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Management of Bipolar Disorder

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Management of Bipolar Disorder MANAGEMENT OF BIPOLAR DISORDER Federal Bureau of Prisons Clinical Guidance NOVEMBER 2016 Federal Bureau of Prisons (BOP) Clinical Guidance is made available to the public for informational purposes only. The BOP does not warrant this guidance for any other purpose, and assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper medical practice necessitates that all cases are evaluated on an individual basis and that treatment decisions are patient- specific. Consult the BOP Health Management Resources Web page to determine the date of the most recent update to this document: http://www.bop.gov/resources/health_care_mngmt.jsp. Federal Bureau of Prisons Management of Bipolar Disorder Clinical Guidance March 2016 TABLE OF CONTENTS 1. PURPOSE ............................................................................................................................................. 1 2. INTRODUCTION ...................................................................................................................................... 1 This Clinical Guidance: What Is Not Covered .................................................................................... 2 3. SCREENING AND DIAGNOSIS .................................................................................................................. 2 Screening Questionnaires ................................................................................................................. 2 TABLE 1. Screening Questions for Depression ............................................................................. 3 DSM-5 Diagnostic Criteria for Manic Episode .................................................................................... 3 DSM-5 Diagnostic Criteria for Hypomanic Episode ............................................................................ 3 DSM-5 Diagnostic Criteria for Bipolar Major Depression .................................................................... 3 Physical Examination and Laboratory Assessment ............................................................................ 3 4. ASSESSMENT ....................................................................................................................................... 4 Initial Assessment ............................................................................................................................. 4 TABLE 2. Initial Clinical Status Assessment ................................................................................. 4 Follow-up Assessments ..................................................................................................................... 4 TABLE 3. Follow-Up Assessment ................................................................................................. 4 Standardized Rating Scales .............................................................................................................. 5 TABLE 4. Standardized Rating Scales for the Evaluation of Mania ............................................... 5 TABLE 5. Standardized Rating Scales for the Evaluation of Depression....................................... 5 Risk Assessment for Suicide or Violence Towards Others ................................................................. 6 TABLE 6. Screening Questions for Assessing Risk of Suicide ...................................................... 6 TABLE 7. Risk Factors for Suicide or Violence Towards Others ................................................... 7 5. TREATMENT CHALLENGES ..................................................................................................................... 7 6. TREATMENT REGIMENS ......................................................................................................................... 8 Acute Mania, Hypomania, or Mixed episode ...................................................................................... 8 TABLE 8. Acute Mania, Hypomania, or Mixed Episode Treatment Recommendations................... 9 Acute Depressive Episode............................................................................................................... 10 TABLE 9. Acute Depressive Episode Treatment Recommendations........................................... 10 Maintenance Therapy ...................................................................................................................... 11 TABLE 10. Maintenance Treatment Recommendations ............................................................. 11 7. STEPWISE APPROACH IN SELECTING TREATMENT REGIMENS .................................................................. 12 TABLE 11. Stepwise Approach to Medical Treatment of an Acute Manic/Hypomanic Episode ..... 12 TABLE 12. Stepwise Approach to Medical Treatment of an Acute Depressive Episode .............. 12 i Federal Bureau of Prisons Management of Bipolar Disorder Clinical Guidance March 2016 8. MEDICATIONS USED IN THE TREATMENT OF BIPOLAR DISORDER.............................................................. 13 Mood Stabilizers .............................................................................................................................. 13 Antipsychotics ................................................................................................................................. 15 Antidepressants .............................................................................................................................. 17 Benzodiazepines ............................................................................................................................. 18 9. TREATMENT OF ANTIPSYCHOTIC SIDE EFFECTS ..................................................................................... 19 Treatment of Side Effects in General ............................................................................................... 19 Treatment of Extrapyramidal Side Effects ........................................................................................ 19 10. NON-MEDICATION INTERVENTIONS FOR BIPOLAR DISORDER .................................................................. 21 Electroconvulsive Therapy (ECT) .................................................................................................... 21 Psychosocial Interventions .............................................................................................................. 21 11. SPECIAL POPULATIONS ...................................................................................................................... 23 Pregnancy ....................................................................................................................................... 23 TABLE 13. Pregnancy Categories of Bipolar Disorder Medications ............................................ 23 Elderly ............................................................................................................................................. 24 TABLE 14. Stepwise Approach to Medical Treatment for Geriatric Bipolar Patients .................... 25 12. PATIENT EDUCATION ......................................................................................................................... 26 DEFINITIONS ........................................................................................................................................... 27 REFERENCES .......................................................................................................................................... 30 APPENDIX 1. INFORMED CONSENT ............................................................................................................ 32 APPENDIX 2. MOOD STABILIZER DOSING AND MONITORING ........................................................................ 33 APPENDIX 3. SIDE EFFECTS OF MOOD STABILIZERS ................................................................................... 34 APPENDIX 4A. LITHIUM DRUG-DRUG INTERACTIONS ................................................................................... 35 APPENDIX 4B. LITHIUM TOXICITY .............................................................................................................. 36 APPENDIX 5. BIPOLAR DOSING FOR SECOND-GENERATION ANTIPSYCHOTICS (SGAS) ................................... 37 APPENDIX 6. BIPOLAR DOSING FOR FIRST-GENERATION ANTIPSYCHOTICS (FGAS) ...................................... 38 APPENDIX 7. SELECTED ADVERSE EFFECTS OF ANTIPSYCHOTIC MEDICATIONS ............................................ 39 APPENDIX 8A. SIDE EFFECTS OF SECOND-GENERATION ANTIPSYCHOTICS (SGAS) ....................................... 40 APPENDIX 8B. MONITORING FOR SECOND-GENERATION ANTIPSYCHOTICS (SGAS) ....................................... 41 APPENDIX 9. NEUROLEPTIC MALIGNANT SYNDROME .................................................................................. 41 APPENDIX 10A. SIDE EFFECTS OF FIRST-GENERATION ANTIPSYCHOTICS (FGAS).......................................... 43 ii Federal Bureau of Prisons Management of Bipolar Disorder Clinical Guidance March 2016 APPENDIX 10B. MONITORING FOR FIRST-GENERATION ANTIPSYCHOTICS (FGAS) ......................................... 44 APPENDIX 11A. ANTIDEPRESSANT DOSING................................................................................................ 45 APPENDIX 11B. ANTIDEPRESSANT SIDE EFFECTS ...................................................................................... 46 APPENDIX 11C. ANTIDEPRESSANT MONITORING .......................................................................................
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