Bipolar Disorder Guidelines: NICE Update

Clinicians treating bipolar disorder and patients with a bipolar disorder diagnosis are aided by the availability of expert opinion guidelines.

In the last post, I reviewed a study that found decreased rates of suicidal behavior in bipolar patients treated with antidepressant drugs.

This review prompted me to look for a recent consensus update on assessment and treatment of bipolar. One recent update came from the UK National Institute for Health and Care Excellence or NICE. This guideline is freely available and I will post a link at the end of this blog post.

I will focus on psychopharmacology in my review but the reader is encouraged to take a look at these excellent guidelines for other details.

The recommendations from the guideline for general maintenance treatment of bipolar disorder in adults in specialty care:

• Do not use gabapentin or topiramate
• Antipsychotic drugs
• Lithium therapy
• Valproate therapy
• Lamotrigine therapy

Recommendations for treatment of mania in specialty care:

• If manic bipolar patient is taking antidepressant consider stopping it
• Electroconvulsive therapy is an intervention that should be considered in those with severe and prolonged mania
• The further treatment of mania follows the maintenance list as above: antipsychotics (haldol, olanzapine, quetiapine or risperidon), lithium, valproate and lamotrigine

Recommendations for treatment of bipolar depression in specialty care:

• Make sure full psychological services are used as a base in treatment
• Add fluoxetine plus olanzapine or quetiapine on it's own
• If no response to initial antidepressant treatment consider a trial with lamotrigine

As you can see from these depression guidelines, the use of standard antidepressants in bipolar depression is not recommended. The exception to this is the use of fluoxetine (covered with olanzapine).

The full pdf guideline from NICE is 59 pages and I would encourage interested reader to go to the website and download the full guide. You can do that by clicking HERE .

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Kendall T, Morriss R, Mayo-Wilson E, Marcus E, & Guideline Development Group of the National Institute for Health and Care Excellence (2014). Assessment and management of bipolar disorder: summary of updated NICE guidance. BMJ (Clinical research ed.), 349 PMID: 25258392

Nicotine Replacement in Schizophrenia

Inpatient psychiatric hospitals increasingly prohibit smoking by patients, staff and family in their units.  Although the public health benefits of smoking restrictions are undeniable, there may be some situations where smoking restrictions have unintended consequences.  One area is the emergency management of patients with serious psychiatric illnesses such as schizophrenia and bipolar affective disorder.

Rates of smoking have been documented to be higher in both schizophrenia and bipolar affective disorder.  The likelihood is high that acute psychiatric emergencies in schizophrenia and bipolar will be accompanied by nicotine dependence.  Clinicians are left making a decision on how to manage nicotine dependence in the context of psychotic decompensation.

Michael Allen and colleagues recently conducted a small study of nicotine dependence management in forty subjects with schizophrenia admitted to a psychiatric emergency service.  Subjects were required to be smokers at the time of admission.  Severity of smoking dependence was assessed using the Fagerstrom scale.  Subjects received standard antipsychotic therapy without restriction but they were randomized to receive either nicotine replacement therapy (21 mg nicotine patch per day) or placebo patch.

Here is a summary of the results of the study:

• Nicotine replacement reduced a measure of agitation by 33% in the first four hours and 23% at 24 hours
• This reduction was statistically significantly more than with antipsychotic alone and placebo
• Subjects with lower nicotine dependence scores tended to show the most response compared to placebo
• The size of the effect of nicotine replacement on agitation reduction approached the level seen with standard antipsychotic therapy

So the beneficial effects of replacing nicotine in the short term in this population is pretty dramatic and of signifcant magnitude.  The authors note that it is possible the 21 mg nicotine patch is insufficient to address nicotine withdrawal in schizophrenics with more severe nicotine dependence.  Since the nicotine patch typically takes several hours to provide significant blood levels, the authors suggest a combination of nicotine gum (with rapid onset) and a patch may be the best strategy.

Encouraging patients with psychotic disorders and mood disorders to quit smoking is an important general health strategy.  However, this study suggests that attempting this during an acute psychotic break is probably counter productive and may be inhumane.  Acute nicotinie withdrawal may exacerbate the agitation of psychosis.  Nicotine withdrawal attempts in this population is probably better suited for periods where psychotic symptoms are under control.  It also makes sense to monitor patients with schizophrenia closely during attempts to stop smoking.  This period may be one of increased risk of psychiatric decompensation.

Photo of Nicotine Patch Courtesy of Wikipedia Creative Commons by RegBarc

Allen MH, Debanné M, Lazignac C, Adam E, Dickinson LM, & Damsa C (2011). Effect of nicotine replacement therapy on agitation in smokers with schizophrenia: a double-blind, randomized, placebo-controlled study. The American journal of psychiatry, 168 (4), 395-9 PMID: 21245085