Bipolar and Related Disorders Flashcards by Steven Roseno

What are the 5 broad catagories of bipolar symptoms?

Manic behavior
Dysphoric behavior
Psychotic
Cognitive

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What are some examples of manic behavior (ie positive symptoms)?

Euphoria
Grandiosity
Pressured speech
Impulsivity
Excessive libido
Recklessness
Social intrusiveness
Diminished need for sleep

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What are some examples of dysphoric behavior (ie negative symptoms)?

Depression
Anxiety
Irritability
Hostility
Violence or suicide

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What are the psychotic symptoms?

Delusions

Hallucinations

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What are the cognitive symptoms?

Racing thoughts
Distractiblity
Disorganization
Inattentiveness

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Which bipolar disorder is rapid cycling more commonly associated with?

BP II

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What are the risk factors for rapid cycling?

Female
Antidepressant use
Thyroid disease
Older age

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What percentage of BP patients have SI? What percent attempt? What percent succeed?

50%
25%
11-19%

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When are BP patients most likely to use alcohol or other drugs?

During manic episodes

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Which BP disorder is most likely to be associated with drugs or alcohol?

BP I

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What are the two arms of somatic therapy for BP disorder?

Psychotropics and ECT

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What is the goal of treatment for BP disorder?

Treat both mania and depression
Prevent recurrence
Improve quality of life between episodes

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What area must be routinely monitored while BP patients are being treated?

Suicide risk
Mood symptoms and activity patterns
Substance use
Sleep hygiene- Change can precipitate symptoms
Medication compliance

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What labs should be checked before starting a patient on lithium?

CBC
EKG
Electrolytes
Renal panel- BUN, creatinine, and UA
Thyroid panel 
TSH

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What labs should be ordered before starting a patient on valproate?

LFTs

CBC

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What labs should be ordered before starting a patient on carbamazepine?

CBC
Platelets
UA
LFT
Kidney function

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What aspects of Bipolar disorder is lithium effective at treating?

Acute mania (60-80%) &amp; bipolar depression 
Maintenance

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What is the main disadvantage of using lithium?

Narro theraputic index

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What is the target blood level of lithium for acute mania? Maintenance?

8 to 1.2

0. 4 to 1.0

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How long do you wait before checking blood levels after starting lithium?

4 days

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At what blood level will mild lithium toxicty present and how does it present?

1.2-1.5
Many general symptoms
Key: Fine hand tremors

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At what blood level with moderate lithium toxicty present and how does it present?

1.5 to 2.0
Gross neurological deficits
- Ataxia
- Nystagmus
- Coarse tremors
- Muscle fasciculations

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At what blood level is severe lithium toxicity reached and how does it present?

2.5
Delirium
Seizures
Brain damage
Resp. problems
Coma
Death

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What do patients need to be sure they do when taking lithium?

Stay hydrated

What are some predictors that a patient will respond poorly to lithium?

``` Mixed states Rapid cycling Young males Poorly compliant Head injuries Severe mania Comorbidity ```

What are the two second generation antiepileptic medications used for BP?

Divalproex/Valproic acid/Depakote | Carbamazepine

When are second generation antiepileptic drugs effective for treating BP disorder?

Acute mania | Patients with poor response to lithium

At what blood level is divalproex most effective?

60 to 90 | 100 to 120 in special circumstances

What are key side effects of divalproex?

``` GI distrubance Weight gain Hepatic dysfunction Tremor Sedation Hair loss ```

What are the most common side effects of carbamazepine?

``` Induction of liver enzymes Sedation Tremor Weight gain Rash ```

What needs to be monitored for all patients taking a second generation antiepileptic?

Plasma levels Hematologic indices Hepatic indices

What are the thrid generation antiepileptics used for BP disorder?

Lamotrigine- Lamictal Gabapentin- Neurontin Topiramate- Topamax Oxcarbazepine- Trileptal

When is lamotrigine effective for treating BP?

Acute and prophylactic bipolar depression

What is a major benefit of using a third generation antiepileptic?

No blood monitoring

What is the main side effect associated with lamotrigine?

Cutaneous rash | May progress to stevens-johnson syndrome

What populations are at an increased risk of a cutaneous reaction when using lamotrigine?

Preadolescents Rapid titration Combined with other agents that may decrease metabolism (divalproex)

When is gabapentin a good adjunct treatment for bipolar?

When anxiety and neuropathic pain are involved

When is topiramate a good adjunct for treating bipolar?

When there is significant weight gain or risk of weight gain

What is the benefit of using oxcarbazepine instead of carbamazepine?

Better tolerated Fewer CNS side effects Fewer DDI

What types of sypmtoms is oxcarbazepine effective for treating bipolar?

Anti-manic Anti-mixed Anit-depressant (Preliminary evidence only)

Which high-potency benzodiazepines are used to treat acute mania?

Clonazepam | Lorazepam

When might benzos be used in BP?

``` Acute mania Insomnia Aggression Anxiety Dysphoria ```

What medications are benzos an adjunct to?

Lithium Carbamazepine Valproate

What type of symptoms are antipsychotics (typical and atypical) mainly used to treat in BP?

Manic | Psychomotor agitation

What are the atypical antipsychotics used to treat bipolar?

``` Olanzapine- Zyprexa Risperidone- Risperdal Quetiapine- Seroquel Ziprasidone- Geodone Aripiprazole- Abilify ```

What is the benefit of using atypical antipsychotics over typical?

Less EPS and TD

What is the main disadvantage of using atypical antipsychotics?

Weight gain metabolic syndrome CV impairments

Which atypical is most effective, but worse for side effects?

Olanzapine

Which atypical has the least side effects, but isn't quite as effective?

Ziprasidone

What is a main side effect of all antipsychotics?

Sedation

What kind of combo therapy may improve outcomes in BP disorder?

Mood stabilizers and atypical antipsychotics

Acording to the APA, what are the first line drugs that should be used to treat a patient presenting with mania?

Lithium or divalproex & an antipsychotic

For less ill patients, what are some acceptable monotherapies?

Lithium Divalproex Olanzapine

What is the preferred treatment for mixed episodes?

Divalproex

What are alternatives to lithium or divalproex?

Carbamazepine or Oxcarbazepine

According to the APA, what is the appropiate course of action when treating a patient who is already on a mood stabilizer, but presenting with bipolar depression?

Optimize the dose

According to the APA, what is the appropiate course of action when treating a patient who is presenting with bipolar depression,but they are not on mood stabilizer? (Consider Mild to moderate, severe, psychotic, and high suicide risk)

Mild to moderate- Lithium or lamotrigine Severe- Antidepressant & mood stabilzer Psychosis or High suicide risk- Add antipsychotic or ECT

What needs to be on the differential for a patient presenting with bipolar symptoms?

``` Bipolar I Bipolar II Cyclothymic Substance/Medication induced Due to another medical condition ```