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QUICK REFERENCE                                         MANAGEMENT OF BIPOLAR DISORDER (2ND EDITION)

                             RISK FACTORS
 KEY MESSAGES
       Identifying risk factors may assist in the early detection of BD:
 KEY MESSAGES dition presenting commonly as
 1.  Bipolar Disorder (BD) is a potentially life-long con    family history of BD

 either bipolar I disorder (BD I) or bipolar II disorder (BD II). BD I is characterised     offspring of maternal age group ≥40 years old
 1.  Bipolar Disorder (BD) is a potentially life-long condition presenting commonly as     young age (<25 years old)   RISK FACTORS
 by episodes of mania, whilst BD II is characterised by episodes of hypomania and

 either bipolar I disorder (BD I) or bipolar II disorder (BD II). BD I is characterised
 depressive episodes.      presence of major depression with attention-deficit hyperactivity disorder (ADHD)
         Identifying risk factors may assist in the early detection of BD:

           low educational level
 by episodes of mania, whilst BD II is characterised by episodes of hypomania and
 2.  BD should be diagnosed based on the Diagnostic and Statistical Manual of Mental     low employment level
             family history of BD
 depressive episodes.
 Disorders Fifth Edition, Text Revision (DSM-5-TR) or International Classification         offspring of maternal age group ≥40 years old
 2.  BD should be diagnosed based on the Diagnostic and Statistical Manual of Mental     young age (<25 years old)
                         DIFFERENTIAL DIAGNOSIS
 of Diseases Eleventh Revision (ICD-11).
 Disorders Fifth Edition, Text Revision (DSM-5-TR) or International Classification

 3.  Antipsychotics (APs) or mood stabilisers, either as monotherapy or combination,     presence of major depression with attention-deficit hyperactivity disorder (ADHD)

             low educational level
 of Diseases Eleventh Revision (ICD-11).
 should  be  used  to  treat  acute  mood  episodes  (mania,  depressive  and  mixed   Common differential diagnoses to be considered:
             low employment level

 3.  Antipsychotics (APs) or mood stabilisers, either as monotherapy or combination,   a) during depressive episode -
 episodes) & as maintenance therapy in BD.
           major depressive disorder
                          DIFFERENTIAL DIAGNOSIS
 should  be  used  to  treat  acute  mood  episodes  (mania,  depressive  and  mixed
 4.  For BD with anxious distress, AAPs may be used.     major depressive disorder with mixed episode

 episodes) & as maintenance therapy in BD.
           adjustment disorder with depressed mood
 5.  For BD with rapid cycling, a combination of mood stabilisers with AAPs or another   Common differential diagnoses to be considered:
 4.  For BD with anxious distress, AAPs may be used.     anxiety disorder
           a) during depressive episode -
 mood stabiliser is the preferred treatment of choice.
              major depressive disorder
 5.  For BD with rapid cycling, a combination of mood stabilisers with AAPs or another
 6.  Antidepressants (AD) may be used as short-term adjunctive treatment but not as    depressive disorder due to another medical condition
              major depressive disorder with mixed episode
           substance-induced depressive disorder
 mood stabiliser is the preferred treatment of choice.
 monotherapy in BD. It should be avoided in mixed episodes & used with caution    schizophrenia or schizoaffective disorder
              adjustment disorder with depressed mood
 6.  Antidepressants (AD) may be used as short-term adjunctive treatment but not as       anxiety disorder
 in rapid cycling BD.
              depressive disorder due to another medical condition
 monotherapy in BD. It should be avoided in mixed episodes & used with caution
 7.  Long-acting AAP injectables may be considered in BD patients who have poor   b) during mania or hypomania episode -
              substance-induced depressive disorder
 in rapid cycling BD.
 adherence to oral medications.    substance-induced bipolar disorder
              schizophrenia or schizoaffective disorder
 7.  Long-acting AAP injectables may be considered in BD patients who have poor

