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Pharmacotherapeutics Theory 2 > Bipolar > Flashcards

Bipolar Flashcards

1
Q

What is Bipolar I Disorder?

A
  • One or more manic or mixed episodes, usually accompanied by major depressive episode
  • Distinct from other sub-types due to distinction in moods
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2
Q

What is Bipolar II Disorder?

A
  • One or more major depressive episodes accompanied by at least one hypomanic episode
  • Don’t have huge episode but a little elevation of mood, depressive phase remains the same
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3
Q

What is Rapid Cycling?

A
  • Rapid swing of moods
  • Defined episode of mania followed by a defined episode of depression
  • Can have short periods of recovery in between
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4
Q

What can substance use contribute to?

A

Substance use can contribute to mood swings

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5
Q

Bipolar patients with any comorbid substance use disorder usually what?

A
  • More severe course of bipolar disorder
  • Longer and more frequent mood episodes
  • Aggressive behaviours
  • Legal problems
  • Poor treatment compliance
  • More frequent suicide attempts
  • More hospitalisation
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6
Q

What are the Causes of Bipolar?

A
  • Likely caused by dysregulation of neurotransmitters, neuroendocrine pathways and secondary messenger systems in the brain
  • Strong genetic basis
  • Environmental triggers
    • Stressful life events, alcohol or substance abuse, changes in sleep-wake cycle may elicit expression of genetic or biological vulnerabilities
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7
Q

Early diagnosis of bipolar can what?

A
  • Early diagnosis and treatment improve prognosis, especially if patient stays on treatment
    • Reduces rate of relapse and increase rate of response
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8
Q

Medication selection in bipolar is what?

A
  • Medication selection is individualised depending on what phase patient is presenting with and is tailored to the individual
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9
Q

How long is a patient on treatment for bipolar?

A

Duration of treatment is indefinite

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10
Q

What are General treatment issues of bipolar?

A
  • Co-management with psychiatrist
  • Teratogenic effects of some mood stabilisers e.g. AED – need reliable contraception method
  • Monotherapy with A/D is contraindicated
    • Increases risk of precipitating manic episode in acute setting
    • Increases risk of rapid cycling in a chronic setting
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11
Q

Episode of acute mania is?

A

A medical emergency

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12
Q

What are the Aims of Treatment of Manic State?

A
  • Contain behavioural disturbances
  • Possibly hospitalisation
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13
Q

Manic relapses in established disease is due to

A
  • Poor treatment adherence
  • Substance abuse
  • Antidepressant use
  • Stressful life events
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14
Q

What are the Goals of Acute Mania?

A
  • To alleviate or shorten the duration of an acute episode
  • To maintain good functioning
  • To prevent further cycles of mania or depression
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15
Q

Treatment of Acute Mania:

  • Treatment must be?
  • Variability of?
  • Other conditions?
  • What else should be done?
A
  • Treatment MUST be individualised
    • Variability of clinical presentation, severity and frequency of episodes
    • Co-morbid medical or substance use conditions – treat at same time
    • Educate patient and caregivers about illness and treatment options
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16
Q

Non-pharmacological and pharmacological treatment of Acute Mania can be used in combination

Non-Pharmacological Treatment includes:

A
  • Enhance adherence with drug regimens
  • Stabilise sleep and wake rhythms and other daily routines
  • Re-engage with social, familial and occupational roles
  • Enhance family relationships and communication
  • Reduce drug or alcohol misuse
17
Q

Bipolar disorders have different illness phases. To be considered a mood stabiliser, a drug should:

A
  • Treat acute depression
  • Treat acute mania
  • Prevent depression
  • Prevent mania

* Note: not all Mood Stabilisers does all of the above. Lithium does all but not first line.

18
Q

Acute Mania Treatment Failure

What should be done?

A
  • Ensure that maximum tolerable drug concentration has been achieved
  • If they haven’t reached max. tolerable drug conc. Switch to a different drug (e.g. from 2nd gen A/P to lithium)
  • Combination treatment (e.g. 2nd gen A/P + lithium/valproate)
  • If patient has failed 2 or more antimanic treatment = ECT
    • Good in bringing remission but patients don’t stay remitted after initial period

* Note: if patient on antidepressant, STOP with immediate effect

19
Q

Withdrawing A/D in Bipolar Depression

A

Usually within 1-2 months of patients getting resolution from depressive phase of bipolar, then they must carry on with treatment with mood stabiliser

20
Q

Failure to respond to bipolar depression therapy

What do you do?

A
  • If using an A/D in combination with a prophylactic drug, change to a different A/D or a different prophylactic drug
  • Augmenting with psychological treatment (e.g. CBT)
    • Enhances treatment adherence
  • ECT especially if the patient has psychosis associated with bipolar
21
Q

How long should treatment of Bipolar be continued for?

A
  • 12 months after first episode
  • Multiple episodes = long term treatment encourages
  • Supportive psychotherapeutic strategies
22
Q

What else should be managed and monitored while on bipolar treatment?

A
  • Management of Comorbidity
    • Actively monitor substance abuse
    • Assess and treat comorbid anxiety/panic disorder
  • Physical health
    • Monitor for metabolic syndrome
    • Cardiometabolic adverse effects
    • Blood pressure, weight, BMI, BGL
23
Q

Prophylaxis Treatment for Bipolar Disorder should be considered in patients who?

A
  • With 2 or more previous episodes of either mania or depression
  • First episode was severe
24
Q

Prophylaxis Treatment is dependent on

A
  • Frequency, severity, age
  • Concurrent illness
25
Q

What drugs are used in Prophylaxis treatment and what else is good?

A
  • Psychological treatment is good for adherence
  • Prophylactic drug usually the same as for acute treatment
26
Q

When is Lithium appropriate to initiate prophylactic treatment?

A
  • After a single manic episode that was associated with significant risk and adverse consequences
  • Two or more acute episodes
  • Significant functional impairment, frequent episodes or significant risk of suicide
27
Q

What are the Symptoms of Lithium Toxicity?

A
  • Thirst
  • Tremor
  • Disorientation
  • Nausea and vomiting
  • Ataxia
  • Acute renal impairment
28
Q

What are the Causes of Lithium Toxicity?

A
  • Interaction with drugs that affect renal function (diuretics, NSAIDs, ACEIs)
  • Reduced fluid intake
  • Fluid loss
29
Q

What is the treatment of Lithium Toxicity?

A
  • Withhold Lithium until blood concentration is back within desired therapeutic range
30
Q

Discontinuation of Lithium

  • What can worsen the natural course of bipolar?
  • Can it be stopped?
  • How should it be stopped?
  • Who are more prone to relapse?
A
  • Intermittent treatment with lithium may worsen the natural course of bipolar illness
  • DON’T start without a clear intention to continue it for at least 3 years
    • If they stop, increase risk of manic relapse
  • Decrease dose gradually over a period of at least a month and avoid serum level reductions of >0.2mmol/L
  • Patients maintained on high lithium levels prior to d/c were particularly prone to relapse

Pharmacotherapeutics Theory 2 (17 decks)

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