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Bipolar Disorder Flashcards

1
Q

Risks factors of bipolar disorder

A
  1. Genetics
  2. Treatment induced
  3. General medical conditions
  4. History of trauma
  5. Physical stressors
  6. Seasonal changes
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2
Q

What treatments induces bipolar disorder?

A
  1. Antidepressants (induces mania, typically in initial few days to 2 weeks)
  2. ECT
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3
Q

Medications/drugs that induces mania (1)

A

Drug-withdrawal states (alcohol, α2-agonists, antidepressants, barbiturates, benzodiazepines, opiates)

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4
Q

Medications/drugs that induces mania (2)

A

Antidepressants (MAOIs, TCAs, 5-HT and/or NE and/or DA reuptake inhibitors, 5-HT antagonists)

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5
Q

Medications/drugs that induces mania (3)

A

DA-augmenting agents (CNS stimulants: amphetamines, cocaine, sympathomimetics; DA agonists, releasers, and reuptake inhibitors)

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6
Q

Medications/drugs that induces mania (4)

A

NE-augmenting agents (α2-antagonists, ß- agonists, NE reuptake inhibitors)

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7
Q

Medications/drugs that induces mania (5)

A

Steroids (anabolic, adrenocorticotropic
hormone, corticosteroids)

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8
Q

Medications/drugs that induces mania (6)

A

Thyroid preparations (T3 or T4)

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9
Q

Medications/drugs that induces mania (7)

A

OTC decongestant (pseudoephedrine)

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10
Q

Medical conditions that induces mania (1)

A

CNS disorders (brain tumour, stroke, head injuries, multiple sclerosis, SLE)

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11
Q

Medical conditions that induces mania (2)

A

CNS Infections (encephalitis, neurosyphilis, sepsis, human immunodeficiency virus)

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12
Q

Medical conditions that induces mania (3)

A

Electrolyte or metabolic abnormalities (calcium
or sodium fluctuations, hyper- or hypoglycemia)

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13
Q

Medical conditions that induces mania (4)

A

Metabolic dysregulation (Addison’s disease, Cushing’s disease, hyperthyroidism (mania), hypothyroidism (depression), menstrual-related or pregnancy-related or perimenopausal mood disorders)

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14
Q

Medical conditions that induces mania (5)

A

Vitamins and nutritional deficiencies (essential amino acids, fatty acids, Vit B)

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15
Q

Key feature of bipolar disorder is _________.

A

History of mania/hypomania not caused by other conditions or substances.

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16
Q

“High mood (manic)” symptoms are _______.

A

Abnormal & persistently elevated/expansive/irritable mood

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17
Q

“High mood (manic)” symptoms - Digfast

A
  1. Distractibility & easily frustrated
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18
Q

High mood (manic)” symptoms - dIgfast

A
  1. Irresponsibility and erratic uninhibited behaviour (activities that are pleasurable but high risk of serious consequences)
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19
Q

High mood (manic)” symptoms -diGfast

A
  1. Grandiosity (inflated self esteem)
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20
Q

High mood (manic)” symptoms - digFast

A
  1. Flight of ideas (racing thoughts)
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21
Q

High mood (manic)” symptoms - digfAst

A
  1. Activity increased
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22
Q

High mood (manic)” symptoms - digfaSt

A
  1. Sleep: need decreased
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23
Q

High mood (manic)” symptoms - digfasT

A

Talkativeness

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24
Q

Duration of mood episodes that is considered mania

A

Symptoms ≥ 1 week

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25
Q

Duration of mood episodes that is considered hypomania

A

Symptoms ≥4 days

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26
Q

How many symptoms of DIGFAST is considered a manic episode?

A

At least 3 symptoms + elevated/expansive mood
4 symptoms if mood is only irritable

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27
Q

Bipolar I = _______ ± depressive episodes

A

Mania

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28
Q

Bipolar II = ______ ± depressive episodes

A

Hypomania

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29
Q

General assessments (1)

A

History of present illness

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30
Q

General assessments (2)

A

Psychiatric hx - Any history of manic/ hypomanic episodes? (starting an antidepressant may cause “manic switch” in patients with underlying bipolar disorder)

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31
Q

General assessments (3)

A

Complete medical & medication history
Reassess adherence to medications on every visit

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32
Q

General assessments (4)

A

Family, social, forensic, developmental & occupational history

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33
Q

General assessments (5)

A

Physical & neurological exam

34
Q

General assessments (6)

A

Mental State Exam (MSE) for accurate diagnosis
* Assess for suicidal/homicidal ideations and risks
* Reassess MSE on every interview to evaluate efficacy & tolerability

35
Q

General assessments (7)

A

Labs
Vital signs, weight & BMI, FBC, U/E/Cr, LFTs, TFTs, ECG,, fasting blood glucose, lipid
panel, urine toxicology; pregnancy test

36
Q

General assessments (6)

A

Other investigations
To exclude general medical conditions or substance-induced/withdrawal symptoms, e.g.
delirium/ psychosis/ depression/ mania/ anxiety/ insomnia/ thyroid dysfunction/ diabetes

37
Q

Which medicine requires genotype testing?

