This guide is part of the Guidelines for the Prevention and Treatment of Mental Disorders in China, which was compiled by the Department of Disease Control of the Ministry of Health and the Psychiatric Branch of the Chinese Medical Association. It refers to and draws on the latest research results and guidance at home and abroad, and experts from the International Committee on Psychotropic Substances** (IPAP) and Harvard Medical School in the United States have also put forward many consulting suggestions. The guide is intended primarily for mental health workers on the front lines, including specialists, general practitioners, hospital psychologists, clinical social workers, and mental health administrators.
First, the first principle
1) The principle of synthesis.
Although various psychotropic drugs for bipolar disorder have made great progress, the efficacy of the acute phase of the prevention of various episodes of bipolar disorder is still unsatisfactory Data** Medical Education Network . A combination of psychotropic medications, physical, physical, psychological (including family) and crisis intervention should be used to improve efficacy, compliance, suicide prevention, social functioning and quality of life.
2) The principle of long-term **.
Bipolar disorder is almost lifelong in a cyclic manner, therefore, bipolar disorder is often a chronic process disorder, and its goal is to adhere to the long-term principle of blocking the anti-process in addition to alleviating acute symptoms. Doctors should clearly explain the importance of long-term term and implementation methods to patients and families before the start of the program, and strive for good compliance.
Long-term can be divided into 3 periods:
1. Acute ** stage.
The goal of this phase** is to control symptoms and shorten the duration of the disease. Caution** should be adequate and complete remission should be achieved to avoid recurrence or worsening of symptoms, and in non-refractory cases, this can usually be achieved in 6 to 8 weeks.
2. Consolidation period.
It begins with complete resolution of acute symptoms and is aimed at preventing recurrence of symptoms and promoting the recovery of social functioning. In general, the dose of the main** drug (e.g., mood stabilizer) should be maintained at acute phase levels during this period. In principle, the length of the consolidation phase is based on the natural course of the attack, but it is not easy to grasp in clinical practice.
Generally, consolidation** is 4-6 months for depressive episodes and 2-3 months for manic mixed episodes. If there is no recurrence, it can be transferred to the maintenance period. It is necessary to cooperate with psychological ** in this period to prevent patients from self-reducing or stopping medication and promote the recovery of their social function.
3. Maintain the first period.
The purpose of this phase is to prevent, maintain good social functioning, and improve the quality of life of patients. During the maintenance phase, the original ** measures can be appropriately adjusted under close observation, or the non-mood stabilizer drugs in combination with ** can be carefully reduced, or the dose can be reduced accordingly. However, experience has shown that prophylaxis is better in those who use a dose close to the first dose than those who use a dose lower than those who are below the dose.
In the case of lithium salts, for example, the blood lithium concentration is generally maintained at 06-0.8mmol l is appropriate. However, maintaining** does not completely prevent the condition of bipolar disorder**. Therefore, patients and families should be educated about the early manifestations of ** so that they can self-monitor and follow up with the doctor. During the maintenance period, blood levels should be closely monitored, and patients should be instructed to have regular follow-up observations. ** Early manifestations may be sleep disturbances or mood swings, which can be managed promptly, such as short-term benzodiazepines (BDZS) or increased doses of the original drug to avoid a complete seizure.
The jury is still out on how long it should be maintained. If you have had multiple episodes in the past, you can consider reducing the dose of the drug while observing and gradually stopping the drug after the disease has stabilized to reach an interval of 2-3 cycles of previous episodes or 2-3 years later, so as to avoid **. During the discontinuation period, if there is any indication, the original regimen should be restored in time, and a longer maintenance period should be given after remission.
3) The principle of joint participation of patients and their families.
Bipolar disorder has a chronic, recurrent recurrent episodic course and requires a long-term duration**. In order to gain the approval and cooperation of patients and their families, it is necessary to provide relevant health education to both of them. Such education should be long-term, regular, or arranged on an as-needed basis. This kind of education is best carried out in the form of a sorority with the participation of doctors and patients and their families, and has a fixed content.
Second, the first strategy
1) Decide on the ** venue.
Hospitalization should be made if you have the following conditions**
Severe patients in the acute stage, who refuse to eat, self-harm or suicide or have a tendency to hurt others, have poor compliance and cannot control their behavior, harass society and family, lack of effective guardians, accompanied by obvious psychiatric symptoms, need to have electroconvulsions due to poor drug effect, accompanied by diseases of vital organs or substance dependence and alcohol dependence at the same time, the elderly, pregnant women and those who need close monitoring if they are frail.
Patients can be treated on an outpatient basis in the following cases**
Those who are allowed to be sick and can comply**, or have a reliable guardian who can ensure the smooth implementation of **;Those who have been in complete remission for more than 1 month after hospitalization**;Those who are already in the maintenance stage. In cities that have the capacity to carry out community mental health services, special disease records should be established in the community. Specialized hospitals can have regular follow-up, and community health institutions are responsible for regular follow-up, drug supply and counseling.
2) Decide on the ** plan.
Regardless of the clinical type, mood stabilizers must be the mainstay of the drug. However, due to the complexity of the clinical phenomenology of bipolar disorder, the seizure form, the characteristics of the course and the physical condition are different, and the clinical management should also have different emphasis. Therefore, a comprehensive and reasonable plan should be developed according to the specific situation of different patients. See the section on "Bipolar Disorder Normalization Procedure".
3) Adjust the ** plan.
1. Efficacy evaluation:
In the acute phase**, weekly follow-up should be followed up and efficacy should be evaluated, and efficacy assessment can be carried out in two ways: clinical assessment and scale assessment. The key to the evaluation of the efficacy of the consolidation and maintenance phases is to understand whether the disease has relapsed or whether the disease has returned to the pre-morbid level.
