Bipolar Flashcards
What is the diagnostic criteria for bipolar I d/o?
Bipolar I “1 for manic, and 1 for 1 week, depressive optional “may have been preceded by and may be followed by hypomanic or major depressive episodes”
Must have manic episode, hypomania or major depressive episode optional
Manic episode
GST PAID + elevated/expansive or irritable mood, 3 of below (GST) if elevated, 4 (PAID) if irritable only, must persist for at least 1 week, nearly every day
Think David:
Grandiosity
Sleep – decreased need for
Talkative, pressured speech
Pleasurable ideas, Painful consequences
Action - lots
Ideas, flight of
Distractibility
Marked impairment in social or occupational functioning, or necessitates hospitalization to prevent harm to self for others, or psychotic features
Hypomanic episode:
persistently elevated, expansive or irritable mood lasting at least 4 days and present most of the day, nearly every day.
GST PAID
Not severe enough to cause marked impairment in social or occupational functioning
Major Depressive Episode
5+ of SIGE CAPS during the same 2 week period, with one either depressed mood or loss of interest/pleasure
DDx for bipolarI/II?
Ddx:
Mood: Major depressive disorder, other bipolar disorders
Anxiety: GAD, PTSD, panic disorder, etc
Substance/medication induced bipolar disorder
ADHD – esp. in adolescents and children – rapid speech, racing thoughts, distractibility, less sleep
Personality d/o: borderline – mood lability and impulsivity
Bipolar:
Cyclothymic for bipolar II – numerous periods of hypomanic symptoms and numerous perids of depressive symptoms that do not meet symptom or duration criteria for major depressive. Bipolar II has major depressive episode, cyclothymic does not.
Schizophrenia spectrum – schizoaffective disorder, schixophrenia, delusional disorder
Substance use disorders
Comorbid with anxiety disorders (3/4) ADHD, substance use.
Diagnostic criteria for bipolar II d/o?
Bipolar II disorder
II for both mania and depression
“current or past HYPOmanic episode and current or past major depressive episode.
Hypomanic episode:
Abnormally and persistently elevated, expansive or irritable mood for at least 4 consecutive days present most of the day, nearly every day. 3 of below if elevated, 4 of below if irritable (GST – 3 PAID -4)
Grandiosity
Sleep, decreased need for
Talkative, pressured speech
Pleasurable activities, painflul consequences
Activities, goal-oriented
Ideas, flight of
Distractibility
Bipolar II is not for manic episode, if manic -> bipolar I, only for hypomanic
Major Depressive Episode:
5 of SIGE CAPS for 2 weeks
think 2-3-4-5 for bipolar 2 weeks SIGECAPS, 3 for elevated 4 irritable 5 SIGE
Sleep
Interest,decreased
Guilt
Energy, decreased
Concentration, decreased
Appetite, decreased
Psychomotor agination or retardation
Suicide, thoughts
Specifiers:
Hypomanic, depressed, with anxious distress, with mixed features, with rapid cycling, with mood-congruent psychotic features, with mood-incongruent psychotic features, with catatonia, with peripartum onset, with seasonal pattern
Specifiers for bipolar?
Specifiers:
Hypomanic, depressed, with anxious distress, with mixed features, with rapid cycling, with mood-congruent psychotic features, with mood-incongruent psychotic features, with catatonia, with peripartum onset, with seasonal pattern
Risks of bipolar?
Risks: high suicide, DSM says about 1/3 lifetime attempt in bipolar I or II, lethality higher in II.
What is cyclothymic d/o? What other d/o are present?
Cyclothymic Disorder
2 years (1 year in kids and adolescents) with numerous periods of hypomanic sypmtoms that do not meet criteria for a hypomanic episode and numerous periods with depressive symptoms that do not meet criteria for a major depressive episode. Hypomanic and depressive periods have been present for at least half the time and the individual has not been without the symptoms for more than 2 months at a time.
