Bipolar Disorder and Mania

Question 1

What does the treatment of bipolar disorder and mania usually consist of?

Answer 1

The control of acute attacks and the long-term treatment of the disorder.

Question 2

For how long does the long-term treatment of bipolar disorder occur for?

Answer 2

At least two years from the last manic episode or up to five years if the patient has risk factors for relapse.

Question 3

Use of which drugs may be helpful in the initial management of agitation in bipolar disorder?

Answer 3

Benzodiazepines however long-term use is not recommended due to risk of dependence.

Question 4

Which drugs can be used to treat acute episodes of mania or hypomania?

Answer 4

Atypical antipsychotic drugs (olanzapine, quetiapine, risperidone), lithium or valproate as alternatives. Carbamazepine can be used in patients who do not respond to lithium.

Question 5

What is the therapeutic range for lithium?

Answer 5

0.4 to 1 mmol/L (0.8 to 1 mmol/L for acute episodes of mania and relapse patients).

Question 6

What warning signs associated with lithium use are a cause for referral and further investigation?

Answer 6

Toxicity, increasing GI disturbances, visual disturbances, CNS disturbances, fine tremor increasing to course tremor, muscle weakness, signs and symptoms of hypothyroidism, signs and symptoms of renal dysfunction, signs and symptoms of benign intracranial hypertension.

Question 7

What serum concentration of lithium is associated with lithium toxicity?

Answer 7

Over 2 mmol/L.

Question 8

What are the symptoms of lithium toxicity?

Answer 8

Seizures, coma, renal failure, arrhythmias, blood pressure changes, circulatory failure, death.

Question 9

What gastrointestinal disturbances are occasionally seen with lithium use?

Answer 9

Vomiting and diarrhoea.

Question 10

What visual disturbances are occasionally seen with lithium use?

Answer 10

Blurred vision.

Question 11

What CNS disturbances are occasionally seen with lithium use?

Answer 11

Drowsiness, unsteadiness, confusion.

Question 12

What are the signs and symptoms of hypothyroidism, occasionally seen with lithium use?

Answer 12

Unexplained fatigue, weight gain, hair loss.

Question 13

What are the signs and symptoms of renal dysfunction, occasionally seen with lithium use?

Answer 13

Polyuria and polydipsia.

Question 14

What are the signs and symptoms of benign intracranial hypertension, occasionally seen with lithium use?

Answer 14

Persistent headache and visual disturbances.

Question 15

When a patient is taking lithium, when should their serum lithium levels be assessed?

Answer 15

Weekly, then every three months once the dose becomes stable.

Question 16

When a patient is taking lithium, when should their renal function be assessed?

Answer 16

Every 6 months.

Question 17

When a patient is taking lithium, when should their cardiac function be assessed?

Answer 17

Every 6 months.

Question 18

When a patient is taking lithium, when should their thyroid function be assessed?

Answer 18

Every 6 months.

Question 19

Is it possible for lithium to have an effect on one’s ability to drive or perform skilled tasks?

Answer 19

Yes

Question 20

There is an increased risk of toxicity when lithium is used with which other drugs?

Answer 20

ACE inhibitors, angiotensin-2 receptor antagonists, loop diuretics, thiazides and related diuretics, NSAIDSs, potassium-sparing diuretics, aldosterone antagonists, metronidazole, SSRIs, tricyclics.

Question 21

There is an increased risk of ventricular arrhythmias when lithium is used with which other drug?

Answer 21

Amiodarone.

Question 22

There is an increased risk of neurotoxicity when lithium is used with which other drugs?

Answer 22

Methyldopa, phenytoin, carbamazepine, diltiazem, verapamil.

Question 23

There is an increased risk of extrapyramidal side effects when lithium is used with which other drugs?

Answer 23

Clozapine, haloperidol, sulpiride, phenothiazines, risperidone, flupentixol, zuclopenthixol.

Question 24

What conditions have been associated with long term lithium use?

Answer 24

Thyroid disorders and mild cognitive and memory impairment.

Question 25

Do carbonate and citrate salts of lithium have the same or different dose equivalents?

Answer 25

Different.

Question 26

What precaution is required when changing a patient from one preparation of lithium to another?

Answer 26

The same as initiation, close monitoring of serum lithium levels weekly until stabilisation.

Question 27

Should patients on lithium be maintained on the same brand?

Answer 27

Yes.

Question 28

What should be given to patients upon initiation with lithium?

Answer 28

A lithium treatment pack.

Question 29

Depletion of which electrolyte can worsen the effects of lithium toxicity? How should this be managed?

Answer 29

Sodium. Adequate salt and water intake should be maintained, especially during illness or hot weather.