bipolar Flashcards
what are the causes
genetics, environmental, endocrine, physical illness (diabetes &thyroid disease or side effects of antihypertensives or benzodiazepines
what is bipolar I
people have severe manic episodes (with major depression episodes)
what is bipolar 2
people experience depressive episodes & less severe manic symptoms (hypomanic episodes)
DSM-V features of manic episode
- inflated self-esteem/grandiosity
-decreased need for sleep (rested after only 3hrs sleep)
-talkative than usual
-flight of ideas
-distractibility
-increase goal directed activity
-excessive involvement in activities with painful consequences
Manic symptoms
-onset 18-30years old
-Mood: elevated, expansive &irritable
-speech: loud/rapid, poor judgment, vulgar
-grandiose delusions
-distracted
-hyperactive
-less need for sleep
-inappropriate dress
-flight ideas
depressive
-previous manic episodes
-feeling worthlessness/ guilt
-increased anger/ irritability
-decreased interest in pleasure
-negative views
-fatigue
-decreased appetite
-constipation
-insomnia
-suicidal
-agitation
what is the diagnosis
-DSM-V for bipolar 1= 1 severe mania episode lasting 7 days
-DSM-V for bipolar 2= 1 episode of hypomania (overactive/excited behaviour) lasting at least 4 days + 1 major depressive episode.
-ICD10 = at least 2 mood episodes of mania or hypomania (bipolar disorder 1 only but does not specify bipolar 2
-Late presentation similar to schizophrenia symptoms
Nice recommendation to specialist care in what situations:
-overactivity/ disinhibited behaviour lasting 4 days+
-suspected mania (urgent)
-suspected severe depression (urgent)
-patient danger to themselves/ others (urgent)
re-referral to secondary care from primary if any of this applies:
-poor/partial response to treatment
-person’s functioning signif declines
-poor adherence to treatment
-intolerable/ medically important side effects from medication
-alcohol/drug misuse suspected
considering stopping meds after period of relatively stable mood
-pregnant/ planning to be pregnant
treatment in secondary care?
-psychological intervention specific for bp
-high intensity therapy e.g. CBT, interpersonal and behavioural couples therapy
pharmacological options in mania
-antipsychotics: haloperidol, olanzapine, risperidone and quetiapine (most drowsy)
-lithium
-antiepileptics: mainly valproate
which of the 3 treatments should not be offered in primary care & why?
lithium, unless there are shared arrangement… has a narrow therapeutic window= toxic to kidneys= lithium blood tests
when to not initiate valproate in primary care
-taking antidepressant & develops mania/hypomania … consider stopping antidepressant
-develops mania/hypomania but not already on antipsychotic/ mood stabiliser… offer 1st line
- antipsychotic ineffective or unacceptable due to side effects, alt med out of the antipsychotic should be tried
-alt antipsychotic not effective at max licensed dose… lithium tried as an addition
- if lithium not effective/ suitable… consider adding valproate
-not to use in women of childbearing age to treat long term/ acute episodes
-if pt on lithium check plasma lithium levels to optimise treatment
What to prescribe
If pt wants long term = lithium but short term= antipsychotic but quitapine and olanzapine= weight gain the most
what to do if pt is taking valporate or another mood stabiliser
increase the dose to max levels according to bnf recommendation… if no improvement consider adding haloperidol, olanzapine, risperidone and quetiapine depending on pt preference & previous response to treatment.
what to prescribe in mixed manic and depressive symptoms:
follow recommendations for treatment of mania & monitor for emergence of depression.
what to prescribe in mixed manic and depressive symptoms:
follow recommendations for treatment of mania & monitor for emergence of depression.
what to do when pt not taking antimanic medication (antipsychotics/mood stabiliser) and antidepressant treatment stopped (what to consider)
- antipsychotic if symptoms severe/ behaviour disturbed or valproate or lithium
- inadequate response: combine antipsychotic & valproate or lithium
- all pts consider adding short term benzodiazepine e.g. lorazepam/ clonazepam
if antidepressant is stopped and pt taking antimanic medication (antipsychotics/mood stabiliser) what to do:
- Taking an antipsychotic: compliance & dose checked… increase if necessary & consider adding valproate or lithium
- Taking lithium: check plasma levels, consider increasing dose to give levels 1.0-1.2mmol/L (for acute episode) + adding antipsychotic
- Taking valproate: check plasma conc, increase dose to give levels up to 125mg/L if tolerated + consider antipsychotic
- Taking lithium & valproate & mania is severe…. add an antipsychotic
- Taking carbamazepine: consider adding an antipsychotic
- all pts consider adding short term benzodiazepine e.g. lorazepam/ clonazepam
1st line treatment for moderate - severe bp depression, with no bp treatment
Fluoxetine with olanzapine or quetiapine or olanzapine or lamotrigine alone
2nd line treatment for someone taking lithium with moderate-severe bp depression:
- check plasma conc. Inadequate= increase dose but if dose at max, add fluoxetine with olanzapine or quetiapine.
- only adding olanzapine or lamotrigine to lithium
- no response to fluoxetine with olanzapine or quetiapine = stopping & adding lamotrigine to lithium.
2nd line for someone taking valproate with moderate-severe bp depression:
- increasing dose within therapeutic range… if there’s still limited response to valproate= add fluoxetine with olanzapine or quetiapine
- only adding olanzapine or lamotrigine to valproate
- no response to fluoxetine with olanzapine or quetiapine = stopping & adding lamotrigine to valproate
what to do during periods of high suicide risks with psychotropic meds
take into toxicity in overdose…. consider limiting quantity supplied
