Bipolar Disorder Flashcards
According to ICD-10:
How many episodes of depression or mania/hypomania is needed?
How long should it last for?
How much time between episodes?
What is the commonest age of onset?
2 or more episodes
> 2 wks
Several months apart
Teens and 20’s
What does rapid cycling BD mean?
What is cyclothymia?
What is dysthymia?
4 affective episodes in one yr
A milder form of BD with persistent instability of mood, involving numerous periods of mild depression and elation.
Chronic depression basically
What is the difference between BD Type 1 and BD Type 2
The main difference between bipolar 1 and bipolar 2 disorders lies in the severity of the manic episodes caused by each type.
A person with bipolar 1 will experience a full manic episode, while a person with bipolar 2 will experience only a hypomanic episode (a period that’s less severe than a full manic episode).
Hypomania - ICD-10:
How long should symptoms last for?
How do you know it is hypomania?
What 2 things are definitely absent from hypomania?
4+ days
Behaviour is definitely abnormal for individual
Psychosis and little functional impairment
Remember, PSYCHOSIS can occur with mania
Hypomania - ICD-10:
List criteria where you’d pick 3 or more to diagnose?:
- Cognition - 1
- Behaviour - 7
Increased activity/physical restlessness
Increased talkativeness
Less sleep
Hypersexuality
Mild spending sprees/other types of
reckless/irresponsible behaviour
Increased sociability
Overfamiliarity
Mania - ICD-10:
What else can come with mania?
Main symptom
How long does this have to last for it to be classed as full blown mania?
Mania with/without psychosis
Elevated/irritable mood
(at least 1 wk)
Mania - ICD-10:
List criteria where you’d pick 3 or more to diagnose?:
- What 3 moods can they present with?
- Cognition - 5
- Behaviour - 5
- Psychotic symptoms - 2
Irritability Euphoria Lability - rapid, often exaggerated changes in mood, where strong emotions or feelings ------- Grandiosity Distractibility/poor concentration Flight of ideas/racing thoughts Confusion Lack of insight ------- Rapid speech Hyperactivity Less sleep Hypersexuality - Increased libido Reckless behaviour (e.g. spending, sex) --------- Delusions Hallucinations
What does mixed affective episode mean?
Mania and depression which may rapidly alternate
Aetiology:
Biological:
- The main one
- Which meds can cause it? - 2
- What illicit drugs can cause it? - 2
What are some organic causes:
- old age - 2
- thyroid - 1
- brain - 1
What should be done first to in the elderly with sudden onset mania?
Genetics - FH
Anti-depressants
Steroids
Amphetamines
Cocaine
Delirium
Dementia
Hyperthyroidism
Encephalitis
CT scan
Aetiology:
Psychological:
Emotional deprivation and childhood abuse
Certain personality types and belief systems
Aetiology:
Social
Lower social class Unemployed Poor social support Shift work/sleep disruption Alcohol/substance misuse ****** Living in urban areas Lack of relationships Adverse life events especially bereavement
DDx of mania:
Schizoaffective disorder - what is it?
What other disease may cause unstable mood especially in children?
Schizoaffective disorder is a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.
The mania will improve with Rx however, the psychotic symptoms will remain
ADHD - Attention deficit hyperactivity disorder (ADHD) is a behavioural disorder that includes symptoms such as inattentiveness, hyperactivity and impulsiveness.
Investigations:
The MDQ and YMRS are self-reported scales. What do they stand for?
What 2 other self-reported scales are used for depression if they present that way? ////////////
HAMD, MADRS and QIDS-C are used by the doc to assess severity. What do they stand for?
Mood disorders questionnaire
Young mania rating scale
Beck scale QIDS-SR - Quick Inventory of Depressive Symptomatology (QIDS) ///////// Hamilton Depression Rating Scale Montgomery and Asberg Scale
Quick Inventory of Depressive Symptomatology, including the Clinician-Rated
Investigations for organic causes or co-morbidities:
Bloods and why?
How to test for illicit drugs?
How to test neurologically? - 3
FBC - raised WBC - infection - encephalitis
TFTs - hyperthyroidism
CRP - inflammation - encephalitis
Also glucose, lipids, U+E, calcium and LFTs
Drug screen - urinary
CT head, MRI and EEG
Biological management of acute mania or hypomania:
What should be done if patient is already receiving Rx? - 3
What should be stopped if they are taking it?
