Bipolar Disorder

Question 1

What is bipolar I?

Answer 1

At least 1 episode of mania and usually bouts of intense depression (but not required); includes at least 1 of the following (psychosis/delusions, hospitalization, interferes with social/work functioning)

Question 2

What is bipolar II?

Answer 2

At least 1 episode of hypomania (>/=4 consecutive days) and at least 1 depressive episode (>/= 2 weeks); does NOT affect social work/functioning, cause psychosis/delusions, or require hospitalization

Question 3

What is mania?

Answer 3

abnormally elevated or irritated mood for at least a week (or any duration if hospitalization required)

Question 4

What are symptoms of mania and when is it diagnosed?

Answer 4

1. inflated self-esteem
2. needs less sleep
3. more talkative
4. jumping from topic to topic
5. easily distracted
6. increased goal-directed activity
7. high-risk pleasure activities
   Diagnosis: >/=3 symptoms (>/=4 if irritated mood)

Question 5

What is psychosis?

Answer 5

loss of contact with reality, abnormal thinking and perception

Question 6

What are treatments for bipolar disorder?

Answer 6

mood stabilizers and antiepileptics are used to stabilize the mood without inducing depression or mania

Question 7

What medications are used to stabilize mania with psychosis?

Answer 7

antipsychotics

Question 8

What medications can exacerbate manic episodes?

Answer 8

Antidepressant monotherapy (OK if used with mood stabilizer)

Question 9

What is preferred treatment for acute mania episodes?

Answer 9

1. lithium
2. valproate
3. antipsychotic (olanzapine, risperidone)

Question 10

What is preferred treatment for acute depressive episode?

Answer 10

1. lithium
2. valproate
3. antipsychotic (quetiapine, lurasidone)
4. lamotrigine

Question 11

What are maintenance therapies for bipolar?

Answer 11

Usually combination with:
1. Lithium
2. Antiepileptics
3. second generation antipsychotics

Question 12

What are antiepileptic therapies used for bipolar?

Answer 12

1. Lamotrigine* (*slow titration required due to risk of severe rash)
2. Valproate
3. Carbamazepine

Question 13

Lamotrigine

Answer 13

Lamictal, Lamictal ODT, Lamictal XR, Lamictal Starter Kit

Question 14

Valproate/Valproic Acid

Answer 14

Depakote

Question 15

Carbamazepine

Answer 15

Equetro

Question 16

What second generation antipsychotics are used to treat bipolar?

Answer 16

1. aripiprazole
2. olanzapine
3. quetiapine
4. risperidone
5. ziprasidone
6. lurasidone (depressive ep)
7. olanzapine/fluoxetine

Question 17

Aripiprazole

Answer 17

Abilify, Abilify Maintena

Question 18

Olanzapine

Answer 18

Zyprexa, Zyprexa Relprevv, Zyprexa Zydis

Question 19

Quetiapine

Answer 19

Seroquel, Seroquel XR

Question 20

Risperidone

Answer 20

Risperdal, Risperidal Consta, Perseris

Question 21

Ziprasidone

Answer 21

Geodon

Question 22

Lurasidone

Answer 22

Latuda

Question 23

Olanzapine/Fluoxetine

Answer 23

Symbyax

Question 24

Lithium

Answer 24

Lithobid

Question 25

What is a boxed warning with lithium?

Answer 25

serum lithium levels should be monitored to avoid toxicity

Question 26

What are warnings with lithium?

Answer 26

1. Serotonin Syndrome 2. renal impairment, hyponatremia, dehydration (all increase toxicity) 3. Avoid in Pregnancy and breastfeeding (cardiac malfunctions in 1st trimester)

Question 27

What are SEs with lithium (therapeutic range)?

Answer 27

1. GI upset (nausea/diarrhea) 2. Cognitive effects 3. Cogwheel rigidity 4. fine hand Tremor 5. Thirst 6. Polyuria/polydipsia 7. Weight gain 8. Hypothyroidism 9. hypercalcemia 10. cardiac abnormalities 11. edema 12. anorexia 13. worsen psoriasis 14. blue/grey skin pigmentation 15. impotence

Question 28

What are SEs with lithium toxicity?

Answer 28

>1.5 mEq/L: Ataxia, Coarse hand tremor, Vomiting, persistent diarrhea, confusion, sedation >2.5 mEq/L: CNS Depression, Arrhythmia, Seizure, Coma

Question 29

What is the therapeutic range for lithium?

Answer 29

Trough level: 0.6-1.2 mEq/L; may need up to 1.5mEq/L for acute mania

Question 30

What should be monitored while on lithium?

Answer 30

1. Lithium levels 2. Renal function 3. Thyroid function (TSH, T4) 4. electrolytes (Ca, K, Na)

Question 31

What drugs increase the concentration of lithium?

Answer 31

1. ACE/ARBs/ Thiazides via decreased salt 2. NSAIDs (aspirin and sulindac preferred)

Question 32

What drugs decrease the concentration of lithium?

Answer 32

1. Increased salt intake 2. caffeine 3. theophylline

Question 33

What drugs increase risk of serotonin syndrome when used with lithium?

Answer 33

1. SSRIs 2. SNRIs 3. Triptans 4. Linezolid 5. Other serotonergic drugs

Question 34

What drugs increase the risk of neurotoxicity when used with lithium?

Answer 34

1. Verapamil 2.Diltiazem 3. Phenytoin 4. Carbamazepine

Question 35

What are counseling points for lithium therapy?

Answer 35

1. take with food or after a meal to lessen GI sx 2. maintain consistent salt intake 3. maintain adequate hydration with non-caffeinated beverages 4. avoid dehydration 5. can impair alertness, use caution

Question 36

What are dosing conversions from lithium citrate syrup to tablets?

Answer 36

5mL lithium citrate =8 mEq Li+ 8 mEq Li+ = 300mg lithium carbonate tabs/caps

Question 37

What are the preferred treatments for bipolar in pregnancy?

Answer 37

1. Lamotrigine 2. Lurasidone (bipolar depression only but safest option)

Question 38

What bipolar treatments should not be used in pregnancy? WHY?

Answer 38

1. valproate- neural tube defects and cognitive effects especially 1st trimester 2. carbamazepine-fetal carbamazepine syndrome (facial abnormalities, etc. especially in 1st trimester 3. lithium- cardiac abnormalities