Bipolar and Drugs Flashcards
What is the crtiteria for manic episode?
- abnormally elevated, expansive, or irritable mood, lasting atleast 1 week
- 3 or more (4 if the mood is only irritable: grandiosity, decreased need for sleep, pressured speech, flight of ideas or racing thoughts, distractibility, increase in activity or psychomotor agitation, risky behavior)
Mixed Bipolar Episode criteria/definition
Criteria for both a major depressive episode and a manic episode; for atleast 1 week
Bipolar I disorder
atleast 1 manic/mixed episode (rule out medical conditions or substance induced mood disorder); distress or impairment in functioning
this is an extreme form of the disorder, and much more manic episodes
What is the defintion of a hypomanic episode?
Same as mania except:
- 4 or more days (can be less now)
- no severe dysfunction
- no psychosis
- no hospitalization
Bipolar II disorder criteria (3)
- atleast: 1 hypomanic episode, 1 major depressive episode (see a lot more depression than manic)
- NEVER manic or mixed
- distress or impairment (but not as severe as bipolar I)
What is cyclothymic disorder?
- many hypomanic and depressive periods
- atleast 2 years (1 in children)
- no major depressive, manic, or mixed episodes
when do bipolar disorders typically develop?
Late adolescence or early adulthood
gender for bipolar I and II
mean age of onset and peak age of onset
bipolar I: male = female
bipolar II: female > male
mean age: 21 yrs
peak age: 15-19
what percentage of bipolar disorder patients remain euthymic for a year?
1/3
euthymic = normal, non-depressed
In terms of neuroimaging, what is the proposed problem with bipolar disorders?
It is a cortical limbic problem: limbic is where emotions reside, and cortical controls the limbic. Suppression of limbic causes a compromise in connection. The suppression fo mood and emotions don’t happen.
main categories of bipolar drug (5)
- Lithium
- Anticonvulsants
- Antipsychotics
- Antidepressants
- Anxiolytics
+ Combination therapy
What are the indications (use) for Lithium? What is its role?
Indications: acute and prophylactic treatment of mania/hypomania (more effective in classic mania)
Role: potential acute and prophylactive treatment of depression
*adjunctive use with other mood stabilizers*
While the MOA of lithium is unclear, what are the implicated actions?
What are the pharmacokinetics/absorption like for Lithium?
Inhibits protein kinase and activates protein phosphatase (targets signal transduction)
Pharmacokinetics: lithium is a salt, so it’s rapidly absorbed and handled like sodium
Litihium has a (low/high) therapeutic index
What is its maximum effectiveness?
low therapeutic index (toxic at lower levels)
max effectiveness: 2-3 weeks
Prior to initiating lithium therapy, what functions shuold be evaluated? What test should be performed?
- renal and thyroid function
- ECG performed
- females of childbearing age should get pregnancy test (teratogenic effects)
which drug causes quite a bit of acne?
Lithium
Major side effects of Lithium (8)
- Cognitive
- Tremor
- GI
- Weight Gain
- Endocrine (thyroid, parathyroid)
- Dermatologic (acne)
- Teratogenic (cardiovascular)
- Renal (impaired concentrating ability, polyuria)
how does dehydration affect serum Lithium levels?
Increases it. Just know there are many medications and conditions that can compromise lithium levels
Increased: Thiazides, NSAIDs, ACE-I, low sodium diet, dehydration, elderly, renal disease
Decreased: Acetazolamide, Mannitol, Aminophylline, Theophylline, Caffeine, Mania, Pregnancy
*Lithium is only metabolized through the kidneys*
3 main anticonvulsants
DIVALPROEX SODIUM
CARBAMAZEPINE
LAMOTRIGINE
Proposed MOA of divalproex sodium (anticonvulsants) - 3
- enhancing GABAergic activity or K+ flow at neuronal membrane
- decreasing DA turnover
- decreasing gluamic acid N-methyl-D-asparate receptor mediated currents
Prior to initiating tx of divalproex sodium what tests do you need to assess and why?
assess liver function, CBC, and platelets (also pregnancy test for women)
dival is metabolized by liver and can compromise its function
drug is not an effective antidepressant
4 MOA of carbamazepina (anticonvulsants)
- blocks voltage-dependent Na channels
- inhibits glutamatergic neurotransmission
- modifies adenosine receptors
- increases extracellular serotonin
What is important to note if pt on carbamazepin and an anti-pscyhotic and why?
It will cause induction of levels of the antipsychotic because carba is metabolized by CYP3A4
side effects of carbamazepine on sodium
hyponatremia
black box warnings for carbamazepine (2)
monitoring levels (3)
- asplastici anemia
- agranulocytosis
(carba side effect is hematopoietic suppression
- blood levels
- CBC, platelets
- LFTs
MOA of lamotrigine (anticonvulsant)
- blocks voltage-gated Na channel
- weak 5Ht3 receptor antagonist
*recall that lamotrigine was first used as tx for epilepsy, then got approved for bipolar treatment
Lamotrigine has favorable side effects. Why though must it be slowly titrated?
A rare side effect is Stevens-Johnson syndrome and toxic epidermal necrolysis
What is the major common risk specific for Antipsychotics?
Metabolic syndrome
When you prescribe an antidepressant for bipolar, what other tx is absolutely essential?
A mood stabilizer (i.e. lithium, anticonvulsants, antipsychotics)
General rule with antidepressants:
treat as unipolar major depression with concomitant mood stabilizer
in terms of antidepressants, what does treatment depend on?
treatment depends on the severity of the depression and current treatment
*mood stabilizer should be restarted if lapsed, and if on mood stabilizer, dose should be increased to the upper end of the therapeutic range*
MOA of clonazepam (anxiolytics)
enhance GABA effects, primarily at GABA-A receptors
