7 - Bipolar Disorder Flashcards
Bipolar 1
Manic + Major depression or mixed episode
*more mania
Bipolar 2
Hypomania + Major depression
*more depression
Cyclothymia
- Fluctuations between subsyndromal depressive and hypomanic episodes
- > 2 years symptoms
Dysthymia
-Chronic subsyndromal depressive episodes
What is the FAST LANE acronym for a manic episode?
- 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)
Describe a manic episode
- > 1 week period
- abnormal + persistently elevated mood (expansive or irritable)
- at least 3 symptoms/4 if irritable
- need for hospitalization - harm others/self; psychosis
Describe a hypomanic episode
- at least 4 days
- abnormal + persistently elevated mood
- no need for hospitalization
Describe a mixed episode
- both major depressive and manic episode
- >1 week symptoms
Describe rapid cyclers
- 4 or more episodes per year
- 15% of BAD patients
- poor long term prognosis
- multiple mood stabilizers
What are risk factors for rapid cycling?
- antidepressants
- stimulant use
- hypothyroidism
- premenstrual period
- post-partum period
What can precipitate acute mania?
- seasonal change
- stressors
- sleep deprivation
- bright light
- ECT
- antidepressants
List depressive symptoms
- depressed mood
- sleep affected
- interest decreased
- guilt/worthlessness increased
- energy decreased
- concentration decreased
- appetite/weight decreased or increased
- psychomotor decreased
- suicidal thoughts
What are treatment goals for BAD (bipolar affective disorder) ?
- shorten episode
- decrease symptoms (response)
- restore function
- eliminate symptoms (remission)
- prevent relapse
- minimize adverse effects of treatment
List the therapeutic classes and examples for treating BAD
1) Mood stabilizers
- lithium
- VPA
- carbamazepine
2) Anticonvulsants
- lamotrigine
- gabapentin
- topiramate
3) 2nd gen AP
- olanzapine
- risperidone
What are some other agents for acute mania?
Other agents for acute mania:
- Typical antipsychotics - haloperidol, chlorpromazine
- Benzos
What are some other agents for acute depression?
Other agents for acute depression:
- antidepressants
- ECT
What is the gold standard for BAD treatment?
lithium man
What type of patients don’t respond to lithium?
- rapid cycling
- mixed states
- comorbid conditions (axis 2, substance abuse)
- absence of episodic bipolar illness in family
- secondary mania
Describe anticonvulsants as mood stabilizers
- Delayed effectiveness acutely (need to use benzos and typical antipsychotics acutely)
- Efficacy chronic prevention of relapse is poor
- Drug interactions are common (watch for additive CNS toxicity)
Are anticonvulsants more or less toxic than lithium?
less toxic (wider therapeutic range)
What kinds of toxicity can anticonvulsants have?
neurologic
Anticonvulsants:
_________ can cause hematologic toxicity
Carbamazepine
Anticonvulsants:
______ can cause a severe rash (SJS)
Lamotrigine
Anticonvulsants:
Which can cause weight gain?
VPA, carbamazepine
Anticonvulsants:
Which can cause weight loss?
topiramate
Anticonvulsants:
What is their place in therapy?
Alternative first line agent to lithium or divalproex:
- as monotherapy in acute mania
- as monotherapy for maintenance treatment
Anticonvulsants:
Can they be combined with lithium or divalproex?
yes
Anticonvulsants:
Second line agent as mono therapy for acute ________
depression
Describe the algorithm for the treatment of BAD
- Assess for secondary causes of mania or mixed states (ex. alcohol or drug use)
- Discontinue antidepressants
- Taper off stimulants and caffeine if possible
- Treat substance abuse
- Encourage good nutrition (with regular protein and essential fatty acid intake), exercise, adequate sleep, stress reduction, and psychosocial therapy.
Describe the initial treatment of Acute Mania in BAD
First, give 2-3 drug combinations: lithium, VPA, or SGA (second gen antipsychotic) plus a Benzo and or antipsychotic for short term adjunctive treatment of agitation or insomnia; lorazepam is recommended for catatonia
Describe the rest of the algorithm for acute mania treatment in BAD
- Do not combine antipsychotics
- Alternative medication treatment options: carbamazepine, if patient does not respond or tolerate, consider oxcarbazepine
- Second, if a drug is inadequate, consider a 3-drug combination: Lithium plus an anticonvulsant plus an antipsychotic
- Anticonvulsant plus an anticonvulsant plus an antipsychotic
- Third, if response is inadequate, consider ECT for mania with psychosis or catatonia; or add clozapine for treatment refractory illness
What typical antipsychotics can be used for acute mania?
haloperidol + chlorpromazine effective
*lithium is more effective than typical antipsychotics for acute mania
Typical antipsychotics may induce ??
major depression
How long do they stay on antipsychotics fora cute mania?
d/c once acute phase stabilized
What can we use to treat acute depression?
- Lithium
- Lamotrigine
What can we use to treat acute depression in the severely ill?
Mood stabilizer + antidepressant
If currently on VPA, what do we add to treat acute depression?
lithium
Should we give antidepressants to BPD patients with manic symptoms ?
Prob not
-antidepressants do not decrease time in recovery and may lead to greater manic symptom severity
Should we combine antipsychotics ?
