Bipolar Disorder

Question 1

Bipolar disorder
-epidemiology
-risk factors

Answer 1

Past psych history - past episodes of mania => needed for diagnosis

Drug, alcohol - stimulants (cocaine, ecstacy, amphetamines) => manic

FHx - 1st degree relatives, high concordance in MZ

Age and sex - 20s, equal prevalence in both sexes

Question 2

Types of bipolar disorder
-difference between mania and hypomania
-what is mania

Answer 2

Type 1 - mania + depression (More common)
Type 2 - hypomania + depression

Mania - severe functional impairment/psychotic symptoms (7+days)
-acute abnormally elevated mood/irritability
- decreased sleep
- flight of ideas
- poor concentration
- increased libido, disinhibition, sex drive, reckless behaviour
- psychosis - grandiose delusions, hallucinations

Hypomania - less severe, no impact of ADLs or psychosis (4+days)

Question 3

Differentiating between depression and bipolar depression
-what is needed for a diagnosis of bipolar

Answer 3

BD
-Early, abrupt onset
-Frequent shorter episodes

1 episode of each or 2 episodes of mania
- Bipolar 1 - M+D
- Bipolar 2 - H+D

Question 4

Initial management of suspected bipolar disorder

Answer 4

Refer to specialist MH to confirm diagnosis, treat acute episode and establish care plan
If manic => urgent
If hypomanic => routine
-RISK ASSESS
Once mood stable, compliant => discharge to local CMHT or GP

May need to detain if attempting to self discharge/refuse admission or treatment
-can change mind very rapidly

Question 5

Medication
- acute manic episodes in secondary care
- long term management to prevent relapse

Answer 5

1st line - atypical antipsychotic (risperidone, olanzepine, quietapine)
-act faster than mood stabilisers
-taper and discontinue antidepressants
If sedation needed - IM lorazepam

Long term plan - lithium
-can add valproate if lithium not enough
-avoid Li if breastfeeding
-avoid valproate unless severe bipolar/no other option

Establish care plan in cases of relapse
-immediate harm => local crisis resolution, HTT
-signs of relapse but not immediate risk => CMHT assessment

Question 6

Lithium
-monitoring
-SE

Answer 6

Has a very narrow therapeutic range
Check levels
-12hrs after 1st dose
-every week until concentration stable
Once stable => every 3 months
After dose changes, check every week until stable

6monthly thyroid and renal check
-hypothyroidism
-nephrotoxicity => polyuria

N+V+D
Fine tremor
Weight gain
IIH
High WCC
HyperPTH, High Ca

Question 7

Lithium toxicity
-presentation
-management

Answer 7

Coarse tremor
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma

Volume resus - saline
-hemodialysis if severe