Specify if with anxious distress
Substance/Medication- Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Virtual cases
Bipolar I disorder, current episode depressed
DDx: premenstrual dysphoric disorder
DDx: substance-induced depressive disorder
DDx: depressive disorder secondary to a medical condition (say hypothyroidism)
DDx: unspecified anxiety disorder
DDx: lithium-induced hypothyroidism
Until you order blood work/imaging or urine drug screen you cannot exclude substances and medical conditions from being underlying cause of depression. Anxiety frequently co-exists with depressed mood and so is reasonable to include on the differential
Major depressive disorder and dysthymia not included on diagnosis because patient has mania. Cyclothymia is characterized by hypomanias and subclinical depression, does not fit. No psychotic features to support schizoaffective d/o.
Reminder: with bipolar, there are specifiers, ex. “current episode depressed.
Term “mixed features” can be used to specify when an individual is experiencing sx from opposite sides: depressed mood + manic episode. Careful not to use mixed episode (old DSM IV language). Patient does not need to satisfy full criteria for depression or mania to be called “mixed features”, only some will suffice. If individual is meeting criteria for major depressive episode and for mania, it is recommended that they are diagnosed with Bipolar I with mixed features.
Li in mania and depression?
If developed depression on bipolar, check that mood stabilizer is in therapeutic range before starting on antidepressant or antipsychotic.
CANMAT guidelines for bipolar:
Mania: Li+ 50-70% improvement, as effective as atypical antipsychotics
Bipolar depression: Li+, if dosed adequately (0.7-1.0 mmol/L) it has antidepressant efficacy
Maintenance: use, monitor serum at trough point (12 h after last dose, want 0.8-1.1 mmol/L), obtain about 5 days after most recent dose titration and every 6-12 months. Lithium is associated with weight gain of 0.7-2.4 kg. GI side effects are common with lithium when first initiated or if dose increased rapidly. Lithium associated with several renal conditions, including diabetes insipidus, nephrotic syndrome,renal failure. Polyuria occurs in up to 20% of patients.
Lamotrigine in mania
Lamictal/Lamotrigine Mania – not effective in acute mania
Lamotrigine mostly used to treat bipolar depression and recommended as 1’line option. Think got mania, grandiosity -> move to Paris, then depressed, speak French and drink wine. 40-80% patients respond. Trouble is lamotrigine is not good for manic episodes, so should not be used as monotherapy for bipolar patients if prevention of mania is an objective. May be beneficial in bipolar II with rapid cycling, where could use it as monotherapy (no mania, hypomania only), anticonvulsant, no weight gain.
Start at 25 mg PO OD titrate to 100 -200 mg PO. S/E tremor, dizziness, ataxia, somnolence, h/a, diplopia and nausea. Stevens-Johnson or toxic epidermal necrosis is rare but serious adverse event. Serum concentrations not correlated with a linical response. Not great for acute mania, only for bipolar depression and maintenance esp. with depressive relapses
Antipsychotics in mania?
Atypical Antipsychotics.
Aripiprazole, Risperidone, Olanzapine, Quetiapine/Ziprasidone approved for treatment of one or more phases of bipolar disorder. As effective as lithium/divalproex for treatment of acute mania.
Epival in mania
Anticonvulsants:
Epival (Divalproex sodium) – equivalent to lithium and carbamazepine in tx of mania. Divalproex sodium is preferred to lithium due to fewer GI effects compared to valprotic acid. Oral loading of divalproex 20 mg/kg/day.
Regular monitoring of serum valproic acid meds is required. Target serum levels are 400-700 mmol/L, serum levels need to be repeated at trough point (12 hr after last dose), serum levels need to be collected 3-5 days after most recent dose titration. High incidence of significant weight gain, nausea, vomiting and diarrhea are commonly reported with lithium and divalproex : 35-45% of patients.
