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Clinical 2 (Part B) > 7 - Bipolar Disorder > Flashcards

7 - Bipolar Disorder Flashcards

1
Q

Bipolar 1

A

Manic + Major depression or mixed episode

*more mania

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2
Q

Bipolar 2

A

Hypomania + Major depression

*more depression

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3
Q

Cyclothymia

A
  • Fluctuations between subsyndromal depressive and hypomanic episodes
  • > 2 years symptoms
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4
Q

Dysthymia

A

-Chronic subsyndromal depressive episodes

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5
Q

What is the FAST LANE acronym for a manic episode?

A
  • 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)
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6
Q

Describe a manic episode

A
  • > 1 week period
  • abnormal + persistently elevated mood (expansive or irritable)
  • at least 3 symptoms/4 if irritable
  • need for hospitalization - harm others/self; psychosis
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7
Q

Describe a hypomanic episode

A
  • at least 4 days
  • abnormal + persistently elevated mood
  • no need for hospitalization
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8
Q

Describe a mixed episode

A
  • both major depressive and manic episode

- >1 week symptoms

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9
Q

Describe rapid cyclers

A
  • 4 or more episodes per year
  • 15% of BAD patients
  • poor long term prognosis
  • multiple mood stabilizers
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10
Q

What are risk factors for rapid cycling?

A
  • antidepressants
  • stimulant use
  • hypothyroidism
  • premenstrual period
  • post-partum period
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11
Q

What can precipitate acute mania?

A
  • seasonal change
  • stressors
  • sleep deprivation
  • bright light
  • ECT
  • antidepressants
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12
Q

List depressive symptoms

A
  • depressed mood
  • sleep affected
  • interest decreased
  • guilt/worthlessness increased
  • energy decreased
  • concentration decreased
  • appetite/weight decreased or increased
  • psychomotor decreased
  • suicidal thoughts
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13
Q

What are treatment goals for BAD (bipolar affective disorder) ?

A
  • shorten episode
  • decrease symptoms (response)
  • restore function
  • eliminate symptoms (remission)
  • prevent relapse
  • minimize adverse effects of treatment
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14
Q

List the therapeutic classes and examples for treating BAD

A

1) Mood stabilizers
- lithium
- VPA
- carbamazepine

2) Anticonvulsants
- lamotrigine
- gabapentin
- topiramate

3) 2nd gen AP
- olanzapine
- risperidone

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15
Q

What are some other agents for acute mania?

A

Other agents for acute mania:

  • Typical antipsychotics - haloperidol, chlorpromazine
  • Benzos
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16
Q

What are some other agents for acute depression?

A

Other agents for acute depression:

  • antidepressants
  • ECT
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17
Q

What is the gold standard for BAD treatment?

A

lithium man

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18
Q

What type of patients don’t respond to lithium?

A
  • rapid cycling
  • mixed states
  • comorbid conditions (axis 2, substance abuse)
  • absence of episodic bipolar illness in family
  • secondary mania
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19
Q

Describe anticonvulsants as mood stabilizers

A
  • 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)
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20
Q

Are anticonvulsants more or less toxic than lithium?

A

less toxic (wider therapeutic range)

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21
Q

What kinds of toxicity can anticonvulsants have?

A

neurologic

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22
Q

Anticonvulsants:

_________ can cause hematologic toxicity

A

Carbamazepine

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23
Q

Anticonvulsants:

______ can cause a severe rash (SJS)

A

Lamotrigine

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24
Q

Anticonvulsants:

Which can cause weight gain?

A

VPA, carbamazepine

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25
Q

Anticonvulsants:

Which can cause weight loss?

A

topiramate

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26
Q

Anticonvulsants:

What is their place in therapy?

A

Alternative first line agent to lithium or divalproex:

  • as monotherapy in acute mania
  • as monotherapy for maintenance treatment
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27
Q

Anticonvulsants:

Can they be combined with lithium or divalproex?

A

yes

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28
Q

Anticonvulsants:

Second line agent as mono therapy for acute ________

A

depression

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29
Q

Describe the algorithm for the treatment of BAD

A
  • 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.
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30
Q

Describe the initial treatment of Acute Mania in BAD

A

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

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31
Q

Describe the rest of the algorithm for acute mania treatment in BAD

A
  • 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
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32
Q

What typical antipsychotics can be used for acute mania?

A

haloperidol + chlorpromazine effective

*lithium is more effective than typical antipsychotics for acute mania

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33
Q

Typical antipsychotics may induce ??

A

major depression

34
Q

How long do they stay on antipsychotics fora cute mania?

A

d/c once acute phase stabilized

35
Q

What can we use to treat acute depression?

A
  • Lithium

- Lamotrigine

36
Q

What can we use to treat acute depression in the severely ill?

A

Mood stabilizer + antidepressant

37
Q

If currently on VPA, what do we add to treat acute depression?

A

lithium

38
Q

Should we give antidepressants to BPD patients with manic symptoms ?

A

Prob not

-antidepressants do not decrease time in recovery and may lead to greater manic symptom severity

39
Q

Should we combine antipsychotics ?

A

NOPE

40
Q

What is the first step for the treatment of BAD - severe depressive episode ?

A

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

41
Q

Treatment of BAD - severe depressive episode:

What are some alternative anticonvulsants ?

A

lamotrigine or valproate

42
Q

What is the second step in treatment of BAD - severe depressive episode?

