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Exam 6 > Bipolar > Flashcards

Bipolar Flashcards

1
Q

Prevalence of bipolar 1 vs bipolar 2

A

0.2% vs 0.4%

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2
Q

bipolar symptom severity score depression vs mania

A

90% vs 70%.

depression impacts people’s lives mroe

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3
Q

bipolar and schizophrenia all cause mortality rate has been going ____ and all cause hazard ratio ____

A

down, up

less likely to die but an danger risk went up

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4
Q

Bipolar disorder is ___ times more likely to die by suicide.
Bipolar type 2 is (greater/lesser) than bipolar 1 to die by suicide

A

20-30

greater

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5
Q

bipolar is dependent on having a _____ state and a _____ state

A

depressive, mania

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6
Q

Unipolar depressive duration and timing

A

6-12 month length

occur every 3-5 years

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7
Q

Bipolar depression duration and timing

A

Depressive episode length 3-6 months
acute manic episode length 2-4
occur yearly, could have 4 episodes a year

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8
Q

Mania definition (how many days, what is pt like)

A

7 day increased mood, irritability, energy or it requires hospitalization

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9
Q

DIG FAST criteria for mania episodes (bipolar 1)

A

Distractibility, Irresponsibility, Grandiosity (inflated self esteem), Flight of ideas, Activity/Agitation (increased goal), Sleep no need, Talkative/pressure speech

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10
Q

Hypomanic state- definitive of bipolar 2

A

4 consecutive days with elevated mood and energy. (unlike bipolar 1 where the person will cause problems in their life but bipolar 2 could have a hypomanic state that is productive and helpful)

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11
Q

SIG E CAPS

depressive episodes

A

Sadness, interest, guilt, energy, concentration, appetite, psychomotor retardation, suicidal thinking

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12
Q

Differences between Bipolar 1 and 2

A

1 week vs 4 days
hospitalization vs DIGFAST X4 if just irritable
marked impairment vs functional mania

both have expansive, irritability or abnormally increased energy

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13
Q

Age of onset for BPD

A

mean age is 18 years

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14
Q

Disruptive mood dysregulation disorder definition

A

impair in functioning, >3 outbursts/week. chronic irritability
increase risk for anxiety and unipolar depression.
Unlike bipolar, its episodic and develop mania

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15
Q

Family history for BPD

A

60-80%. concordance for monozygotic twins is 40-45%

really high odds ratio for BPD (24.47)

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16
Q

Other things on the differential for someone with BPD

A

MDD, Schizo, schizoaffective, adhd (no affective), borderline (hard time maintaining relationships), SUD, prednisone

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17
Q

BPD treatments always

A

mood stabilizer/ second messenger modifier

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18
Q

Lithium as treatment for BPD benefits, risks

A

Benefits: effective for all phases (depression, mania, maintenance), disease modifying (decreases suicidality)
Risks: tremor, hypothyroid, CKD/ESRD (kidney), epstein anomaly, toxic

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19
Q

What is ebstein’s anomaly

A

atrialization of right ventricle: RA invades space of normal RV

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20
Q

Difference in resolving an acute mania vs depressive episode?

A

mania-> lots of meds, can be resolved more quickly. poly pharmacy is the way
depressive-> takes longer to resolve and need to watch the patient

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21
Q

_________ has the highest comorbidity with SUD (used as a coping mechanism)

A

Bipolar. must stabilize these patients in the clinic-> if not there might relapse

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22
Q

First step to treating bipolar is _______ previously prescribed mood stabilizer or initiate new 2 or 3 drug combinations (_____, _______, ______)
PLUS ______ or ______ (as needed)

A

optimize
lithium, valproate, SGA
benzodiazepine, antipsychotic-> pull these away as the mania resolves

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23
Q

Second step to treat bipolar is combining ____ drugs

Third step is ____

A

3 (lithium plus anticonvulsant plus antipsychotic or 2 antipsychotic and not lithium)
ECT

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24
Q

DO NOT USE _______ TO TREAT BIPOLAR DEPRESSION

The preferred treatment is

A

SSRIs (antidepressants)

lithium or atypical antipsychotics (quetiapine, lurasidone)

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25
Q

The true mood stabilizing medication is ______. This will help both acute mania and depression

A

Lithium. long term prevention of manic or depressive episodes

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26
Q

Valproic acid (depakote) and carbamazepine are best to treat _______ in bipolar disorder.

A

actue mania.

It will help prevent manic episode recurrence. Carbamazepine reserved for patients not responding to other meds

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27
Q

Lamotrigine is most beneficial for _____________ in bipolar disorders

A

preventing depressive episode recurrence. usually combined with another medication

28
Q

For BPD, atypical antipsychotics such as ______, ______, ______ are used for acute mania and maintenance

??? check this slide 7

A

Quetiapine (Seroquel), lurasidone (Latuda), cariprazine (Vraylar)

29
Q

Antidepressants, if used for BPD, should be used _________

A

in combination with mood stabilizers or antipsychotics.

risk of manic switch

30
Q

sufficient treatment trial is _____ for BPD treatments

A

2 weeks. partial response -> push dose

continue therapy for 1 year. take away meds in a chronic setting.

