Bipolar Disorder Flashcards
Bipolar Disorder, definition
Cyclical disorder characterized by fluctuations in mood, energy, and activity
Bipolar 1
Any manic episodes, or mixed episodes + major depressive disorder
Often precipitated from substance abuse. Watch out for antidepressant use (can be diagnostic if manic episodes emerge during antidepressant treatment - medication OR ECT)
Bipolar 2
Recurrent major depressive episodes, with at least one hypomanic episode
NOT precipitated from substance abuse
Definition of mania
AKA manic: includes symptoms of psychosis, hallucinations, delusions
Definition of hypomania
Less-severe mood elevation
Is mania or hypomania more likely to require hospitalization?
Mania
What is Cyclothymic Disorder?
Constant fluctuations between hypomania and depression (not clinically major depressive disorder)
Can worsening manic symptoms emerging from antidepressant treatment be diagnostic for bipolar 1 or bipolar 2?
Bipolar 1 only! Antidepressant treatment via medications or ECT can worsen symptoms of mania*. Mania only occurs in Bipolar 1, therefore this phenomenon can only be diagnostic for bipolar 1.
Side note: if a full hypomanic episode emerges during antidepressant treatment, this is sufficient diagnostic evidence for bipolar 2.
A random patient MA is refusing to eat and in a catatonic state (immobile, lack of movement). What is the best treatment for this patient?
ECT! Electrical conduction alterations over the course of several treatments for this patient population has proven more helpful than medication alone.
Definition of mixed symptoms
Meets criteria for both major depressive episodes and manic episodes changing everyday for 1 week
What is rapid cycling?
More than 4 polar episodes (manic, hypomanic, depressive, or mixed) within 1 year. May require hospitalization
What are the four domains of bipolar disorders?
- Manic or hypomanic behavior (euphoria, grandiosity, excessive libido, recklessness)
- Psychosis (delusions, hallucinations)
- Dysphoria (depression, anxiety, irritability, suicide)
- Cognition (racing thoughts, distractibility)
Psychiatric co-morbid conditions to bipolar disorder
Personality disorders Alcohol or substance abuse Anxiety and panic disorders ADHD OCD Social phobias Eating disorders
Medical co-morbid conditions to bipolar disorder
Migraine MS Cushing's Brain tumor Head trauma
General first-line treatment combination for bipolar disorders
Antipsychotic + mood stabilizer
FDA-labeled indication for lithium
Acute*** and maintenance treatment of mania
How do we monitor efficacy of lithium?
Trough concentration.
- 0.6-1.2 mEq/L for acute mania episodes
- 0.6-1.0 mEq/L for maintenance
At what trough concentration can people experience lithium toxicity? What are the symptoms?
> 1.5 mEq/L, more likely as it approaches >2.5 mEq/L
Symptoms: severe vomiting and diarrhea, tremor, ataxia, seizures, cardiac arrhythmias, coma, kidney damage
Treatment for lithium toxicity
Discontinue lithium, IV hydration, osmotic diuresis or hemodialysis
Keep watching and monitoring! Lithium can take even longer to leave CNS than the serum concentrations show.
Main adverse effect to lithium? How do we treat it?
What other common adverse effects are common with lithium?
Polyuria, treat with HCTZ (paradoxical effect)
Other common effects include GI upset, tremor, hypothyroidism, glucose dysfunction, weight gain
Most common drug interactions to lithium
Increase [lithium] - thiazides, NSAIDs, ACEis, Loops
Decrease [lithium] - caffeine
Valproic acid and divalproex indication
Acute treatment of mania only. Particularly useful for patients with rapid-cycling, mixed mood, substance abuse
Maintenance treatment is off label. Along with migraine prophylaxis
What is the goal serum concentration for divalproex?
50-125 mcg/mL
What black box warnings are associated with both valproic acid and divalproex?
Hepatitis, pancreatitis, mitochondrial disease
What are the most common drug interactions with valproic acid and divalproex?
