bipolar clinical Flashcards
what is bipolar disorder
stages of mania/hypomania and depression, with potentially stable moods between episodes - functioning is impaired
epidemiology of bipolar disorder
1% of population
commonly between 18-24 years old
what are the risk factors for bipolar disorder
genetics
being male
exposure to triggers
- trauma
- sudden cessation of mood stabiliser
- ECT
- goal attainment events
- disrupted circadian rhythms
what are the physical risks of bipolar disorder to the patient
obesity
heart disease
HTN
poor memory
higher death risk by infection of respiratory disease
what are the mental risks of bipolar disorder to the patient
greater suicide risk
substance misuse issues
what are the social risks of bipolar disorder to the patient
poor performance
financial issues
violence/promiscuity
which drugs can cause drug induced bipolar
hallucinogens
CNS stimulants - amphetamines, caffeine
antidepressants
antipsychotics
what are the differential diagnosis for bipolar disorder
schizophrenia
unipolar depression
substance misuse
ADHD
BPD
SAD
PTSD
anxiety
organic causes
what are the 4 types of bipolar disorder
I - classic manic depression - mania and/or depression
II - depression with at least one hypomanic episode
III- pseudounipolar depression - recurrent mixed states
rapid cycling - 4 + mood episodes in a year
what are the non-pharmacological treatment options for bipolar disorder
talking therapies - good for early treatment if given w meds
CBT ineffective
psychotherapy and CBT NICE recommended
what are the options for pharmacological treatment for bipolar
mania/hypomania acute and relapse prevention
- lithium, valproate, olanzapine, quetiapine, aripiprazole (carbamazepine, risperidone, benzos, haloperidol)
bipolar depression
- lithium, quetiapine
(carbamazepine)
what is the indication for quetiapine
Monotherapy for acute mania/depression and relapse prevention
what monitoring is required for quetiapine, olanzapine and aripiprazole
weight/BMI - weekly for 6 them at 12 weeks
HbA1c
Lipids - before and at 12wks
ECG
BP/pulse - after each dose change
what are the side effects of quetiapine
sleepiness
dizziness
dry mouth
weight gain
postural hypotension
anticholinergic s/e
what is the indication for olanzapine
mania and relapse prevention who are lithium/valproate non-responders
olanzapine s/e
sedation - take on
weight gain
postural hypotension
anticholinergic s/e
metabolic syndrome
interaction between olanzapine and smoking
induces CYP1A2 - metabolises olanzapine - do not stop if already smoker
what is the indication for aripiprazole
acute mania and relapse prevention in people who have responded acutely
aripiprazole s/e
akathisia
insomnia
gi upset
EPSEs
postural hypotension
palpitations
what is the indication for lamotrigine in BD
prevention of relapse of bipolar depression
lamotrigine s/e
drowsiness
dizziness
headache
nausea
oedema
bone marrow suppression
stevens johnsons syndrome
prescribing warnings with lamotrigine
titration must be by the book - low and slow as per BNF
what is the indication for valproate in BD
mania and relapse prevention
- depakote and episenta
what are the monitoring requirements for valproate in BD
height
weight
FBCs
LFTs - before and over 6-12m
blood cell count - before and at 6m
valproate s/e
weight gain
gi irritation
diarrhoea
hair loss
hepatic dysfunction
thrombocytopenia
what is mania
elevated mood for 7 days or more, with severe functional impairment and psychotic features
what is hypomania
elevated mood for 4 days, with increased or decreased function and no psychotic features
what are the diagnostic symptoms of mania/hypomania
abnormal elation of mood
inability to concentrate
flight of ideas
obsessive preoccupation with an idea
overactive/intrusive
risk taking
what are the presenting symptoms of mania/hypomania
euphoric mood
bright/untidy appearance
low sleep requirements
increased drive/energy
reduced insight
pressure of speech
what is bipolar depression
- Symptom or part of bipolar mood disorder including other phases
- Antidepressants usually ineffective
what are the symptoms of bipolar depression
decreased energy
badly sleeping
doing less
loss of interest
what is the indication for lithium in BD
1st line in prevention of bipolar relapse - depression and mania
what is the MOA of lithium
alkali metal - not fully understood, modifies production and turnover of certain neurotransmitters
what are the C/I for lithium
hypersensitivity
cardiac disease/insufficiency
low sodium
severe renal impairment
addisons disease
untreated hypothyroidism
breastfeeding
brugada syndrome
cautions in using lithium
renal impairment
avoid in pregnancy
ECT and other meds that reduce epileptic threshold
QTc prolongation and other meds that do so
lithium monitoring requirements
ECG
RF (6m)
thyroid (6m)
weight/bmi
calcium
U&Es
FBC
plasma - weekly til stable for 4 weeks then 3m for 1 year, then 6m
which groups of patients are at risk for high/low lithium plasma levels
elderly
risk of impaired renal/thyroid function
raised calcium
poor adherence
poor symptom control
>0.8mmol/L on last bloods
how are lithium serum levels tested
blood test - 12hr post dose - 0.1-1.1mmol/L
what are the side effects of lithium
upset stomach
fine tremor of hands
metallic taste
ankle oedema - reduce dose
increased thirst ad urine - RF
weight gain
what levels is lithium toxic
> 1.5 is fatal >2mmol/L is urgent
what are the symptoms of lithium toxicity
severe hand tremor
nausea
diarrhoea
muscle weakness
slurring
blurred vision
confusion
which medications can increase lithium levels
NSAIDs
ACEi/ARB - increased reabsorption in kidney
COX2i
metronidazole
SSRIs
diuretics
which medications can decrease lithium levels
sodium bicarbonate
caffeine
what is the interaction between lithium and amiodarone
ventricular arrythmia
what are the counselling points for lithium
OD night - minimise renal damage
6m to fully establish
take regularly
stop over 4 weeks minimum
bipolar pathophysiology
dendritic spine loss, altered cellular connectivity and neural plasticity
