bipolar

Question 1

how would you explain what bipolar disorder is

Answer 1

bipolar disorder is a mental health condition characterized by reccurent fluctuations in mood and behavior encompassing extreme ends of the human experiences

experience intense high where you feel energetic, euphoric and may engage in impulsive behavior, or even feel irritable

but also episodes of extreme low where you feel sad, hopeless and lose interests in activities you used to enjoy

Question 2

what are the risk factors of bipolar disorder

Answer 2

• genetics
• hx of trauma
• physical stressors
• seasonal changes
• medications
• treatment induced
• medical conditions

Question 3

what are the medical conditions that can lead to risk of bipolar

Answer 3

vitamins/ nutrition deficiencies
- essential AA
- fatty acids
- vitD

endocrine
- hypothyroidism (depression)
- hyperthyroidism (mania)
- pregnancy/ menstrual related

electrolyte/ metabolic abnormalities
- Ca/ Na fluctuations
- hyper/ hypoglycemia

CNS infections
- neurosyphillis
- HIV
- encephalitis

CNS disorders
- brain tumor
- head injuries
- multiple sclerosis

Question 4

what are the treatments that can increase the risk of bipolar disorder

Answer 4

• ECT
• SSRIs due to increase NE/DA in first few days to 2w of treatment

Question 5

what are the medications that can increase risk of mania

Answer 5

drugs of abuse
- ROH
- marijuana

drugs of withdrawal potential
- BZP
- ROH
- opiates

DA-augmenting agents

NE-augmenting agents

antidepressants
- TCA
- MAOI
- 5HT/ NE/ DA reuptake inhibitors
- 5HT antagonists

thyroid preparations
- T3
- T4

xanthines
- caffeine
- theophylline

OTC
- weight loss
- decongestants

herbal
- st john’s worst

steroids

Question 6

what are the differentials for bipolar disorder

Answer 6

• MDD
• drug/ substance induced
• anxiety disorder
• schizoaffective disorder
• personality disorder
• attention deficit hyperactive disorder

Question 7

what is the presentation and diagnostic criteria for bipolar disorder (DSM-5)

Answer 7

for depressive sx
- 5 or more of In SAD CAGES for >2w with functional impairment

for manic sx
- 3 or more of DIGFAST for 1w and longer with functional impairment with elevated mood

D istractability/ easily frustrated
I rresponsibility and erratic uninhibited behavior
G randiosity
F light of ideas
A ctivity level increased
S leep need decreases
T alkativeness

Question 8

what are the general assessments for bipolar disorders

Answer 8

1. HPI
2. psychiatric hx
3. substance use hx
4. complete medical and medication hx
5. family, occupational, developmental and social hx
6. physical and neurological exam
7. mental state exam
8. labs and other investigations

Question 9

what are the psychiatric rating scales for bipolar disorder

Answer 9

clinican-rated
for mood,
- young mania rating scale
*gold standard

for general/ functional,
- clinical global impression (CGI)
- global assessment of functioning (GAF)

for QoL
- short form 36

Question 10

what are the goals of therapy for bipolar disorder

Answer 10

• reduce frequency, severity and duration of mood episodes
• prevent suicide
• maximise adherence to therapy
• minimise treatment related ADR
• regain psychosocial functioning

Question 11

what is the non-pharmacological management for bipolar disorder

Answer 11

• psychoeducation (recognising early s/sx of mania and depression, charting mood changes, identifying and avoiding psychosocial/ physical stressors/ drugs/ substances that can trigger a mood episode, coping strategies, developing a crisis intervention plan, importance of compliance)
• stress reduction/ relaxation
• nutrition (regular intake of protein-rich food and drinks, essential fatty acids, and supplemental vitamins)
• exercise
• sleep hygiene (regular sleep wake cycle and good night routine)
• psychotherapy (CBT)

Question 12

what is the pharmacological management of bipolar disorder

Answer 12

for mania
- antipsychotics (FGA haloperidol; SGA olanzapine, quetiapine, risperidone (avail as LAI), aripiprazole)
- lithium

for depression
- antipsychotics (SGA olanzapine, quetiapine)
- lithium
- LTG (blocks voltage sensitive Na+ and Ca2+ channels)

*lithium is first line for maintenance and relapse, and for suicide prevention
- VPA can be as add on therapy (normalises Na+ and Ca2+ channels, increase GABA, decrease DA turnover, may decrease PKC)

Question 13

what are the side effects of lithium

Answer 13

acne, tremor, fatigue, weight gain, nausea, ECG changes, polyuria, hypothyroidism, diabetes insipidus, cognitive impairment

Question 14

what is the moa of lithium

Answer 14

• normalises/ inhibits secondary messenger system, may decrease PKC
• decrease 5HT reuptake and decrease DA release

Question 15

what is the monitoring parameters of lithium

Answer 15

• TFT
• RFT
• urinalysis
• EKG
• pregnancy test
• FBC
• electrolytes

Question 16

what is the concern with lithium, elaborate on the presentation and risk factors

Answer 16

1. lithium toxicity
   - mild (1.5-2.0): N/V, loose stools, coarse hand tremors, confusion, lethargy, lightheadedness
   - moderate (2.0-2.5): severe N/V/D, slurred speech, blurred vision, profound lethargy, tinnitus, apathy, ataxia, worsening confusion
   - severe (3.0 and higher): severe N/V/D, increased deep tendon reflexes, stupor, coma, seizures, death, seriously impaired consciousness

risk factors of lithium toxicity are STAND
- S odium depletion
- T hiazides
- A CEi/ARB
- N SAIDs
- D ehydration

2. neurotoxicity
   risks with concom
   - CBZ
   - diltiazem
   - losartan
   - PHT
   - methyldopa
   - levodopa
   - metronidazole
   - verapamil

Question 17

what is the target serum concentration for lithium

Answer 17

*within 5 days
- for acute mania, 0.8-1.0mEq/L
- for maintenance, 0.6-1.0

Question 18

how to manage bipolar disorder in pregnancy and elderly

Answer 18

pregnancy
- avoid VPA due to risk of neural tube defects
- avoid CBZ due to teratogenic risk
- avoid lithium due to risk of ebstein’s anomaly
- consider use of olanzapine, quetiapine, risperidone but monitor for s/e like gestational DM

elderly
- avoid CBZ due to many DDI and risk of decreased sodium
- LTG not heavily influenced by age

Question 19

what is the monitoring for bipolar disorder

Answer 19

• initially q2w f/b q1m f/b q3m