents relapse and recurrence in in bipolar I disorder
patients with recent manic or hypomanic episodes. – More effective in preventing episodes of the manic/hypomanic type,
including mixed episodes, than preventing depressive episodes. – In rapid cycling patients – useful in acute phase but is not likely to
prevent recurrences. – Reduces the high suicide rates associated with mood disorders.
Lithium – Responder signature
• Essential features– Recurrent mood disorder– Episodic course of illness– Remission is complete between episodes
• Indicative features– Predominance of depressive episodes !– Absence of rapid cycling pattern– Episodic course in another family member– No significant psychiatric comorbidity– Classic pattern of mood episodes
Metabolic effects of Lithium
Lithium: a review of its metabolic adverse effectsCallum Livingstone and Hagen RampesJournal of Psychopharmacology, May 2006; vol. 20: pp. 347 - 355.
Monitoring – Lithium (ISBD)• Baseline
– Thyroid stimulating hormone– Serum calcium
• Serum levels – Trough levels at steady state (> 5 days) on initiation of therapy,
until two consecutivelevels within the therapeutic range are established for the same dosage
– At steady state after dose changes– Every 3–6 months and as clinically indicated at stable dosages
for theduration of treatment• Longitudinal
– Urea and creatinine every 3–6 months for the duration of treatment
– Serum calcium, thyroid stimulating hormone, and weight at 6 months, then annually
Ng F, Mammen OK, Wilting I, Sachs GS, Ferrier IN, Cassidy F, Beaulieu S, Yatham LN, Berk M. The International Society for Bipolar Disorders (ISBD) consensus guidelines for the safety monitoring of bipolar disorder treatments. Bipolar Disord 2009: 11: 559–595.
Anticonvulsants - MS• Valproate, (divalproex)
– strong evidence - effectiveness in mania,– moderately strong evidence - benefits in prophylaxis of recovered
states– recent proof-of-concept evidence for benefits in bipolar depression.
• Lamotrigine has – strong evidence for evidence in maintenance treatment of bipolar
depression– Lamotrigine - ineffective in mania and has lacked efficacy in acute
bipolar depression• Carbamazepine
– Strong evidence for effectiveness in mania, – lacks adequate studies in other aspects of bipolar disorder treatment. – Adverse effects and inducer
Monitoring – Anticonvulsants (ISBD)
• Baseline – Valproate and carbamazepine: check for history of haematological or hepatic
disease• Serum levels n
– Valproate and carbamazepine: 2 levels to establish therapeutic dose (separated by 4 weeks for carbamazepine), then as clinically indicated
• Longitudinal n – Valproate a : weight, full blood count, liver function test and inquiry of
menstrual changes (for women of reproductive age) every 3 months for the first year, then annually
– Carbamazepine: monthly full blood count, liver function test, and electrolytes, urea, and creatinine for the first 3 months, then annually; review oral contraceptive efficacy
– Carbamazepine and lamotrigine: remind patients to promptly withhold medications and seek medical attention within 24 h of emergence of dermatological eruptions
– Valproate and carbamazepine: advice on bone health
Antipsychotics• Typical antipsychotics,
– Haloperidol - clear evidence on the efficacy of on the treatment of acute mania.
– Faster onset of action of haloperidol as compared to either lithium or atypical antipsychotics.
– Risk of tardive dyskinesia, extrapyramidal side effects and a possible increased risk of non-adherence.
• Atypical antipsychotics – has been demonstrated for aripiprazole, clozapine, olanzapine,
quetiapine, risperidone and ziprasidone. – Limitations - risk of weight gain and dyslipidemia. – Comparison among different atypical antipsychotics agents are
difficult to determine as there are no conclusive head to head studies.– There is also a paucity of studies comparing atypical antipsychotics
with lithium.
Monitoring – Antipsychotics (ISBD)
• Baseline – Inquire about personal or family history of cardiac
problems, including congenital long QT syndrome• Longitudinal
– Weight: monthly for the first 3 months, then measures every 3 months for the duration of treatment
– Blood pressure and fasting glucose: every 3 months for the first year, then annually
– Fasting lipid profile: at 3 months after initiating treatment, then annually
– Electrocardiogram and prolactin levels where clinically indicated
Copyright © 2009 Blackwell Publishing Ltd. Published by Munksgaard International Publishers Ltd. 2
Medicating mood with maintenance in mind: bipolar depression pharmacotherapy.Malhi, Gin; Adams, Danielle; Berk, Michael. Bipolar Disorders. 11 Sup 2:55-76, June 2009.