NOPE
What is the first step for the treatment of BAD - severe depressive episode ?
First, optimize current mood stabilizer or initiate mood-stabilizing medication; lithium or quetiapine
Alternatively, can do fluoxetine/olanzapine combination
*If psychosis is present, add an antipsychotic
Treatment of BAD - severe depressive episode:
What are some alternative anticonvulsants ?
lamotrigine or valproate
What is the second step in treatment of BAD - severe depressive episode?
If response is inadequate, consider carbamazepine or adding antidepressant
What is the third step in treatment of BAD - severe depressive episode?
If response is inadequate, consider a three drug combination:
- Lithium plus lamotrigine plus an antidepressant
- Lithium plus quietapine plus antidepressant
What is the fourth step treatment of BAD - severe depressive episode?
If response is inadequate, consider ECT for treatment-refractory illness and depression with psychosis or catonia
When should mania symptoms resolve with mood stabilizers?
7 days
When should depression symptoms resolve with mood stabilizers?
2-3 weeks, up to 6 weeks
After remission of acute mania, continue with _____ ______
mood stabilizers
After 2-6 months of acute mania, what should you do?
taper mood stabilizers + discontinue adjunctive meds
After the 1st episode of acute mania, what should d/c mood stabilizers ?
after 1 year
Who should get life long treatment of mood stabilizers for acute mania ?
people who have recurrent episodes, severe episodes, family hx, rapid onset mania
For those with depressive episodes, continue on with ____ _____
mood stabilizer
For those with depressive episodes, how long should they be on anti-depressants?
continue 6-12 weeks after remission then taper over 2-4 weeks
What is the therapeutic concentration range of lithium for acute mania ?
0.8-1.2 mmol/L
What is the therapeutic concentration range of lithium for chronic mania?
0.6 - 1.2 mmol/L
How does your fluid status affect lithium levels?
Lithium acts like sodium
(sodium follows water)
Anytime your fluid status changes, your lithium levels change
When do you need to alter the therapeutic range of lithium ?
If dosed OD at HS
How do you alter the therapeutic range of lithium ?
Increase by 10% if t1/2 = 40 hours
Increase by 26% if t1/2 = 16 hours
What is the rational for OD dosing ?
- decrease urine volume
- compliance
What baseline lab tests need to be done for lithium ?
- TSH, T4
- BUN, sCr
- Electrolytes
- WBC
- Weight
- Pregnancy test
When should you draw a level of lithium ?
In 4-5 t1/2 so 4-5 days
Then every week until stable
What drugs will increase concentrations of lithium ?
- NSAIDs
- ACEi and ARBs
- Diuretics
What drugs will decrease concentrations of lithium ?
- High sodium levels
- theophylline
- caffeine
What drugs will increase neurotoxicity of lithium ?
- antipsychotics
- SSRIs
- carbamazepine
What are the initial dose related adverse effects of lithium ?
- fine hand tremor
- GI upset
- mild polyuria, polydipsia
- muscle weakness
- cognitive impairment
What are some moderate dose related adverse effects of lithium ?
- coarse tremor, twitching
- recurrence of GI upset
- slurred speech
- vertigo
- confusion
- sedation, lethargy
- hyperreflexia
What are some severe dose related adverse effects of lithium ?
- seizures
- stupor
- coma
- CV collapse
What are some chronic adverse effects of lithium ?
- Neurological (tremor, decreased concentration, impaired memory, cogwheel rigidity)
- Renal (nephrogenic diabetes insipidus; nephrotoxicity)
- CV (non-specific t-wave changes, PVCs)
- PVC = premature ventricular contractions
- Hypothyroidism
- Leukocytosis
- Weight gain
- Dermatologic (acne, psoriasis, alopecia, rash)
Can you proportion the dose of lithium ?
Yes - it has linear kinetics
What is the therapeutic range of VPA for efficacy?
VPA does not have a therapeutic range for efficacy for mood stabilization. Monitoring of VPA is for compliance and toxicity.
Describe the effect of the drug interaction between:
VPA and Lamotirgine
increase lamotrigine
Describe the effect of the drug interaction between:
VPA and warfarin
increase INR
Describe the effect of the drug interaction between:
VPA and carbamazepine
decrease valproate
Describe the effect of the drug interaction between:
VPA and fluoxetine
increase valproate
Describe the effect of the drug interaction between:
VPA and TCAs
increase TCA
Describe the effect of the drug interaction between:
VPA and clozapine
increase cloazpine
Describe the effect of the drug interaction between:
VPA and ASA
increased free VPA
What are some adverse effects of valproic acid ?
- sedation, lethargy
- nausea, vomiting, diarrhea
- fine tremor
- dizziness
- unsteadiness
- weight gain
- alopecia
- Rare: thrombocytopenia, liver toxicity
What are some baseline labs to monitor for VPA ?
TSH, T3, liver enzymes, CBC with diff +platelets, pregnancy test, weight
When should you monitor VPA levels ?
at 2-4 days, repeat q5-7 until stable
Why do we start low and go slow for lamotrigine ?
due to the possibility of a rash
SE of lamotrigine ?
Common:
- dizziness, headache, diplopia
- somnolence, ataxia, nausea, asthenia
Uncommon:
-anorexia, weight gain, amnesia, confusion, nervousness, nystagmus, parenthesis, vertigo
