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CNS > Bipolar Disorder > Flashcards

Bipolar Disorder Flashcards

1
Q

What are the potential factors for Bipolar Disorder?

A

Genetic factors, environmental factors, biochemical factors, endocrine factors, physical illness or side effects of medication

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2
Q

What is Bipolar 1?

A

Where people have severe manic episodes (often interspersed with episodes of major depression).

Mania last one week

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3
Q

What is Bipolar 2?

A

Where people experience depressive episodes and less severe manic symptoms - classed as hypomanic episodes

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4
Q

What are features of a manic episode?

A
  • Inflated self-esteem or grandiosity
  • Decreased need for sleep
  • More talkative / pressure to keep talking
  • Racing thoughts
  • Distracted
  • Increase in goal-directed activity or psychomotor agitation
  • Excessive involvement in activities that have a high potential for painful consequences
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5
Q

What are features of depressive episode?

A
  • Suicidal preoccupation
  • Negative views
  • Feeling of hopelessness
  • Fatigue or low energy
  • Low appetite
  • Previous manic episodes
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6
Q

How is Bipolar I and II diagonised?

A

Bipolar I – At least seven consecutives days of severe mania

Bipolar II – At least four days of hypomania and at least one major depressive episode

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7
Q

What does NICE not recommend in primary care of Bipolar Disorder?

A

The use of questionnaires

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8
Q

When should a patient be referred to specialist care from primary care according to NICE?

A
  • When the patient has had overactivity or disinhibited behaviour which has lasted for 4 days or more
  • Suspected mania (urgent)
  • Suspected severe depression
  • When the patient is a danger to themselves or others (urgent)
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9
Q

Which is the typical medication for Bipolar Disorder?

A

Haloperidol

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10
Q

When should a patient be referred to secondary care according to NICE?

A
  • Poor or partial response to treatment
  • Person’s functioning decline significantly
  • Treatment adherence is poor
  • Side-effects developed from medications
  • Comorbid alcohol n drug misuse suspected
  • Person considering stopping medication after a period of relatively stable mood
  • Woman with bipolar disorder is pregnant or planning pregnancy
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11
Q

What most happen when patients start taking Lithium?

A

Regular blood test for Lithium levels
- Initally once a week
- Then can go to once a month or 6 weeks.

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12
Q

What are the therapies available in secondary care for Bipolar Disorder?

A
  • A psychological intervention
  • High-intensity therapy such as cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy
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13
Q

What are the main groups of medications used in mania and hypomania - give examples of them?

A

Antipsychotics such as haloperidol, olanzapine, risperidone and quetiapine

Lithium

Antiepileptics such as Valproate

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14
Q

Which medications cannot be initiated in primary care for the management of mania and hypomania?

A

Lithium cannot be initiated in primary care, in patients that have never taken it before, unless there are shared care arrangements in place

Valproate cannot be initiated in primary care

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15
Q

Should a patient with mania or hypomania be given antidepressants?

A

Ideally no.
If already taking it, it should be considered to stop the antidepressant.

If taking antidepressants in combination with a mood stabiliser, consider stopping the antidepressant too.

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16
Q

What should be given if Lithium is ineffective or not suitable?

A

If lithium is ineffective, give Valproate

If lithium is not suitable, Quetiapine or Olanzapine

17
Q

What would you offer a patient who develops mania or hypomania and is not already taking antipsychotic or mood stabiliser?

A

They should be offered haloperidol, olanzapine, risperidone or quetiapine.

18
Q

What are the steps to prescribing an antipyschotic or mood stablisier? - for treatment of mania or hypomania

A

They should be offered haloperidol, olanzapine, risperidone or quetiapine.

If any is ineffective or unacceptable, an alterantive medication out of the list should be tried instead.

If the alternative antipsychotic is not effective at the maximum license dose, lithium could be tried as an ADDITION.

If Lithium is not effective or not suitable, consider adding valporate INSTEAD.

19
Q

Who can valporate not be given to?

A

Women of childbearing age

20
Q

What should be done if a person is already taking Lithium?

A

The plasma lithium levels should be checked to optimise treatment.

Depending on patient’s preference, consider adding haloperidol, olanazpine, quietpine or risperidone.

21
Q

What should be done if a person is already taking valporate or mood stabiliser?

A

Depending on clinical response, consider increasing the dose, up to maximum if necessary.

If no improvement, consider adding haloperidol, olanzapine, risperidone or quetiapine, depending on paient’s preference and previous response to treatment.