First-line recommendations for acute bipolar depression
Bipolar depression
Medicating mood with maintenance in mind: bipolar depression pharmacotherapy. Malhi, Gin; Adams, Danielle; Berk, Michael. Bipolar Disorders. 11 Sup 2:55-76, June 2009.
Bipolar depression• Partitioning treatment into acute and maintenance
therapy is difficult based on the paucity of current evidence.
• Lithium and lamotrigine - first-line treatment in preference to valproate.
• For acute episodes, quetiapine and olanzapine equally efficacious
• Antipsychotics – significant side effects – lack of both long-term research data
• Lithium and the anticonvulsants – slower to effect symptomatic change
Medicating mood with maintenance in mind: bipolar depression pharmacotherapy. Malhi, Gin; Adams, Danielle; Berk, Michael. Bipolar Disorders. 11 Sup 2:55-76, June 2009.
Copyright © 2009 Blackwell Publishing Ltd. Published by Munksgaard International Publishers Ltd. 2
Medicating mood with maintenance in mind: bipolar depression pharmacotherapy.Malhi, Gin; Adams, Danielle; Berk, Michael. Bipolar Disorders. 11 Sup 2:55-76, June 2009.
Efficacy of pharmacological agents as phase-specific treatments in bipolar disorder based on available evidence
Psychological therapies
Lam DH, Burbeck R, Wright K, Pilling S. Psychological therapies in bipolar disorder: the effect of illness history on relapse prevention – a systematic review. Bipolar Disord 2009: 11: 474–482.
MCQ 1
The proportion of patients that develop a depressive episode and
then go on to develop an episode of mania within 10 years is
approximately
a. 1 in 2
b. 1 in 10
c. 1 in 4
d. 1 in 50
e. 1 in 200
MCQ 1 • Ans B• In community studies, one in ten patients who begin with a depressive episode go on to develop an
episode of mania within 10 years. If the illness begins at a younger age, the switch happens earlier. This rate increases to nearly 50% if severely depressed hospitalised patients are considered. Long term follow up studies blinded for severity and number of previous episodes show much lesser conversion rates (3.2%). It is known that the majority of bipolar patients, particularly women, begin with depressive episodes. Among hospitalised depressed patients followed up for nearly a decade 1% a year converted to bipolar I and 0.5% a year converted to bipolar II. However, this conversion rate is less for outpatients with depression. Factors associated with a change of polarity from unipolar to bipolar were younger age, male sex, family history of bipolarity, antidepressant induced hypomania, hypersomnic and retarded phenomenology, psychotic depression, and postpartum episode. The mean age at which the switch occurs is 32 years. The average number of previous episodes in those who switch varies between two and four. The huge differences in switch rates probably reflect the severity of the initial depression, the length of follow-up, and the expanding definitions of bipolar II disorder.
• • Angst J, Sellaro R, Stassen HH, et al. Diagnostic conversion from depression to bipolar disorders:
results of a long-term prospective study of hospital admissions. Journal of Affective disorders 2005: 84;149-157
• Stein G & Wilkinson G., eds. Seminars in General Adult Psychiatry, 2nd edn. Gaskell, 2007, p. 18.•
MCQ 2
Which of the following is true with regard to longitudinal course of
bipolar disorder?
a. The duration of mood episodes decreases progressively
b. Initial episodes have more rapid onset than the later episodes
c. The interval between episodes decreases progressively
d. Seasonal pattern is more common in bipolar type 1 than type 2
e. Later episodes are more likely to be triggered by life events than the initial
episodes
MCQ 2• Ans. C• In any patient with bipolar disorder, the duration of individual mood episodes
tends to be relatively stable throughout the course, with mania lasting shorter than depression generally. But the onset may become more rapid with age. The interval from one episode to the next tends to decrease through the course of illness though some evidence suggests a tendency for the inter-episode intervals to stabilize after around five episodes. Patients with seasonal patterns are more commonly of bipolar II subtype than bipolar I. The first episode is more likely to be triggered by life events than later episodes. Ambelas confirmed the strong correlation between stressful life events and first manic admissions; this association weakens as the illness progresses. This is particularly true for younger bipolar patients with mania rather than depression. This is consistent with the hypothesis of kindling phenomenon in bipolar disorders.
