Bipolar - 3 Flashcards
Line 0 - A patient comes in with Bipolar Depression
Offer evidence based psychological intervention -specific for bipolar
or
Offer a high intensity psychological intervention in line with Nice recommendations for depression
What are hi intensity psychological options for depression (NICE)
CBT
Interpersonal therapy
Behavioural couple therapy
Line 1- patients come in with moderate to severe Bipolar depression who is not on any bipolar treatments
Offer olan + fluoxentine
or
Quetiapine
What if patients did not want fluoxetine in Line 1
Offer Olan alone or Lamotrigine alone
What if patient in line 1 did not respond to olan+ fluoxetine or quetiapine?
Offer Lamotrigine alone
Line 2
what if patients with bipolar epression already are on lithium
-Check lithium level to optimize
-if necessary add combined olan +fluoxetine (fluox is optional for patient)
or
add quetiapin
What if patient in line 2 did not respond to que and olan addition
Add lamotrigine
Line 3
what if a patiet comes in with bipolar depression on valproate
_ increase dose to max
if no response
_add fluoxetine + olan (fluox optional) or quetiapine
What if patients in line 3 still did not improve
Add lamotrigine to valproate
Is lamotrigine level routinely checked
No
Target dose for lamotrigine
200 mg
(some might need 400 mg)
Mechanism of action Lamotrigine
Blocks calcium channel ==> inhibition of excitatory
Starting dose for lamotrigine
25 mg
start low and go slow
Titration for lamotrigine
In-patients —-25 mg / day until reach 100 mg then 50 mg /day
outpaitients —25 mg/2 weeks
Line 0 For long term biplar depression
Offer psychological interventions which prevent relapse
(indiviual, damily or group)
Line 1 1st line long term pharama Rx for bipolar depression
Lithium
Line 2 patient on long rerm Rx with lithium does not respond
add Valproate
Iine 3 patient with bipolar depression not suitable for long term management with lithium
Valproate + olan
or
valproare + quetiapine (if has hx of good response)
How common is bipolar II in older adults
Rare
ICD 11 requires how mong the mood insrability to last for cyclothymic disorder
2 years or more
How long does ICD11 requires symptoms for hypomanic episodes (bipolar II
Several days (not specified like dsm 5 [3 day])
How ICD 11 requires mixed episodes to be?
Precense of several manic and depressive symptoms, simultaneously or alternatively, for 2 weeks…
what drugs are known (good evidence) to induce mania?
Levadopa
Corticosteroids
Anabolic-androgenic steroid
Antdepressants (TCAs & MAOIs)
Best treatments for drug-induced mania
_Aripirazole (Aro30)
_Quetiapine (750-800)
_Olanzapine (Ola20)
_Risperidone (RIs16+)
what other treatment can be affective for drug induced mania but with more side effects?
Tomoxifen
what are side effects of tamosifen
Uterine Malignancy
Thromboembolic
Embro-foetal toxicity
what mood stabilizer cause contraceptive failure?
Carbamazepine
Pheytoin
Topiramate
Drugs safe in females with mania who are on contraceptives
For preg gall
Gabapentin
ANtipsychotics
Lamotrigine
Lithium
Only if nothing else is available…last resort is valproate
