Bipolar

Question 1

bipolar disorder

Answer 1

episodes of major depression interspersed w. periods of mania or hypomania

Question 2

Manic episode

Answer 2

period of abnormally elevated or irritable mood lasting at least 1 week: inflated self esteem, dec need for sleep, talkative, racing thoughts, distractability, dec judgement, hard to treat

Question 3

Hypomania

Answer 3

less exaggerated form of mania

Question 4

Pathophysiology of bipolar disorder

Answer 4

changes in the limbic system, basal ganglia, and hypothalamus leads to dysregulation of neurotransmitter systems, fluctuations in norepi/DA, fluct in intracerebral ca level, endocrine dysfunction, fam hx, environment

Question 5

Bipolar 1

Answer 5

mood disorder w/ 1 manic/hypomanic and 1 depressive episode, episodes are followed by sx free periods

Question 6

Bipolar 2

Answer 6

major, recurrent depressive episodes w/ hypomania, suicidal thoughts, usually does not require hospitalization

Question 7

Clinical course of bipolar

Answer 7

1st episode usually Manic, untreated episodes can last for months, most have multiple episodes

Question 8

Goal of Tx

Answer 8

control sx, reduce frequency of cycling, cure is not realistic, likely lifelong therapy, use BZD and antipsychotics for acute episodes

Question 9

TX options

Answer 9

mood stabilizers- lithium, anticonvulsants- valproate, carbamazepine, lamotrigine, oxcarbazepine, AAPs, consider acute vs maintenance, current mood state, longitudinal hx of pt, comorbidities, side effects

Question 10

Lithium

Answer 10

gold standard, effective in classic mania w/ euphoria, 100% renally eliminated, long term maintence therapy but 30% do not respond, dec # and severity of episodes, lots Dis

Question 11

Lithium MOA

Answer 11

mono-valent cation, Li, effects anion exchanges and Na transport in nerves, normalizes synaptic transmission of NE, 5HT, DA, takes 5-14 d onset

Question 12

Lithium ADRs

Answer 12

tetatogenic cat X, early onset- polyuria, polydipsia, dry mouth, hand tremor, GI upset, HA, memory impairment, long term- polyuria, polydipsia, tremor, hypothyroidism, acne, EKG changes, inc WBC

Question 13

Toxicity w/ Lithium

Answer 13

Mild- more severe hand tremor, GI, confusion, ataxia, slurred speech, mod-severe- muscle tremor, coma, seizure, hyperreflexia, CV colapse, death

Question 14

Lithium advantages

Answer 14

will control manic pt w/out feeling drugged, will normalize mood, very good prevention to dec mood swings, less severe relapse, blood conc monitoring, cheap

Question 15

Lithium disadvantages

Answer 15

narrow therapeutic range, pt compliance, toxicity knowledge, delayed onset, rapid cyclers are poor responders, expense of blood tests

Question 16

Depakote

Answer 16

3-5 d onset, more effective for rapid cyclers, mixed episodes, dose may be limited by GI, also sedation, minor elevations in LFTs, wt gain, hyperammonemia, hyperandrogenism syndrome in young females

Question 17

Carbamazepine (Tegretol)

Answer 17

more effective for rapid cyclers, mixed episodes, 1-2 w onset, many DI, induces its own metabolism, good add on or 2nd line, sedation, N/V rash hypotension

Question 18

Lamotrigine (Lamictal)

Answer 18

indicated for maintenance tx of BP 1 disorder, effective in depressive spectrum of bipolar disorders, not for a manic state, more effective as add-on

Question 19

Other tx options

Answer 19

oxcarbazepine (but hypoNa), gabapentin, topiramate (good if migraines), AAP (all proven effective, use in addition to other agents

Question 20

Treatment guidelines

Answer 20

lithium, VPA, CBZ, AP, short term BZDs, maintenance- monotherapy if possible, lithium, VPA, lamotrigine, depressed phase- use anti-depressants cautiously, flip into mania