31
Q

Lithium mechanism potentially is through signal transduction cascades through inhibition of ______

A

glycogen synthase kinase 3

32
Q

______ is a monovalent cation is rapidly absorbed, widely distributed, not protein bound, not liver metabolized, excreted unchanged in liver

A

lithium

easy to move Li intracellular, limited ways to get it out

33
Q

Lithium is dependent on ____ for elimination

A

kidneys. filtered by flomerulus

34
Q

___% of lithium is reabsorbed in kidneys. Same spot as ___ so if those levels go down-> higher Li reabsorption

A

80

Na

35
Q

Lithium has a ____ therapeutic index

A

NARROW (0.6-1mEq/L-> need to keep it here not in the lab reference range)
must monitor if new medication is added

36
Q

Li has a ___ hour half life. first steady state will be on day __

A

24 hour. day 6

Obtain Li level if suspect toxic, drug drug interaction, change in renal fxn or Na change

37
Q

What is the basic workup to be able to prescribe lithium

A 
BMP (check Na and renal fxn)
CBC + differential (causes leukocytosis)
EKG
Thyroid fxn
Pregnancy
Weight
38
Q

Giving lithium with ____ can reduce AEs

A

food

39
Q

Early AEs with lithium include ______ and _______ which might diminish overtime. There can also be ____ and lethargy.

A 
Polydipsia and polyuria (get BMPs)
Muscle weakness (also diminish with time)
40
Q

_______________ is an AE for Li that occurs mostly during first weeks of treatment. it an be treated with a lower dose, nightly Li, or add a ____

A

Benign fine hand tremor

β blocker

41
Q

Nausea is another AE of Lithium that is seen more with __________ and can be resolved with _______ or ________

A

immediate release Li at peak onset.

give Lit with food or sustained release

42
Q

Diarrhea is another AE of Lithium that is seen more with __________ and can be resolved with _______

A

sustained release Li

Immediate release Li

43
Q

Nephrogenic Diabetes Insipidus is a late adverse effect of lithium. Li decreases sensitivity of ______ response at ______ in kidney
Pt: “I’m peeing a lot”

A

Antidiuretic hormone (ADH)
V2 receptors
Kidneys are unable to concentrate urine-> decrease absorption of fluid-> excrete fluid-> hypernatremia

44
Q

Treatment for nephrogenic diabetes insidious includes _______, ______, ______

A

amiloride (midamor) -> ups V2 response. keep Li same bc blocks Li resorption
decrease Li
discontinue Li

45
Q

Decrease in renal function is something seen in chronic Li treatment and __________ should be done

A

get a BMP, monitor Li, may need to decrease Li overtime

46
Q

Hypothyroidism can happen from Li because it _____________

As treatment start ________ (medication) and check TSH

A

inhibits thyroid hormone synthesis and release
levothyroxine
do not stop lithium

47
Q

Anything that ________ or affects ________ can lead to increase Li levels-> Li toxicity

A

decreases renal function, affects Na/water balance

48
Q

Dehydration and periods of vomitting and diarrhea can lead to Li toxicity because

A

need to keep fluids consistent.

49
Q

Fine hand tremor becomes course hand tremor at Li levels ____. Other things at this level are

A

> 2mEq/L

worsening GI, urinary incontinence, unstable gait, slurred speech, poor concentration, drowsiness, apathy

50
Q

When someone has Li toxicity, what is the treatment plan

A

hold Li, give fluids, check serial Li levels

Li is dialyzable. (check again 8 hours later bc redistributed)

51
Q

Li is pregnancy category ___, with_____ being a malformation seen. _________ is discouraged

A

D. worst risk is 1st try. causes ebstein’s anomaly (tricuspid value malformation)
Breastfeeding

52
Q

Mechanism of Depakote is

A

inhibit voltage sensitive Na channels-> diminish excitatory-> potentiate gaba

53
Q

Depakote has a ____ therapeutic index. dosed based on ___

A

wide (50-125mcg/ml). weight

used for acute mania

54
Q

Depakote is metabolized through _______.

Protein binding is ______

A

glucuronidation

high

55
Q

AEs of depakote is _________ and _______

A

hepatotoxicity and thrombocytopenia. get LFTs and CBC

56
Q

Depakote is pregnancy category __

A

X

57
Q

Carbamazepine induces ________ so need to check dosage 3 weeks after starting

A

its own metaolism

58
Q

Carbamazepine is pregnancy category ___. Highest risk of ______, which can be supplemented with folic acid

A

D

neural tube defects

59
Q

Carbamazepine has a _____ therapeutic index

A

narrow, 4-12 mcg/mL

60
Q

Lamotrigine is metabolized by _____. It has _____ drug-drug interactions

A

glucuronidation

few

61
Q

Most prominent AE from lamotrigine is _____ and best way to reduce it is _____

A

SJS, toxic epidermal necrolysis.

slow dose titration

62
Q

______ increases lamotrigine levels due to lamotrigine’s clearance-> increased risk of ____

A

depakote, SJS

63
Q

Lamotrigine is pregnancy category ___

A

C

64
Q

Carbamazepine adverse effects include:

A

D’s (diplopia, dizziness, drowsiness, GI discomfort, blood dycrasias)
SJS
Hepatotoxcitiy, hyponatremia
Osteomalacia-> monitor vita and Ca+

65
Q

Atypical antipsychotics can be used as ______ for mania, but they can also be used in combo with _____

A

monotherapy

Li, Depakote, carbamazepine (early symptom relief then could discontinue, some could take a week to work)

66
Q

Atypical antipsychotics are pregnancy category ___

A

C

67
Q

The atypical antipsychotics that are FDA approved for acute bipolar depression + maintenance are

A

quetiapine, lurasidone, cariprazine, olanzapine-fluozetine

Exam 6 (14 decks)

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