Bipolar Disorder Flashcards
Conditions that precipitate mania
Stroke Traumatic brain injury Eilepsy HIV/AIDS Systemic Lupus Erythematosus Vitamine B12 deficiency Cushing's disease Sleep deprivation Light exposure Extreme stress Wilson's disease
Medications that precipitate mania
Alcohol Bronchodilators Caffeine Cocaine Stimulants Steroids Tricyclic antidepressants Hallucinogens Dopamine agonists Pseudoephedrine Interferon
Types of Bipolar Disease
Bipolar I Bipolar II Cyclothymia Mixed episodes Rapid-cycling
Bipolar I characterization
Classic type:
Manic and depressive episodes.
Bipolar II characterization
Less severe manic episodes than Bipolar I.
Cyclothymia characterization
Chronic milder form:
Hypomania (less intense) and depression for at least two years.
Mixed Episodes characterization
Mania and depression simultaneously.
Rapid-cycling characterization
Four or more episodes of mania, depression, or both within one year.
Bipolar I Tx
Step 1: - Li, VPA, or SGA - Li or VPA + SGA Step 2: - Alternative first line agent. - Combination of two: Li, VPA, or SGA Step 3: - Combination of two: Li, VPA, SGA, CBZ, FGA, OXC Step 4: - ECT - Adjunctive clozapine - Li + (VPA or CBZ or OXC) + SGA
Mania Tx
Euphoric hypomania/mania or psychotic mania:
- Li, VPA, aripiprazole, quetiapine, risperidone, ziprasidone
Dysphoric or mixed episodes:
- Divalproex (VPA), risperidone, aripiprazole, ziprasidone
Secondary options:
- CBZ
- Olanzapine
Combinations
- Li + VPA, Li + AAP (risperidone, quetiapine, olazapine)
- CBZ or OXC + AP (haldol, perphenazine)
Bipolar II Tx
Step 0: - If on Li, increase dose to > 0.8 mEq/L Step 1: - Anti-manic + LTG - Anti-manic + QTP Step 2: - Alternative first-line agent (Li, VPA, OFC, QTP, LTG) Step 3: - One: Li, LTG, QTP, OFC, VPA, CBZ - QTP + LTG - Add SSRI, BUP, or VEN Step 4: - MOAIs, TCAs, other SGAs, OC, or other combos. - Adjunctive ECt, Adjunctive NAC, Adjunctive T3 (triiodothyronine)
Severe Depression associated with Bipolar Tx
Step 1:
- QTP, LTG, or OFC
Step 2-4:
- Same as Bipolar II
Lithium Indications
Acute mania
Maintenance in BPI
Maintenance in BPII
Lithium serum levels
0.5-1.0 mEq/L
Lithium prophylactic benefits
Better for manic episodes than depression recurrence.
Lithium long term effects
5-fold decrease in suicide risk.
Neuroprotective effects.
Lithium side effects
Cognitive dulling and memory impairments. Tremor, mostly of hands. Weight gain. Edema. Dermatitis. Polyuria (70%) Diabetes Insipidus (12-20%) Hypothyroidism (30%) - breakthrough depression Leukocytosis Pregnancy category D - cardiac malformations, first trimester.
Lithium drug interactions
NSAID's - Increase Li ACEI's - Increase Li Thiazide diuretics Na/Li balance required - low Na causes high Li Haloperidol - Encephalopathy
Lithium toxicity
GI upset, N/V/D, tremor, dystonia, hyperreflexia, ataxia, cardiac dysrhythmias. Neurotoxicity: Confusion, stupor, decreased cognition, and restlessness. Nephrotoxicity - Dialysis when > 4 mEq/L - Nephrogenic diabetes insipidus Hypothyroidism Hypotension Can be caused by hehydration.
Encephalopathy due to Li + Haldol
Symptoms:
- Weakness, fever, tremor, lethargy, fluctuating cognition, delirium, ataxia, rigor in extremities, akinesia.
Valproic Acid side effects
Acute manic patients:
- Sedation, N/V, dizziness.
Maintenance patients:
- Weight gain, reduced platelets and WBC, increased ammonia levels (encephalopathy in toxicity), and alopecia
Lamotrigine notable side effect
Serious skin rashes - Stevens-Johnson Syndrome rash.
- Correlation with fast titration, or combo with VPA
Possible Aseptic Meningitis.
Symbyax (Olanzapine + Fluoxetine) Side effecs
Hypotension
Weight gain
