Bipolar I + II Disorders (DSM/PsychDB) + Trials Flashcards
what is the “main” part of bipolar I diagnosis
must meet criteria for a manic episode
criterion A for a manic episode
a DISTINCT period of abnormally and persistently ELEVATED, EXPANSIVE or IRRITABLE mood
AND
abnormally and persistently INCREASED ACTIVITY or ENERGY
lasting at least ONE WEEK and present most of the day, nearly every day
(OR any duration if hospitalization is necessary)
criterion B for manic episode
during period of mood disturbance and increased energy or activity THREE OR MORE of the following symptoms are present to a SIGNIFICANT degree and represent a NOTICEABLE CHANGE from usual behaviour (FOUR if mood is only irritable)
- inflated self esteem or grandiosity
- decreased need for sleep (i.e feels rested after only 3 hours of sleep)
- more talkative than usual or pressure to keep talking
- flight of ideas or subjective experience that thoughts are racing
- distractibility (ie attention too easily drawn to unimportant or irrelevant external stimuli) as reported or observed
- increase in goal oriented activity (either socially, at work or school, or sexually) OR psychomotor agitation (ie purposeless non goal directed activity)
- excessive involvement in activities that have a high potential for painful consequences (i.e engaging in unrestrained buying sprees, sexual indiscretions or foolish business investments)
how many diagnostic features are listed in criterion B for mania
7
how many diagnostic features must be present from criterion B for mania
3 (4 if mood is only irritable)
how long must symptoms of mania persist to meet criteria
one week
criterion C for mania
mood disturbance is sufficiently severe to caused marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others
OR
there are psychotic features
criterion D for mania
the episode is not attributable to the physiological effects of a substance or another medical condition
what is the diagnosis for a full manic episode that emerges during antidepressant treatment (ie medication, ECT) but persists at a fully syndromal level beyond physiological effects of that treatment
this is sufficient evidence for a manic episode and therefore bipolar I diagnosis
how many manic episodes in patients lifetime are required for diagnosis of bipolar I disorder
at least one
criterion A for hypomanic episode
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least FOUR CONSECUTIVE days and present most of the day, nearly every day
criterion B for hypomanic episode
same as for mania
(3 of the 7 features–4 if irritable mood only)
criterion C for hypomania
the episode is associated with an UNEQUIVOCAL CHANGE in functioning that is UNCHARACTERISTIC of the individual when not symptomatic
criterion D for hypomania
the disturbance in mood and the change in functioning are OBSERVABLE by others
criterion E for hypomania
episode is NOT severe enough to caused marked impairment in social or occupational functioning or to necessitate hospitalization
*If there are psychotic symptoms the episode is by definition manic
criterion F for hypomania
the episode is not attributable to physiological effects of med/substance/other tx or another medical condition
what if someone gets more irritable, edgy or agitated following antidepressant use? is that hypomania?
if criteria are met for hypomania even after removal of antidepressant (after the hypomania emerged with antidepressant use) then its hypomania
BUT be careful–> one or two symptoms, like agitation or irritability, are not taken as sufficient evidence of bipolar diathesis
do you get hypomania in bipolar I?
yes–common
BUT not sufficient for diagnosis of bipolar I
what is the time criteria for hypomania
at least FOUR consecutive days
what symptom(s) are REQUIRED for a diagnosis of major depressive episode
either DEPRESSED MOOD and/or LOSS OF INTEREST OR PLEASURE
(must have at least one of these)
–> in kids and teens mood can be irritable instead of depressed
how many diagnostic features are listed in criterion A for major depressive episode
9
how many symptoms must be present to meet criterion A for major depressive episode
at least 5
criterion A for major depressive episode
FIVE or more of the following sx have been present during the same 2 week period and represent a CHANGE from previous functioning
at least one must be either depressed moor or anhedonia
- DEPRESSED MOOD most of the day, nearly every day, as indicated by either subjective report (i.e feels sad empty or hopeless) or observation made by others (i.e appears tearful)
–> in kids and teens mood can be IRRITABLE - markedly DIMINISHED INTEREST or PLEASURE in all, or almost all, activities most of the day, nearly every day (by subjective account or observation)
- significant WEIGHT LOSS when not dieting, or WEIGHT GAIN–> change of more than 5% body weight in a month–> OR decrease or increase in appetite nearly every day
- insomnia or hypersomnia nearly every day
- psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
- fatigue or loss of energy nearly every day
- feelings of WORTHLESSNESS or excessive or inappropriate GUILT (which may be delusional) nearly every day (not merely self reproach or guilt about being sick)
- diminished ability to think or concentrate or indecisiveness, nearly every day (either subjective or objective)
