Bipolar Disorder Flashcards
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Indications:
MOA:
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Bipolar Disorder:
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 of mania)
Each mood episode represents a drastic change from an individual’s usual mood and behavior.
Some episodes include symptoms of both mania and depression, which is called a mixed state. Individuals may seek help during a depressive episode, which can lead to a misdiagnosis of depression only.
Bipolar disorder is classified as ____________ or ____________. Which differ primarily by the severity of _______ experiences.
Bipolar 1 OR Bipolar 2
mania
The _______ are used to diagnose bipolar disorders and a ________ should be done prior to starting treatment to rule out a drug-induced mania.
DSM-5 criteria
toxicology screen
What is mania?
Definition:
abnormally elevated or irritable mood for at least a week (or any duration if hospitalization is needed)
What is mania?
Symptoms:
- 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 (buying sprees, sexual indiscretions, gambling)
Drug treatment:
- mood stabilizer (lithium)
- antiepileptic
- SGAs
What is the goal for drug treatment?
Where do mood stabilizers fit in therapy?
Where do antiepileptic medications fit for therapy?
Where do SGAs fit for therapy?
- Stabilize the mood without inducing depression or mania
- Mood stabilizers (lithium) treat both states (depressive or manic) without inducing either state
- The antiepileptics also treat both mania and depression without inducing either state*
- Antipsychotics, while not traditional mood stabilizers, can help stabilize the mood when mania occurs with psychosis
Why can’t we use antidepressants as monotherapy in bipolar disorder?
- Antidepressants can INDUCE or exacerbate a manic episode when used as monotherapy. So, they should only be used in combination with a mood stabilizer if treating bipolar disorder.
For Acute Treatment - this is determined by the type of episode patient is having.
For a MANIC episode: 1st line treatment is ___________1_______
A combination of an _____2________ + ________3______ is preferred for severe episodes.
1)- Valproate, Lithium or an antipsychotic- SGA
2) SGA + 3) lithium OR valproate
For Acute Treatment - this is determined by the type of episode patient is having.
For a DEPRESSIVE episode: 1st-line treatment is _______1_______. _____2______ can be added OR used as alternatives.
1) antipsychotic-SGA (quetiapine/lurasidone)
2) lithium, valproate, or lamotrigine
_______________ is required for ALL
____________ (due to the suicide risk)
____________ (due to increased risk of death in elderly patients with dementia-related psychosis)
MedGuides
antidepressants
antipsychotics
Treating bipolar disorder in Pregnancy is complex since the common mood stabilizers have known ______________.
teratogenic effects
Treating Bipolar disorder in pregnancy
- ___________1_________ exposure in pregnancy can increase the risk of fetal anomalies, including neural tube defects, fetal ____________ syndrome, and long term adverse cognitive effects.
AVOID in pregnancy, if possible, especially during the first trimester.
1) Valproate
2) fetal valproate syndrome
what are characteristics of fetal valproate syndrome:
Treating Bipolar disorder in pregnancy
- ________________ exposure in pregnancy can cause fetal _____2______ syndrome, which can result in _____3_____.
AVOID in pregnancy, if possible, especially during the first trimester.
1) carbamazepine
2) fetal carbamazepine syndrome
3) facial abnormalities and other significant issues
Treating Bipolar disorder in pregnancy
- ____________ exposure in pregnancy can cause an increase in congenital cardiac malformations and other abnormalities.
lithium
what are characteristics of fetal valproate syndrome:
what are characteristics of fetal carbamazepine syndrome:
During pregnancy: __________ is a safer option relative to other mood stabilizers.
__________ are safer choices than valproate, carbamazepine, or lithium. __________ has the most favorable safety profile in pregnancy but its use is limited since it is only approved for Bipolar depression.
lamotrigine
SGAs
lurasidone (Latuda)
Lithobid
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lithium
Class: mood stabilizer
Indications: Bipolar Disorder
MOA: MOA is proposed to work by influencing the reuptake of serotonin, and/or NE or by moderating glutamate levels in the brain.
Dosage forms: tablet, capsule, syrup
Dosing:
Start: 150-900mg/day, divided BID-TID
Usual range: 900-1800mg/day, divided BID-TID——TID-QID
ER- take BID
titrate slowly, as tolerated.
Take with or after meals to reduce nausea.
Therapeutic range: 0.6-1.2 mEq/L (trough level)
Acute mania may require up to 1.5mEq/L initially.
