Bipolar disorder

Question 1

Definition of bipolar disorder?

Answer 1

Episodic depressed/elated moods with increased activity (mania/hypomania)

Question 2

Difference between mania and hypomania?

Answer 2

Hypomania has no psychotic features and is usually not severe enough to cause marked functional impairment or require hospitalization

Question 3

Definition of rapid cycling bipolar disorder?

Answer 3

At least 4 manic/hypomanic/depressed/mixed episodes within 12 months

Question 4

Initial management of suspected bipolar disorder in GP?

Answer 4

Referral to psychiatry; urgency depending on risk assessment

Question 5

Chronic disturbance of mood consisting of periods of subclinical depression and hypomania

Answer 5

Cyclothymia

Question 6

Auditory hallucinations in bipolar vs schizophrenia?

Answer 6

Bipolar more often second person (i.e. talking directly to them), schizophrenia more often 3rd person (e.g. a running commentary)

Question 7

Drugs/substances which may mimic mania?

Answer 7

Cocaine, ecstasy, amphetamines

Question 8

Organic brain disease which may mimic bipolar? (5)

Answer 8

Frontal lobe dementia
Multiple sclerosis
Epilepsy
Encephalitis
Space-occupying lesion

Question 9

Iatrogenic mimics of bipolar? (4)

Answer 9

Corticosteroids
Dopamine agonists e.g. pramipexole, levodopa
Prescribed stimulants e.g. methylphenidate
Antidepressants

Question 10

DVLA guidance during acute mania?

Answer 10

Should stop driving; need to contact DVLA; insurance may not be valid if they continue to drive

Question 11

Management of acute mania?

Answer 11

Therapeutic trial of oral antipsychotic; tapering of antidepressant

Question 12

First-line treatment for prevention of relapse in bipolar disorder?

Answer 12

Lithium

Question 13

Second-line, if lithium is a) ineffective b) not tolerated?

Answer 13

a) add valproate

b) valproate or olanzapine monotherapy

Question 14

Important considerations with valproate?

Answer 14

Teratogenic; avoid in women of child-bearing age if able, and ensure adequate contraception if not

Question 15

Lithium monitoring a) Levels b) other monitoring

Answer 15

a) Weekly levels until dose is constant for four weeks; then monthly for 6 months; then 3 monthly
b) 6 monthly U&Es, TFTs

Question 16

Signs of lithium toxicity? (5)

Answer 16

Blurred vision
D&V
Hypokalaemia
Drowsiness
Ataxia

Question 17

How should lithium be prescribed?

Answer 17

By brand; varies in bioavailabiltiy

Question 18

Plasma lithium target levels?

Answer 18

0.6mmol/L to 1mmol/L

Question 19

Adverse effects of lithium? (4)

Answer 19

Thyroid derangement, goitre
Hyperparathyroidism
Nephrotoxicity
Nephrogenic diabetes insipidus

Question 20

Commonly-encountered interactions for lithium? (5)

Answer 20

Diuretics (particularly thiazide)- cause rapid increase in lithium levels
NSAIDs- may increase levels
ACE inhibitors- decrease renal excretion and can also precipitate AKI
QT prolonging drugs
Drugs that cause hypokalaemia

Question 21

Which drug may be used in addition, if depressive episodes are a troublesome/disabling feature?

Answer 21

Lamotrigine

Question 22

Management of women with bipolar who are planning a pregnancy?

Answer 22

Re-referral to CMHT for discussion of treatment options

Question 23

Management of acute depressive episodes in bipolar? (2)

Answer 23

Fluoxetine + olanzapine/quetiapine

Quetiapine monotherapy