Bipolar disorder and mania

Question 1

What are the symptoms of bipolar disorder and mania?

Answer 1

Mania
- High energy
- Overly ambitious plans
- Risky, harmful acts
- Easily distracted
- Hallucinations, delusions
Depression: low mood

Question 2

What is the treatment for bipolar disorder and mania?

Answer 2

Acute episodes + maintenance
- Lithium
- Valproate
- Antipsychotics (Quetiapine, Risperidone (for acute only), Olanzapine)
Antidepressants CI in acute manic episodes - elevates mood, worsening mania

Question 3

What is the indication for lithium?

Answer 3

prescribe by BRAND
- Bipolar disorder
- Recurrent depression
- Aggressive + self harm

Question 4

What is the target therapeutic index of lithium?

Answer 4

0.4-1MMOL
- 12H after dose
- Regular monitoring: 3-6M

Question 5

What are the signs of lithium toxicity?

Answer 5

GREEN
GI effect: V + D
Renal: polyuria, hypernatremia
Eyes: blurred vision
Extrapyramidal symptoms (tremor)
Nervous system (confusion, drowsy)
- Counselling: report signs of lithium toxicity
- Counselling: adequate fluids, avoid diet changes that affect sodium

Question 6

What increases the risk of lithium toxicity?

Answer 6

Hyponatraemia
Renal impairment
Low fluid intake
- Caution: concomitant diuretics, intercurrent illness
- CI: low sodium diet, dehydration
- Monitor: electrolytes

Question 7

What are the side effects of lithium?

Answer 7

Hypothyroidism
- Monitor: TFT
- CI: untreated hypothyroidism
- Counselling: Report signs of hypothyroidism (Weight gain, cold intolerance)
Nephrotoxicity
- Monitor: RFT
- Counsel: Report renal dysfunction (Polyuria, polydipsia)
QT prolongation
- Monitor: cardiac function, ECG if CVD/risk factor
- Caution: cardiac disease, QT prolongation
Benign intracranial hypertension
- Counsel: Report persistent headaches + visual disturbances
Lower seizure threshold
- Monitor: epilepsy

Question 8

Can you take lithium when pregnant?

Answer 8

Teratogenic
- Child bearing women: effective contraception
Also present in breast milk + cause toxicity in infant

Question 9

What are the interactions of lithium?

Answer 9

• Diuretics (Hyponatraemia) → INC lithium levels = toxicity
• Nephrotoxic drugs (RED renal excretion) → INC lithium levels = toxicity
• Effervescent analgesics (paracetamol, sodium containing antacids) → RED lithium levels = therapeutic failure
• Serotonergic drugs (Antidepressants, methadone, tramadol, St John’s Wort, sumatriptan) → Serotonin syndrome
• Drugs that prolong QT interval (Antipsychotics, citalopram + escitalopram, macrolides, methadone) → arrhythmias
• Drugs that cause hypokalaemia → INC risk of torsade de pointes
• Antipsychotics, TCA antidepressant → INC neurotoxicity