Bipolar Disorder

Question 1

How is bipolar disorder categorized?

Answer 1

It is characterized by fluctuations in mood from an extremely sad or hopeless state to an abnormally elevated, overexcited or irritable mood called mania or hypomania (a milder form fo mania). Each mood episode represents a drastic change from an individual’s symptoms of both mania and depression

Question 2

How is bipolar disorder classified?

Answer 2

Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by the severity of mania experienced

Question 3

What is cyclothymia?

Answer 3

Cyclothymia is a related disorder consisting of periods of hypomanic and depressive symptoms without meeting criteria for a major depressive, manic or hypomanic episode

Question 4

What are some possible complications of bipolar disorder?

Answer 4

Bipolar disorder can reduce quality of life or cause problems with relationships and employment. It can also lead to drug abuse, anxiety disorders and suicide

Question 5

What is the definition of mania?

Answer 5

Abnormally elevated or irritable mood for at least a week (or any duration if hospitalization is needed)

Question 6

What are the symptoms of mania?

Answer 6

• Inflated self-esteem
• Needs less sleep
• More talkative than normal
• Jumping from topic to topic
• Easily distracted
• Increase in goal-directed activity
• High-risk, pleasurable activities (e.g. buying sprees, sexual indiscretions, gambling)

Question 7

How do you diagnose mania?

Answer 7

Exhibits > 3 symptoms (if mood is only irritable, exhibits > 4 symptoms)

Question 8

Describe Bipolar I

Answer 8

At least one episode of mani, and usually, bouts of intense depression (a depresssive episode is not required for diagnosis). Mania is associated with at least one of the following: significant impairment in social/work functioning, psychosis/delusions or requires hospitalization

Question 9

Describe Bipolar II

Answer 9

At least one episode of hypomania (lasting > 4 consecutive days) and at least one depressive episode (lasting > 2 weeks). Hypomania does not affect social/work functioning, does not causes psychosis nor require hospitalization

Question 10

What is the definition of bipolar depression?

Answer 10

Predominant symptoms of depressive episode include feelings of sadness or depressed mood and/or loss of interest in previously enjoyed activities

Question 11

What is the definition of psychosis?

Answer 11

Severe mental condition where there is a loss of contact with reality, involves abnormal thinking and perception (e.g. hallucinations and delusions)

Question 12

How do you diagnose bipolar disorder?

Answer 12

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria are used to diagnose bipolar disorders

*A toxicology screen should be done prior to starting treatment ot rule out drug-induced mania

Question 13

What is the goal of treatment of patients with bipolar disorder?

Answer 13

The goal of treatment is to stabilize the mood without inducing a depressing or manic state

Question 14

Which medications can treat both mania and depression without inducing either state?

Answer 14

The traditional mood stabilizers, such as lithium and antiepileptic drugs (valproate, lamotrigine and carbamazepine), treat both mania and depression without inducing either state

Question 15

Which medications can be used toe help stabilize the mood when mania occurs with psychosis?

Answer 15

Antipsychotics

Question 16

When can antidepressants be used for the treatment of bipolar disorder?

Answer 16

Antidepressants can induce or exacerbate a manic episode when used as monotherapy, so they should only be used inc combination with a mood stabilizer

Question 17

How do you select a treatment for bipolar disorder?

Answer 17

• The side effect profile of the drug
• The patient’s medication history and first-degree relatives’ medication history; if the patient or a family member responded well to a drug, the same drug might be a reasonable option
• The drug formulations available and cost

Question 18

What is the acute treatment for a manic episode?

Answer 18

First-line treatment is valproate, lithium or an antipsychotic. A combination of an antipsychotic + lithium or valproate is preferred for severe episodes

Question 19

What is the acute treatment of a depressive episode?

Answer 19

First-line treatment is lithium, but lamotrigine can be used as an alternative

Question 20

What are maintenance medications that can be used for bipolar disorder?

Answer 20

Lithium and valproate are preferred for maintenance monotherapy, but lamotrigine, carbamazepine and second-generation antipsychotics are alternatives. Antipsychotics or antidepressants may be added to lithium or valproate for maintenance therapy

Question 21

What is required with all antidepressants and with all antipsychotics?

Answer 21

MedGuides

Question 22

Why is treating bipolar disease in pregnancy complex?

Answer 22

Common mood stabilizers are teratogenic

Question 23

What can valproate exposure do in pregnancy?