Lamotrigine and antidepressants
Side effects for valproic acid and divalproex
GI, tremor, weight gain, thrombocytopenia, drowsiness
Carbamazepine FDA indication
Acute treatment of mania not first line due to tolerability and drug interactions
Off-label: maintenance treatment, neuropathic pain.
Carbamazepine drug interactions
know these
Anticonvulsants Antidepressants Antipsychotics Oral Contraceptives Antiretroviral drugs Benzodiazepines Macrolide antibiotics Azole antifungals Grapefruit juice
What does it mean that carbamazepine is an auto-inducer and why is that important?
An autoinducer means that carbamazepine is both a substrate and inducer for several CYP enzymes. After prolonged use, the half life of carbamazepine can actually decrease, requiring higher concentrations
What is the benefit to using oxcarbazepine compared to carbamazepine?
There are fewer drug-drug interactions, however it causes more GI side effects and increases the risk of hyponatremia.
What is the goal serum concentration for carbamazepine
4-12 mcg/mL
What is the role of benzodiazepines in treatment of bipolar disorders?
Used to stabilize patients during acute manic episodes. Usually PRN dosing inpatient management- not home use
What is lamotrigine, how is it dosed, and how is it used for bipolar treatment?
Mood stabilizing drug. Can cause SJS, so slowly titrate the dose up. So it makes sense that this medication should only be used for maintenance treatment.
What to do if patient is on divalproex and lamotrigine was started without catching the interaction?
Decrease the lamotrigine dose by 50%
What is the role of Second Generation Antipsychotics in the treatment of bipolar disorders?
SGA’s are first line treatment and should be used even if there are not any current psychotic symptoms
Remember: antipsychotics + mood stabilizers = 1st line
Which SGA’s are best for mania?
Remember, the ZA crazy Queen ORCA
Z - ziprasidone
A - aripiprazole
crazy = mania
Q - quetiapine
O - olanzapine
R - risperidone
C - cariprazine
A - asenapine
Which SGA’s are best for depression?
Quetiapine
Olanzapine+fluoxetine
Lurasidone
What is the role of antidepressants in treatment of bipolar disorders?
Use not recommended - can precipitate either mania or hypomania (remember potential use in diagnosing of the disorder).
Use should be reserved as a list ditch effort with a mood stabilizer
How does treatment change in pediatric populations?
Lithium can be used 12 years and up. Maybe carbamazepine and divalproex
Aripiprazole, asenaprine, risperidone, olanzapine, quetiapine can be used 10 years and older
More sensitive to adverse effects, start with low dosages and titrate up
How does treatment change in geriatric populations?
Shoot for lower serum concentrations
Lithium = 0.4/1 mEq/L
Carbamazepine = 4=12 mcg/mL
Valproic acid = 25-100 mcg/mL
How does treatment change in pregnancy and postpartum populations?
Although there is teratogenic risk, the risk of bipolar relapse is more harmful for the pregnancy. Generally recommendedd to NOT discontinue despite teratogenic properties.
Can consider First Generation Antipsychotics because they have less teratogenicity, but there is not as much evidence for use in bipolar disorders.
Acute treatment of manic episode
1st line = Lithium or VPA/DVP + SGA (ZA crazy Queen ORCA)
- Can’t use combination? Make sure suicidal patients receive lithium, psychotic patients receive SGA.
- Optimize treatment before augmenting
Alternative 1st line = Olanzapine, carbamazepine, or oxcarbazepine
2nd line = Consider adding another mood stabilizer
Acute treatment of depressive episode
1st line = monotherapy lithium, quetiapine, lurasidone, or lamotrigine
- if suicidal, use lithium
Alternative 1st line = olanzapine/fluoxetine, valproic acid, divalproex, or carbamazepine
2nd line = Add a mood stabilizer
Maintenance treatment of bipolar disorder
After stabilization for 4-6 months, simplify regimen by lowering doses/serum level goals.
Taper off medications until using one agent if at low risk of relapse.
