Bipolar Disorder - Differential Diagnoses

 Following organic and functional disorders might mimic symptoms of Bipolar Disorder

• Anxiety disorders (ex. generalized anxiety disorder, panic disorder etc.)
• Hyperthyroidism
• Cushing's disease/ syndrome
• Multiple sclerosis
• Post Traumatic Stress Disorder
• Schizo-affective disorder
• Schizophrenia
• Attention Deficit Hyperactivity Disorder

Ref: 

1. World Health Organization(WHO). (1993). The ICD-10 classification of mental and behavioural disorders. World Health Organization.
2. Price AL, Marzani-Nissen GR. Bipolar disorders: a review. Am Fam Physician. 2012 Mar 1. 85(5):483-93

Bipolar Disorder - Types (DSM-5)

 Bipolar Disorder, as per the Diagnostic and statistical manual of mental disorders (5th ed.), includes the following types

1. Bipolar 1 : this is diagnosed when symptoms of mania last 7 days or more. Also, can be diagnosed when an individual has severe mania which requires hospitalization. 
2. Bipolar 2 : diagnosed when an individual has symptoms of hypomania, preceded or followed by a major depressive episode
3. Cyclothymic disorder : Includes symptoms of hypomania and depression that last for 2 years or more in adults, not severe enough to warrant a diagnosis of the above 2 conditions. 

Ref:

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Bipolar Disorder - Introduction

 It is a psychological disorder, coded as F31 in ICD 10 [1], characterized by unusual and pervasive changes in their mood. A person suffering from biploar disorder can go from feeling extremely sad to feeling extremely happy within a few days or in some case, in a few hours. 

Symptoms of this disorder are spread over a spectrum. Someone with severe symptoms, is easy to diagnose while diagnosing someone who is on the lower side of this spectrum is challenging. 

Ref:

1. World Health Organization(WHO). (1993). The ICD-10 classification of mental and behavioural disorders. World Health Organization.

Treatment of Malaria In India - Update part 2

Treatment of Severe Plasmodium Falciparum Malaria 

Should not be treated on out patient basis, as it requires parenteral administration of antimalarials and has a risk of mortality. 

1. Artesunate: It is the drug of choice. It should be given in a dose of 2.4 mg/kg IV on admission (0 hour), then at 12 hours and 24 hours and then once daily till the patient takes orally or for 7 days. Then, they should get full course of ACT for 3 days (Table 1). However, ACT containing MQ should be avoided in cerebral malaria due to possibility of development of neuropsychiatric complication

2. Quinine: It is an acceptable alternative to AS. It should be given at a dose of 20 mg quinine salt/kg of body weight in 5% dextrose/dextrose saline, over 4 hours, on admission. It is followed by 10 mg/kg of body weight 8 hourly infusions which should be started 8 hours after the 1st loading dose. The infusion rate should not exceed 5 mg/kg of body weight/hour. Initial loading dose should not be given if patient has already taken quinine. If quinine therapy is used beyond 48 hours, the dose should be reduced to 7 mg/kg of body weight 8 hourly till patient takes orally. Then, he should be given oral quinine in a dose of 10 mg/kg of body weight 8 hourly to complete 7 days of therapy. Quinine injection must not be given as bolus injection. It is always given in IV infusion. Doxycycline in a dose of 3 mg/kg of body weight per day for 7 days is to be added when the patient starts taking orally. Doxycycline is contraindicated in pregnancy and children below 8 years of age. In those cases, instead of doxycycline, clindamycin is to be given in a dose of 10 mg/kg of body weight 12 hourly for 7 days

3. Artemether: It should be given in the dose of 3.2 mg/kg of body weight intramuscularly on admission and 1.6 mg/kg of body weight intramuscularly once per day for 4 more days. Then, ACT is to be given for 3 days

4. Alpha-beta artemether: It should be given in a dose of 150 mg/day for 3 days intramuscularly. It is not recommended for children. It should be followed by ACT for 3 days. 

References

1. Guidelines for the Treatment of Malaria 2010 (2nd edition). World Health Organization, 20, Avenue Appia-CH-1211 Geneva 27.

2. Guidelines for Diagnosis and Treatment of Malaria in India 2011 (2nd edition). Government of India, National Institute of Malaria Research, New Delhi.

Treatment of Malaria In India - Update part 1

I had posted treatment guidelines for malaria in 2014, as per the existing guidelines. 

Newer guidelines have been introduced since. Hence, this update. 

1. Treatment of Uncomplicated Plasmodium Falciparum Malaria 

Artemisinin combination therapy (ACT) is the drug of choice for all confirmed cases of uncomplicated PF cases. This should be combined with primaquine (PQ) (0.75 mg/kg body weight or 45 mg) on day-2. The ACT recommended in the National Program in India is artesunate (AS) + sulfadoxine and pyrimethamine (SP). Oral AS monotherapy is banned in India.

2. Treatment of Uncomplicated Plasmodium Vivax malaria

Chloroquine is the drug of choice of Plasmodium vivax (PV) cases. It is given at a dose of 10 mg/kg (600 mg) on day-1 and day-2 and 300 mg on day-3. Primaquine at a dose of 0.25 mg/kg (15 mg/day) for 14 days is tobe added to prevent relapse. Primaquine is contraindicated in G6PD deficiency cases, infants and pregnant women.