22
Q

What must not be used to treat mania or hypomania?

A

Lamotrigine

23
Q

What is the first line treatment for Moderate or severe bipolar depression?

A

If not taking a drug to treat their bipolar disorder - fluoxetine combined with olanzapine OR quetiapine on its own, depending on patient’s preference and previous treatment.

If patient prefers, offer olanzapine (without fluoextine) or lamotrigine on its own.

24
Q

What is the second, third line treatment for moderate or severe bipolar depression?

A

If no response to fluoextine combined with olanzapine or quetiapine, consider lamotrigine on its own.

25
Q

What should be done to a patient that is taking Lithium for the treatment of bipolar disorder depression?

A

Plasma lithium levels should be checked. If okay, increase the dose of lithium; if at maximum level, add fluoxetine combined with olanzapine OR add quetiapine, depending on patient’s preference or previous treatment.

If patient prefers, consider offering olanzapine (without fluoextine) OR lamotrigine to lithium.

If no response to adding fluoextine combined with olanzapine or quetiapine, stop addition treatment and consider adding lamotrigine to lithium.

26
Q

What should be done to a patient that is taking Valproate for the treatment of bipolar disorder?

A

Consider increasing dose of valproate within the therapeutic range.
If the maximum dose has been reached and there is limited response to valporate, add fluoxetine combined with olanzapine OR add quetiapine, depending on patient or previous treatment.

If patient prefers, consider adding olanzapine (without fluoxetine) or lamotrigine to valporate.

If no response to adding fluoxetine combined with olanzapine or adding quetiapine, stop additional treatment and consider adding lamotrigine to valproate.

27
Q

What are the NICE recommendations for the long-term management of Bipolar Disorder?

A

First take into account previous drugs given to them - which have not been effective and which have. Discuss with patient if they would prefer to continue with that treatment or switch to lithium - explain lithium is the most effective long-term treatment for BD.

Offer lithium as first-line, long-term treatment for BD. If not effective, add valporate or olanzapine instead. Or last choice being quetiapine.

Disucss benefits and risks of each drug with patient.

Before stopping medication, tell them how to recognise early signs of relapse and what to do if symptoms recur.
Stop medication gradually and monitor for signs of relapse.

28
Q

What is the NICE recommendation for Bipolar Disorder?

A

First line - Lithium monotherpay.

Second line - Olanzapine, aripiprazole, OR quetiapine in combination with valporate or lithium.

Third line - Alternative antipyschotic such as lurasidone, asenapine, ziprasidone OR alternative mood stabiliser (carbamazepine, lamotrigine) in combination.

Forth line - Antipsychotic with two mood stabilisers

29
Q

What kind of drug is Lithium?

A

A mood stabiliser

30
Q

What are the key points to remember when using Lithium?

A

It should not be started unless continuing for at least 3 years as short term use can worsen the course of illness.

It takes at least a week to achieve a response

Abrupt discontinuation leads to rebound mania - so decrease risk of relapse by decreasing the dose of lithium gradually over 1 month

Individual lithium preparations are not bioequivalent so cannot substituted

31
Q

What are the side effects of Lithium?

A

The side effects directly relate to plasma levels

  • > 1mmol/L - transient mild GI symptoms, fine hand tremor, thirst, polyuria, hypothyroidism, mental dulling, nephrotoxicity
  • Toxicity: >1.5mmol/L - anorexia, nausea and vomiting, muscle weakness and twitching, drowsiness, coarse hand tremor
  • > 2mmol/L - disorientation, seizures, coma and death
32
Q

Which drugs cannot be used with Lithium and why?

A

Diuretics reduce renal clearance of lithium, espcically thiazides - loop diuretics are a little safer.

NSAIDs increase serum lithium levels by up to 40% and reduce renal excretion of lithium.

High dose Haloperidol taken with Lithium can cause severe neurotoxicity - but is widely prescribed as it is a useful combination

SSRIs - can cause SSRI-induced hyponatraemia to occur but is useful combination. Interactions are rare with this.

ACEI and A2RAs decrease excretion of lithium, and can precipitate renal failure - extra care and monitoring needed.

33
Q

Patient Counselling for Lithium?

A

Salt-free diet is contraindicted

Maintain adequate fluid balance

Vomiting and diarrhoea will lead to sodium depletion, which will increase plasma lithium concentration

CNS (5 decks)

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