Contraindications:
Warnings:
renal impairment, hyponatremia, and dehydration (increase lithium toxicity)
**Serotonin Syndrome
Side Effects:
- GI upset (nausea/diarrhea), *cognitive effects, *cogwheel rigidity (stiffness when elevating appendage in increments), *fine hand tremor, thirst, polyuria/polydipsia, *weight gain, hypothyroidism
blue-gray skin pigmentation
Monitoring:
- serum lithium levels should be monitored to avoid toxicity
- renal function, thyroid function (TSH, FT4), electrolytes (calcium, potassium, sodium)
Pearls/Notes:
- Treats both mania and depression without inducing either state*
- renally cleared; no CYP interactions
- Avoid in pregnancy; associated with cardiac malformations in first trimester; avoid in breastfeeding
- Maintain adequate hydration with non-caffeinated fluids (Caffeine can decrease levels)
Drug-Drug/Food interactions:
When Lithium level is > 1.5mEq/L:
Toxicity symptoms include-
ataxia (loss of muscle coordination)- impaired coordination
coarse hand tremor
vomiting
persistent diarrhea
confusion
sedation
When Lithium level is >2.5 mEq/L
Toxicity symptoms include-
CNS depression
arrhythmia
seizure
coma
Lithium Drug Interactions:
Lithium levels will Increase with:
**-decreased salt intake, sodium loss (*with ACE inhibitors, ARBs, thiazide diuretics)
**- NSAIDs: aspirin and sulindac are safer options
Lithium Drug Interactions:
Lithium levels will Decrease with:
-increase salt intake, caffeine and theophylline
Lithium Drug Interactions:
increased risk of serotonin syndrome if lithium is taken with _________
SSRIs, SNRIs, Triptans, Linezolid (Zyvox), and other serotonergic agents
Lamictal
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lamotrigine
Class: antiepileptic
Indications: bipolar depression
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- rash
- *increased risk of RASH when used with Valproate
Pearls/Notes:
- Treats both mania and depression without inducing either state*
- Not useful for Acute mania due to slow titration required
Drug-Drug/Food interactions:
Depakote, Depakene
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valproate/valproic acid derivatives
Class: antiepileptic
Indications: bipolar disorder
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Side Effects: *weight gain
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- Treats both mania and depression without inducing either state*
- Valproate inhibits lamotrigine metabolism, so starting with a much lower dose of lamotrigine.
Drug-Drug/Food interactions:
Equestro
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carbamazepine
Class: antiepileptic
Indications: dipolar disorder
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- Treats both mania and depression without inducing either state*
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Abilify
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aripiprazole
Class: second generation antipsychotic (SGA)
Indications: schizophrenia,
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-FDA approval for adjunctive therapy in major depressive disorder
Drug-Drug/Food interactions:
Zyprexa
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olanzapine
Seroquel
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-FDA approval for adjunctive therapy in major depressive disorder
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quetiapine
Risperidal
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risperidone
Geodon
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ziprasidone
Latuda
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lurasidone
Saphris
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asenapine
Vraylar
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cariprazine
Symbyax
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olanzapine + fluoxetine
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Indications: bipolar depression
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Bipolar disease used to be called Manic Depressive disorder
Bipolar 1 classification:
- At least one episode of ___________ and usually, bouts of intense depression (a depressive episode is not required for diagnosis)
- ____________ is associated with at least one of the following: __________________
mania
mania
significant impairment in social/work functioning, *psychosis/delusions, or requires hospitalization.
Define Mania:
What are the symptoms?
- abnormally elevated or irritable mood for at least a week (or any duration if hospitalization is needed)
Symptoms:
- Inflated Self-esteem
- Needs less sleep “sleeping less”
- More talkative than normal
- Jumping from topic to topic
-Easily distracted
- Increase in goal-directed activity
- high risk, pleasurable activities (buying sprees, sexual indiscretions, gambling)
Diagnostic criteria for Mania:
- patient has abnormally ELEVATED or IRRITABLE mood for at least 1 week, (OR any duration if hospitalization is needed) AND patient
- exhibits > or = 3 symptoms (if mood is only irritable, then exhibits > or = 4 symptoms)
Bipolar 2 classification:
- At least one episode of ________ (lasting > or = 4 consecutive days) and at least one depressive episode (lasting > or = 2 weeks)
- ___________ does NOT affect social/work functioning, does NOT cause psychosis and does NOT require hospitalization.
- does NOT have _________
hypomania
hypomania
mania
Define Psychosis:
Severe mental condition where there is a loss of contact with reality, involves abnormal thinking and perception (hallucinations and delusions)
Hallucinations: sensing something that is NOT present. (ex. Imaginary voices, Jacob with girl communicating telepathically)
Delusions: a belief about something real that is not true. (ex. imagining that your family (which is real) wishes to hurt you.)
(Jacob- hearing his brothers saying hurtful mean things)
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- symptoms of toxicity: nausea or diarrhea, slurred speech, or feel shaky and confused
- 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 (Na & Li inverse relationship)
- maintain adequate hydration with non-caffeinated fluids
- Avoid dehydration (excessive sweating, diarrhea, vomiting and prolonged heat/sun exposure). Can increase lithium levels and side effects.
- Avoid in pregnancy/breastfeeding
- Notify healthcare provider immediately for worsening nausea and diarrhea, slurred speech or confusion
- Can impair alertness, use caution while driving or during other tasks requiring you to be alert.
