Bipolar disorders

Question 1

What are bipolar disorders?

Answer 1

affective disorders involving both mania/hypomania + depression
episodes separated by intervals of remission (euthymia)

Question 2

Symptoms of hypomania/mania

Answer 2

inflated self-esteem or grandiosity
decreased need for sleep
pressure of speech
flight of ideas or racing thoughts
distractibility
increase in goal-directed behaviour or psychomotor agitation
risk taking behaviour (lack of judgement)

Question 3

Define mania

Answer 3

distinct period of abnormally + persistently elevated, expansive or irritable mood and persistently increased goal-directed activity or energy, lasting at least 1 week

(hypomania = same but shorter, 4 days, and not severe enough to cause marked impairment of functioning)

Question 4

Define depression

Answer 4

persistent low mood, most of the day, nearly every day for the same 2 week period (may be emptiness, lack of feelings)

Question 5

Define anhedonia

Answer 5

diminished interest or pleasure in activities most of the day, nearly every day

Question 6

Biological symptoms of depression

Answer 6

loss of appetite + weight loss
insomnia or hypersomnia
early morning wakening
fatigue and loss of energy
diminished concentration, indecisiveness
reduced libido

Question 7

Describe bipolar I disorder

Answer 7

classic manic-depressive disorder
mania alone or mania + depression
M=F

Question 8

Describe bipolar II disorder

Answer 8

hypomania + depression
F>M

Question 9

Describe bipolar III disorder

Answer 9

heterogeneous
recurrent depression +:
- family history of bipolar disorder
- antidepressant-induced hypomanic switching
- premorbid hyperthermic/dysthmic or cyclothymic temperament

Question 10

Complications of bipolar disorder

Answer 10

consequences of manic + depressive episodes (interpersonal, economic, medical)
increased general mortality regardless of age
suicide in 15-20%
substance abuse in ~60%

Question 11

Comorbidity in bipolar disorder

Answer 11

psychosis
alcohol + stimulant abuse
ADHD
dramatic cluster PD eg. borderline
bulimia
social phobia
panic attacks
obsessive-compulsive phenomena

Question 12

Pharmacological management of bipolar disorder

Answer 12

best for mania = lithium
other options = carbamazepine, divalproex, lamotrigine, gabapentin, typical antipsychotics, atypical antipsychotics

Question 13

Why should antidepressant monotherapy be avoided in bipolar disorder?

Answer 13

can induce mania in the absence of a concurrent mood stabiliser

Question 14

Pharmacokinetics of lithium

Answer 14

rapid absorption in upper GIT
peak levels after 2-3h
unbound in serum
not metabolised
renal excretion at constant rate
levels obtained at 12h, after 5-7 days

Question 15

Monitoring of lithium treatment

Answer 15

monitor mood (lithium database)
attempt to give all daily dosage at night
ask about adherence at each assessment
treat sleep disturbance
add other psychotropic if response limited

lithium levels every 3 months
renal function every 6 months
thyroid function every year
discontinue lithium slowly and only if absolutely needed

Question 16

Use of lithium in pregnancy and lactation

Answer 16

teratogenic
can cause ebsteins anomaly
close monitoring in pregnancy if necessary
stop at onset of labour
re-introduce first week post-partum (preferable first day)
advise against breastfeeding

Question 17

Adverse effects of lithium

Answer 17

thirst, polydipsia, polyuria
weight gain + tremor
precipitates or worsens skin problems
mild impairment of attention + memory
T wave flattening/inversion
hypothyroidism + non-toxic goitre
impaired renal tubular function
impaired glomerular function
leucocytosis

Question 18

When should patients on lithium be referred for specialist renal opinion?

Answer 18

eGFR decreasing more than 4 per year
progressive rise in serum creatinine in more than 3 tests
proteinuria
haematuria
sx of chronic renal failure
eGFR<30

Question 19

When do signs of lithium toxicity appear and what are the early and late sx?

Answer 19

signs appear at levels >1.3mmol/l

early = worsened side effects, nausea, vomiting, course tremor

late = disorientation, dysarthria, convulsions, coma

Question 20

Treatment of lithium toxicity

Answer 20

admission
rehydration
anticonvulsants
haemodialysis of lithium >3mmol/l, coma or non-response after 24h

Question 21

Drug interactions with lithium

Answer 21

increase lithium levels:
- diuretics
- NSAIDs
- ACE-is

Question 22

Indications for sodium valproate in bipolar disorder

Answer 22

treatment-refractory mania
rapid cycling bipolar disorder
most effective in non-psychotic patients

Question 23

Main side effects of quetiapine

Answer 23

sedation and weight gain (metabolic syndrome)

Question 24

When is quetiapine useful in bipolar disorder?

Answer 24

highly effective in acute and maintenance treatment of both mania + depression