Bipolar Disorder

Question 1

What is a manic episode?

Answer 1

Distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting AT LEAST 1 WEEK.

*Duration doesn’t matter is hospitalization is necessary

Question 2

To call it a Manic episode you must have how many of the characteristics and for how long…

Answer 2

Must have 3 of the characteristics
4 if the mood is irritable
A week long

Question 3

Criteria for Manic Episode…

Answer 3

• Inflated Self esteem and gradiosity
• Decreased need for sleep
• More talkative
• Racing thoughts
• Distractibility
• Increased goal directed activity
• Excessive involvement in activities with potential for high painful consequences

Question 4

HYPOmania Episodes…

Answer 4

Period of abnormal mood similar to manic (dx criteria same), but lasts 4 days and is not sever enough to:

• CAUSE MARKED IMPAIRMENT IN SOCIAL OR OCCUPATIONAL FUNCTIONING
• CAUSE HOSPITALIZATION

Question 5

To call it a Major Depressive Episode you must have what….

Answer 5

5 of the criteria during the same 2 week period with one of the symptoms being:

• Depressed Mood
• Loss of Interest

Question 6

Major Depressive Episode Criteria….

Answer 6

• Depressed Mood
• Diminished interest/pleasure
• Weight loss or gain
• Insomnia or LOTS OF SLEEP
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Worthlessness or guilt
• Cant concentrate
• Thoughts of death

Question 7

Bipolar ONE Disorder Criteria….

Answer 7

Have ONE Manic Episode

But current/Most recent episode can be manic/hypomanic/depressed/Unspecified

Question 8

Rapid cycling…

Answer 8

AT LEAST 4 episodes in 12 months

Question 9

Bipolar TWO Disorder Criteria…

Answer 9

History or Presence of:
-One or more Major Depressive Episodes
-At least one Hypomanic Episodes
NOOOOOOO MANIC EPISODES*

Question 10

Cyclothymic Disorder Criteria…

Answer 10

FOR AT LEAST TWO YEARS

• Hypomania symptoms without meeting criteria for an actual episode
• Depressive symptoms without meeting criteria for an actual episode

During the 2 years, pt not without symptoms for 2months at a time*

Question 11

Manic Episode: Pt has never been treated before and is SEVERELY episodic right now, whats treatment look like?

Answer 11

Lithium or Valproate
IN COMBO WITH
Antipsychotic (Olanzapine, SGAs)

Question 12

Manic Episode: Pt has never been treated before and is having an episode right now, whats treatment look like?

Answer 12

Since not SEVERE:

Monotherapy–>Lithium, Valproate, Antipsychotic (Olanzapine)

Short Term Adjunct Benzo–>Lorazepam

Alternates: Carbamazepine and Oxcarbazepine in lieu of Lithium or Valproate or other SGA

Question 13

If Manic Episode has mixed features what is best? Lithium or Valproate?

Answer 13

Valproate

Question 14

Best Benzo to treat Catatonia

Answer 14

Lorazepam

Question 15

Manic Episode: Symptoms are inadequately controlled after 10-14 days of treatment with optimized doses of first line meds what are your options?

Answer 15

• Add another 1st line med
• Add Carbamazepine Oxcarbazepine
• Add an Antipsychotic if one not already
• Switch Antipsychotic is already on one

Question 16

SGA that is particularly helpful in Refractory manic epis

Answer 16

Clozapine

Question 17

Indication for severe treatment resistant mania

Answer 17

ECT

Question 18

Acute Depression: Patient has never received treatment what is the possible treatment?

Answer 18

• Lithium or Lamotrigine

- Quetiapine and Lurasidone –>Monotherapy

Question 19

ECT is considered for….

Answer 19

Life-threatening inanition, suicidality, or severe depression, tx resistant depression or catatonic features

Question 20

Acute Depression: Pt has breakthrough depressive episode on the maintenance treatment, what do you do?

Answer 20

• Optimize the medication dose

- Make sure serum levels are within range, may need to increase dosing to get to the higher levels of that range

Question 21

Acute Depression: Pt fails to respons to optimized maintenance treatment, what are options?

Answer 21

• Add an antipsychotic
• Add Lamotrigine
• Adjuct Antidepressant: Bupropion or Paroxetine

Question 22

For ACUTE TX of Depression, when should you initiate antidepressants?

Answer 22

ONLY as adjunct if previous positive response to antidepressants

Question 23

When should you avoid giving an antidepressant?

Answer 23

RAPID CYCLING

Also if “mixed features”

Question 24

For MAINTENANCE TX of Depression, when should antidepressants be considered?

Answer 24

If patient relapses into a depressive episode after stopping antidepressant therapy

Question 25

Lithium MOA ADR

Answer 25

-Alters sodium transport, Alters met of neurotransmitters including catecholamines and serotonin

ADRs: Tremor, Polyuria/polydipsia, Wt gain, Renal impairment, Thyroid Probs, Cognitive slowing, Sedation
PREGNANCY-EPSTEINS ANOMALY*

Question 26

DDI: Lithium and Diuretics

Answer 26

Diuretics will increase lithium levels

Question 27

DDI of Lithium and Neuromuscular blockers

Answer 27

Respiratory Depression

Question 28

DDI: Lithium and ACE

Answer 28

Increase lithium levels

Question 29

DDI: Lithium and NSAIDs

Answer 29

Increase Lithium level

Question 30

DDI: Lithium and Theophylline

Answer 30

Decrease Lithium

Question 31

Diseases in which you should not give Lithium

Answer 31

Nephrogenic Diabetes insipidus

Interstitial Nephritis

Question 32

Starting Dose for Lithium, and lithium goal plasma levels

Answer 32

Start 300mg 2-3x day

Plasma: 0.6-1.2 mEq/L

Question 33

Valproate ADRs

Answer 33

Wt gain
Increased Liver enzymes
Polycystic Ovaries
Hep/Pancreatitis

CAUSE NEURAL TUB DEFECT IN PREGGO

Question 34

Valproate serum levels increased by

Answer 34

Erythromycin
Fluoxetine
Aspirin
Ibuprofen

Question 35

Valproate Serum Levels decreased by

Answer 35

Carbamazepine

Phenobartbital

Question 36

Valproate Dosage forms

Answer 36

IR: 15mg/kg/day divided dose
ER: 25mg/kg/day

Question 37

Valproate Serum conc goals

Answer 37

50-100ug/mL

Question 38

When should you draw trough levels of Valproate

Answer 38

Just before scheduled IR divided doses

18-24 hours after the single daily ER dose

Question 39

Carbamazepine ADRs

Answer 39

Ataxia
Nausea
Dizzines

BAD FOR PREGGO
Craniogacial defects, fingernail hypoplasia, developmental delay