Bipolar Disorder

Question 1

Bipolar I = ???
(1) Mania +- Depressive episodes
(2) Hypomania + Depressive episodes

Answer 1

(1) Mania +- Depressive episodes

Question 2

Mania is defined as a duration of at least:

Answer 2

1 week w/ functional impairment

Question 3

the Goals of treatment for Bipolar disorder are:

Answer 3

(1) Reduce frequency, severity, duration of mood episodes
(2) Prevent suicide

Question 4

what Non-pharmacological treatment are suitable for Bipolar Disorder?

Answer 4

Psychoeducation - to recognise early s&s;
Psychotherapy;
Stress reduction techniques;
Sleep hygiene

Question 5

S&S of Bipolar Mania are:

Answer 5

DIGFAST

Distractability
Irresponsibility
Grandiosity
Flight of ideas
Activity increased
Sleep (need is decreased)
Talkativeness

Question 6

Pharmacological Tx for Bipolar Mania:

Answer 6

(1) OQRA-Halo (Olan, Quet, Risp, Aripiprazole, Haloperidol)
(2) Lithium
(3) Valproate

Question 7

Pharmacological Tx for Bipolar Depression:

Answer 7

(1) Lithium
(2) QOF (Quet, Olan w/ Fluoxetine), Lurasidone, Cariprazine
(3) Lamotrigine

Question 8

Which agents are not suitable for use during pregnancy?

Answer 8

Lithium
Valproate
Carbamazepine

Question 9

Risk factors for Lithium toxicity are:

Answer 9

Sodium (low)
Thiazides use
ACEi/ARBs
NSAIDS
Dehydration

Question 10

Monitoring tests for Lithium are:

Answer 10

At Baseline and 6-12 monthly:
- Thyroid
- Metabolism (FBG, Lipids, BMI)
- FBC
- Renal panel
- TDM

Perform physical exam at Baseline.
NO need to check LFTs.

Question 11

What agents should be considered for Renal and Hepatic Impairment?

Answer 11

Hepatic - Lithium
Renal - Valproate

Question 12

Which agents require TDM?

Answer 12

Lithium
Valproate
Carbamazepine
Lamotrigine

Question 13

What should you take note of before initiation of Carbamazepine?

Answer 13

1. Pregnancy
2. PGx - HLA-B*15:02
3. FBC, LFTs, electrolytes
4. Risk of rash, SLE/TEN

Monitor w/ TDM -> twice in the 1st year, then annually.
Will take about 2-4 weeks to reach steady state.

Question 13

Which agent is best for a patient with Bipolar disorder and suicidal ideation?

Answer 13

Lithium

Question 13

When should you perform TDM?

Answer 13

Lithium - 5-7d after initiation; take sample 12hrs after previous dose.
Valproate - at least 2-3d after initiation of dose changes; take Trough sample.
CBZ - draw sample morning before 1st dose of the day; take Trough sample.
Lamotrigine - same as CBZ.

Question 14

What medications may induce mania?

Answer 14

• alcohol intoxication
• Drug withdrawal states
• Antidepressants
• DA-augmenting agents (CNS stimulants, DA agonists)
• NE agents (alpha antagonists, beta agonists)
• Steroids (corticosteroids)
• Thyroid prep

Question 15

What is the long-term pharmacological care plan for bipolar patients?

Answer 15

If recurrent episodes, maintain long-term Lithium, Quetiapine, Olan w/ Fluoxetine, Lurasidone, Cariprazine or Lamotrigine.

Question 16

Which agents need to be stopped 12 hours just before ECT (for severe / treatment-resistant mania/depression)?

Answer 16

Lithium;
Anticonvulsants (Valproate, CBZ, Lamotrigine);
Benzodiazepines.