- recurrent thoughts of death (not just fear of dying), recurrent SI without specific plan, or suicide attempt or specific plan for committing suicide
what is considered “significant weight change” per the DSM in the context of diagnostic features of major depressive episode
change of more than 5% of body weight in a month
what is a mnemonic for dx features of major depressive episode
M-SIGECAPS
mood
sleep
interest
guilt/worthlessness
energy/fatigue
concentration/thinking/indecisiveness
appetite/weight loss or gain
psychomotor changes (slowing or agitation)
suicide/thought of death
criterion B for major depressive episode
symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
criterion C for major depressive episode
episode not attributable to physiological effects of substance/med/tx or another medical condition
can you diagnose a major depressive episode during a period following a significant loss (i.e bereavement, financial ruin)
yes–> consider whether symptoms understandable/appropriate to loss or whether there is also a major depressive episode present in addition
what are the criteria for diagnosis of bipolar I disorder
A–> criteria have been met for at least one manic episode (per criteria A-D for manic episode)
B–> occurrence of the manic and major depressive episodes is not better explained by schizoaffective disorder, schizophreniform disorder, schizophrenia, delusional disorder, or other unspecified schizophrenia spectrum and other psychotic disorder
what terms are used to code bipolar I disorder in diagnosis
based on current severity and symptoms
mild, moderate, severe
with psychotic features
in partial remission
in full remission
unspecified
current or most recent episode manic
current or most recent episode hypomanic
current or most recent episode depressed
current or most recent episode unspecified
how should coding terms be listed in the diagnostic recording of bipolar I disorder
bipolar I disorder–> type of current or most recent episode–> severity+ psychotic + remission specifiers–> as many specifiers without codes as apply to current or most recent episode
list the specifiers (without codes) that can be applied to a diagnosis of bipolar I disorder (there are 10)
with anxious distress
with mixed features
with rapid cycling
with melancholic features
with atypical features
with mood-CONGRUENT psychotic features
with mood-INCONGRUENT psychotic features
with catatonia
with peripartum onset
with seasonal pattern
how is the mood in a manic episode often described
euphoric, excessively cheerful, high or “feeling on top of the world”
can at times have such a highly infectious quality that it is easily recognized as excessive
may be characterized by UNLIMITED and HAPHAZARD enthusiasm for interpersonal, sexual or occupational interactions
what feature of mood may be present in mania/hypomania but is NOT one of the diagnostic criteria
lability
(rapid shifts in mood over brief periods of time)
how might the “increased activity” of mania present
may engage in multiple, overlapping new projects
projects often initiated with LITTLE KNOWLEDGE of the topic
nothing seems out of the individuals reach
may manifest as UNUSUAL HOURS of the day
how might inflated self esteem present in an adult
range from uncritical self confidence to marked grandiosity
may reach delusional proportions
despite lack of any particular experience or talent, individual may embark on complex tasks such as writing a novel or seeking publicity for some impractical invention
how might inflated self esteem present in children? why can this be a bit harder to detect than in adults?
“In children, overestimation of abilities and belief that, for example, they are the best at a sport or the smartest in the class is NORMAL
BUT
… when such beliefs are present despite CLEAR EVIDENCE TO THE CONTRARY or the child attempts feats that are clearly DANGEROUS and, most important, represent a CHANGE from the child’s normal behavior, the grandiosity criterion should be considered satisfied.
what is one of the most common features of mania
decreased need for sleep
*often heralds onset of a manic episode
how does decreased need for sleep differ from insomnia
insomnia–> person wants to sleep or feels need to sleep but CANT
decreased need–> doesnt feel drive to sleep
how does decreased need for sleep differ from insomnia
insomnia–> person wants to sleep or feels need to sleep but CANT
decreased need–> doesnt feel drive to sleep
what is a mnemonic for mania/hypomania sx
DIG FAST
Distractability
Indiscretion
Grandiosity
Flight of ideas
Activity increase
Sleep deficiency
Talkativeness
how might speech in bipolar I be described
rapid
pressured
loud
difficult to interrupt
may talk continuously without regard for others wishes to communicate
often intrusive manner or without concern for relevance of what is said
how does flight of ideas present
nearly continuous flow of accelerate speech with abrupt SHIFTS from one topic to another
if severe–> speech may become disorganized, incoherent, particularly distressful to the individual
*reflects thought racing at rate faster than can be expressed through speech–> thoughts can be experienced as so crowded its even difficult to speak (criterion B4)
how might the increased activity criterion present in mania in adults?
