Bipolar Flashcards
1
Q
Bipolar Essential Concepts
A
- Sustained mania of 7 plus days is definitely needed for BP1 diagnosis
- Mania generally requires pharmacotherapy
- BP2 have hypomania and usually MDD episodes
- Cyclothymia have two years plus of hypomania with minor depressive episodes
- Mania is NEEDED for diagnosis of BP
6
2
Q
Identifying Bipolar Depression
A
- family history of BP
- Family history of SUD.
- Comorbid SUD.
- Suicide attempts.
- onset <25 years of age.
- Mood reactivity.
- Restlessness.
- Psychomotor agitation.
- Psychomotor retardation.
- Shorter depressive episodes.
- More previous depressive episodes.
- Guilt.
- Melancholia.
3
Q
DIGFAST- Mania
A
Distractibility Irritability Grandiosity Flight of ideas Activity increase Sleep decrease Talkativeness
4
Q
Bipolar Psychotic Denial
A
- There is a frank loss of memory for present or past manic events. Patients do not remember their past manic transgressions.
- Hypomanic episodes are less impairing but are a clear change from usual functioning.
- Hypomanic episodes last four days or longer.
5
Q
Questionnaires for Bipolar
A
Altman Self-Rating Mania Scale (ASRM)
1. A positive score of 6 or more is suggestive of hypomania or mania
- Takes 2 minutes to complete and score.
Mood Disorders Questionnaire (MDQ)
1. Asks historical questions to detect previous mania episodes
6
Q
Bipolar Prescribing Basics
A
- Ideally use a single agent that can treat both the highs and lows of BD
- Mood stabilizing, anti-epileptic drugs (AEDs) and second-generation antipsychotics (SGA) are monotherapy treatments of
choice for mania and depressive spells. - Antidepressant monotherapy is NOT advised and their use in combination with a stabilizing agent is controversial.
- Lithium and SGA’s are the first line treatments.
- AEDs are more effective in treating mania versus depression.
- Important to treat aggressively as BD can become more resistant to treatment and more disabling as the number of manic
events increases.
7
Q
Approved BP Antidepressants
A
SGAs-
Olanzapine-Fluoxetine (Symbyax)
Quetiapine (Seroquel XR)
Lurasidone (Latuda)
SSRI or NDRI is used only if another mood stabilizer is already present.
8
Q
Mania Prescribing Tips ala Schwartz
A
- do not use Lamictal/lamotrigine
- If psychosis is present, use a SGA
- Severe mania- SGA or divalproex as high initial loading dose
- Use solid monotherapy of successive agents.
- Dosing must be therapeutic, achieve adequate blood levels, or use full FDA dose range when levels are not defined.
9
Q
BD Dosing Guidelines ala Schwartz
A
- Identify the pattern of phenotypic symptoms.
- Choose from a list of proven effective drugs.
- Start dosing low and escalate through an approved dosing range.
- Assess for effectiveness.
- Continue medication if effective or cross-titrate to a new drug if ineffective.
10
Q
BD Neuroanatomy
A
Findings:
- abnormal fronto-cortical, striatal (caudate, putamen, nucleus accumbens, olfactory tubercle), amygdala.
- After repeated cycling, there can be frontal lobe volume loss (left > right) and hypofunctioning of advanced prefrontal cortical
structures. - Subgenual prefrontal cortex is associated with higher mood functioning.
- Volume increase and hyperactivity in the deeper, limbic system structures (amygdala, anterior striatum, thalamus).
11
Q
Bipolar Polypharmacy Do’s ala Schwartz
A
- Start low dose to minimize side effects.
- Use a loading dose for severe mania or psychotic mania.
- Escalate dosing within full range.
- Monitor for weight gain, skin changes, abnormal movements, and organ damage.
- Add AED or SGA for treatment resistant cases or to improve maintenance.
- Check blood levels.
12
Q
Bipolar Polypharmacy Don’ts ala Schwartz
A
- Add two SGAs together for mania.
- Add two sodium channel blocking AEDs for mania.
- Add an unopposed antidepressant without proper prior mood stabilizer titration.