2. Adjustment**If the effect is not satisfactory, the cause needs to be found.
First, reasons outside the protocol: First, attention should be paid to whether the patient is compliant**, especially for outpatients. If adherence is not good, try to improve and, if necessary, hospitalize**. Second, the patient may have other medical conditions, drug dependence, or other psychiatric disorders that require reassessment of the diagnosis and then targeting**. Third, the patient may have chronic psychological stress factors, which can be addressed with appropriate psychological **.
Second, factors related to the ** regimen: such as improper drug selection (use of drugs that have not been effective in the past), insufficient dose, insufficient course of treatment, unreasonable combination of drugs, etc., at this time, readjust the type or dose of drugs, or need to combine drugs, use synergists or use electroconvulsions**. For more information, please refer to the Drugs section and the Normalization Procedures section.
3. Drugs**
1) The principle of drug **.
1. First of all, use the safest and most effective drugs, mainly mood stabilizers.
2. According to the needs of the condition, there are two types of mood stabilizers in combination with drugs, mood stabilizers plus antipsychotics or benzodiazepines, and mood stabilizers plus antidepressants. In combination medications, it is important to understand the drug interactions produced by the induction or inhibition of metabolic enzymes.
3. Regularly monitor the blood concentration to evaluate the efficacy and adverse reactions Due to the low index of lithium salt, the amount and the amount of poisoning are close to each other, and the blood lithium concentration should be dynamically monitored. Carbamazepine or valproate ** mania should also reach the level of antiepileptic blood concentrations. Blood should be taken 12 hours after the last dose (e.g., the next morning) to measure the blood glucose concentration.
4. If the efficacy of a drug is not good, it can be changed or added to another drug to judge that a mood stabilizer is ineffective, and factors such as poor compliance and low blood concentration should be excluded, and the medication time should be greater than 3 weeks. If the above factors are not effective, another mood stabilizer may be used or added.
2) Mood stabilizers.
1. Commonly used mood stabilizers.
1) Lithium carbonate.
2) Valproate.
3) Carbamazepine.
2. Candidate mood stabilizers.
1) Lamotrigine.
2) Topiramate.
3) Gabapentin.
4) second-generation antipsychotics.
3. Selection of mood stabilizers.
For bipolar acute manic or bipolar hypomanic episodes, lithium is preferred**. If the immediate linkage lithium salt lacks efficacy, valproate or carbamazepine is used, or valproate or carbamazepine is added to lithium salt. If lithium is not tolerated**, valproate or carbamazepine is used. For fast-cycling or mixing that lacks an ideal response to lithium, valproate or carbamazepine, or in combination with a candidate mood stabilizer, should be used first**. For bipolar depressive disorder, lamotrigine may be preferred, and short-term antidepressants may be used if necessary. For refractory cases, lithium and valproate or carbamazepine can be used in combination, and if it is still ineffective, candidate mood stabilizers can be added on the basis of the original **, or effect-enhancing agents can be added according to the situation.
4. First-generation antipsychotic drugs.
For authors with acute manic or mixed episodes of excitability, agitation, aggression, or psychotic symptoms, depression with psychotic symptoms may also be used in combination with a first-generation antipsychotic for a short period of time in the early stages.
5. The application of synergists and the combination of drugs**.
For patients with refractory bipolar disorder, particularly those with refractory rapid cycling episodes, candidate mood stabilizers, calcium channel antagonists (isobodine 80-120 mg day for 2 days, nimodipine 40 to 90 mg day for 2-3 days), thyroid hormones (T325-50 μg d, T480-200ug d for 4 to 6 weeks-HT1A receptor antagonists (e.g., buspirone, cardioxine) may be considered as synergists in combination with classic mood stabilizers.
6. The use of antidepressants in bipolar disorder.
In bipolar disorder, the use of antidepressants may induce a manic or hypomanic episode, or increase the frequency of cycles, or precipitate rapid cycles that make it more difficult. Therefore, antidepressants should be used with caution during depressive episodes of bipolar disorder. If the depressive symptoms are severe and last more than 4 weeks, and depression is the main clinical phase of the previous episode, antidepressants can be combined with mood stabilizers under the premise of full use of mood stabilizers. In general, butylphenylpropion with little irritation effect can be preferred, followed by 5-HT reuptake inhibitors, and TCAS with strong irritability effect can be selected as much as possible
Fourth, electric convulsions**
For severe depression, treatment-resistant depression or mania in bipolar disorder, as well as unstoppable episodes of rapid circulation, electroconvulsions** are one of the best options for rapid-onset, safe and effective treatment. In particular, it should be used in patients who refuse to eat, are stupor, and are at risk of serious self-harm or suicide. Electroconvulsions** may also be considered in patients who are extremely agitated, ineffective or intolerant of medications**, and who are unable to accept medications** due to medical conditions**. The dose of the drug should be appropriately reduced.
Caution must be exercised in the use of tics due to the presence of the following medical conditions or diseases that increase the risk of seizures**: pregnancy, cerebral mass lesions and other lesions with increased intracranial pressure, active intracranial hemorrhage, unstable heart disease, aneurysm or cerebrovascular malformation, retinal detachment, pheochromocytoma, diseases that may cause anesthesia accidents (such as severe respiratory and hepatic and renal diseases), fresh fractures, etc. If the elderly, children, pregnant women, and the frail and sick need to be conditioned, it is advisable to take a non-convulsive method**.
5. Psychology of bipolar disorder**
1. Medication compliance is an important part of psychology, because more than 75% of the medication is related to failure to adhere to medication
2. The first year after the onset of the disease is a critical period for patients to understand and adapt to the disease, restore self-awareness and improve compliance.