• Stein G & Wilkinson G., eds. Seminars in General Adult Psychiatry, 2nd edn. Gaskell, 2007, p. 27-29
• Ambelas A. Life events and mania: a special relationship? Br J Psychiatry 1987; 150: 235–240.
MCQ 3
Polyuria can be a troublesome side effect with lithium therapy. Which
of the following is NOT correct with response to lithium related
polyuria?
a. It is seen in one –third of those treated with lithium
b. It is usually reversible
c. Once daily dose produces more polyuria than multiple doses a day
d. Amiloride is an useful intervention
e. Dose reduction may alleviate polyuria
MCQ 3• Ans . C• Lithium related polyuria and polydipsia are seen in nearly one-third
of those treated. Polyuria is usually reversible in early stages but may become obstinate with longer duration of therapy. When once daily preparation of lithium is used instead of multiple divided doses, the frequency of polyuria seems to be lesser; but a direct correlation between plasma peaks and polyuria is not clearly demonstrated in clinical samples. Dose reduction or use of amiloride can be tried in those who have troublesome levels of polyuria. Amiloride has relatively lesser propensity to cause electrolyte disturbances when co-prescribed with lithium compared to other diuretics.
• Stein G & Wilkinson G., eds. Seminars in General Adult Psychiatry, 2nd edn. Gaskell, 2007, p. 34
MCQ 4
Compared to general population, the risk of Ebstein’s anomaly in
children of mothers exposed to lithium during the first trimester of
pregnancy is
a. 2 – 3 times higher
b. 10 – 20 times higher
c. 50- 80 times higher
d. 100 – 120 times higher
e. 4 - 5 times higher
MCQ 4• Ans : B• The risk of major congenital anomalies in children exposed
to lithium in uterus is 4-12%. This is nearly 3 times higher than non-exposed foetuses. The UK National Teratology Information Service has concluded that lithium increases the risk of cardiac malformations of around eight-fold. First trimester exposure to lithium increases the risk of Ebstein’s anomaly by nearly 10-20 times, bringing the absolute risk to 0.05-0.1%.
• Stein G & Wilkinson G., eds. Seminars in General Adult Psychiatry, 2nd edn. Gaskell, 2007, p. 36
• Williams, K & Oke, S. Lithium and pregnancy. Psychiatric Bulletin , 2000: 24; 229-231
MCQ 5
1. Which of the following predicts good prophylactic effect of lithium
in bipolar disorder?
a. Absence of family history of bipolar disorder
b. Presence of neurological signs
c. ‘Depression- Mania-well interval’ pattern of bipolar course
d. Good antimanic efficacy during acute episode
e. Absence of complete inter-episode recovery
MCQ 5• Ans: D• Various clinical, biological and genetic factors that predict lithium
responsiveness in prophylaxis of bipolar disorder have been studied. Presence of typical features of bipolar disorder, good inter-episode clinical recovery, family history of bipolar disorder, having mania as first bipolar episode, good response to lithium in acute manic phase predict lithium responsiveness. Presence of neurological signs, comorbid substance use and presence of rapid cycling predict poor response to lithium. Lithium response in a sample composed of relatives of lithium-responder probands was 67% compared to 30% in comparison group; this indicates that lithium responsiveness may have certain degree of heritability.
• Stein G & Wilkinson G., eds. Seminars in General Adult Psychiatry, 2nd edn. Gaskell, 2007, p. 40
• Grof P, Duffy A, Cavazzoni P, et al. Is response to prophylactic lithium a familial trait? J Clin Psychiatry. 2002;63:942-947
Further reading
– Goodwin and Jamison’s book– Bipolar disorders journal (2009 Suppliment)– New Oxford Textbook of Psychiatry
– MCQs – Palaniyappan, Krishnadas Best of 5 MCQs for MRCPsych Paper 1,2 and 3
Fin