Bipolar disorders Flashcards
What are bipolar disorders?
affective disorders involving both mania/hypomania + depression
episodes separated by intervals of remission (euthymia)
Symptoms of hypomania/mania
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)
Define mania
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)
Define depression
persistent low mood, most of the day, nearly every day for the same 2 week period (may be emptiness, lack of feelings)
Define anhedonia
diminished interest or pleasure in activities most of the day, nearly every day
Biological symptoms of depression
loss of appetite + weight loss
insomnia or hypersomnia
early morning wakening
fatigue and loss of energy
diminished concentration, indecisiveness
reduced libido
Describe bipolar I disorder
classic manic-depressive disorder
mania alone or mania + depression
M=F
Describe bipolar II disorder
hypomania + depression
F>M
Describe bipolar III disorder
heterogeneous
recurrent depression +:
- family history of bipolar disorder
- antidepressant-induced hypomanic switching
- premorbid hyperthermic/dysthmic or cyclothymic temperament
Complications of bipolar disorder
consequences of manic + depressive episodes (interpersonal, economic, medical)
increased general mortality regardless of age
suicide in 15-20%
substance abuse in ~60%
Comorbidity in bipolar disorder
psychosis
alcohol + stimulant abuse
ADHD
dramatic cluster PD eg. borderline
bulimia
social phobia
panic attacks
obsessive-compulsive phenomena
Pharmacological management of bipolar disorder
best for mania = lithium
other options = carbamazepine, divalproex, lamotrigine, gabapentin, typical antipsychotics, atypical antipsychotics
Why should antidepressant monotherapy be avoided in bipolar disorder?
can induce mania in the absence of a concurrent mood stabiliser
Pharmacokinetics of lithium
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
Monitoring of lithium treatment
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
Use of lithium in pregnancy and lactation
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
Adverse effects of lithium
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
When should patients on lithium be referred for specialist renal opinion?
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
When do signs of lithium toxicity appear and what are the early and late sx?
signs appear at levels >1.3mmol/l
early = worsened side effects, nausea, vomiting, course tremor
late = disorientation, dysarthria, convulsions, coma
Treatment of lithium toxicity
admission
rehydration
anticonvulsants
haemodialysis of lithium >3mmol/l, coma or non-response after 24h
Drug interactions with lithium
increase lithium levels:
- diuretics
- NSAIDs
- ACE-is
Indications for sodium valproate in bipolar disorder
treatment-refractory mania
rapid cycling bipolar disorder
most effective in non-psychotic patients
Main side effects of quetiapine
sedation and weight gain (metabolic syndrome)
When is quetiapine useful in bipolar disorder?
highly effective in acute and maintenance treatment of both mania + depression
