Bipolar and Treatment Flashcards
List the diagnostic criteria for Mania/Hypomania
- persistent elevated or irritable mood and persistent increased goal directed activity or energy
- > =3 of the following if mood if elevated or >=4 if mood is only irritable (GST PAID)
- Grandiosity
- Sleep need is decreased
- Talkative
- Pleasurable activities with painful consequences
- Agitation or activity increased: increased goal orientated activity or psychomotor agitation
- Ideas are racing
- Distractible - mania when episode lasts >1 weeks with either severe impairement or hospitalization
- hypomania when episode lasting 4-6 days with no psychosis, severe impairement or hospitalization
Differentiate between bipolar 1 and bipolar 2
Bipolar 1
- patient has at least one episode of mania
- lack insight causing hospitalization, legal problems and financial difficulties
- onset at 18
- have manic episodes before depressive episode
Bipolar 2
- has at least one hypomania episode and 1 major depressive episode
- impulsivity leads to substance use, debt, promiscuity, relationship difficulties
- onset in 20s
- usually have depressive episodes, anxiety or eating disorder before diagnosis
List the specifiers for bipolar disorder
- anxious distress
- mixed features when criteria for hypomania and depression met simultaneously for >=1 weeks
- rapid cycling when >=4 mood episodes in last year
- melancholic features
- atypical features
List the criteria for cyclothymic disorder
- > =2 years of numerous periods of hypomania that do not meet criteria for hypomania episode and numerous periods of depressive symptoms that do not meet criteria for MDD
- hypomanic and depressive symptoms present for at least half of the time - never symptoms free for >2 months at a time
List the differential diagnosis for bipolar
Medical - hyperthyroidism - malignancy - anorexia - renal failure - cerebral insult Substances - Alcohol - PCP - Hallucinogens
List the initial work up needed before starting Lithium
- CBC to rule out blood dyscrasia
- electrolytes, BUN, creatinine to rule out electrolyte imbalance
- TSH
- ECG to rule out sick sinus syndrome
- BhCG
- metabolic baseline: weight, BMI, waist circumference, blood pressure, fasting glucose, lipid profile
List the side effects of Lithium
THE MAGIC WAND
- Tremor
- Hypothyroidism
- ECG - bradycardia, T wave flattening/inversion, sinus node dysfunction
- Muscle weakness
- Alopecia
- GI Upset
- Increased WBC - transient
- Cardiac abnormality - Ebtein anomaly, teratogenicity
- Weight gain
- Acne
- Neurological symptoms with lithium toxicity
- Diabetes insipidus
List possible causes of Lithium toxicity
Increase Lithium Levels - NSAID - thiazide diuretics - ACE inhibitor - tetracycline - anticonvulsants Decrease Lithium levels - caffeine - salt - osmotic diuretic - carbonic anhydrase inhibitors
Discuss the presentation of lithium toxicity
- symptoms develop peripheral to central
- patient should be hospitilized if lithium level is >2 or have symptoms
Peripheral - nausea
- vomiting
- cramping
- diarrhea
Central - tremors
- hyper-reflexia
- ataxia
- mental status changes
- coma
- seizures
Discuss the dosage and monitoring of Lithium
Dosages
- adults 500-1500mg daily to aim for level of 0.5-1.2
- elderly 150-600mg daily to aim for level of 0.4-0.8
Monitoring
- monitor every 5 days until steady state reached then monitor every 3-6 months
- repeat kidney function, TSH, ECG every 6-12 months
- repeat BMI every month for 3 months then 3 times a year
- waist circumference, blood pressure, fasting blood glucose, and lipid profile at 3 months and then annually
List the indications for valproic acid and initial investigations
- used for acute bipolar mania and maintenance
- 1st line for bipolar depression in combination with litium, SSRI or NDRI
- 2nd line for monotherapy bipolar depression
Investigations - CBC, liver enzymes
- bhCG
- metabolic baseline
List the side effects of valproic acid
TURN SO BALD & FAT
- Tremor
- Unsteadiness
- rashes, possible Steven-Johnson syndrome
- Nausea and GI upset
- Sedation
- Oligomenorrhea and PCOS
- blood dyscrasia
- Alopecia
- Liver enzyme elevation
- Dysarthria
- fat
- ammonia level increase
- teratogen
Discuss the dosage and monitoring for valproic acid
Dosage
- start at 250mg BID or TID or 250mg QHS for elderly
- increase to 750-3000mg daily divided BID
- therapeutic level 350-800 umol/L
Monitoring
- repeat CBC and liver monthly for 6 months then every 6 months
- measure valproic level weekly until steady state then monthly for 6 months then every 6 months
List the indications for lamotrigine
- maintenance treatment or hypomania
Discuss the side effects of lamotrigine
RASH
- rash
- activation or ataxia
- spaced out
- headache
