Bipolar Flashcards
What is Bipolar I Disorder?
- One or more manic or mixed episodes, usually accompanied by major depressive episode
- Distinct from other sub-types due to distinction in moods
What is Bipolar II Disorder?
- 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
What is Rapid Cycling?
- Rapid swing of moods
- Defined episode of mania followed by a defined episode of depression
- Can have short periods of recovery in between
What can substance use contribute to?
Substance use can contribute to mood swings
Bipolar patients with any comorbid substance use disorder usually what?
- 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
What are the Causes of Bipolar?
- 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
Early diagnosis of bipolar can what?
- Early diagnosis and treatment improve prognosis, especially if patient stays on treatment
- Reduces rate of relapse and increase rate of response
Medication selection in bipolar is what?
- Medication selection is individualised depending on what phase patient is presenting with and is tailored to the individual
How long is a patient on treatment for bipolar?
Duration of treatment is indefinite
What are General treatment issues of bipolar?
- 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
Episode of acute mania is?
A medical emergency
What are the Aims of Treatment of Manic State?
- Contain behavioural disturbances
- Possibly hospitalisation
Manic relapses in established disease is due to
- Poor treatment adherence
- Substance abuse
- Antidepressant use
- Stressful life events
What are the Goals of Acute Mania?
- To alleviate or shorten the duration of an acute episode
- To maintain good functioning
- To prevent further cycles of mania or depression
Treatment of Acute Mania:
- Treatment must be?
- Variability of?
- Other conditions?
- What else should be done?
- 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
Non-pharmacological and pharmacological treatment of Acute Mania can be used in combination
Non-Pharmacological Treatment includes:
- 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
Bipolar disorders have different illness phases. To be considered a mood stabiliser, a drug should:
- 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.
Acute Mania Treatment Failure
What should be done?
- 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
Withdrawing A/D in Bipolar Depression
Usually within 1-2 months of patients getting resolution from depressive phase of bipolar, then they must carry on with treatment with mood stabiliser
Failure to respond to bipolar depression therapy
What do you do?
- 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
How long should treatment of Bipolar be continued for?
- 12 months after first episode
- Multiple episodes = long term treatment encourages
- Supportive psychotherapeutic strategies
What else should be managed and monitored while on bipolar treatment?
- 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
Prophylaxis Treatment for Bipolar Disorder should be considered in patients who?
- With 2 or more previous episodes of either mania or depression
- First episode was severe
Prophylaxis Treatment is dependent on
- Frequency, severity, age
- Concurrent illness
What drugs are used in Prophylaxis treatment and what else is good?
- Psychological treatment is good for adherence
- Prophylactic drug usually the same as for acute treatment
When is Lithium appropriate to initiate prophylactic treatment?
- 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
What are the Symptoms of Lithium Toxicity?
- Thirst
- Tremor
- Disorientation
- Nausea and vomiting
- Ataxia
- Acute renal impairment
What are the Causes of Lithium Toxicity?
- Interaction with drugs that affect renal function (diuretics, NSAIDs, ACEIs)
- Reduced fluid intake
- Fluid loss
What is the treatment of Lithium Toxicity?
- Withhold Lithium until blood concentration is back within desired therapeutic range
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?
- 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
