Bipolar

Question 1

how would you manage mania in a patient with known bipolar ?

Answer 1

stop any antidepressants if they are on any

add antipsychotic
e.g. Olanzapine or Haloperidol

if already on mood stabiliser then increase to maximum dose. if this doesn’t work then consider starting antipsychotic i.e. olanzapine or haloperidol

Question 2

how would you differentiate between hypomania and mania ?

Answer 2

mania typically lasts > 7 days
severe impact on functioning ability in social and work life
psychotic symptoms

hypomania typically lasts 3-4 days
decreased or elevated functioning and doesn’t affect social and work life
no psychotic symptoms

Question 3

what are characteristic psychotic symptoms in mania ?

Answer 3

grandiose delusions

auditory hallucinations

Question 4

describe the primary referral system for patients presenting with mania and hypomania.

Answer 4

mania - urgent referral to CMHS

hypomania - routine referral to CMHS

Question 5

what is an alternative to lithium for prevention medication for bipolar ?

Answer 5

Na valproate

Question 6

what is the drug of choice for depression in bipolar patients ?

Answer 6

SSRI - fluoxetine

Question 7

what co-morbidites are people with bipolar at risk of ?

Answer 7

2-3x increased risk of CV disease, diabetes and COPD

Question 8

what is cyclic bipolar and what is the first line treatment ?

Answer 8

4 or more episodes of mania within 12 months

1st line = na valproate

Question 9

what baseline tests should you do when starting a patient on lithium ?

Answer 9

TSH
U&E
B-hcg (teratogenic)

Question 10

what’s the difference between bipolar type 1 and type 2?

Answer 10

type 1 - depression + mania

type 2 - depression and hypomania

Question 11

what is puerperal psychosis ?

Answer 11

rapid onset psychosis that occurs within the first 2 weeks post party
can be first presentation for bipolar
increased risk of bipolar type 1

Question 12

post partum psychosis is linked to what type of bipolar ?

Answer 12

type 1

Question 13

describe the monitoring of patients who are on lithium .

Answer 13

TSH and U&E’s every 6 months
lithium levels every 3 months

lithium levels checked 1 week after dose change and weekly thereafter until blood levels are stable
lithium levels should be checked 12 hours after the dose is taken

Question 14

side effects of lithium ?

Answer 14

GI: nausea, vomiting, diarrhoea, decreased appetite 
nephrotoxic
- polyuria: nephorgenic diabetes insipidus 
acne 
weight gain 
hair loss 
tremor 
sedation
thyroid hyperplasia - hypothyroidism 
benign leukocytosis

Question 15

what change in blood test can lithium cause ?

Answer 15

leukocytosis (non-significant)

- advice that if patients experience symptoms then they can be investigated/treated

Question 16

what factors influence a positive response to lithium ?

Answer 16

pure mania
positive FH response to lithium
mania followed by depression

Question 17

what baseline tests should be carried out before starting a patient on Na valproate ?

Answer 17

FBC - thrombocytopenia
LFT - hepatitis
bHCG - teratogenic

Question 18

side effects of Na valproate ?

Answer 18

P450 inducer 
thrombocytosis 
hepatitis 
pancreatitis 
weight gain 
tremor 
hair loss 
sedation 
nausea/vomiting

Question 19

what is the blood target level of Na valproate ?

Answer 19

50 - 125 mmol/L

Question 20

what is the blood target level of lithium ?

Answer 20

0. 4 - 1 mmol/L

0. 8 - 1 mmol/L in acute mania or previous relapse

Question 21

what are contraindications to lithium use ?

Answer 21

addisons disease

cardiac disease associated with rhythm disorder