1.  General guidelines about Bipolar Affective Disorder

The fundamental disturbance is a change in mood or affect, usually to depression (with or without associated anxiety) or to elation. This disorder is characterized by repeated (i.e.at least two)

episodes in which the patient’s mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (mania or hypomania), and on others of a lowering of mood and decreased energy and activity (depression).

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 length about 6 months), though rarely for more than a year, except in the elderly. Episodes of both kinds often follow stressful life events or other mental trauma, but the presence of such stress is not essential for the diagnosis. The first episode may occur at any age from childhood to old age. The frequency of episodes and the pattern of remissions and relapses are both very variable, though remissions tend to get shorter as time goes on and depressions to become commoner and longer lasting after middle age.

Although the original concept of “manic-depressive psychosis” also included patients who suffered only from depression, the term “manic-depressive disorder or psychosis” is now used mainly as a synonym for bipolar disorder.

History taking and examination including MSE                                                                                                                      Annexure 1

2.  a) Investigations required

a. Psychometric investigations: Mood Disorder Questionnaire (MDQ), YBOCS

b)  Laboratory: (if physical complications are present)

c)  Comorbidity: Anxiety, substance use disorder and conduct disorder.

d)      Differential Diagnosis: Personality disorder, Cyclothymia, Psychotic disorder, ADHD.

3.  Treatment

a) Psychopharmacology

National Formulary of India. Antipsychotics for acute mania (Olanzapine, Haloperidol, Chlorpromazine, Fluphenazine) and short term Benzodiazepines (Diazepam, Lorazepam, Alprazolam, Nitrazepam)

Primary mood stabiliser can be lithium, valproate or carbamazepine as shown in the table below.

·        Take plenty of fluids (summers) with no salt restriction

·        Reduce or stop lithium temporarily on developing fever, loose motions, vomiting or any condition leading to fluid loss

·        ACE inhibitors, diuretics and NSAIDs along with Lithium increase risk of toxicity

·        Gastrointestinal upset, dysarthria, ataxia, coarse tremor followed by impaired consciousness, fasciculation, myoclonus, seizures, and coma are signs of toxicity

·        Monitoring for features of lithium toxicity should be routinely done and appropriate referral done accordingly.

b)  Psychosocial Intervention

a.  If patient is in early stage

i)      Psychoeducation:Nature of illness, etiology, progression, consequences, prognosis, treatment.

ii)  Address current psychosocial stressors

iii)  Activity scheduling

iv)  Physical activities

b.  If patient is in mid or late stage

i)  Cognitive Behavioural Therapy (CBT)

4.  Follow-up

a.  Psychiatry OPD/ DMHP

·       Initially once in two weeks for 2 months

·       Monthly check up for 1 year.

b.  Physical check-up at OPD

c.  Through telephonic conversation/TeleManas 14416/18008914416

5.  Referrals

a.   Depending upon the severity and complications of the patient, he/she may need to be referred to Psychiatry department.

b.  To TeleManas

c.  To the nearest DMHP

d.  To psychiatry OPD at Kulikawn Hospital or ZMC

e.  To higher centers outside Mizoram through Referral Board.