“The increase in goal-directed activity often consists of excessive planning and participation in multiple activities, including sexual, occupational, political, or religious activities. Increased sexual drive, fantasies, and behavior are often present. Individuals in a manic episode usually show increased sociability (e.g., renewing old acquaintances or calling or contacting friends or even strangers), without regard to the intrusive, domineering, and demanding nature of these interactions. They often display psychomotor agitation or restlessness (i.e., purposeless activity) by pacing or by holding multiple conversations simultaneously.129Some individuals write excessive letters, e-mails, text messages, and so forth, on many different topics to friends, public figures, or the media.”
how might the increased activity criterion for mania present in kids/teens?
“The increased activity criterion can be difficult to ascertain in children; however, when the child takes on many tasks simultaneously, starts devising elaborate and unrealistic plans for projects, develops previously absent and developmentally inappropriate sexual preoccupations (not accounted for by sexual abuse or exposure to sexually explicit material), then Criterion B might be met based on clinical judgment. It is essential to determine whether the behavior represents a change from the child’s baseline behavior; occurs most of the day, nearly every day for the requisite time period; and occurs in temporal association with other symptoms of mania.”
for criteria for mania to be met, the person must have marked impairment in social or occupational functioning, require hospitalization OR what other feature to meet criterion C
psychotic features by definition satisfies this criteria
list medications/treatments that may induce symptoms of mania
steroids
L-dopa
antidepressants
stimulants
ECT
how are insight and judgment typically affected during manic episodes
typically impaired/poor
list some features supporting diagnosis of bipolar I but that are not explicitly in the dx criteria
patients often do not perceive they are ill or in need of treatment-> may vehemently resist same
may change makeup, personal dress, appearance to be more sexually suggestive or flamboyant
some may perceive sharper sense of smell, taste, hearing, vision
gambling and antisocial behaviours may be present
may become hostile and physically threatening to others
moods may shift quickly
what is the estimated 12 month prevalence of bipolar I in the USA
0.6%
what is the lifetime male:female ratio for bipolar I
about equal
(1.1:1)
what is the mean age at onset of the first mood episode (either hypomanic, manic or depressive) in bipolar I disorder
18 years
*onset occur throughout the lifecyle, with first onsets in the age 60s or 70s
what should you rule out/consider if someone presents with first onset of manic symptoms in late mid-life or late life?
consider medical conditions i.e frontotemporal NCD and of substance ingestion/withdrawal
what % of people who have a single manic episode go on to have recurrent mood episodes
more than 90%
what % of manic episodes occur immediately before a major depressive episode
about 60%
how do you meet criteria for the “rapid cycling” specifier
4 or more mood episodes (depressive, hypomanic or manic) within one year
is bipolar disorder more common in high income or low income countries
more common in HIGH income countries (1.4% vs 0.7%)
list environmental risk factors for bipolar disorder
high income country
separated, divorced or widowed individual (compared to those who are married or who have never been married)
what is one of the strongest and most consistent risk factors for bipolar disorder
family history of bipolar disorder
what is the increased risk of bipolar disorder in adult relatives of those with bipolar I or II disorders?