A

If response is inadequate, consider carbamazepine or adding antidepressant

43
Q

What is the third step in treatment of BAD - severe depressive episode?

A

If response is inadequate, consider a three drug combination:

  • Lithium plus lamotrigine plus an antidepressant
  • Lithium plus quietapine plus antidepressant
44
Q

What is the fourth step treatment of BAD - severe depressive episode?

A

If response is inadequate, consider ECT for treatment-refractory illness and depression with psychosis or catonia

45
Q

When should mania symptoms resolve with mood stabilizers?

A

7 days

46
Q

When should depression symptoms resolve with mood stabilizers?

A

2-3 weeks, up to 6 weeks

47
Q

After remission of acute mania, continue with _____ ______

A

mood stabilizers

48
Q

After 2-6 months of acute mania, what should you do?

A

taper mood stabilizers + discontinue adjunctive meds

49
Q

After the 1st episode of acute mania, what should d/c mood stabilizers ?

A

after 1 year

50
Q

Who should get life long treatment of mood stabilizers for acute mania ?

A

people who have recurrent episodes, severe episodes, family hx, rapid onset mania

51
Q

For those with depressive episodes, continue on with ____ _____

A

mood stabilizer

52
Q

For those with depressive episodes, how long should they be on anti-depressants?

A

continue 6-12 weeks after remission then taper over 2-4 weeks

53
Q

What is the therapeutic concentration range of lithium for acute mania ?

A

0.8-1.2 mmol/L

54
Q

What is the therapeutic concentration range of lithium for chronic mania?

A

0.6 - 1.2 mmol/L

55
Q

How does your fluid status affect lithium levels?

A

Lithium acts like sodium
(sodium follows water)

Anytime your fluid status changes, your lithium levels change

56
Q

When do you need to alter the therapeutic range of lithium ?

A

If dosed OD at HS

57
Q

How do you alter the therapeutic range of lithium ?

A

Increase by 10% if t1/2 = 40 hours

Increase by 26% if t1/2 = 16 hours

58
Q

What is the rational for OD dosing ?

A
  • decrease urine volume

- compliance

59
Q

What baseline lab tests need to be done for lithium ?

A
  • TSH, T4
  • BUN, sCr
  • Electrolytes
  • WBC
  • Weight
  • Pregnancy test
60
Q

When should you draw a level of lithium ?

A

In 4-5 t1/2 so 4-5 days

Then every week until stable

61
Q

What drugs will increase concentrations of lithium ?

A
  • NSAIDs
  • ACEi and ARBs
  • Diuretics
62
Q

What drugs will decrease concentrations of lithium ?

A
  • High sodium levels
  • theophylline
  • caffeine
63
Q

What drugs will increase neurotoxicity of lithium ?

A
  • antipsychotics
  • SSRIs
  • carbamazepine
64
Q

What are the initial dose related adverse effects of lithium ?

A
  • fine hand tremor
  • GI upset
  • mild polyuria, polydipsia
  • muscle weakness
  • cognitive impairment
65
Q

What are some moderate dose related adverse effects of lithium ?

A
  • coarse tremor, twitching
  • recurrence of GI upset
  • slurred speech
  • vertigo
  • confusion
  • sedation, lethargy
  • hyperreflexia
66
Q

What are some severe dose related adverse effects of lithium ?

A
  • seizures
  • stupor
  • coma
  • CV collapse
67
Q

What are some chronic adverse effects of lithium ?

A
  • 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)
68
Q

Can you proportion the dose of lithium ?

A

Yes - it has linear kinetics

69
Q

What is the therapeutic range of VPA for efficacy?

A

VPA does not have a therapeutic range for efficacy for mood stabilization. Monitoring of VPA is for compliance and toxicity.

70
Q

Describe the effect of the drug interaction between:

VPA and Lamotirgine

A

increase lamotrigine

71
Q

Describe the effect of the drug interaction between:

VPA and warfarin

A

increase INR

72
Q

Describe the effect of the drug interaction between:

VPA and carbamazepine

A

decrease valproate

73
Q

Describe the effect of the drug interaction between:

VPA and fluoxetine

A

increase valproate

74
Q

Describe the effect of the drug interaction between:

VPA and TCAs

A

increase TCA

75
Q

Describe the effect of the drug interaction between:

VPA and clozapine

A

increase cloazpine

76
Q

Describe the effect of the drug interaction between:

VPA and ASA

A

increased free VPA

77
Q

What are some adverse effects of valproic acid ?

A
  • sedation, lethargy
  • nausea, vomiting, diarrhea
  • fine tremor
  • dizziness
  • unsteadiness
  • weight gain
  • alopecia
  • Rare: thrombocytopenia, liver toxicity
78
Q

What are some baseline labs to monitor for VPA ?

A

TSH, T3, liver enzymes, CBC with diff +platelets, pregnancy test, weight

79
Q

When should you monitor VPA levels ?

A

at 2-4 days, repeat q5-7 until stable

80
Q

Why do we start low and go slow for lamotrigine ?

A

due to the possibility of a rash

81
Q

SE of lamotrigine ?

A

Common:

  • dizziness, headache, diplopia
  • somnolence, ataxia, nausea, asthenia

Uncommon:
-anorexia, weight gain, amnesia, confusion, nervousness, nystagmus, parenthesis, vertigo

Clinical 2 (Part B) (30 decks)

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