Bipolar Affective Disorder Flashcards
What is Bipolar disorder?
A disorder characterised by at least 2 episodes of long-term changes in mood at least one of which has to be hypomanic, manic or a mixed episode. 90% of those who have manic episodes will develop depression at some point.
What is the epidemiology of bipolar disorder?
1-2% in the population usually beginning typically aged 15-19 for boys and 20-24 for girls. There is an equal distribution within the two genders. People with Bipolar disorder have 20x the normal risk of suicide.
What causes bipolar disorder?
Genetic
Neurologic illness – infection, stroke, neoplasm, epilepsy, and multiple sclerosis
Metabolic disturbance
Childhood experiences
Personality traits
Drugs – illicit, steroid and antidepressants
Describe the symptoms of hypomania
Hypomania Mildly elevated mood or irritable mood Increased energy and activity Increased self esteem Sociability, talkativeness and over familiarity Increased libido Reduced sleep Difficulty concentrating on one thing No psychotic symptoms No impairment of daily living and so no need for inpatient treatment
Describe the symptoms of mania
Mania Elevated mood for a week Increased energy Grandiosity and increased self esteem Pressure of speech Flight of ideas/racing thoughts Distractible Reduced need for sleep Increased libido Social inhibitions lost Can include psychotic symptoms
What is a mixed effective state?
Mixed affective state = rapid alternation between hypomania, mania and depression.
What are dysthymia and cyclothymia?
Dysthymia – chronic low mood not fulfilling criteria for depression
Cyclothymia – mild periods of elation/depression with early onset/chronic course and commonly seen in relative of those with bipolar disorder, present for more than 2 years.
What is the difference between Bipolar I and II in the DSM cefinitions?
Bipolar I – Mania +/- Depression
Bipolar II – Depression and Hypomania
What is a mood disorder with psychosis?
Mood Disorder with Psychosis = a single instance of a mood disorder with psychotic symptoms only present during the mood change.
What is schizoaffective disorder?
Schizoaffective Disorder – combination of Schizophrenia and mood disorder, Often the symptoms of schizophrenia predate the mood changes.
What investigations should be completed in someone suspected of being manic/hypomanic?
FBC
Us and Es
ECG
CT
How is acute mania managed?
Acute mania – Atypical antipsychotic e.g. Quetiapine, risperidone or Sodium Valproate. Stop any antidepressants and urgent referral to community mental health team
How is an acute depressive episode managed in someone with known bipolar affective disorder?
Acute depressive episode – Fluoxetine and olanzapine, Quetiapine alone, olanzapine alone or lamotrigine alone. Talking therapies
How is an acute hypomanic episode managed?
Hypomania – referral to community mental health team
How is Bipolar disorder/mood disorders managed long term?
Following treatment of an acute episode and diagnosis of Bipolar disorder they should have a long-term management plan which is usually a mood stabiliser – Lithium or sodium valproate but can be continuation of treatment for mania.
When is ECT indicated in mood disorders?
ECT for prolonged severe manic episodes or depressive symptoms
What pschotherapy should be offered in Bipolar disorders and what specifically are they used to treat?
Psychotherapy – CBT, Psychodynamic, mindfulness and psychoeducation. Most affective in those with insight. These should target dealing with a cycling disorder, anxiety about whether they are just having a good time or recurrence and other problems caused by manic episodes e.g. hypersexuality, overspending etc.
Why is lithium used in mood disorders?
Unknown mechanism of action, but notably lowers noradrenaline and increases serotonin synthesis. Has a very narrow therapeutic window. Lithium reduces suicide rates, has a license for reduction of self-harm and can be used to augment antidepressants.
What monitoring should take place in a patient on/starting lithium?
- At baseline – FBC, U&E including calcium, BMI, TFTs and and optional pregnancy test. ECG if any cardiovascular disease or risk factors for it
- After starting – check lithium levels weekly until it has been stable for 4 weeks.
- Check Li levels one week after any dose change.
- Measure lithium levels every 3 months for the next year and then every 6 months after that. If unstable, old, on diuretic, NSAIDs or ACE-I (all 3 increase Li) or previous lithium levels were high then test every 3 months. Minimum effective dose is 0.4mmol/l but we aim for 0.6-0.8mmol/l
- Every 6 months check weight, U&Es including calcium, TFTs (more often if renal impairment)
What side effects should be looked out for with lithium use?
Side effects – fine tremor, GI symptoms, T wave flattening, weight gain, idiopathic intracranial hypertension, leucocytosis, and nephrogenic diabetes insipidus
Long term side effects – Hypothyroidism and Nephrotoxicity
Gently rising Li levels suggests progressive nephrotoxicity
What are the signs of lithium toxicity?
Signs of lithium toxicity – reduced vision, D&V, reduced potassium, ataxia, coarse tremor, dysarthria, and coma.
How is lithium toxicity managed?
Treated with supportive measure and sometimes dialysis. Should drink lots of water to avoid risk of toxicity.
Can lithium be stopped suddenly?
Abrupt cessation of lithium can induce a manic episode so must be gradual.
If lithium doses are altered what needs to be monitored?
After a change in dose lithium levels should be taken a week later and 12 hours after the last dose.
What are the risk factors for suicide in bipolar disorder?
Previous attempt, family history, early onset, extent of depressive symptoms, increasingly bad affective signs, mixed affective states, rapid cycling, abuse of alcohol or drugs
What is sodium valproate?
GABA mediated inhibition
What are the side effects of sodium valproate?
Sedation, ataxia, tremor, alopecia, pancreatitis and weight gain
Liver damage so monitor LFT’s due to hepatotoxicity risk
Teratogen: neural tube defects
How do antidepressants and anti-psychotics affect sodium valproate?
Antidepressants inhibit action of valproate. Antipsychotics antagonise valproate by lowering seizure threshold.
How does aspirin affect sodium valproate?
Aspirin competitive binding causing valproate increase
What is lamotrigine?
VGNa Channel Blockers
What are the side effects of lamotrigine?
Dizziness, drowsiness, ataxia, numbness, and tingling
Serious skin rashes – Steven’s Johnson syndrome
How does lamotrigine interact with sodium valproate?
Valproate increased concentrations due to competitive binding
What must you be careful about when prescribing lamotrigine with contraceptives?
Oral contraceptives reduce lamotrigine concentrations.
What is carbamazepine?
VGNa Channel Blockers
What are the side effects of carbamazepine?
CNS: dizziness, drowsiness, ataxia, numbness and tingling.
GI upset and vomiting
Rashes, hyponatraemia, and severe bone marrow suppression
How do antidepressants interact with carbamazepine?
Antidepressants all interfere with its action
How does carbamazepine effect CYP450?
Strong CYP450 inducer so much so that is reduces its own half-life. Also affects contraceptives and warfarin
Can antidepressants be used alongside lithium?
Antidepressants during Lithium treatment may be required, recommended to use SSRIs or venlafaxine. TCAs are contraindicated as they can cause iatrogenic mania.
How do mood stabilisers/anti-convulsants effect platelets?
Note all anti-convulsant can cause thrombocytopenia so check FBC after starting.
Can lithium be combined with other mood stabilisers?
Yes and is often trialed
