Bipolar Flashcards
Suicide risk in BAD?
15-19%
Equal risk in BAD I and 2
But more completed in BAD 2 (4%)
Conversion rate from MDD to BAD?
5-10% (adults)
20-40% (CAP)
BAD genetics?
CACNA1C on 12p3
ANK3
COMT
BDNF
More cohort effect than MDD
1 parent = 25%
2 parents = 50-75%
MZ twins = 45-70%
1st degree relative = 5-10%
Functional imaging:
- HYPO in PREFRONTAL
- HYPER in LIMBIC
BAD co-morbidities?
Anxiety disorders (75%) –> most common OCD, more co-morbid in kids than adults
Substance use disorder (33-45 or 50%)
Personality d/o (42%) –> OCPD (18%), BPD (16%), avoidant (12%), paranoid (11%), histrionic (10%)
ADHD
Mania criteria
Expansive/irritable mood +
Increased energy +
at least 3/7 (4 if mood irritable)
x 1 WEEK (less if hospitalized)
Hypomania criteria
x 4 DAYS
No psychotic symptoms
No hospitalization
Cyclothymia
At least 2 YEARS
(1 year in CAP)
Symptoms present for at least HALF the time
Never without symptoms for more than 2 MONTHS
Criteria for a major depressive, manic or hypomanic episode have never been met
Rapid cycling
4 episodes in 12 months
13-20% BAD
No family risk (not genetic)
Associated with women antidepressant substances hypothyroid BAD2 menopause temporal lobe dysfunction alcohol/caffeine
BAD co-morbid with ADHD
Stabilized with mood stabilizer/AP FIRST
Then
Adjunct methylphenidate or amphetamines
BAD in elderly
Lithium level 0.4-0.7
RISPERDAL if need an AP
BAD increases risk of Alzheimer’s (MORE THAN MDD)
BAD co-morbidities in kids
ADHD (90% kids, 50% adults) ODD (80%) Anxiety d/o (52%) OCD CD
KIDS HAVE ++ PSYCHOTIC SYMPTOMS IN BAD BUT LESS PSYCHOTIC SYMPTOMS IN MDD COMPARED TO ADULTS
Psychological treatment in maintenance?
1st line PSYCHOEDUCATION
2nd line CBT, family-focused therapy
3rd line IPSRT, peer support
Adjunctive psychosocial treatment reduces recurrence rates by about 15%!
Psychological treatment in bipolar depression?
2nd line CBT, FFT, IPSRT
Treatment of agitation in BAD
1st line ABILIFY IM ATIVAN IM LOXAPINE INHALED (level 1) OLANZAPINE IM
Acute mania response rate?
50% respond to mono therapy in 3-4 weeks
Combination treatment is more efficacious than Lithium or Epival alone
Acute mania treatment?
Monotherapy: LITHIUM SEROQUEL EPIVAL Asenapine Abilify Invega Risperdal Cariprazine
Combo: SEROQUEL + Li/DVP ABILIFY + Li/DVP RISPERDAL + Li/DVP Asenapine + Li/DVP
2nd line: Zyprexa, Tegretol, Lithium + DVP, ECT, Haldol
Most common suicide method in BAD depression?
Self-poisoning (medication, drugs)
Treatment BAD1 depression?
1st line SEROQUEL LATUDA + LI/DVP LITHIUM LAMICTAL (mono or adjunct) LATUDA
2nd line EPIVAL SSRI/Wellbutrin adjunct ECT Cariprazine Zyprexa + Prozac
NOT RECOMMENDED:
Abilify
Antidepressant mono therapy
BAD 1 maintenance treatment?
1st line LITHIUM SEROQUEL EPIVAL LAMICTAL ASENAPINE SEROQUEL + LI/DVP ABILIFY + LI/DVP ABILIFY
BAD guideline nuggets?
EPIVAL ONLY 2ND LINE IN BIPOLAR 1 DEPRESSION
LATUDA NOT FOR MAINTENANCE
LITHIUM + EPIVAL COMBO ONLY 2ND LINE IN MANIA
PSYCHOEDUCATION ONLY 1ST LINE IN MAINTENACE
NO FIRST LINE THERAPY IN BIPOLAR DEPRESSION
2ND LINE THERAPY IN BIPOLAR DEPRESSION = CBT AND FFT
ONLY FIRST LINE IN BAD2 DEPRESSION IS SEROQUEL
MONOTHERAPY WITH ZOLOFT AND EFFEXOR SECOND LINE
NO LATUDA OR EPIVAL IN BIPOLAR 2!!
BAD 2 MAINTENANCE 2ND LINE IS EFFEXOR OR PROZAC MONOTHERAPY
LATUDA ONLY FIRST LINE IN DEPRESSION IN KIDS
EPIVAL ONLY FOR MAINTENANCE IN KIDS
SEROQUEL ONLY FOR MANIA IN KIDS (and lower down)
Hypomania treatment?
Same as mania!
Bipolar 2 depression treatment?
1st line
SEROQUEL
2nd line LITHIUM LAMICTAL WELLBUTRIN ADJUNCT ECT ZOLOFT EFFEXOR XR
NOT RECOMMENDED = Paxil
Bipolar 2 maintenance treatment?
1ST LINE
SEROQUEL
LITHIUM
LAMICTAL
2nd LINE
EFFEXOR
PROZAC
Child and adolescent BAD treatment
MANIA
1ST LINE LITHIUM RISPERDAL ABILIFY ASENAPINE SEROQUEL
DEPRESSION
1ST LINE
LATUDA
2ND LINE
Lithium
Lamictal
MAINTENANCE
1ST LINE
ABILIFY
LITHIUM
EPIVAL
Geriatric BAD treatment
MANIA
1ST LINE
LITHIUM
EPIVAL
2ND LINE
Seroquel
DEPRESSION
1ST LINE SEROQUEL LATUDA LITHIUM LAMICTAL
MAINTENANCE
1ST LINE
LITHIUM
EPIVAL
LAMICTAL
BAD co-morbidities treatment
ETOH: LITHIUM + EPIVAL COMBO
(Seroquel not effective)
Cannabis: LITHIUM and/or EPIVAL
(Seroquel not effective)
Stimulants: LITHIUM, EPIVAL, Seroquel, Risperdal, Wellbutrin
Opioids: METHADONE
BPD: EPIVAL, LAMICTAL
Lithium complications?
Hypothyroid
Hypercalcemia
Hyperparathyroidism
Epival complications?
PCOS
sedation
hyperammonemic encephalopathy
Lamictal
10% benign rash
0.3-1% serious rash
