Bipolar Disorder: Ott [Do with Depression]

Question 1

What is the way that we defined Bipolar DIsorder?

Answer 1

• cyclical, Life-long disorder with recurrent extreme fluctuation in moods, energy and behavior

Question 2

What are some of the symptoms that related to Bipolar disorder?

Answer 2

• Mood: EUPHORIC, elated, irritable
• Activity: IMPULSIVE, aggressive, sleep issues
• Behavior: CHALLENGING, flamboyant, intrusive
• Cognitive: GRANDIOSITY, delusion, distraction

Question 3

How does the DSM-5 describe Mania?

Answer 3

• A period of abnormally and persistently elevated or irritable mood; lasting 1 week and persent most of the days

Question 4

How do we determine is some has mania?

Answer 4

• Grandiosity, decreased sleep, pressured speech, many ideas, distractions, increase in goals-directed activity, activities at end in poor decisions
• NEED AT LEAST 3 or 4 IF IRRITABLE

Question 5

What are some of the stages of Mania?

Answer 5

• Hypomania: Mild euphoria, expansive speech, reduced sleep
• Mania: Grandiosity, Euphoria, Irritable
• Mania with Psychosis: Hallucinations, Delusions

Question 6

What are the two class for bipolar disorder?

Answer 6

• Bipolar I
• Bipolar II

Question 7

What is Bipolar I Disorder?

Answer 7

• 1 episode of MANIA causing PSYCHOSIS OR DELUSIONS, or REQUIRES HOSPITALIZATION

Question 8

What is Bipolar II Disorder?

Answer 8

• 1 episode of HYPOMANIA [NO affect on social/work functioning & NO hospitalization] and at least 1 depressive episode

Question 9

What are some drugs that can induced Mania?

Answer 9

• Antidepressants [MAOI, TCAs, Reuptake Inhibitors
• Dopamine Agonist
• Hallucinogens
• Steroids
• REALLY ANYTHING THAT AFFECTS SEROTONIN & DOPAMINE LEVELS

Question 10

What are some of the treatment goals for Bipolar Disorder>

Answer 10

• Resolution of Mood Symptoms
• Reduce Side Effects
• Prevention
• Adherence
• Education

Question 11

What are some of the Non-Pharmacologic treatments for Bipolar disorder?

Answer 11

• Education, Psychotherapy, Sleep Hygiene, Stress Reduction, Good Eating, Exercise

Question 12

What are some of the Pharmacolotherapy options for Bipolar Disorder?

Answer 12

• Mood Stabilizers: Lithium, Valproate, carbamazepine, Oxcarbazepine, Lamotrigine, Topiramate
• Antipsychotics: Atypical

Question 13

What is the way that Lithium is used in Treatment of Bipolar Disorder?

Answer 13

• FDA approved fro acute mania and maintenance therapy
• Slow onset

Question 14

What are some important things to note about Lithium?

Answer 14

• DECREASE SUICIDE RISK
• AVOID in patient with CrCl <30
• Reaches steady state after 3 DAYS
• Slow onest [1-2 weeks]

Question 15

What are the levels of Lithium Toxicity?

Answer 15

• 1.5-2 mEq/L [N/V/D, Ataxia, Tremor, Drowsiness]
• 2-2.5 mEq/L [Anorexia, Delirium, N/V]
• > 2.5 mEq/L [Seizures, Renal Failure, Death]

Question 16

What are way that increase Lithium Toxicity and how can we manage it?

Answer 16

• Dehydration [Na & H2O will follow] & Risk of Suicide
• Managed: Hemodialysis

Question 17

What are some of the drug interaction for Lithium?

Answer 17

• INCREASE Li LEVELS: NSAIDs, ACEi/ARBs, Thiazides, Caffeine
• DECREASE Li LEVELS: Osmotic Diuretics, Caffeine
• Caffeine has a sweet spot

Question 18

What are some of side effects for Lithium?

Answer 18

• SHORT TERM: Nausea, Vomiting, Diarrhea, Muscle weakness, Trouble thinking, weight gain
• LONG TERM: Hypothyroidism, Kidney issues [decrease CrCl by 2], Diabetes, Ance, Depression, Tremor

Question 19

What is Ebstein’s Anomaly?

Answer 19

• Displacement of the tricuspid value during pregnancy while taking lithium

Question 20

What is the way that Valporate is used to help treat Bipolar Disorder?

Answer 20

• FDA approved for acute mania and maintenance therapy - most formulations are NOT interchangeable
• Slow onset

Question 21

What are some of the drug interactions for Valproate?

Answer 21

• Lamotrigine: ENHANCES side effects
• Phenytoin: Hepatotoxicity a/o hyperammonemia
• Warfarin: Elevated INR

Question 22

What are some of the warnings associated with Valproate?

Answer 22

• Hepatotoxicity [higher in <2 year olds]
• Teratogenicity [low IQ, DICUSS birth control]

Question 23

What are some of the side effects of Valproate?

Answer 23

• Weight Gain, Alopecia, Increased LFT, PCOS, Sedation, Pancreatits, HYPERAMMONEMIA

Question 24

What are the mood stabilizers that are used?

Answer 24

• Carbamazepine [Tegretol]
• Oxcarbazepine [Trileptal]
• Lamotrigine [Lamictal]
• Topiramate [Topamax]

Question 25

What is important to know about Carbamazepine [Tegretol]?

Answer 25

• 2nd or 3rd line
• Thrombocytopenia

Question 26

What is important to know about Oxcarbazepine [Trileptal]?

Answer 26

• 2nd or 3rd line
• Hyponatremia

Question 27

What is important to know about Lamotrigine [Lamictal]?

Answer 27

• 1st line for DEPRESSIVE symptoms [NOT useful for acute or manic episodes
• TITRATION DOSING!!

Question 28

What is important to know about Topiramate [Topamax]?

Answer 28

• Add on
• SLOW DOSE TITRATION to avoid cognitive issues
• Heat Intolerance [heat stroke]
• Kidney Stone

Question 29

What is the Lamotrigine [Lamictal] Titration Dosing?

Answer 29

WITH UGT INHIBITOR [Valproate]
- HALF the normal dose
NO INTERACTION [Normal]
- 25mg EVERYDAY x 14d; 50mg EVERYDAY x14d; 100mg EVERYDAY x 7d; 200mg
WITH UGT INDUCER [Carbamazepine, Phenytoin]
- DOUBLE the normal dose