Bipolar Disorder Flashcards
What are the diagnostic criteria for BP?
Diagnostic criteria
Bipolar disorder
ICD-10: ≥2 episodes of depression or mania, lasting ≥2 weeks, several months apart, one of which must be mania or hypomania.
DSM-5: bipolar 1 disorder is ≥1 manic (or mixed) episode (± depressive episode), with mania often predominant, and bipolar 2 disorder is a hypomanic episode plus a major depressive episode, with depression often predominant.
Can be mania only (15% of patients).
Rapid cycling bipolar disorder: 4 affective episodes in one year.
Cyclothymia
A milder form of bipolar disorder with persistent instability of mood, involving numerous periods of mild depression and elation.
At what age does BP commonly occur and what is the lifetime risk?
Onset is usually in teens and 20s.
1/70 lifetime risk.
What are the signs and symptoms of BP?
Mania
≥7 days of:
Elevated energy or activity: grandiosity, extravagance, rapid speech, pressure of speech, ↑libido, ↓sleep.
Elevated or unstable mood: euphoria, irritability, lability.
Thought disorder: flight of ideas, poor concentration, confusion.
Psychosis: grandiose delusions and ↓insight. Hallucinations also seen in 15% of patients.
Hypomania
Milder form, with no psychosis and little functional impairment.
Often consists of mild mood elevation, increased activity, flight of ideas, and reduced sleep.
Mixed affective episode
Mania and depression, which may rapidly alternate.
DSM-5 uses the term ‘with mixed features’ when depressive symptoms co-occur with a manic episode.
What are the risk factors for developing BP?
Family history.
Stressful life events.
Which differentials other than BP should be considered?
DDx: Mania Bipolar disorder. Schizoaffective disorder. Unlike in bipolar, the mania will improve quickly with treatment, while the psychotic features may remain. Organic: delirium, dementia, hyperthyroidism, encephalitis. Get CT head in elderly patients presenting with first episode of mania. Drug use: amphetamines, cocaine, antidepressants (especially venlafaxine), steroids, levodopa. DDx: Unstable mood Bipolar disorder. Cyclothymia Borderline personality disorder. Schizoaffective disorder. Psychotic depression. ADHD
Which investigations are useful in BP?
Rating scales:
Mood Disorders Questionnaire (MDQ).
Young Mania Rating Scale (YMRS).
Investigate organic causes or co-morbidities based on clinical judgement:
Bloods: FBC, TFT, CRP. Also glucose, lipids, U+E, Ca2+, and LFT, more for the treatments you may start.
Drug screen, usually urinary.
Neurological: head CT or MRI, EEG.
Which biological management strategies are used in bipolar disorder?
Overview:
Treatment should begin in secondary care, but stable patients can be discharged to primary care.
Management plans should be developed in consultation with patients and carers, especially around steps to take in an acute episode.
Biological
Acute mania or hypomania:
1st line: oral antipsychotic – quetiapine, olanzapine, haloperidol, or risperidone. If one is ineffective, switch to another.
2nd line: add lithium, or valproate if ineffective.
If they are already taking lithium, check the levels and increase if necessary. If they are taking an antidepressant, stop it.
Benzodiazepines – e.g. PO clonazepam – may be added, especially if there is insomnia or agitation.
Acute, moderate to severe bipolar depression:
1st line: fluoxetine plus olanzapine, or quetiapine monotherapy.
2nd line: lamotrigine.
If they are already taking lithium, check the levels and increase if necessary.
Avoid long-term anti-depressants, but if considered necessary, do not give without a mood stabiliser.
Mild depression may not require any specific treatment, except regular monitoring.
Long-term maintenance:
1st line: lithium. Patients who started an antipsychotic or antidepressant during acute illness should switch to lithium, usually within 4 weeks.
2nd line: lithium plus valproate. Alternatively, consider valproate, olanzapine, or quetiapine monotherapy, especially if they were effective in acute mania. Do not offer valproate to women of childbearing age.
Other options: lamotrigine, especially if depression predominates, or carbamazepine.
Continue treatment for at least 2 years, and possibly much longer.
Which psychological management strategies are used in bipolar disorder?
Psychoeducation for patients and families has been shown to improve symptoms and reduce relapses. This includes information about getting help in a crisis.
Psychological therapies specific for bipolar disorder usually focus on self-monitoring thoughts and behaviours, relapse triggers, and crisis management. Can be individual, group, or family based.
Alternatively, high-intensity psychological intervention for depression: CBT, IPT, or behavioural couples therapy.
Which social management strategies are used in bipolar disorder?
Help with financial, work, and education problems that result from the illness. This can involve, with the patient’s consent, direct contact with the relevant organisations.
Encourage smoking cessation and healthy lifestyle, as patients with bipolar are at increased risk of lifestyle-related diseases. NICE also recommends annual BP, lipids, glucose, and HbA1c for this reason.
Assess the needs of carers and provide support.
Which complications can occur in bipolar disorder and how does the prognosis look?
Recurrence: 50% in 1 year and 70% within 4 years.
Tendency for time gap between episodes to narrow with age.
High risk of death from suicide during depressive episodes.
Psychosocial impacts: increased rate of divorce, job loss, financial harm from over-spending.
How does lithium work? Which side effects can occur? How should monitoring be carried out- what can affect renal function and increase lithium levels?
Mechanism
Unclear, but hypotheses include that it stabilises glutamate levels in the synaptic cleft by acting on glutamate receptors.
Side effects
GI and GU:
Most commonly nausea and abdominal pain. Diarrhoea, vomiting, and constipation also occur.
Polydipsia and polyuria affects 30%. Nephrogenic diabetes insipidus occurs in 10%.
↑Weight
Dry mouth and/or metallic taste in mouth initially.
Neurological:
Fine tremor Sedation Impaired memory and concentration. Headache Skin:
Alopecia
Acne
Metabolic:
Hypothyroidism
↑PTH and ↑Ca2+.
Toxicity:
Diarrhoea and vomiting. Advise patients to seek medical help if these develop.
Weakness, drowsiness, coarse tremor, ataxia, and hyperreflexia.
If severe, renal failure and coma.
May be triggered by MR BAD: Metronidazole, Renal failure, Bendroflumethiazide, ACEi, Dehydration.
If it occurs, stop lithium and provide supportive care.
Interactions
The following can impair renal function and increase lithium levels:
CV: ACEi, thiazides.
NSAIDs: avoid if possible. If using, take regularly (not PRN), and monitor lithium closely.
Contraindications
Severe kidney or heart disease.
Addison’s
Avoid if possible in pregnancy, especially first trimester, due to risk of teratogenicity including Ebstein’s anomaly (tricuspid valve malformation). Ideally, should also be avoided in the rest of pregnancy and breastfeeding.
Caution in those with thyroid disease.
Monitoring
Has a narrow therapeutic index, so careful titration and monitoring is needed. Prescribe by brand name to ensure correct dose.
Check serum levels weekly until stable, then every 3 months. Measured 12 hrs after dose. Aim for 0.4-1.0 mmol/L. After first year, 6-monthly monitoring can be done.
Check U&E, TFT, and weight at baseline and every 6 months.
Check Ca2+ at baseline and annually.
Key advice for patients: signs of toxicity, avoid NSAIDs, and notify doctor if pregnant.
If stopping, do it gradually over 3 months.
