Bipolar affective disorder - BPAD

Question 1

How does Bipolar present?

Answer 1

Variety of ways and is recurrent,treatment gives a control and not a cure.

Question 2

At what age does bipolar usually present?

Answer 2

(lifetime incidence 4500,) under 30s

Question 3

What are acute mania episodes?

Answer 3

episode that runs over a short course

Question 4

What is a mixed affective disorder?

Answer 4

manic and depressive episodes occurring
simultaneously within a short period of time.

Question 5

What is rapid cycling?

Answer 5

4 episodes experienced in 12 months

Question 6

What is unipolar depression?

Answer 6

Only depression experienced

Question 7

What is the pathophysiology for bipolar?

Answer 7

Mania- episodes can last 2 weeks- 4months
occurring less frequent than depression

Question 8

What is hypomania?

Answer 8

Elevated mood but not quite manic state,normal affect-
variation in facial expression and tone of voice.

Question 9

What about depression?

Answer 9

episodes may last 6-12 months

Question 10

What are depressive episodes associated with?

Answer 10

Disruption of
noradrenaline,dopamine,serotonin and glutamate systems. Manic episodes may be due to hyperdopaminergic state,depletion of gab and excess glutamate. Those with bipolar have a greater conc of neurons in their locus coreleus,responsible for arousal, alertness and via mesolimbic projections have a role to play in motivation,drive and response to stress.

Question 11

What is bipolar 1 and who does it affect?

Answer 11

Characterised by one or more manic epsiodes and one or more drepressive episodes,accompanied by at least 1 hypomanic episode- depressive episodes dominate!

Question 12

What is bipolar 2 and who does it affect?

Answer 12

Characterised by one of more major depressive episodes,accompanied by at least one hypomanic episode- depressive episodes dominate.Risk of suicide highest during depressive episode. Higher risk of prevelance in females.

Question 13

What is the diagnosis of bipolar?

Answer 13

distinct periods of abnormal mood for more than 7 days
-depressive symptoms- lowered mood,anergia(abnormal lack of energy),annedonia(loss of capacity to experience pleasure),weight changes,insomnia,suicidal idetions

Question 14

Manic symptoms

Answer 14

euphoria,expansive or irritable,with 3 associated features present to a significant degree – Increased self esteem,Grandiosity,increased aberrant speech,psychomotor agitation,overactivitiy,fight of ideas,racing thoughts,pleasure seeking,reduce need to sleep- no physiological reality,reduced ability to concentrate,symptoms msut be severe enough to cause distress or impairment in social,occupational or other areas.

Question 15

What are the different bipolar rating scales and what are they used for?

Answer 15

They can be used to confirm diagnosis and assess the severity,establisha. Baseline and monitor the response to treatment
- Mood disorder questionnaire- MDQ
- Young mania rating scale – YMRS
- Montgomery asperrgers depression rating scare - MADRS

Question 16

What is the prognosis for bipolar disorder?

Answer 16

In a 12 year follow up, bipolar pts found to be symptomatic for half their lives – most common complaint is depression,mani or hypomania.
- Mortality is high due to likelihood of self negelect,accidental death – risk taking behaviour
- Mixed affective disorders = most debilitating and have highest suicide rates of all subsets of BPAD.
- Lifetime risk of death at 19%
- - annually 0.4% of pts with BPAD commit suicide, interanational average 0.017%

Question 17

What are the treatment options for bipolar?

Answer 17

There is no cure- just control- aim is to
manage symptoms,prevet relapse and minimise side effects = enhance compliance.

Question 18

What are the mood stabilisers and prophylactic agents that can be given and how
are they beneficial?

Answer 18

Lithium - Prophylactic agents

Question 19

Explain the use of lithium

Answer 19

0.4-1.2 g PO OD or BD, agjust doseaccording to serum
lithium concentration, doses are initially divided throughout the day but OD is
reffered when serum lithium conc is stabilised(0.4 and 1 mmol/l)
- It interacts with the transport of monovalent and divalent cations in neurons
- Lithium has been shown to change the inward and outward currents of glutamate
active between cells at a healthy stable level
- Tremor muscles weakness,nausea,increased urination =se

Question 20

Lithium toxicity

Answer 20

SIGN OF TOXICITY and require withdrawal – increased gastrointestinal
disturbance,polyuria,CARDIAC ARRYTHMIAS,BLOOD PRESSURE,RENAL FAILURE
- -Lithium may enhance the neurotoxic effect of TCAs and Antipsychotocs agents.It
may enhace toxic effects of tramadol.tH ERISK MAY INCREASE SERUM LITHIUM LEVELS.nSAIS MAY IINCREASE SERUM CONC = TOXICITY.SSRIs- may cause serotonin syndrome.Sodium amy increase excretion of lithium .Renal and thyroid function tests needed, monitor blood and renal – 12 hours after dose.Care taken with elderly and renally impaired
- Ebsteins anomaly may be cause by lithium = causes heart defects in the foetus of given during pregnancy.

