Bipolar Flashcards
Side effects of Lithium
Common:
GI: Metalic taste, Wt gain, N and V and D
CNS: Fatigue, vertigo and headache,
Haem: Leukocytosis
Endocrine: Hypothyroidism - common esp F, HyperPTH
Nephrogenic DI: Polydipsia and polyuria - reduced response to ADH oedema Fine tremor Muscular weakness and extrapyramidal feature Cognitive - memory loss ? T wave flattening and inversion Leukocytosis Teratogenicity: Ebstein abnormally CVS.
Side effects of Atypical antipsychotics
Extra pyramidal symptoms and metabolic disturbances
or QT prolongation, Cardia problems and rarely neuroleptic malignant syndrome.
Interactions of Risperidone
Carbamazepine
What monitoring is required for Lithium
Monitor twice weekly until stable for 4 weeks.
12 hour after last dose after 5-7 days of stable dosing.
Repeat every dosage adjustment or 3-6 months.
Aim for 0.6-0.8mmol/L.
Before starting Kidney function test as Lithium is renal excretion.
Electrolyte as lithium affect Na and water regulation and can Inhibit ADH. (Monitor every 3-6 months)
TFT - can cause Hypothyroidism. (6-12 months).
Parathyroid Hormone and Wt 12m.
Different types of Bipolar
Bipolar 1 = Mania but can’t function
Bipolar 2 = Hypo mania but can still function
DSM V criteria of manic Episode
A) A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day.
B) During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present, significant degree and represent a noticeable change from usual behavior:
G - Grandiosity
S - sleep decrease need
T - Talkative
P - pleasurable activités with painful consequence
A - Goal directed activity
I - Flight of idea
D- Distractability
C) The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalisation to prevent harm to self or others or there are psychotic features.
D) The episode is not attributable to the physiological effects of a substance or medication
Note: Criteria A-D constitue a manic episode. At least one lifetime manic episode = Bipolar 1
DSM V criteria for a hypomanic Episode
A) A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day.
B) During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present, significant degree and represent a noticeable change from usual behavior:
G - Grandiosity
S - sleep decrease need
T - Talkative
P - pleasurable activités with painful consequence
A - Goal directed activity
I - Flight of idea
D- Distractability
C) The Episode is associated with an unequivocal change in functioning that is uncharacteristic of the individual when not symptomatic.
D) The disturbance in mood and the change in functioning are observable by others.
E) The mood disturbance is NOT SEVERE ENOUGH to cause marked impairment in social or occupational functioning or to necessitate hospitalisation. If there are psychotic features, the episode is, by definition, Manic
F) The episode is not attributable to the physiological effects of a substance
Note: Criteria A-F constitute a hypomanic episode. Hypomanic episodes are common in bipolar 1 disorder but are not required for the diagnosis of bipolar 1 disorder.
Male vs female for bipolar
Equal prevalance
Examination finding for Bipolar
G I - excited, talkative, sometimes amusing and frequently hyperactive. +/- grossly psychotic and disorganised and require physical restraints and IM sedation
Appearance
Attitude
Behaviours
Mood and affect - euphoric, irritable, low frustration tolerance (leads to anger and hostility), may be emotional labile by switching from laughter to irritability to depression in minutes to hours.
Speech - can’t be interrupted while speaking, intrusive nuisances. often disturbed. louder, more rapid and difficult to interrupt the more manic they get. Filled with jokes, puns, rhymes endplays on words and irrelevancies. Worsen as concentration fades and flight of ideas and clanging and neologism appear
Thought process - easily distracted, unrestrained and accelerated flow of ideas.
Thought content - Self-confidence and self aggrandisement
Perceptions - Delusion in 75%. Include: great wealth, extraordinary abilities or power.
Cognition
Alertness
orientation - intact
Attention - easily distractible
Memory - intact
visuospatial functioning
Language functions
Executive functions -
Impulse control?- 75% assertive or threatening. Attempt suicide and homicide
Insight - little insight into disorder.
Judgement - Impaired (hallmark feature). Break laws, sexual, finances,
Treatment for Acute mania
Medical emergency - admit, R and R then ITO
Mood stabilisers agents - Lithium or/and
Antipsychotic - Risperidone, olanazepine, Quetiapine
Sedative for the short term - diazepam or lorazepam
Treatment for bipolar depression
Antidepressant in combination with prophylaxis drug as antidepressants cause hypomania or Mania.
Anticonvulsant Lamotrigine shows antidepressant effects in bipolar.
Quetiapine
Maintenance treatment of bipolar
Educate patient and family about condition
Statistics - 50% relapse in first 5 months off lithium
90% of patients who have a manic episode with have another episode in their life. average is 4 in 10 yrs. 5-10% have 4 episodes in a year (rapid cycling)
Risk assessment - 10-15% of bipolar patient completed suicide.
Inpatient vs out patient
MDT - Specialist psychiatric care, GP, psy
CBT, Assertive community treatment, social skills programs. Shown to improve compliance
Manage comorbidity - monitor for substance use, anxiety and panic disorders.
Maintain physical health - quit smoking, CVS risk factors.
Work and family life
Medication - lithium, carbamazepine and valproate
Continue Medications for adequate duration - 1st episode continue for 1 yr, if multiple episode an long term is needed.
First line Lithium carbonate 125-500mg orally twice a day for 2 weeks and then dose adjust.
AE - Sedation, cognitive impairment, tremor, wt gain, rash
If using valproate or carbamazepine then liver and haematological functioning prior to and just after starting.
ECT - May cause a manic episode in bipolar patients but has been shown to be anti manic intervention with 80% experiencing marked improvement.
MOA of lithium
modulate the NT induced activation of second messenger systems
Indications for lithium
Acute mania, prophylaxis of bipolar, treatment resistance depression, adjunct to antipsychotic in schizophrenia etc.
Interactions of lithium
Concentrations are increased on ACEi’s, NSAID, Diuretic
Concentrations are decreased on Antacids, theophylline
