Bipolar Affective Disorder

Question 1

What is bipolar disorder?

Answer 1

Characterised by recurrent episodes of depression and mania or hypomania

Question 2

What age do symptoms typically start in bipolar disorder?

Answer 2

Under 25

Question 3

What is bipolar disorder associated with?

Answer 3

Suicide

Question 4

What are depressive episodes?

Answer 4

Episodes which feature :
- Low mood
- Anhedonia
- Low energy

Can be severe

Question 5

What are manic episodes?

Answer 5

Episodes involving excessively elevated mood and energy

Significantly impacts their normal functions
Very disinhibited
Unable to function
More than 7 days

Question 6

What are hypomanic episodes?

Answer 6

Milder symptoms of mania without significant impact on their function
Only lasts a few days
Able to continue functioning
No feelings of grandiosity
Less than 7 days

Question 7

What are mixed episodes?

Answer 7

Mix of symptoms or rapid cycling between mania and depression

Question 8

What are features of mania?

Answer 8

• Elevated mood
• Irritability
• Energetic
• Insomnia
• Grandiosity, ambitious plans, excessive spending, risk taking
• Disinhibition
• Flight of ideas
• Pressured speech
• Psychosis

Question 9

How is bipolar disorder diagnosed?

Answer 9

Diagnosis made by specialist

Based on

Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

Question 10

What is Bipolar affective disorder 1?

Answer 10

Two distinct mood episodes

Involves at least one episode of mania

Question 11

What is Bipolar affective disorder 2?

Answer 11

One episode of major depression

One episode of hypomania

Question 12

What is cyclothymia?

Answer 12

Milder symptoms of hypomania and low mood

Symptoms not severe enough to significantly impact their function

Question 13

What is unipolar depression?

Answer 13

Person only has episodes of depression without hypomania or mania

Question 14

How is an acute episode of bipolar disorder managed?

Answer 14

Secondary care specialists should manage it

Requires referral for urgent mental health assessment or hospital admission

Question 15

How is an acute manic episode treated?

Answer 15

Antipsychotics (olanzapine, quetiapine, risperidone or haloperidol) first line

Mood stabilisers

Lithium and sodium valproate
Existing antidepressants tapered and stopped

Question 16

What treatment options are used for an acute depressive episode?

Answer 16

Olanzapine + fluoxetine
Antipsychotics (olanzapine or quetiapine)
Lamotrigine

Question 17

What is the long-term management of bipolar disorder?

Answer 17

Lithium

Question 18

Why are serum lithium levels monitored so closely?

Answer 18

Lithium toxicity occurs if dose and levels too high

Target range is 0.6-0.8mmol/L

Question 19

When are serum lithium levels monitored?

Answer 19

12 hours after most recent dose

Question 20

After changing dosage in lithium use when should serum lithium levels be checked?

Answer 20

Checked after 1 week and weekly until the levels are stable

Question 21

What are the adverse effects of lithium?

Answer 21

Fine tremor
Weight gain
CKD
Hypothyroidism and goitre
Hyperparathyroidism and hypercalcaemia
Nephrogenic diabetes insipidus

Question 22

What are some signs of lithium toxicity?

Answer 22

Coarse tremor
Nausea
Vomiting
Confusion
Ataxia
Muscle weakness
Seizures

Question 23

Why can you get hypothyroidism and goitre in lithium use?

Answer 23

Inhibits production of thyroid hormones

Question 24

What are some alternatives to lithium for long-term management of bipolar disorder?

Answer 24

Sodium valproate
Olanzapine

Question 25

What are the strict rules in place for sodium valproate and why?

Answer 25

Teratogenic

Causes neural tube defects and developmental delay if used in pregnancy

Strictly avoided in childbearing women unless no suitable alternatives

Question 26

What are the main side effects of sodium valproate?

Answer 26

VALPROATE

Vomiting
Alopecia
Liver toxicity
Pancreatitis/ Pancytopenia
Really big (weight gain)
Oedema
Anorexia
Tremor
Enzyme inhibiton

Question 27

How does sodium valproate work?

Answer 27

Blocks voltage-dependent sodium channels to suppress high frequency neuronal firing

Inhibitior of CYP hepatic enzmyes

Question 28

What must a female patient of childbearing age do when taking sodium valproate?

Answer 28

• Patient must use effective contraception
• Sign an annual risk acknowledgement form

Question 29

What does duration of untreated psychosis lead to?

Answer 29

Leads to poorer prognosis

Question 30

Why does bipolar have a high rate of suicide?

Answer 30

After recovering from mania, patients often highly embarrassed from their symptoms during mania

Or if they bought expensive items e.g. a car and are financially struggling

Question 31

What is a grandiose delusion?

Answer 31

Hightened sense of self-worth/power/knowledge or believes they have powers no one else does

Question 32

What is a Biazarre delusion?

Answer 32

Perosn adamant about a belief that is not possible, understable or related to normal life

Question 33

What is circumstantiality?

Answer 33

Inability to answer a question without giving excessive, unnecessary detail

Question 34

How does carbamazepine work?

Answer 34

Bind to voltage-dependent sodium channels to inhibit high frequency neuronal firing

Induces liver enzymes

Question 35

What serious condition can carbamazepine cause?

Answer 35

Steven-Johnson Syndrome

Avoid in South asians / HLAB1502 enzyme

Question 36

What are the side effects of carbamazepine?

Answer 36

Confusion
Ataxia
Rashes
Blurred vision
Aplastic anaemia
Bone marrow suppression
ADH release
Eosinophilia