Bipolar

Question 1

Bipolar Depression (old name: Manic depression)

Answer 1

• Occurs in about 1% of the adult population
• Symptoms typically develop in late adolescence/early adulthood
• Women show an increased incidence over men (around 20%)
• Shows strong genetic component
• Characterised by dramatic mood swings, from overtly “high” to the “low” of very sad or hopeless

Question 2

Diagnosis

Answer 2

• Defined in the Diagnosis and statistical manual for mental disorders DSM-IV
• It can be difficult since patients often enjoy the manic or hypomanic episodes so may only visit GP when depressed, also symptoms can be confused with anxiety or schizophrenia
• A questionnaire may be used by the doctor if mania suspected. These may include questions like-
  
  • Have you ever found yourself to be abnormally talkative and speaking-very quickly?
  • Have you been so manic that people thought you were not yourself

Question 3

Symptoms of a ‘high’ (mania)

Answer 3

• Overly good, euphoric mood
• Increased energy, activity and restlessness
• Racing thoughts, talking fast, jumping from one idea to the next
• Provocative, intrusive or aggressive behaviour
• Needs little sleep
• Unrealistic beliefs in one’s abilities and powers
• Increased sexual drive
• Abuse of drugs, particularly cocaine, alcohol and sleeping medications
• A denial that anything is wrong

Question 4

A bipolar range of mood from depression to mania

Answer 4

Question 5

Cycling

Answer 5

• Mania (peak)
• Depression (bottom)
• Normality (middle)
• 4 episodes over 12 months are known as rapid cycling
• Some patients have multiple episodes with a single week or even day

Question 6

Cycling of mania and depression

Answer 6

• Bipolar I disorder- recurrent episodes of mania and possibly depression
• Bipolar II disorder- Recurrent episodes of hypomania and depression
• Can NOT giving antidepressants
  
  • The graph will mood upwards with a greater period of time being spent in mania
• We try to dampen the graph so the oscillations will stay around the normal mood line

Question 7

Dont give antidepressents

Answer 7

• If left untreated Bipolar will deteriorate into a worse and worse condition

Question 8

Clinical Intervention in mania

Answer 8

• There are two principle aims in the treatment of bipolar disorder
  
  • Short term control of acute maina
  • Long term (prophylactic) treatment to maximise the time interval between episodes

Question 9

Treatment of acute mania

Answer 9

• Over mania is controlled with neuroleptic Olanzepine (nb atypical anti-psychotics not only block D₂ receptors but also 5-HT_2A receptors)
• Valporate but remember restrictions in women of childbearing age. Carbamezapine can be used but note the greater risk of cardiotoxicity and increased propensity for drug interactions
  
  • Blocking excitability
• nb the therapeutic benefit of mood stabilisers is delayed
• If sedation is a priority a BZ such as lorazepam can be administered

Question 10

Mood stablising drugs

Answer 10

• Lithium carbonate most commonly used as prophylactic to control mania as well as depression
• Recent use as prophylactic or in acute phase has increased as they have better side-effect and safety profile
• Has to build up for 6 months or more

Question 11

Li- MOA

We don’t actually no

Answer 11

• Mood
  
  • Decrease in: Mania; Depression; Mood stabilisation; Suicidality
• Cognition
  
  • Altered cognitive function
• Structure
  
  • Neuroprotective: Increase global grey matter vol; Amygdala, hippocampus, PFC
• Neurotransmission- Increased GABA: Decreased excitatory transmission
• Cellular and intracellular changes: 2^nd messenger (PKC, Ionositol, AC; increased anti-oxidant; Neuroprotective

Question 12

Patient care

Answer 12

• An important aspect is the teaching of patients to recognise the early symptoms of manic relapse
• Compliance with the lithium treatment is particularly important
• Monitoring of lithium blood concentrations after 1 week and then every 3 months

Question 13

Lithium PK

Answer 13

• Lithium is rapidly absorbed from the GI tract
• Li has an elimination half lifeof 24 hr
• Steady state levels are thus not obtained until about day 5
• Li dose must be titrated carefully to obtain blood levels between 0.5-1.2 mmol/L
• Severe toxicity occurs above 2 mmol/L

Question 14

Side effects of Li

Answer 14

• Approximately 30% of patients can not tolerate the ADR
• Therapeutic plasma levels of Li are associated with
  
  • GI discomfort and nausea
  • Neurological symptoms (which may dissipate) such as fatigue, malaise, muscle weakness
  • Decreased water reabsorption by the kidney
  • Weight gain. This is a frequent cause of non-compliance

Question 15

Li- Long half-life but narrow therapeutic window

Moderate

Answer 15

• Moderate (1.5-2.0 mmol/L
  
  • GI
    
    • Vomiting
    • Abdominal pain
    • Dry mouth
  • Neurological
    
    • Ataxia
    • Dizziness
    • Slurred speech
    • Lethargy or excitement
    • Muscle weakness

Question 16

Severe (2-2.5 mmol/L)

Answer 16

• GI
  
  • Anorexia nervosa
  • Persistent vomiting
• Neurological
  
  • Blurred vision
  • Muscle fasciculation
  • Clonic limb movements
  • Convulsions
  • Delirium
  • Syncope
  • Coma
  • Circulatory failure

Question 17

w