Bipolar Disorder Flashcards
Bipolar one disorder
Mania with Major depressive episodes
includes anything where mania results in hospitalization
Bipolar two disorder
hypomania with major depressive episodes
Mixed episode in bipolar disorder
mania and depression all at the same time
rapid cycling in bipolar disorder
4 major depressive or manic episodes in a 12 month period
What is Bipolar disorder often misdiagnosed as?
Why?
What happens when it is misdiagnosed this way
Unipolar depression because patients often present with depression and manic episodes are not brought to the attention of the physician
Physician describes antidepressants which can swing patient into a manic episode
Diagnosis of a manic episode
At least one week with at least 3/7 symptoms
DIG FAST
Distractibility
Increased activity or psychomotor activity
Grandiosity- inflated self esteem
Flight of ideas
Activities that are dangerous, hypersexual, or goal directed
Sleep- decreased need (1-2 hours/ night)
Talkative or pressured speech
Diagnosis of Hypomania
same set of DIG FAST symptoms but alsting at least 4 days
but not severe enough for a marked change in social or functional impairment
Epidemiology
average age of onset is 21
first presents in females as depressive episode, males as manic episode
Etiology
Most genetic of all psychological disorders
stressful or exciting events can trigger an episode
getting off of the rhythm can also trigger an episode
What is suicide rate in untreated bipolar disorder
other issues in untreated
10-20%
higher rate of job loss
divorce, violence, incarceration, and STDs
Concurrent social functioning issues
Substance abuse- inc risk of suicide
many patients lack insight into their disease making it hard to tx
What is compliance like
50-75% dont maintain their drug regimen
90% relapse
What happens if TCA’s or SNRI’s are given to these patients
Mania or rapid cycling
Triggers for Bipolar Episodes
avoid triggers such as sleep deprivation, antidepressants without a mood stabilizer, alcohol
Role of ECT in bipolar management
Bilateral ECT is used for acute mania and acute depression.
indicated in drug resistant mania
Pregnancy
Role of psycho education in bipolar management
Important for pt to learn to recognize the signs early so that they can take preventative measures
Li
Lithium
Li MOA
Not well understood
Gold standard to tx bipolar disorder is
Li
Why is Li the gold standard in bipolar tx
stabilizes acute mania, prevents relapse of mania and depression
does more to prevent mania than prevent depression
decreases suicide rate
how does Li compare to other drugs for dealing with depression
Better than many other drugs for dealing with depression in bipolar disorder
What is the metabolism/ Pharmacokinetics of Li?
how is it handled in the body
Rapidly absorbed, not metabolized, no protein binding
steady state is reached in 5 days but takes 1-2 weeks to see full effects
Renal excretion
Does Li have psychotropic effects in pts who dont have bipolar disorder?
no psychotropic effects
What should patients use while waiting for Li take effect
takes 1-2 weeks
should use adjunctive therapy
What are the AE of Li
Dose dependent tremor psoriasis/ rash weight gain acne hypothyroid GI discomfort (N/V/D, GI pain)
What renal or urinary complications can be caused by LI
reduces the ability to concentrate the urine
causes interstitial fibrosis and gloerulosclerosis
dose dependent DI
polydipsia and polyuria
How should dif GI AE be handled
N/V and pain are caused by irritation of GI, this is early onset so take it with food or use sustained release or divided dose
Diarrhea is caused by colon irritation from unabsorbed Li –> use liquid or immediate release dosage
What are the signs of acute Li intoxication?
How is it avoided?
Seizures, Arrhythmia
GI, coordination issues, cognition issues, permanent neurologic impairments, kidney damage
Maintain adequate Na and fluid intake
What drugs increase the level of Li
NSAIDs- interfere with PGE synthesis –> dec elimination
ACE and ARB- RAAS
Thiazide diuretics- inc Li reab in distal tubule b/c inc Na reab
What effect does GFR have on serum Li
as GFR dec serum Li increases
What is the role fluid and Na balance in Li serum concentration
Dehydration inc Na reab as does low Na –> both inc Li reab so inc Li levels
Hyponatremia and dehydration lead to Li toxicity
CI for Li
Renal dysfunction
Pregnancy- Cat D- Ebstein’s anomaly
cardiac dysfunction
Anticonvulsants used in the tx of Bipolar disorder
Valproate
Carbamazepine/ Oxcarbazepine
Lamotrigine
Valproate MOA
enhances GABA to break acute mania and manage mixed mania
Also affects Na channels
Indications for Valproate
Superior to Li in mixed mania and rapid cyclers
alternative to Li
AE for Valproate
weight gain PCOD hepatotoxicity neutropenia thrombocytopenia
CI for Valproate
pregnancy- causes neural tube defects and lowers IQ
What baseline tests should be done before giving someone Li
CBC- b/c may cause thrombocytopenia SCr and BUN to monitor renal function Thyroid function test- may cause hypothyroid Urinalysis- may cause polyuria Electrolytes
What blood tests should be monitored while taking Li
Li levels
CBC
SCr/ BUN
urine TSH
what stage of bipolar disorder are higher therapeutic levels of Li required
during acute mania
remember Li has a narrow therapeutic index
Carbamazepine/Oxcarbazepine- indications
when Li and Valproate fail
Lamotrigine MO
blocks voltage gated Na channels to block excitatory glutamate and aspartate
How long does it take to achieve a therapeutic dose
2 months of titrating up
Why does it take so long to titrate to a therapeutic dose
AE include Steven’s johnson syndrome (toxic necrotizing epidermolysis) and HA. Titrate up to avoid the rash
What is the black box warning on Lamotrigine
Steven’s Johnson syndrome
what effect does valproate have on Lamotrigine levels
Valproate inc Lamotrigine levels
Lamotrigine indications
used with Li b/c better at managing the depression but is not effective for stabilizing or preventing mania
What drugs are used to treat acute agitations
atypical antipsychotics
BZD- clonazepam, lorazepam
Antidepressants- SSRIs, venlafaxine, buproprion
What is the role of atypical antipsychotics in bipolar disorder
fast acting monotx to be used with Li or valproate
the pt may have to be on these long term for mood stabilization
indicated over BZDs in psychosis and acute mania
what is the role of BZDs in tx bipolar disorder
used to dec agitation and insomnia- they do not tx the dz
What is role of antidepressants in tx of bipolar disorder
use cautiosly and make sure use with a mood stabilizer otherwise it can throw them into mania.
careful with pts with a history of going into acute mania or rapid cyclers when given an antidepressant
what is the theory explains why anticonvulsants work
Kindling theory
DOC for depression phase of bipolar disorder
Li and Lamotrigine
DOC for mixed and rapid cyclers
Valproate and Carbamazepine
DOC for pregnancy in bipolar disorder
Antipsychotics
ECT