Question 21

Sodium Valporate

Answer 21

valproate in steps: 1- 2g daily – plasma conc of 30-100 ug/ml.
- used to prevent major seizures,valoprate should not be discontinued suddently can
cause and precipitate status epilepticus if this happens!!!!
- Na channel blocker and reduces t type calcium channel currenst which prevent
srepetitive and sustained firing of avtion potential.Down regulates the arachidonic
acid AA cascade – stabilising moooooood
- May cause hepatic and renal failure + pancretitis.the rate of congenital malformation
among babies born to mothers on valproate os 4 times higher than rate rate among
mothers using ither anti seizures.
- Hyperammonaniae = nausea, vomiting and ataxia – so ammonia levels need to be
monitored.
- Antipsychotocs and anti convulsant agents interact with avlporate (CYP 2D9 and
CYP3A4)

Question 22

What is mania and how is it treated?

Answer 22

Anti- depressant must be withdrawn,give prophylactic agent
-Start antipsychotic
- haloperidol (2-10mg) daily
- Risperidone(initially 2mg titrated to 4-6 mg)
-olanazapine(5-20mg daily)
-quetiapine( initially 50mg daily,titrated to 400-800mg daily)
- Selective D2 antagonists cause D2 blockade in mesolimbic pathway producing the therapeutic relief of positive symptoms.D2- receptor binding is loose allowing for fast dissociation.SGAs also have additional receptor occupancies that give secondary therapeutic effect.
-5HT2A antagonism reduces negative symptoms and 5HT1A creates partial agoinism that reduces negative symptoms.

Question 23

What are the side effects of mania treatment?

Answer 23

Anti cholinergic sedative effects,metabolic disorders due to interefence with ypothalamus -so weight gain and hyperglycaemia, raside cholesterol and triglycerides levels, muscuarinic side effects= dry mouth,blurred vision,tachycardia,agitation,urinary retention,constipation

Question 24

Depression and its treatment

Answer 24

-Fluoxetine – 25mg nightly +olanzipines 6mg, quintepine 400-800mg on it own.
Depending on the persons preference consider olanzapine without fluzoteien or lamotrigine on its own,if there is no response to fluoxetine combine with olanzipines or quietniapine. If a pt develops depression and they are already taking lithium , check plasma lithium level.If lithium level max- same pathway as above.

Question 24

How is lamotrigine given? why? and what are the steps that are put in place for it?

Answer 24

it is given with valproate initially 25mg titrated to 100mg daily. If without valproate then titrated to 200mg daily .
It inhibits Na currents by selectively binding to the inactivated state of the sodium ion channels and so supresses the release of the excitatory amino acid glutamate.
Se – aggretion,agitation,diarrhoea,dizziness,dry mouth and fatigue.

Question 24

How are SSRIs given?

Answer 24

Fluoxetine – 20-60mg nightly
Selective inhibition of the reuptake or serotonin at the presynaptic membrane = increased synaptic concentration of serotonin in the CNS. The serotonin response aat 5HT1A and 5HT2A receptors is enhanced,causing enhanced sertonegric neuro transmissions.
The therapeutic effect of SSRI may not be seen for 4-6 weeks. Side effects include drowsiness,nausea,dry mouth,akathsia – restless ness, insomnia,darrhoea, sexual dysfunction.
Fluoxetine has the longest washout period – 4-5 weeks – the risk of serotonin syndrome is high during transition.
SSRIs are substrates for cyp450 3A4 metobolic enzymes.Drugs that are metabolised by 3A4 should not be given with SSRIs as the risk of adverse effects increases.Nsaid use with SSRI increases the risk of GI bleeding

Question 25

What about benzodiazepines, when would you consider them and why are they used?

Answer 25

Lorzepam – 4mg daily, clonazepam 2mg daily, benzodiazipines bined to GABA – a receptors and induces chloride ions conduction.The threshold for AP firing increases the inhibitory effects og gamma- aminobutynic acid – GABA, such as sleep induction,hypnosis,memory,anxiety,epilepsy se= drowsinessloss of conc, in order to stop BDZ- gradually reduce the dose

Question 25

What are the best steps that are put in place for rapid cycling and the treatment
options that are actually suitable?

Answer 25

means that someone is diagnosed with bipolar or
depression has experienced four or more episodes within 2 month period.Suitable treatment would be the withsrawal of antidepressants and evaluating the triggers – substance misuse?- optimising prophylactic agents – lithium is less effective for rapid cycling patients.Start:olanzapine,clozapine,lamotrigine,risperiode,thyroxine,quetiapine.