Bipolar affective disorders

Question 1

Features of mania

Answer 1

Grandiosity, risk taking, racing thoughts, pressured speech, distractible, aggression, impulsivity, psychosis, self confident, social disinhibition

Question 2

Features of depression

Answer 2

Loss of interest, Guilt, anhedonia, hopelessness, suicidal plans, self-depreciation

Question 3

Aetiology

Answer 3

• Genetics/Hereditary
• Structural and Functional Brain abnormalities
• increased hyperactivity of monoamines (serotonin, noradrenaline and dopamine)
• decreased GABA function in all GABAergic pathways in depressed and manic states

Question 4

Lithium

Answer 4

Indications: Acute mania and hypomania, antidepressant augmentation, prophylaxis in bipolar disorder and recurrent depression
Possible MOA: Inhibits second messenger enzymes, modulation of G-proteins, signal transduction cascades further down, increase synaptic plasticity
Contraindications: Thyroidopathies, Pregnancy, Renal impairment, sick sinus syndrome, breast-feeding
Precautions: nephrotoxic (renally excreted), changes in body salt concentrations, check U+E and serum creatinine before starting, hypothyroidism (TFT before starting and at 6 months interval)
Side-effects: Cardiac arrhythmia, polyuria, polydipsia, nausea, GI upset
Interactions: NSAIDs, verapamil, diltiazem, diuretics, alcohol, antipsychotics

Question 5

Carbamazepine (anticonvulsant)

Answer 5

Induces own metabolism (autoinduction of liver enzymes)
Precautions: Leucopenia (risk of infections and fevers) - take baseline FBC and every 2 weeks for first 2 months and then every 3-6 months
Toxicity: severe diplopia, sedation, ataxia, nausea
Contraindications: Pregnancy and breast-feeding
Side-effects: agranulocytosis, aplastic anaemia, dizziness
Interactions: Lithium and antipsychotics (increase CNS effects), MAOIs, Ca channel blockers,
Increased concentration with verapamil, cimetidine, erythromycin
Decreased concentration with phenytoin and phenobarbitone

Question 6

Valproate (anticonvulsant)

Answer 6

Indications: acute mania, maintenance treatment of bipolar disorder
Type: Semisodium valproate (depakote) - acute mania
Precautions: check renal and liver function at baseline and then 6 monthly, check FBC at baseline and then 6 monthly
Contraindications: pregnancy, breast-feeding, hepatic disease
Side-effects: nausea, vomiting, ataxia, hair loss, moderate weight gain
Interactions: complex interaction with other anticonvulsants, potentiates activity of aspirin and warfarin, increases lamotrigine levels

Question 7

Lamotrigine (anticonvulsant)

Answer 7

Half the dose with valproate and twice the dose wit carbamazepine
Precautions: Monitor for rash
Contraindications: Pregnancy, hepatic impairment
Side effects: rash, diplopia, ataxia
Interactions: valproate increases levels, lamotrigine may increase levels of carbamazepine epozide metabolite
Possible alternative for pregnancy