Monitoring
Bipolar disorder requires lifelong treatment and management. Monitor patients experiencing acute episodes frequently until symptomatic improvement persists. Consider psychiatric hospitalisation for severe depression, suicidal thinking, or mania to protect the patient and others, and to allow daily monitoring and treatment planning. See patients discharged from hospital weekly, as the immediate post-discharge period may be associated with greater risk for non-adherence with treatment, relapse, and suicide.[296]
In addition to patient self-report of symptoms, collateral information from family and the use of objective rating scales of mood can enhance the monitoring of patient progress with treatment. The Patient Health Questionnaire for adults (PHQ-9) may be used to assess response to treatment of depressive symptoms (this questionnaire is still being used in clinical practice, despite the release of DSM-5-TR), while the Young Mania Rating Scale (YMRS) is commonly used to measure changes in manic symptoms in response to treatment.[98] Young Mania Rating Scale Opens in new window Ongoing suicide risk monitoring and mitigation is essential.
Careful monitoring of treatment-emergent side effects (e.g., somnolence, fatigue, akathisia, extrapyramidal side effects e.g., movement disorders, weight gain, metabolic syndrome, hypertension, lithium toxicity) at each consultation is recommended.[84][297]
Many commonly used medications in bipolar disorder (including lithium, antipsychotics, carbamazepine, valproate semisodium, and clozapine) require ongoing, individualised laboratory monitoring schedules to assess for the presence of treatment-related adverse effects, including thyroid, renal and liver dysfunction, neutropenia (with clozapine), and the development of metabolic syndrome with antipsychotics.[29] Monitoring of lithium is particularly complex, given its narrow therapeutic index, and propensity for dose-related side effects and for serious interactions with other medications. Regular measurement of plasma lithium levels is required, with increased frequency of monitoring needed during treatment initiation and dose titration/reduction.[29] Service arrangements vary, but in practice responsibility for monitoring may be shared between primary and secondary care. It is strongly advisable that primary care centers responsible for monitoring lithium levels have a robust call/recall safety netting system in place, e.g., with a monthly computerised search of the electronic patient record, and regular review dates for prescriptions.
For many patients, ongoing monitoring/management of substance use is an essential component of long-term bipolar management, with appropriate referral as indicated.[298]
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