Divalproex is a mood stabilizer which is indicated int eh treatment of bipolar mania and bipolar maintenance (in monotherapy) and in bipolar depression when combined with lithium or with antidepressant. Can be started at 250-500 mg PO QHS. Therapeutic doses range between 1200-1500 mg daily but should be titrated to a serum level between 350-700 mmol/L. possible adverse effects include GI symptoms, sedation, tremor, weight gain, hair loss, ataxia, dysarthria, hepatotoxicity, hemorrhagic pancreatitis, encephalopathy. Baseline measurements should include BMI, waist circumference fasting blood glucose, and fasting lipids. Consider baseline bone density depending on patient risk factors. Measure drug levels 3-5 days after initiating therapy and subsequently with all dose change sand medication additions/discontinuations once the medication has reached a steady state.
Divalproex: started at 250-500 mg PO QHS, therapeutic doses btween 1200 and 1500 mg daily, should be titrated to serum of 350 to 700 mmol/L. S/e GI, sedation, tremor, weight gain, hair loss, ataxia, dysarthria, fatal hepatotoxicity, hemorrhagic pancreatitis, lethargy, cognitive changes, encephalopathy. Do baseline CBC + differential, LFT, lipid profile, weight and BMI. Do baseline bone density and serum testosterone. Measure 3-5 days post initiation of therapy. Can breastfeed.
tegretol = carbamazepine (anticonvulsant) in mania
Tegretol/Carbamazepine Mania – anticonvusltant med that demonstrated efficacy similar to lithium and divalproex in treatment of mania, but safety and tolerability issues make it 2’ line. Need to monitor serum carbamazepine levels, monitor at trough approximately 12 hrs after last dose, obtain serum about 3-5 days after most recent dose titration, no weight gain.
Pharma guidelines in mania
Recommendations:
First line: lithium, divalproex, olanzapine, risperidone, quietiapine, aripiprazole, ziprasidone, lithium/divalproex + risperidone/quietiapine/olanzapine
Second line: carbamazepine, oxcarbazepine, ECT, lithium+divalproex
Li+ in mania
Lithium will control acute mania and prevent relapse in ~ 80% of patients with Bipolar I. There is 0.1% of serious cardiac abnormality, Ebstein’s anomaly, if given in pregnancy. Use lithium for bipolar mania, bipolar depression and in bipolar maintenance. Lithium is tarted at 600 mg PO QHS. Therapeutic doses are typically between 900 and 1500 mg PO per day, it can be given QHS or divided into BID or TID dosing. Common adverse effects of lithium include GI symptoms, weight gain, acne, hypothyroidism, tremor, teratogenicity and renal impairment. Lithium concentration must be monitored Q4-5 days when initiating therapy. The target range is 0.6-1 for bipolar depression. Patients over 45 yo or with history of cardiac problems, should receive baseline ECG.
1’ line for bipolar
Test renal and thyroid function!
renal: Q 2-3 months for 6 months, than Q 6-12 months. thyroid 1-2x during first 6 months, then q6-12 months.
Lamotrigine in bipolar
Lamotrigine is a mood stabilizer indicated int eh treatment of bipolar depression. Lamotrigine is tarted at 25 mg PO daily and titrated to 100 and 200 mg daily. Common adverse effects of lamotrigine include etremor, dizziness, ataxia, somnolence, headache, diplopia and nausea. Stevens-Johnson syndrome or toxic epidermal necrolysis is rare but serious adverse event associated with this medication. Lamotrigine serum concentration have not been correlated with clinical response. Labs not useful. Slower titration reduces the risk of Stevens-Johnson syndrome.
1’ line for bipolar
olanzapine+SSRI in bipolar
olanzapine + SSRI
Olanzapien is an atypical antipsychotic that is indicated in the management of bipolar mania (mono), bipolar maintenance (mono), and in biplar depression when combined with SSRI. Olanzapine can be started at 10-15 mg PO daily. Therapeutic doses 5-20 mg daily. Potential s/e include weight gain, lipid and glucose changes, EPS, NMS, QT prolongation, sedation, and orthostatic hypotention. Baseline measurements should include BMI, waist circumference, fasting blood glucose, fasting lipids. Olanzapine is associated with the great risk of weight gain out of the atypical antipsychotics (except clozapine).