Check adherence
Check drug levels and adjust the dose
Taper and stop any antidepressants
////////
Antidepressants as they make it worse
Biological management of acute mania or hypomania:
What is the first line? Give some examples
What can be added as second line? - 2
What can be added short term to help with insomnia or agitation? Give one example
Why should Rx in pregnancy women be done carefully?
Oral antipsychotics - quetiapine, olanzapine, haloperidol, risperidone
Add lithium or valproate
Benzodiazepines - clonazepam
Some drugs can cause teratogenicity such as valproate.
Management of acute mania or hypomania:
Biological - What should be measured initially?
Psychological Rx
Social - what should be considered?
Weight/BMI
Information and advice - psychoeducation
Consider the location of care
Address risks
Role of MHA
Offer support to the family
Biological management of acute, moderate to severe bipolar depression:
First-line - combo of antidepressant + antipsychotic - what are they? - why is it done this way? - (F+O)
First-line - what antipsychotic can be given on its own? - Q
Second-line - What anticonvulsant can be given which reduces the frequency of episodes?
Fluoxetine + olanzapine
Antidepressants shouldn’t be prescribed without an anti-manic Rx
Quetiapine
Lamotrigine - needs to be carefully titrated due to small therapeutic window
Lamotrigine
Long term biological management:
Meds used to prevent mania? - 4
Meds to prevent depression? - 4
Lithium Valproate Olanzapine Quetiapine //////////////////////////// Lithium Quentiapine Lurasidone Lamotrigine
Psychological Rx:
What should be done first?
Psychological therapies are suggested?
What can be done for depression?
Psychoeducation for patient and family - improves symptoms and reduces relapse
Self-monitoring thoughts and behaviours
Relapse triggers
Crisis management
CBT
IPT - Interpersonal Psychotherapy
Behavioural couples therapy
Social Rx:
Who can be contacted in relation to finances, work and education?
What should be encouraged?
People with bipolar disorder have their bP, lipids, glucose and HbA1c checked annually. Why?
What do you also need to provide if they are not able to cope independently anymore?
Direct contact with relevant organisations
Smoking cessation
Healthy lifestyle
Increased risk of lifestyle-related diseases - HTN
Carers and support
Risk Assessment:
They are 15x more likely to commit suicide. When does this tend to happen?
What increases the risk of suicide?
What psychosocial impacts may they have?
Depressive episodes
Previous attempt FH Early-onset BD The extent of depressive symptoms Rapid cycling Abuse of alcohol and drugs
Increased rate of divorce, job loss, financial harm from overspending
Risks to consider for the patient and others:
Overspending Disinhibition (incl. promiscuity) Driving Children Violence Self-neglect Suicide
Lithium:
MOA unknown
Side effects:
- GI - 4
- GU - 2?
- GU - What happens in 10% of patients?
- Weight
- Mouth
- What do you taste initially?
Nausea and vomiting
Abdo pain
D or C
Polydipsia
Polyuria
Nephrogenic diabetes insipidus
Weight gain
Dry mouth
Metallic taste
Lithium:
Side effects:
- Neurological - 4
- Skin - 2
- Metabolic - thyroid, one electrolyte is raised
Fine tremor
Sedation
Impaired memory and concentration
Headache
Alopecia
Acne
Hypothyroidism
Calcium
Lithium Toxicity:
Main symptom
What happens if severe? - 2
What can trigger it?
D&V
Renal failure and coma
Some meds - such as metronidazole, ACEi
Lithium:
Interactions - some drugs may impair renal function and increase lithium levels:
What CV drugs may cause impaired renal function?
What pain med may also cause it?
ACEi, thiazides
NSAIDs
Lithium - Contraindications?
Pregnancy - teratogenic - Epstein’s - tricuspid valve malformation
Thyroid disease
Lithium - Monitoring:
Why is toxicity common and what is needed as a result?
What is monitored?
How often and for how long?
Narrow therapeutic index
Titration and monitoring
Serum levels checked
Weekly until stable
Lithium - Monitoring:
After how long are tests done every 6 months?
What is checked as well every 6 months as a baseline?
What is checked annually?
Key advice given to patient? - 3
How should it be stopped?
1 yr
U+E, TFTs and weight
Calcium levels as it can cause hypercalcaemia
Look out for signs of toxicity
Avoid NSAIDs
Notify doc if pregnant
Gradually as can cause mania in 50% of patients if suddenly discontinued
