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bipolar > bipolar > Flashcards

bipolar Flashcards

1
Q

what are the causes

A

genetics, environmental, endocrine, physical illness (diabetes &thyroid disease or side effects of antihypertensives or benzodiazepines

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2
Q

what is bipolar I

A

people have severe manic episodes (with major depression episodes)

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3
Q

what is bipolar 2

A

people experience depressive episodes & less severe manic symptoms (hypomanic episodes)

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4
Q

DSM-V features of manic episode

A
  • 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
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5
Q

Manic symptoms

A

-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

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6
Q

depressive

A

-previous manic episodes
-feeling worthlessness/ guilt
-increased anger/ irritability
-decreased interest in pleasure
-negative views
-fatigue
-decreased appetite
-constipation
-insomnia
-suicidal
-agitation

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7
Q

what is the diagnosis

A

-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

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8
Q

Nice recommendation to specialist care in what situations:

A

-overactivity/ disinhibited behaviour lasting 4 days+
-suspected mania (urgent)
-suspected severe depression (urgent)
-patient danger to themselves/ others (urgent)

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9
Q

re-referral to secondary care from primary if any of this applies:

A

-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

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10
Q

treatment in secondary care?

A

-psychological intervention specific for bp
-high intensity therapy e.g. CBT, interpersonal and behavioural couples therapy

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11
Q

pharmacological options in mania

A

-antipsychotics: haloperidol, olanzapine, risperidone and quetiapine (most drowsy)
-lithium
-antiepileptics: mainly valproate

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12
Q

which of the 3 treatments should not be offered in primary care & why?

A

lithium, unless there are shared arrangement… has a narrow therapeutic window= toxic to kidneys= lithium blood tests

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13
Q

when to not initiate valproate in primary care

A

-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

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14
Q

What to prescribe

A

If pt wants long term = lithium but short term= antipsychotic but quitapine and olanzapine= weight gain the most

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15
Q

what to do if pt is taking valporate or another mood stabiliser

A

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.

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16
Q

what to prescribe in mixed manic and depressive symptoms:

A

follow recommendations for treatment of mania & monitor for emergence of depression.

16
Q

what to prescribe in mixed manic and depressive symptoms:

A

follow recommendations for treatment of mania & monitor for emergence of depression.

17
Q

what to do when pt not taking antimanic medication (antipsychotics/mood stabiliser) and antidepressant treatment stopped (what to consider)

A
  1. antipsychotic if symptoms severe/ behaviour disturbed or valproate or lithium
  2. inadequate response: combine antipsychotic & valproate or lithium
  3. all pts consider adding short term benzodiazepine e.g. lorazepam/ clonazepam
18
Q

if antidepressant is stopped and pt taking antimanic medication (antipsychotics/mood stabiliser) what to do:

A
  1. Taking an antipsychotic: compliance & dose checked… increase if necessary & consider adding valproate or lithium
  2. Taking lithium: check plasma levels, consider increasing dose to give levels 1.0-1.2mmol/L (for acute episode) + adding antipsychotic
  3. Taking valproate: check plasma conc, increase dose to give levels up to 125mg/L if tolerated + consider antipsychotic
  4. Taking lithium & valproate & mania is severe…. add an antipsychotic
  5. Taking carbamazepine: consider adding an antipsychotic
  6. all pts consider adding short term benzodiazepine e.g. lorazepam/ clonazepam
19
Q

1st line treatment for moderate - severe bp depression, with no bp treatment

A

Fluoxetine with olanzapine or quetiapine or olanzapine or lamotrigine alone

20
Q

2nd line treatment for someone taking lithium with moderate-severe bp depression:

A
  1. check plasma conc. Inadequate= increase dose but if dose at max, add fluoxetine with olanzapine or quetiapine.
  2. only adding olanzapine or lamotrigine to lithium
  3. no response to fluoxetine with olanzapine or quetiapine = stopping & adding lamotrigine to lithium.
21
Q

2nd line for someone taking valproate with moderate-severe bp depression:

A
  1. increasing dose within therapeutic range… if there’s still limited response to valproate= add fluoxetine with olanzapine or quetiapine
  2. only adding olanzapine or lamotrigine to valproate
  3. no response to fluoxetine with olanzapine or quetiapine = stopping & adding lamotrigine to valproate
22
Q

what to do during periods of high suicide risks with psychotropic meds

A

take into toxicity in overdose…. consider limiting quantity supplied

bipolar (3 decks)

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