Bipolar Disorder

Question 1

Conditions that precipitate mania

Answer 1

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

Question 2

Medications that precipitate mania

Answer 2

Alcohol
Bronchodilators
Caffeine
Cocaine
Stimulants
Steroids
Tricyclic antidepressants
Hallucinogens
Dopamine agonists
Pseudoephedrine
Interferon

Question 3

Types of Bipolar Disease

Answer 3

Bipolar I
Bipolar II
Cyclothymia
Mixed episodes
Rapid-cycling

Question 4

Bipolar I characterization

Answer 4

Classic type:

Manic and depressive episodes.

Question 5

Bipolar II characterization

Answer 5

Less severe manic episodes than Bipolar I.

Question 6

Cyclothymia characterization

Answer 6

Chronic milder form:

Hypomania (less intense) and depression for at least two years.

Question 7

Mixed Episodes characterization

Answer 7

Mania and depression simultaneously.

Question 8

Rapid-cycling characterization

Answer 8

Four or more episodes of mania, depression, or both within one year.

Question 9

Bipolar I Tx

Answer 9

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

Question 10

Mania Tx

Answer 10

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)

Question 11

Bipolar II Tx

Answer 11

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)

Question 12

Severe Depression associated with Bipolar Tx

Answer 12

Step 1:
- QTP, LTG, or OFC
Step 2-4:
- Same as Bipolar II

Question 13

Lithium Indications

Answer 13

Acute mania
Maintenance in BPI
Maintenance in BPII

Question 14

Lithium serum levels

Answer 14

0.5-1.0 mEq/L

Question 15

Lithium prophylactic benefits

Answer 15

Better for manic episodes than depression recurrence.

Question 16

Lithium long term effects

Answer 16

5-fold decrease in suicide risk.

Neuroprotective effects.

Question 17

Lithium side effects

Answer 17

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.

Question 18

Lithium drug interactions

Answer 18

NSAID's - Increase Li
ACEI's - Increase Li
Thiazide diuretics
Na/Li balance required - low Na causes high Li
Haloperidol - Encephalopathy

Question 19

Lithium toxicity

Answer 19

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.

Question 20

Encephalopathy due to Li + Haldol

Answer 20

Symptoms:

- Weakness, fever, tremor, lethargy, fluctuating cognition, delirium, ataxia, rigor in extremities, akinesia.

Question 21

Valproic Acid side effects

Answer 21

Acute manic patients:
- Sedation, N/V, dizziness.
Maintenance patients:
- Weight gain, reduced platelets and WBC, increased ammonia levels (encephalopathy in toxicity), and alopecia

Question 22

Lamotrigine notable side effect

Answer 22

Serious skin rashes - Stevens-Johnson Syndrome rash.
- Correlation with fast titration, or combo with VPA
Possible Aseptic Meningitis.

Question 23

Symbyax (Olanzapine + Fluoxetine) Side effecs

Answer 23

Hypotension

Weight gain