 8.  Electroconvulsive  therapy  should  be  considered  in  both  bipolar  manic  &    bipolar & related disorder due to another medical condition
           schizophrenia or schizoaffective disorder
           b) during mania or hypomania episode -
 adherence to oral medications.
 depressive episodes in indicated situations (refer to Algorithm 1 & 2).     borderline personality disorder
              substance-induced bipolar disorder
 8.  Electroconvulsive  therapy  should  be  considered  in  both  bipolar  manic  &
 9.  Psychosocial interventions & psychotherapies should be offered as an adjunctive    ADHD
              bipolar & related disorder due to another medical condition
 depressive episodes in indicated situations (refer to Algorithm 1 & 2).
 treatment for BD especially in relapse prevention.       schizophrenia or schizoaffective disorder
 9.  Psychosocial interventions & psychotherapies should be offered as an adjunctive
                             CO-MORBIDITIES
 10. Shared  decision-making  in  weighing  risks  vs  benefits  of  pharmacological    borderline personality disorder
              ADHD
 treatment for BD especially in relapse prevention.
 treatment should be done in pregnant & lactating women with BD.   Psychiatric co-morbidities include:

   10. Shared  decision-making  in  weighing  risks  vs  benefits  of  pharmacological     drug abuse    CO-MORBIDITIES
 treatment should be done in pregnant & lactating women with BD.     anxiety disorder

         Psychiatric co-morbidities include:
   This Quick Reference provides key messages & a summary of the main recommendations     borderline personality disorder
             drug abuse

 in the Clinical Practice Guidelines (CPG) Management of Bipolar Disorder (Second Edition).      ADHD
             anxiety disorder
   This Quick Reference provides key messages & a summary of the main recommendations     anti-social personality disorder
             borderline personality disorder
 Details of the evidence supporting these recommendations can be found in the above
             ADHD
 in the Clinical Practice Guidelines (CPG) Management of Bipolar Disorder (Second Edition).      eating disorder
    CPG, available on the following websites:        anti-social personality disorder

 Details of the evidence supporting these recommendations can be found in the above     eating disorder   REFERRAL CRITERIA
 Ministry of Health Malaysia: www.moh.gov.my
 CPG, available on the following websites:

 Academy of Medicine Malaysia: www.acadmed.org.my   REFERRAL CRITERIA

 Malaysian Psychiatric Association: www.psychiatry-malaysia.org    BD can be managed in primary care EXCEPT in the following conditions:
 Ministry of Health Malaysia: www.moh.gov.my


          BD can be managed in primary care EXCEPT in the following conditions:
 Academy of Medicine Malaysia: www.acadmed.org.my    unsure of diagnosis     intolerable or medically important adverse events of

                                 medication
 Malaysian Psychiatric Association: www.psychiatry-malaysia.org    complex presentation of mood episodes    intolerable or medically important adverse events of
 CLINICAL PRACTICE GUIDELINES SECRETARIAT
        unsure of diagnosis

 Malaysian Health Technology Assessment Section (MaHTAS)    acute exacerbation of symptoms    psychiatric co-morbidities
                                 medication
        complex presentation of mood episodes

 Medical Development Division, Ministry of Health Malaysia    increased risk of harm to self or others    psychotherapeutic needs
                                  psychiatric co-morbidities
        acute exacerbation of symptoms
 CLINICAL PRACTICE GUIDELINES SECRETARIAT
                                  psychotherapeutic needs
        increased risk of harm to self or others
 Level 4, Block E1, Precinct 1
 Malaysian Health Technology Assessment Section (MaHTAS)    marked impairment in social or    ambivalent or wanting to stop any medication after a
      occupational functioning
                                 period of relatively stable mood
                                  ambivalent or wanting to stop any medication after a
        marked impairment in social or
 Federal Government Administrative Centre 62590
 Medical Development Division, Ministry of Health Malaysia
                                 period of relatively stable mood
        occupational functioning
 Putrajaya, Malaysia
 Level 4, Block E1, Precinct 1    poor or partial response to treatment    special population -
        poor or partial response to treatment
                                 o  pregnant or planning a pregnancy
 Tel: 603-88831229
 Federal Government Administrative Centre 62590    poor treatment adherence    special population -
        poor treatment adherence
                                 o  pregnant or planning a pregnancy
 E-mail: htamalaysia@moh.gov.my         o  children & adolescents
 Putrajaya, Malaysia
                                 o  children & adolescents
 Tel: 603-88831229               o  co-morbidity with alcohol or substance misuse
                                 o  co-morbidity with alcohol or substance misuse
 E-mail: htamalaysia@moh.gov.my
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