Bipolar Disorder Flashcards
What are the key risks a person with bipolar disorder faces?
Episodes of (hypo)mania and depression
High suicide rate
High substance abuse co-morbiditiy
Mixed affective states - mix of mania and depression - high risk for suicide.
90% recurrence of manic episodes
What are the key features of mania?
Minimum lasts a week
Psychotic features - delusion of granduer and voices
Typically requires hospital admission
Severe - major life impact
What are the key features of hypomania?
Minimum 4 days
No psychotic features
Managed in community
Less severe - often still manage to go to work
Compare bipolar disorder type 1 and type 2
Type 1 = one or more manic episodes and one or more depressive episodes - can also have hypomania
Type 2 - recurrent major depressive episodes and hypomanic episodes (no mania)
What are the ICD-11 criteria for bipolar disorder?
Affective episodes should be prominent, with marked disturbance of mood.
Manic and hypomanic episodes should be characterized by a persistently elevated, expansive or irritable mood.
What are the shared features of a hypomanic and manic episode?
Elevated mood
Intense irritability
Physical symptoms - increased energy or decreased sleep.
Ambitous and grandeours ideas
What is the key epidemiology of bipolar disorder?
Affects up to 3% of global population
Both genders
Co-morbid with substance misuse.
High genetic link
Most commonly diagnosed in teenage years or early 20s.
What are the aetiological factors contributing to bipolar disorder?
Genetic - strong genetic link with potential for inheritance
Triggers - stressful events, physical illness, illicit substance misuse
Medication: manic switch by SSRIs when treating a depressive episode
What are the key clinical features of bipolar disorder?
Depressive phase - low mood, worthlessness, low energy and suicidal ideation
Manic phase - elevated or irritable mood, inc self esteem, sleep disturbance, impulsivity, psychotic, pressured speech
Additional: psychotic, risk taking behaviours
What investigations are done to rule out organic causes for bipolar disorder?
Substance misues - urine toxicology and amphetamine levels.
Delirium - infection, TFT, VitB12 and folate
What is the recommended process for making referrals when a patient presents with bipolar?
Hypomania - routine referall to CMHT
Mania/severe depression - urgent referall to CMHT
What treatment can be used for an acute/new bipolar episode?
Newly started SSRI should be stoped
Mania with agitation - IM neuroleptic or benzo, potential psychiatric admission
Withou agitation - oral antipsychotic (haloperidol), may switch, then add sedatives or mood stabiliisers,
Lithium and ECT - often last line
What is the treatment for acute depression in bipolar disorder?
Mood stabilizer dose increased
If no mood stabiliser consider SSRI and atypical antipsychotic cover.
What is the chronic treatment for bipolar disorder?
Typically starts 4w post resolution of acute.
Maintenance: mood stabiliser (Lithium first line or valproate second line)
Psychotherapy - high intensity - CBT or interpersonal.
What is the link between the manic and the depressive episodes in bipolar disorder?
Manic episodes often lead straight into a depressive episode
Depression can last longer than the elevated state - can be complicated by guilt/shame from what happened during manic episode
High risk of suicide during this period
What are the first line antipsychotics used in mania?
Quetiapine
Olanzapine
When is lithium used in bipolar disorder?
Second line with anti-psychotics if mood not controlled ap these alone
Is a mood stabiliser.
Used if depression or suicidality if a concern
What is the main risk of valproate?
No longer used in females under 55yrs due to risk of tetrogenicity
What is the guidance regarding the use of anti-depressants in bipolar disorder?
SHould only be used alongside mood stabilisers
In isolation = inc risk of manic episode
When is ECT used in bipolar disorder?
Used in prolonged, treatment resistant, life-threatening mania.
What is the thereapuetic range for lithium?
0.4 to 1.0 mmol/L
What are the signs of lithium toxicity?
Blurred vision
Coarse tremor
Nausea/diarrhoea
Anorexia
Increased urination/incontinence
Ataxia
Confusion
Dysarthria
ECG changes
Muscle twitches
Seizures
Death
What is the treatment for lithium toxicity?
Hospital admission
Stop lithium
Monitoring
What is important to monitor/know when using lithium?
Monitor - plasma lithium levels, weight, eGFR, TFT
NSAIDs, ACEi/ARBs, are contraindicated as affect kidney as does lithium - can increase plasma levels
Should not be stopped suddenly (unless toxicity) as can cause rebound mania