Answer 23

Valproate exposure in pregnancy can increase the risk of fetal anomalies, including neural tube defects, fetal valproate syndrome and long-term adverse cognitive effects. Avoid in pregnancy, if possible, especially during the first trimester

Question 24

What can carbamazepine exposure do in pregnancy?

Answer 24

Carbamazepine exposure in pregnancy can cause fetal carbamazepine syndrome, which can result in facial abnormalities and other significant issues. Avoid in pregnancy, if possible, especially during the first trimester

Question 25

What can lithium exposure do in pregnancy?

Answer 25

Lithium exposure in pregnancy can cause an increase in congenital cardiac malformations and other abnormalities

Question 26

What is recommended for treatment of bipolar disorder in pregnancy?

Answer 26

During pregnancy, lamotrigine is a safer option relative to the other mood stabilizers. SGAs are safer choices than valproate, carbamazepine or lithium. Lurasidone has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for bipolar depression

Question 27

What anticonvulsants are used for the treatment of bipolar disorder?

Answer 27

Lamotrigine, Valproate/Valproic Acid derivatives, Carbamazepine

Question 28

What generation of antipsychotics are preferred for the treatment of bipolar disorder?

Answer 28

The first-generation antipsychotics have a higher incidence of EPS than SGAs, so SGAs are preferred

Question 29

What second generation antipsychotics are used for bipolar disorder?

Answer 29

Aripiprazole, Olanzapine, Quetiapine, Risperidone, Ziprasidone, Lurasidone, Olanzapine/Fluoxetine

Question 30

What is the MOA of Lithium?

Answer 30

Lithium is proposed to work by influencing the reuptake of serotonin and/or norepinephrine or by moderating glutamate levels in the brain. Glutamate is the primary excitatory neurotransmitter, so high levels could cause mania

Question 31

What is a boxed warning of lithium?

Answer 31

Serum lithium levels should be monitored to avoid toxicity

Question 32

What are some warnings associated with Lithium?

Answer 32

Renal impairment, hyponatremia and dehydration (increase lithium toxicity), serotonin syndrome

Question 33

What are some side effects of Lithium within therapeutic range?

Answer 33

GI upset (nausea/diarrhea), cognitive effects, cogwheel rigidity, fine hand tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism, hypercalcemia, cardiac abnormalities, edema, anorexia, worsening psoriasis, blue-gray skin pigmentation, impotence

Question 34

What are some side effects of Lithium when in toxic levels?

Answer 34

> 1.5 mEq/L: ataxia, coarse hand tremor, vomiting, persistent diarrhea, confusion, sedation

> 2.5 mEq/L: CNS depression, arrhythmia, seizure, coma

Question 35

What are monitoring parameters of Lithium?

Answer 35

Serum lithium levels, renal function, thyroid function (TSH, FT4), electrolytes (calcium, potassium, sodium)

Question 36

What are some notes about Lithium?

Answer 36

• Renally cleared; no CYP450 interactions

- Avoid in pregnancy; associated with cardiac malformations in first trimester; avoid in breastfeeding

Question 37

What are some drug interactions with Lithium?

Answer 37

• Lithium levels increase with decreased salt intake, sodium loss, NSAIDs
• Lithium levels decrease with increased salt intake, caffeine and theophylline
• Increased risk of serotonin syndrome if lithium is taken with SSRIs, SNRIs, triptans, linezolid and other serotonergic drugs
• Increased risk of neurotoxicity (e,g, ataxia, tremors, nausea) if lithium is taken with Verapamil, Diltiazem, Phenytoin and Carbamazepine

Question 38

What is the conversion between lithium formulations?

Answer 38

5 mL lithium citrate syrup = 8 mEq of lithium ion

8 mEq of lithium ion = 300 mg lithium carbonate tabs/caps

Question 39

What are key counseling points of Lithium?

Answer 39

• Take with food or at end of meal to reduce nausea
• Maintain consistent salt intake. Changes in salt intake can alter lithium levels in the body
• Maintain adequate hydration with non-caffeinated fluids
• Avoid dehydration which can increase lithium levels and side effects
• Avoid in pregnancy/breastfeeding
• Notify healthcare provider immediately for worsening nausea or diarrhea, slurred speech or confusion
• Can impair alertness, use caution while driving or during other tasks requiring you to be alert