Quietiapine in bipolar
Quetiapine is an atypical antipsychotic that is indicated int eh managmenet of bipolar mania, bipolar depression and bipolar maintenance (all as monotherapy). Can be started at 50 mg PO BID, quetiapine XR can be strated at 300 mg PO Q evening. Therapeutic doses are typically between 300 and 600 mg daily for bipolar depression (higher doses recommended for mania). Potential side effects include weight gain, lipid and glucose changes, EPS, NMS, QT prolongation, sedation, and orthostatic hypotention. Baseline measuremt should include BMI, waist circumference, fasting blood glucose, and fasting lipids
SSRIs in bipolar
SSRIs are indicated as an adjuvant in the treatment of bipolar depression when combined with lithium, divalproex or olanzapine. They are not to be sued as monotherapy in bipolar depression, only unipolar depression. SSRIs include: citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine and sertraline.
Decision tree for bipolar?
What are first line treatments for maintenance of bipolarI disorder?
first line for maintenance of bipolar I
- Lithium
- Epival
- Lamotrigine (but cannot be used for acute episodes)
- Carbamazepine
- Antipsychotics
- Olanzapine
- Quietiapine
- Aripiprazole
- NOT RISPERIDONE
Biological approach to bipolar?
Bio: good medication compliance
Importance of birth control due to teratogenic risks of certain meds
Monitor for s/e
Arranged follow-up thorugh a mental health team or outpatient psych
Order labs to monitor s/e
Psychological approach to bipolar?
Psychoeeducation
Combining pharmacotherapy with psychotherapy such as CBC or IPSRT (interpersonal and social rhythm therapy to reduce recurrence risk
Family therapy can be helpful if there are issues at home
Take proactive approach to weight maintenance by focusing on healthy foods and remaining active
Minimize stress
Maintain regular sleep cycles
Social approach to bipolar?
Social
Educate patient and family in risk factors for relapse and aid in early ID of symptoms
Encourage patient to be actively involved in support networks and community resources
Chart illess retrospectivel to identify early symptoms, triggers, etc
Arrange regular follow-ups
Abstain from ilicit drugs and minimize alcohol use
If cost of meds an issue, may be eligible for plan G
Bipolar - relapse - med strategies?
If relapse:
- ensure compliance and search for other precipitating factors (stress, poor sleep, substances)
- continue to optimize dose, minimize s/e
- add adjuvant or discuss switching. Best to remain on med they were on when they responded to acute mania.
Essentially: check serum levels + ensure compliance
Then: optimize, add adjuvant, or switch
Then: monitor -> continue, adjust, switch, add agent
Li - levels and investigations required, including frequency?
Li – gold standard. Indicated for bipolar mania, bipolar depression and bipolar maintenance (all in monotherapy). Start at 600 mg PO QHS. (Little lithium is 6). Therapeutic doses are typically 900 – 1500 mg PO dialy. Can be given QHS, or dividided into BID/TID. Common adverse effects include GI symptoms, weight gain, acne, hypothyroidism, tremor, teratogenicity, renal impairment., seizures. “also fatigue, dizziness, tremor, weakness, memory problems, bradycardia, ECG changes, hypothyroid, hyperparathyroid, weight gain, GI, polyuria, sexual s/e, acne.” Monitor lithium concentration Q 4-5 days when initiating therapy. Target 0.6 -1.0 mmol/L for maintenance. > 45 or with hx of cardiac problems -> ECG
Classic mania – 80% response rate.
Investigations:
Lithium serum level: once a week for 2 weeks, then Q 3 months, or after 5 days
Check if changed dose. Check at trough, 9-12 hrs post dose.
Lytes
CBC+differential + TSH = Q 6 months
Renal function
Ca++ Q 2 years
ECG if > 45 yrs or history of cardiac problems Q 5 years
Weight, BMI
AIMS for all.
