Bipolar disorder and mood stabilizers Flashcards
Epidemiological statistics
BP1- lifetime prevalence 0.6%, affects both genders equally
BP2- lifetime 0.4%, more common in females than men
Illness characteristics
A. BP1
Mean age diagnosis late 20s
onset teens
1:3 manic:depressive
almost 50% experience recurrence in 2 years
30-60x tike of suicide, especially depression/mixed/rapid cycling
B. BP2
median age onset 29 (later)
risk of suicide as high as BD 1
30% history of suicide attempts
Treatment responsiveness
Age of onset and depressive burden appears to be predictive of future prognosis
Classic BD1 patients likely to respond better to lithium than to other medications. Lithium also protects against suicide
Management of BD
- Assess risk
setting of treatment
clarify diagnosis
look for sx, suicidal/SH attempts, compliance - Investigations
FBC, UEG, CMP, LFTS, ECG, vitamins, syphillis, UDS
bHCG
serum levels
+/- MRI/CT, urine, CXR, EEG - Treatment of acute psychological sx
cease antidepressant
Acute mania- valproate or lithium or olanzapine or risperidone
Benzo +/-
No respose- combine Lithium, AP or valproate
No response- 3 drug combinations/clozapine or above with CBZ oe oxcarb/ECT - Acute depressive sx
optimise
No response - lamotrigine aug with lithium or valproate (caution drug interaction)
Or quetiapine 300-600 (BOLDER 1 and BOLDER 2)
or Olanzapine + fluoxetine
No- add AD/ECT if severe
No- MAOI, TCA,, AP not previously tried, pramiprexole, inositol, stimulants, thyroid - Maintenance- Hypomani/mania
Level 1: frequent. recent or severe= Lithium, if not, Li, Valp, or LTG
Level 2: Alternative olanzapine, aripiprazole
Level 3: CBZ or clozapine
Level 4: Quetiapine, risperidone, ziprasidone
Level 5: typical, OXC, ECT - Maintenance + most recent episode depression
Level 1: severe/recent manic- LTG + antimanic
Level 2: Li
Level 3: antimanic + antiD
Level 4: Val, CBZ, ari, cloz, olan, quet, risp, zipras - Psychological therapies
CBT
IPSRT
Family focussed psychoeducation - Social interventions
Accommodation
financial
relationships
employment
legal interventions- driving, AVO, guardianship during illness, EPOA
Factors increasing the risk of acute relapse in depression
1. Concurrent factors Female Life events/social stress Comorbid medical illness Poor compliance Persistent insomnia Personality Substance use Stress Poor supports Unemployment
2. Depressive features Severity Duration Presence of psychosis Residual sx Treatment resistance
Shared content elements of evidence based psychological interventions
Improve ability to recognise changes in mood and signs of prodromal periods, and to respond
quickly and effectively (via pre-planning) to these prodromal symptoms
Increase knowledge about and acceptance of BD, including acceptance of, and adherence to
medication regimens
Encourage daily monitoring of mood and sleep
Improve interpersonal communication, particularly in the family
Improve significant others’ understanding of BD, including ability to identify and productively
respond to prodromal symptoms
Re-engage with social, familial and occupational roles
Improve stress response and emotion regulation skills, especially around goals and reward
activation
Proactively stabilise sleep/wake and other social rhythms
Identify and critique maladaptive thoughts and beliefs, particularly in relation to the self and the
disorder
Reduce drug or alcohol misuse
When might valproate be more effective
in mixed states
Rapid cycling disorder
> 4 episodes in 12 months
Principles of management of rapid cycling
Exclude non-compliance Organic Co-morbidities Substance use Subclinical hypothyroidism Trial alternate mood stabiliser alone/combination
Important specifiers and subtypes in BD DSM5
- BPAD 1- one manic
- BPAD2- 1 hypomanic + depressive
- Cyclothymic- 2 years hypomanic sx, and depressive sx
- Anxious distress- tense, restless, concentration difficulties= higher risk of suicide, treatment non-response and longer duration of illness
- Short duration hypomanic
- Mixed features
