Bipolar - Block 3 Flashcards
What is depressive episode criteria?
- Period of depressed mood or loss of interest/pleasure
- Irritable (child/adolescent)
- Last at least 2 weeks
- Affects previoud functioning
Manic eisode criteria?
A distinct period of abnormally and persistently elevated, expansive, or irritable mood for 1 week (plus 3 or more):
1. Distractability
2. Indiscretion or irresponsible
3. Grandiosity
4. FLight of ideas
5. Activity (increased goal directed activit)
6. Sleep (decreased)
7. Talkativeness (pressured speech)
How long do episodes last?
Manic: 1 week
Depression: 2 weeks
What are the classifications of bipolar disorders?
- Bipolar 1: manic episode
- Bipolar 2: hypomanic episode + major depressive episode
- Cyclothymic disorder: 2 yr of subsyndromal mood cycling
- bipolar (NOS: not otherwise specified)
What is the criteria for hypomania?
- Same as mania without functional impairment
- 4 days
- Absence of psychosis
How do we diagnose bipolar?
- DSM categorical diagnosis (screenign)
- Non-DSM features: exam findings, course of illness, prabilistic approach
- Collateral info
How do we screen for bipolar?
Mood disorder questionaire (MDQ):
1. 13 questions based off of DSM criteria
2. Fairly sensitive
3. Takes about 5 minutes
4. Screen every patient with depression
What is the DSM 5 diagnosis for bipolar 1?
- One or more Manic Episode or Mixed Manic Episode
- Zero, Minor or Major Depressive Episodes often present
- May have psychotic symptoms
What is the DSM 5 diagnosis for bipolar 2?
- At least one or more Major Depressive Episode
- One or more Hypomanic Episode
- No full Manic or Mixed Manic Episodes, no psychotic features
What are the alternative diagnosis for bipolar?
- MDD
- ADHD
- Normal mood swings
- Schizoaffective disorder
- Schizo/delusional disorder
- Substance induced bipolar
What is the goal for bipolar tx?
- Reduction of current sx
- Prevention of relapse
- No cure
psychotherapies for bipolar?
- Psycho-Education
- Family Interventions
- Multifamily Psycho-education Groups (MFPG)
- Cognitive-Behavioral Therapy (CBT)
- RAINBOW Program
- Interpersonal and Social Rhythm Therapy (IPSRT)
- Schema-focused Therapy
- Light Therapy
- Electro-Convulsive Therapy (ECT) & Repeated Transcranial Magnetic Stimulation (r-TMS)
- Circadian Rhythm- Melatonin
- Nutritional Approaches- Omega-3 Fatty Acids
- Medication
Medications used for bipolar?
- Lithium (mood stabilizers)
- Anticonvulsants (valproate, carbamazepine, lamotrigine)
- SGA (aripiprazole, olanzapine, combination olanzapine and fluoxetine, lurasidone, paliperidone, quetiapine, risperidone, and ziprasidone)
- Antidepressants
What is the first line for any phase of BP?
Mood stabilizer (lamictal, lithium)
Indication for classical AD?
Triggers mania don’t use
Indication for atypical AD and SSRI?
Wellbutrin and SSRI don’t cause a switch to mania
SGAs for acute depressive episodes?
quetiapine and olanzapine (also combo olanzapine-fluoxetine had greater effect than mono)
Tx for acute bp mania?
- Lithium (mood stabilizer)
- Valproic acid
- Carbamexapine XR
- Atypical antipsychotics
What is a good option for more depression prone patients?
Lamotrigine
Useful for frequent relapse?
Log acting injectables: risperidone IM Q2W
Relapse prevention tx?
Olanzapine and aripiprazole
Alt first line from lithium?
Valproate
Lithium
Indication, Moniotring
Indication: protects from suicide, acute mania and maintencace
Monitoring: target (0.6-1.2 mEq/L)
* Toxic: ≥1.5 mEq/L
* Sz: ≥2.5
* Check levels 5 days after any dose increase
* Monitor every 6 months in stable patients
* Sweating a lot can affect levels
Lithium ADR?
Lithium side effects
Movement in the form of tremors in hands
Nephrotoxicity
Obesity- weight gain /hypothyroidism
Pregnancy defects
DDI of litium?
- NSAIDs, ACE inhibitors and diuretics, can increase serumlithium concentrations
- Theophylline and caffeine lower levels
- SS with SSRI, SNRI, Linezolid, triptans
Lithium monitoring?
Valproate
Indication
Indication: Acute maniac episodes, maintenance mainly
ADR: GI discomfort can switch to ER, Fetal neural tube defects
Valproate monitoring
Carbamazepine
Indication
Indication: acute maniac episodes
ADR: Constipation, SJS
Lamotrigine
Indication, ADR
Indication: acute depression, monotherapy or combo (first line) safer in regnancy
ADR: RASH, menstrual irregularities, tinnitus, SJS
APs used for BP?
ADR
Olanzapine and quetiapine (bipolar depression)
Risperidone (long acting inj) manotherapy or as adjunct (lithium or valproate for maintenance tx
ADR: weight gain, DM, hyperprolactimeia, EPS
Symbyax
Indication, ADR
Indication: bipolar depression (olanzapine prevent a switch to mania)
Counseling: HS due to olanzapine sedation
Advantages and disadvantages of Symbyax?
Advantage: Not more expensive than combo given separately
Disadvantages: potential overuse of olanzapine (sedation and weight gain)
Montioring for SGA
BZD
Indication
Indication: Acute mania, adjunct to mood stabilizers