A

HLA-B*1502 prior to starting Carbamazepine

38
Q

Gold standard of rating scales

A

Young Mania Rating Scale (YMRS)
- Rater administered, not used clinically

39
Q

Goals of treatment (1)

A
  1. Reduce frequency, severity & duration of mood episodes
40
Q

Goals of treatment (2)

A
  1. Prevent suicide
41
Q

Goals of treatment (3)

A
  1. Maximise adherence to therapy
42
Q

Goals of treatment (4)

A
  1. Minimise adverse effects i.e. employ medications with the most acceptable tolerability and fewest drug interactions
43
Q

Goals of treatment (5)

A

Acute Treatment Phase:
- Eliminate mood episode with remission of symptoms

44
Q

Goals of treatment (6)

A

Maintenance/ Continuation Treatment Phase:
- Reduce frequency, duration & severity of recurring mood episodes.
- Reduce suicidal ideation or attempts
– Regain psychosocial functioning
– Avoidance of stressors or substances that may precipitate an acute mood episode

45
Q

Non-pharmacological (1)

A

Recognising early signs & symptoms of mania and depression

46
Q

Non-pharmacological (2)

A

Psychotherapy

47
Q

Non-pharmacological (3)

A

Stress reduction techniques

48
Q

Non-pharmacological (4)

A

Sleep hygiene

49
Q

Treatment framework

A

a) Short course of PRN benzodiazepines
b) Start mood stabiliser for acute treatment (& maintenance therapy)

50
Q

What is the short course of PRN benzodiazepines for?

A

Help patient relax & sleep, within hours.
Taper off when condition improved and mood stabiliser optimised.

51
Q

Which drug has the strongest evidence to reduce suicide?

51
Q

Which drug has the strongest evidence to reduce suicide?

52
Q

Onset of effectiveness for stabilising mood

A

About 3-5 days

53
Q

Initial monotherapy for mania (1)

A

Antipsychotics
SGA: Olanzapine, Quetiapine, Risperidone, Aripiprazole
FGA: Haloperidol

54
Q

Initial monotherapy for mania (2)

A

Lithium
- 1st line for maintenance & relapse/suicide prevention

55
Q

Initial monotherapy for mania (3)

A

Least preferred - Valproate
Avoid in pregnancy/women with childbearing potential

56
Q

Combination therapy for mania

A

Lithium ± Valproate ± Antipsychotics

57
Q

Initial monotherapy for bipolar & depression (1)

A

Lithium
- 1st line for maintenance & relapse/suicide prevention

58
Q

Initial monotherapy for bipolar & depression (2)

A

Antipsychotics
- Quetiapine, Olanzapine + Fluoxetine combination

59
Q

Initial monotherapy for bipolar & depression (3)

A

Lamotrigine
- Does not have any manic properties

60
Q

MOA of Lithium

A

Normalise/inhibits secondary messenger systems, may reduce PKC
Decreases 5HT reuptake and DA release

61
Q

Dosing of Lithium

A

Initial: 400-800mg/day
Max: 1.8g/day

62
Q

Target concentration of Lithium

A

Steady state in 5 days
Acute mania = 0.8 – 1.0 mEq/L
Maintenance = 0.6-1.0 mEq/L

63
Q

More serious side effects of Lithium

A

Tremours
Polyuria
Hypothyroidism
ECG changes
Nausea

64
Q

Lithium toxicity with:

A

STAND
1. Decreased Na
2. Thiazides
3. ACEi/ARBs
4. NSAIDs
5. Dehydration

65
Q

Less serious side effects of Lithium

A
  1. Weight gain
  2. Fatigue
  3. Cognitive impairment
  4. Diabetes insipidus
66
Q

_____ and _____ can enhance renal elimination of Li+

A

Caffeine
Theophylline

67
Q

Lithium has no effect on ___________.

A

Hepatic metabolising enzymes
100% renal CL

68
Q

Carbamazepine metabolism

A

CYP3A4 (major), CYP2C8 (minor)
Auto-induction of enzymes (start low before titrating)

69
Q

TDM for Lithium

A

Take samples 12hrs after previous dose
5-7 days after initiation/dose or formulation change
2 times weekly in acute stage
Every 3 months in 1st year, subsequently every 306 months

70
Q

TDM for Sodium Valproate

A

Trough sample (drawn morning before 1st dose)
At least 2-4 days after initiation or dose change

71
Q

TDM for CBZ

A

Trough sample (drawn morning before 1st dose)
Every 1-2 weeks during initiation (auto induction takes 2-4 weeks to reach SS)
Bi-anually for 1st year, annually after.

72
Q

How long does patient need to be on drug before switching or augmenting?

A

No response within 2-4 weeks

73
Q

What is considered rapid cycling?

A

≥4 mood episodes per year

74
Q

Omit Lithium, Anticonvulsants and Benzodiazepines (at least ___ hrs) just before ECT,

75
Q

Recurrent depressive episodes require _________, Quetiapine or ‘Olanzapine + Fluoxetine’, Lamotrigine, Lurasidone, or Cariprazine.

A

Long term Lithium

76
Q

Pregnancy

A

Avoid Valproate
Quetiapine, Olanzapine, Risperidone but monitor for side effects (e.g. gestational diabetes_

77
Q

Breastfeeding

A

Risk vs Benefit. ALL mood stabilisers are secreted into breastmilk

78
Q

CVD

A

Valproate: monitor for increased BP & HR, peripheral edema

79
Q

Hepatic impairment

80
Q

Renal impairment

81
Q

Elderly

A

Lamotrigine????

54 CNS (13 decks)

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