bipolar clinical

Question 1

what is bipolar disorder

Answer 1

stages of mania/hypomania and depression, with potentially stable moods between episodes - functioning is impaired

Question 2

epidemiology of bipolar disorder

Answer 2

1% of population
commonly between 18-24 years old

Question 3

what are the risk factors for bipolar disorder

Answer 3

genetics
being male
exposure to triggers
- trauma
- sudden cessation of mood stabiliser
- ECT
- goal attainment events
- disrupted circadian rhythms

Question 4

what are the physical risks of bipolar disorder to the patient

Answer 4

obesity
heart disease
HTN
poor memory
higher death risk by infection of respiratory disease

Question 5

what are the mental risks of bipolar disorder to the patient

Answer 5

greater suicide risk
substance misuse issues

Question 6

what are the social risks of bipolar disorder to the patient

Answer 6

poor performance
financial issues
violence/promiscuity

Question 7

which drugs can cause drug induced bipolar

Answer 7

hallucinogens
CNS stimulants - amphetamines, caffeine
antidepressants
antipsychotics

Question 8

what are the differential diagnosis for bipolar disorder

Answer 8

schizophrenia
unipolar depression
substance misuse
ADHD
BPD
SAD
PTSD
anxiety
organic causes

Question 9

what are the 4 types of bipolar disorder

Answer 9

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

Question 10

what are the non-pharmacological treatment options for bipolar disorder

Answer 10

talking therapies - good for early treatment if given w meds
CBT ineffective
psychotherapy and CBT NICE recommended

Question 11

what are the options for pharmacological treatment for bipolar

Answer 11

mania/hypomania acute and relapse prevention
- lithium, valproate, olanzapine, quetiapine, aripiprazole (carbamazepine, risperidone, benzos, haloperidol)
bipolar depression
- lithium, quetiapine
(carbamazepine)

Question 12

what is the indication for quetiapine

Answer 12

Monotherapy for acute mania/depression and relapse prevention

Question 13

what monitoring is required for quetiapine, olanzapine and aripiprazole

Answer 13

weight/BMI - weekly for 6 them at 12 weeks
HbA1c
Lipids - before and at 12wks
ECG
BP/pulse - after each dose change

Question 14

what are the side effects of quetiapine

Answer 14

sleepiness
dizziness
dry mouth
weight gain
postural hypotension
anticholinergic s/e

Question 15

what is the indication for olanzapine

Answer 15

mania and relapse prevention who are lithium/valproate non-responders

Question 16

olanzapine s/e

Answer 16

sedation - take on
weight gain
postural hypotension
anticholinergic s/e
metabolic syndrome

Question 17

interaction between olanzapine and smoking

Answer 17

induces CYP1A2 - metabolises olanzapine - do not stop if already smoker

Question 18

what is the indication for aripiprazole

Answer 18

acute mania and relapse prevention in people who have responded acutely

Question 19

aripiprazole s/e

Answer 19

akathisia
insomnia
gi upset
EPSEs
postural hypotension
palpitations

Question 20

what is the indication for lamotrigine in BD

Answer 20

prevention of relapse of bipolar depression

Question 21

lamotrigine s/e

Answer 21

drowsiness
dizziness
headache
nausea
oedema
bone marrow suppression
stevens johnsons syndrome

Question 22

prescribing warnings with lamotrigine

Answer 22

titration must be by the book - low and slow as per BNF

Question 23

what is the indication for valproate in BD

Answer 23

mania and relapse prevention
- depakote and episenta

Question 24

what are the monitoring requirements for valproate in BD

Answer 24

height
weight
FBCs
LFTs - before and over 6-12m
blood cell count - before and at 6m

Question 25

valproate s/e

Answer 25

weight gain gi irritation diarrhoea hair loss hepatic dysfunction thrombocytopenia

Question 26

what is mania

Answer 26

elevated mood for 7 days or more, with severe functional impairment and psychotic features

Question 27

what is hypomania

Answer 27

elevated mood for 4 days, with increased or decreased function and no psychotic features

Question 28

what are the diagnostic symptoms of mania/hypomania

Answer 28

abnormal elation of mood inability to concentrate flight of ideas obsessive preoccupation with an idea overactive/intrusive risk taking

Question 29

what are the presenting symptoms of mania/hypomania

Answer 29

euphoric mood bright/untidy appearance low sleep requirements increased drive/energy reduced insight pressure of speech

Question 30

what is bipolar depression

Answer 30

- Symptom or part of bipolar mood disorder including other phases - Antidepressants usually ineffective

Question 31

what are the symptoms of bipolar depression

Answer 31

decreased energy badly sleeping doing less loss of interest

Question 32

what is the indication for lithium in BD

Answer 32

1st line in prevention of bipolar relapse - depression and mania

Question 33

what is the MOA of lithium

Answer 33

alkali metal - not fully understood, modifies production and turnover of certain neurotransmitters

Question 34

what are the C/I for lithium

Answer 34

hypersensitivity cardiac disease/insufficiency low sodium severe renal impairment addisons disease untreated hypothyroidism breastfeeding brugada syndrome

Question 35

cautions in using lithium

Answer 35

renal impairment avoid in pregnancy ECT and other meds that reduce epileptic threshold QTc prolongation and other meds that do so

Question 36

lithium monitoring requirements

Answer 36

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

Question 37

which groups of patients are at risk for high/low lithium plasma levels

Answer 37

elderly risk of impaired renal/thyroid function raised calcium poor adherence poor symptom control >0.8mmol/L on last bloods

Question 38

how are lithium serum levels tested

Answer 38

blood test - 12hr post dose - 0.1-1.1mmol/L

Question 39

what are the side effects of lithium

Answer 39

upset stomach fine tremor of hands metallic taste ankle oedema - reduce dose increased thirst ad urine - RF weight gain

Question 40

what levels is lithium toxic

Answer 40

>1.5 is fatal >2mmol/L is urgent

Question 41

what are the symptoms of lithium toxicity

Answer 41

severe hand tremor nausea diarrhoea muscle weakness slurring blurred vision confusion

Question 42

which medications can increase lithium levels

Answer 42

NSAIDs ACEi/ARB - increased reabsorption in kidney COX2i metronidazole SSRIs diuretics

Question 43

which medications can decrease lithium levels

Answer 43

sodium bicarbonate caffeine

Question 44

what is the interaction between lithium and amiodarone

Answer 44

ventricular arrythmia

Question 45

what are the counselling points for lithium

Answer 45

OD night - minimise renal damage 6m to fully establish take regularly stop over 4 weeks minimum

Question 46

bipolar pathophysiology

Answer 46

dendritic spine loss, altered cellular connectivity and neural plasticity