7 - Bipolar Affective Disorder Flashcards
1
Q
Types of bipolar affective disorder
A
- Bipolar 1 -> manic + major depression or mixed episode
- Bipolar 2 -> hypomania + major depression
- Cyclothymia -> fluctuations between subsyndromal depressive & hypomanic episodes; > 2 years of sx
- Dysthymia -> chronic subsyndromal depressive episodes
2
Q
Manic episode sx
A
FAST LANE
- Flight of ideas
- Activity increased (goal directed)
- Sleep decreased (but feels rested)
- Talk increased (pressure of speech)
- Lability increased
- Attention decreased (distractible)
- Narcissistic increased (grandiose)
- Excessive increased (hedonistic)
3
Q
Compare and contrast manic vs. hypomanic vs. mixed
A
Manic
- > 1-week period
- Abnormal & persistently elevated mood
- At least 3 sx/ 4 if irritable
- Need for hospitalization – harm others/ self, psychosis
Hypomanic
- At least 4 days
- Abnormal & persistently elevated mood
- No need for hospitalization
Mixed
- Both major depressive and manic episodes
- > 1-week sx
4
Q
What are rapid cyclers?
A
- 4 or more episodes/year
- Poor long-term prognosis
- Multiple mood stabilizers
- Risk factors = antidepressants, stimulant use, hypothyroidism, premenstrual period, postpartum period
5
Q
Causes of acute mania
A
- Seasonal change
- Stressors
- Sleep deprivation
- Bright light
- ECT
- Antidepressants
6
Q
Depressive sx
A
D SIG E CAPS
- Depressive mood
- Sleep decreased
- Interest decreased (anhedonia)
- Guilt/ worthlessness increased
- Energy decreased
- Concentration decreased
- Appetite/ weight decreased
- Psychomotor decreased
- Suicide/ thoughts of death increased
7
Q
Tx for goals for bipolar
A
- Shorten episode
- Decrease sx (response)
- Restore function
- Eliminate sx (remission)
- Prevent relapse
- Minimize adverse effects of tx
8
Q
Therapeutic classes of drugs for bipolar
A
- Mood stabilizers – lithium, valproate, carbamazepine, lamotrigine, gabapentin, topiramate, olanzapine, risperidone
- Other agents for acute mania
- Typical antipsychotics – haloperidol, chlorpromazine
- BZDs
- Other agents for acute depression
- Antidepressants
- ECT
9
Q
Describe px who may not respond to lithium
A
- Rapid cyclers
- Mixed states
- Comorbid conditions (ex: substance abuse)
- Absence of episodic bipolar illness in family
- Secondary mania
10
Q
Advantages and disadvantages to anticonvulsants as mood stabilizers
A
- Wider therapeutic range than lithium
- Neurologic toxicity
- Carbamazepine – hematologic
- Lamotrigine – severe rash
- Weight gain = valproic acid, carbamazepine; weight loss = topiramate
11
Q
Role of atypical antipsychotics for BAD
A
- Alternative first line agent to lithium or divalproex as monotherapy in acute mania or for maintenance therapy
- Can be used in combination w/ lithium or divalproex
- Second line agent as monotherapy for acute depression
12
Q
Maintenance tx for BAD
A
- No difference in olanzapine vs. divalproex for recurrence of affective episodes
- Higher d/c rate for olanzapine likely b/c of metabolic side effects
13
Q
Initial tx for BAD (non-pharms)
A
- Assess for secondary causes of mania or mixed states (ex: alcohol or drug use)
- D/c antidepressants
- Taper off stimulants & caffeine if possible
- Treat substance abuse
- Encourage good nutrition (w/ regular protein & essential fatty acid intake), exercise, adequate sleep, stress reduction, & psychosocial therapy
14
Q
Algorithm for tx of acute mania of BAD
A
- 1st, 2 or 3 drug combinations – lithium, valproate, or SGA plus BZD and/or antipsychotic for short-term adjunctive tx of agitation or insomnia
- Don’t combine antipsychotics
- Alternative medication tx options = carbamazepine (oxcarbazepine if pt doesn’t respond or tolerate)
- 2nd, if response if inadequate, consider 3 drug combination – lithium + anticonvulsant + antipsychotic OR anticonvulsant + anticonvulsant + antipsychotic
- 3rd, if response is inadequate, consider ECT for mania w/ psychosis or catatonia, or add clozapine for tx refractory illness
15
Q
Role of typical antipsychotics for BAD
