65. Bipolar Disorder

Question 1

Bipolar classifications and definitions: Bipolar I

Answer 1

at least 1 episode of mania, and usually, bouts of intense depression (depressive episode is not required for dx)

Mania is a/w with at least 1 of the following: sig impairment in social/work functioning, psychosis/delusions, or requires hospitalization

Question 2

Bipolar classifications and definitions: Bipolar II

Answer 2

At least 1 episode of hypomania (lasting ≥4 consecutive days) and at least 1 depressive episode (lasting ≥2 weeks)

Hypomania does NOT affect social/work functioning, dose not cause psychosis not require hospitalization

Question 3

Bipolar disorder is characterized by ___

Answer 3

fluctuations in mood from an extremely sad or hopeless state to an abnormally elevated, overexcited, or irritable mood called mania or hypomania (milder)

Question 4

Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by the severity of ____

Answer 4

mania experienced

Question 5

DSM-5 criteria for mania

Answer 5

Abnormally elevated or irritable mood for at least 1 week (or any duration if hospitalization is needed)

≥ 3 symptoms (if mood is only irritable, exhibits ≥ 4 symptoms):
- inflated self-esteem
- needs less sleep
- more talkative than normal
- jumping from topic to topic
- easily distracted
- increased in goal-directed activity
- high-risk, pleasurable activities (E.g. buying sprees, sexual indiscretions, gambling)

Question 6

The goal of bipolar treatment is to ___

Answer 6

stabilize mood without inducing depressive or manic state

Question 7

Traditional mood stabilizers, such as ____ , treat both mania and depression without inducing either state

Answer 7

lithium and antiepileptic drugs (valproate, lamotrigine, and carbamazepine)

Question 8

Antipsychotics, while not traditional mood stabilizers, can stabilize mood when amnia occurs with ___.

Answer 8

psychosis

Question 9

Antidepressants can induce or exacerbate ___ episode if used as monotherapy, so should only be used in combo with _____ for bipolar treatment

Answer 9

manic
mood stabilizer

Question 10

When selecting treatment for bipolar disorder, what should you consider?

Answer 10

side effect profile
pt’s med history and first-degree relatives’ med hx - if pt or fam member responded well to a drug, same drug might be reasonable option
Drug formulations available and cost

Question 11

Acute treatment for manic episode

Answer 11

antipsychotic (e.g. olanzapine, risperidone), lithium, or valproate
Combo of antipsychotic + lithium or valproate is preferred for severe episodes

Question 12

Acute treatment of depressive episode

Answer 12

First line treatment is antipsychotic (e.g. quetiapine, lurasidone)
Lithium, valproate, or lamotrigine can be added or used as alternatives

Question 13

Maintenance treatment for bipolar disorder

Answer 13

medications that were effective for acute episodes should be continued to avoid relapse
These include, lithium, antiepileptic drugs, and SGAs
Combo might be more effective than monotherapy at preventing relapse

Question 14

Why are MedGuides required with all antidepressants and antipsychotics?

Answer 14

Antidepressants = primarily d/t suicide risk
Antipsychotics = d/t increased risk of death in elderly pts with dementia-related psychosis

Question 15

Lamotrigine (Lamictal, Lamictal ODT, Lamictal XR, Lamictal starter kit) requires slow titration d/t risk of ___. do not use for acute mania

Answer 15

severe rash

Question 16

Examples of antiepileptic drugs used in bipolar disorder

Answer 16

lamotrigine (Lamictal)
Valproate/valproic acid derivatives (Depakote)
Carbamazepine (Equetro)

Question 17

Which SGAs are used in bipolar disorder?

Answer 17

Aripiprazole (Abilify)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Lurasidone (Latuda) - can use alone or in combo with mood stabilizers for bipolar depressive episodes
Olanzapine/fluoxetine (Symbyax) - can use alone for acute depresive episodes

Question 18

Therapeutic range of lithium (Lithobid)

Answer 18

0.6-1..2 mEq/L (trough)

Question 19

Warnings for lithium (Lithobid)

Answer 19

Serotonin syndrome
Renal impairment, hyponatremia, and dehydration (increased lithium tox)

Question 20

Side effects of lithium (within therapeutic range)

Answer 20

GI upset, cognitive effects, cogwheel rigidity, fine hand tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism
Others: hypercalcemia, cardiac abnormalities, edema, anorexia, worsening psoriasis, blue-gray skin pigmentation, impotence

Question 21

Side effects of lithium toxicity > 1.5 mEq/L

Answer 21

ataxia, coarse hand tremor, vomiting, persistent diarrhea, confusion, sedation

Question 22

Side effects of lithium toxicity > 2.5 mEq/L

Answer 22

CNS depression, arrhythmia, seizure, coma

Question 23

Monitoring for lithium

Answer 23

Serum lithium levels (trough), renal function, thyroid function (TSH, FT4), electrolytes (Ca, K, Na)

Question 24

How is lithium cleared?

Answer 24

renally cleared
No CYP450 interactions

Question 25

Concern with lithium and pregnancy

Answer 25

avoid in pregnancy
a/w with cardiac malformations in first trimester; avoid in breastfeeding

Question 26

Lithium levels increase with ____

Answer 26

decreased salt intake, sodium loss (e.g. with ACEi/ARBs, thiazide diuretics)
NSAIDs - aspirin and sulindac are safer options

Question 27

Lithium levels decrease with ____

Answer 27

increased salt intake, caffeine, and theophylline

Question 28

Increased risk of serotonin syndrome if lithium is taken with ____

Answer 28

SSRIs, SNRIs, triptans, linezolid, and other serotonergic drugs

Question 29

Increased risk of neurotoxicity (e.g. ataxia, tremors, nausea) if lithium is taken with ___

Answer 29

verapamil, diltiazem, phenytoin, and carbamazepine

Question 30

___ lithium citrate syrup = ____ lithium ion
___ of lithium ion = ____ lithium carbonate tabs/caps

Answer 30

5mL lithium citrate syrup = 8 mEq lithium ion
8 mEq lithium ion = 300 mg lithium carbonate tabs/caps

Question 31

During pregnancy, ____ is a safer option relative to other mood stabilizers (valproate, carbamazepine, lithium) for bipolar disorder. SGAs are also safer than valproate, carbamazepine, or lithium. ___ has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for bipolar depression.

Answer 31

Lamotrigine
Lurasidone

Question 32

Concern with valproate in pregnant pts with bipolar disorder

Answer 32

increase risk of fetal anomalies, including neural tube defects, fetal valproate syndrome and long-tern adverse cognitive effects
avoid in pregnancy, esp during 1st trimester

Question 33

Concern with carbamazepine in pregnant pts with bipolar disorder

Answer 33

fetal carbamazepine syndrome, which can result in facial abnormalities and other significant issues
avoid in pregnancy esp during 1st trimester

Question 34

Concern with lithium in pregnant pts with bipolar disorder

Answer 34

can cause increase in congenital cardiac malformations and other abnormalities