Intended for healthcare professionals

Practice Practice Pointer

Monitoring drug interventions in people with bipolar disorder

BMJ 2023; 380 doi: https://doi.org/10.1136/bmj-2022-070678 (Published 07 February 2023) Cite this as: BMJ 2023;380:e070678
  1. Syed Zaidi, academic foundation year 2 doctor1,
  2. Adrian H Heald, consultant in diabetes and endocrinology and honorary senior lecturer2 3,
  3. Ravindra B Belgamwar, consultant psychiatrist and honorary senior lecturer4,
  4. Anthony A Fryer, professor of clinical biochemistry5
  1. 1Department of Clinical Biochemistry, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
  2. 2Department of Diabetes and Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
  3. 3The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
  4. 4Lymebrook Mental Health Centre, Bradwell Hospital, Newcastle-under-Lyme, Staffordshire, UK
  5. 5School of Medicine, Keele University, Stoke-on-Trent, UK
  1. Correspondence to AA Fryer a.a.fryer{at}keele.ac.uk

What you need to know

  • At each consultation, assess patients with bipolar disorder for potential adverse effects of medication, and consider how they may be monitored going forward.

  • In patients taking lithium, discuss and look out for signs of toxicity, especially if renal function is deteriorating

  • In patients taking antipsychotics, assess for extrapyramidal side effects and signs of metabolic syndrome

  • In those taking anticonvulsants, look for agranulocytosis with carbamazepine, pancreatitis with valproate, and Stevens-Johnson syndrome with lamotrigine

  • Ensure women and girls of childbearing age with bipolar disorder are offered pre-conception counselling by a specialist to discuss risk and benefits of ongoing use of medication. For those taking valproate, ensure that they are enrolled in a pregnancy prevention programme

Bipolar disorder often affects a younger population (peak onset between 15 and19 years),22 and is associated with substantially reduced life expectancy because of complex factors including common comorbidities.1 Type 1 bipolar disorder affects around 1% of the population (around 45 million people worldwide); and bipolar spectrum disorders affect 2.5% of the population, although some studies suggest this may be as high as 5%.2

Long term treatment of bipolar disorder includes pharmaceutical and psychological interventions (involving individual or family). Pharmacological interventions require careful monitoring of potential side effects; this can be done either in primary or in secondary care per the local shared care arrangements.

This article presents a summary of monitoring requirements, to aid general practitioners who are increasingly responsible for prescribing medications for bipolar disorder. The UK NHS recommends annual health checks, which include both physical and laboratory assessment, for people with bipolar disorder.3 These monitoring requirements can be incorporated into the annual health check, although some medications require more frequent monitoring.

Which medications require monitoring?

Pharmacological treatment for bipolar disorder includes mood stabilisers (eg, lithium, valproate, carbamazepine, and lamotrigine), antipsychotics, and antidepressants, either alone or …

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