A
- Acute mania – haloperidol & chlorpromazine effective
- May induce major depression
- D/c once acute phase stabilized
16
Q
Tx options for acute depression in BAD
A
- Lithium, lamotrigine (first option = lithium; if already on lithium then add lamotrigine – this will likely stabilize mood, don’t need to go to antidepressant)
- If severely ill – mood stabilizer + antidepressant (olanzapine + fluoxetine)
- If currently on VPA – add lithium
17
Q
Tx options for severe depressive episode in BAD
A
- 1st, optimize current mood stabilizer or initiate mood-stabilizing medication (lithium or quetiapine; alternative = fluoxetine/ olanzapine combination)
- If psychosis present, initiate an antipsychotic in combination w/ above
- Don’t combine antipsychotics
- Alternative anticonvulsants = lamotrigine, valproate
- 2nd, if response inadequate, consider carbamazepine or adding antidepressant
- 3rd, if response inadequate, consider 3 drug combination (lithium + lamotrigine + antidepressant; lithium + quetiapine + antidepressant)
- 4th, if response inadequate, consider ECT for tx-refractory illness & depression w/ psychosis or catatonia
18
Q
Tx duration for BAD
A
- Sx resolution w/ mood stabilizers –> mania = 7 days; depression = 2-3 weeks, up to 6 weeks
- Acute mania –> after remission, continue w/ mood stabilizers; after 2-6 months taper & d/c adjunctive meds; 1st episode d/c mood stabilizer after 1 year; lifelong tx for recurrent episodes, severe episodes, family hx, & rapid onset mania
- Depression –> continue on mood stabilizer; antidepressant continue 6-12 weeks after remission then taper over 2-4 weeks (to prevent swing to mania)
19
Q
Describe the PK of lithium (therapeutic range, when to take sample, when to increase dose)
A
- Lithium = gold standard for tx
- Therapeutic concentration range
- Acute = 0.8 – 1.2 mmol/L
- Chronic = 0.6 – 1.2 mmol/L
- 300 mg = 0.3 mmol/L
- Take sample in morning before AM dose (12 h after last evening dose)
- Rationale for OD dosing = decrease urine volume & compliance; can increase nausea
- Acute mania increases clearance; increase dosage to maintain level but may need to decrease dose for chronic maintenance tx; monitor!!
20
Q
Lithium monitoring endpoints
A
- Effectiveness
- Adherence
- Education
- Dosage (volume status, renal status, serum concentrations)
- Monitor every week until stable
- Drug interactions
- Toxic signs & sx
21
Q
Lithium – drug interactions
A
- Increased concentrations –> NSAIDs, ACE inhibitors, ARBs, diuretics (fine to take Li w/ ACE/ARB, but anytime there is a change in ACE/ARB must change Li as well)
- Decreased concentrations –> high sodium levels, theophylline, caffeine
- Increased neurotoxicity –> antipsychotics, SSRIs, carbamazepine (if must use in combo w/ any of these, keep Li serum concentrations at lower end of normal)
22
Q
Lithium – dose related adverse effects
A
- Initial = fine hand tremor, GI upset, muscle weakness
- Moderate (1.5 – 2.5 mmol/L) = twitching, slurred speech, confusion
- Severe (> 2.5 mmol/L) = seizures, stupor, coma, CV collapse
- *Chronic toxicity may cause sx to be manifested at lower levels
23
Q
Lithium – chronic adverse effects
A
- Neurological (tremor, impaired memory)
- Renal (nephrogenic diabetes insipidus, nephrotoxicity)
- CV (non-specific T wave changes)
- Hypothyroidism
- Weight gain
24
Q
Valproic acid – therapeutic range, SE, when to test levels, dosing
A
- Dosed BID or TID; take same way each day
- Therapeutic range not well established for mood disorder (50 – 125 mg/L, up to 150 mg/L)
- SE – sedation, N/V, fine tremor, dizziness
- Test levels at 2-4 days, then q5-7days until stable
25
Q
Lamotrigine - dosing, SE
A
- Dosed once daily
- Initial = 25 mg OD x 2 weeks, then 50 mg OD x 2 weeks, then 100 mg OD up to 200 mg OD or 100 mg BID
- Most often used for px w/ bipolar depression, but still second or third line b/c of severe rash
- Rash most often seen at 2-8 weeks, some > 6 months
- Common SE = dizziness, headache, somnolence, nausea