average 10-fold increased risk
–> magnitude of risk increases with degree of kinship
bipolar disorder likely shares a genetic origin with what other psychiatric condition
schizophrenia
–> reflected in familial co-aggregation of schizophrenia and bipolar disorders
incomplete inter-episode recovery in bipolar disorder is more likely to happen if the patient has what symptoms? (its a specifier)
mood INCONGRUENT psychotic features
what population in the USA had significantly lower 12 month prevalence of bipolar I disorder compared to african americans or whites
afro-caribbeans
are females or males more likely to experience rapid cycling
females
females with bipolar disorder are more likely to be comorbid with which disorders compared to men
higher rates of lifetime eating disorders compared to men
more likely to experience depressive symptoms than males
higher lifetime risk of AUD compared to men (and also compared to the general population)
by how much is suicide risk increased in those with bipolar disorder compared to the general population
15x lifetime risk compared to general population
bipolar disorder may account for what % of all completed suicides
25% (1/4)
what two features are associated with greater risk of suicide attempt or completion in those with bipolar disorder
past history of suicide attempt
% days spent depressed in the past year
what % of those with bipolar disorder show severe impairment in work role function between episodes (vs those that recover fully between episodes)
30%
ddx bipolar I disorder
MDD
other bipolar disorders
GAD, panic disorder, PTSD, other anxiety disorders
Substance/med induced
ADHD
personality disorders
disorders with prominent irritability
how might anxiety disorder be mistaken for bipolar disorder
anxious ruminations may be taken for racing thoughts
efforts to minimize anxious feelings may be taken as impulsive behaviour
can response to mood stabilizers during a substance/med induced mania be taken as diagnostic for bipolar disorder
no
what symptoms can overlap between ADHD and bipolar disorder
rapid speech
racing thoughts
distractability
less need for sleep
but ADHD = chronic and bipolar = episodic
what sx are common in both BPD and bipolar disorder
mood lability
impulsivity
*bipolar is EPISODIC
what diagnosis should you consider in a kid/teen whose irritability is persistent (i.e not clearly episodic) and particularly severe
disruptive mood dysregulation disorder
what disorders are most frequently comorbid with bipolar disorder
anxiety disorder
(i.e panic attacks, social anxiety disorder, specific phobia)
ADHD
any disruptive, impulsive control or conduct disorder
(i.e IED, ODD, CD)
any substance use disorder
what class of disorders are MOST frequently comorbid with bipolar?
anxiety disorders–> occur in about 3/4 of those with bipolar
ADHD, any disruptive, impulse control or conduct disorder, and any SUD occur in what % of those with bipolar disorder
over half
what medical conditions are common in those with bipolar I disorder (in rates above those of then general population)
metabolic syndrome
migraines
what comorbidity increases risk of suicide attempt in bipolar disorder
AUD
what % of those whose symptoms meet criteria for bipolar disorder also have an AUD
more than half
what two things are required for a diagnosis of bipolar II disorder
to meet criteria for current or past hypomanic episode
AND
to meet criteria for current or past major depressive episode
*bipolar I only requires you to meet criteria for mania, but in bipolar II you need BOTH hypomania AND depression
criterion A for bipolar II disorder
criteria have been met for at least ONE hypomanic episode and at least ONE major depressive episode
criterion B for bipolar II disorder
there has NEVER been a manic episode
criterion C for bipolar II disorder
occurrence of the hypomanic episode(s) and major depressive episode(s) is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder
criterion D for bipolar II disorder
the symptoms of DEPRESSION or the UNPREDICTABILITY caused by frequent alternation between periods of depression and hypomania, causes clinically significant distress or impairment in social, occupational or other important areas of functioning
what are the specifiers for bipolar II disorder
same as bipolar I (i.e anxious distress etc)
must you have clinically significant impairment during a hypomanic episode to meet criteria for hypomania
NO–> but must have impairment in either depressive episodes or due to hypomanic FLUCTUATIONS to meet criteria for bipolar II disorder
how do you length and frequency of the depressive episodes in bipolar II disorder compare to those in bipolar I
tend to be LONGER and MORE FREQUENT in bipolar II
in what mood phase do those with bipolar II typically present to care
during depressive episode
rarely complain of hypomania
why is bipolar II disorder not considered a milder form of bipolar I
because those with bipolar II disorder tend to have greater chronicity of illness + spend on average more time depressed than those with bipolar I (which can be disabling)
what feature of bipolar II may contribute to patient ambivalence about seeking treament
some experience more creativity when hypomanic–> some people get attached to this and thus are ambivalent about possibly giving this up if treated
what feature has been found in unaffected family members of those with bipolar II
higher creativity
what is the 12 month prevalence of bipolar II disorder internationally
0.3%
(0.8% in the USA)
what is the average age at onset of bipolar II
mid-20s (slightly later than bipolar I but earlier than MDD)
in what % of those initially diagnosed with MDD will the dx change to bipolar II when hypomanic becomes more evident later
about 12% of people will have dx adjusted
when can bipolar II disorder begin
in late adolescence and throughout adulthood
how do the # of total lifetime mood episodes compare between bipolar II disorder, bipolar I and MDD
total # tends to be higher in bipolar II disorder compared to the other two disorders
*but those with bipolar I are more likely to experience hypomania than those with bipolar II
what % of those with bipolar II disorder have 4+ mood episodes within previous 12 months
5-15% (rapid cycling)
what % of those with bipolar II disorder will ultimately develop a manic episode
about 5-15% (and thus changes dx to bipolar I)
NON-episodic irritability in youth is associated with greater risk of what disorders in adulthood
anxiety disorders and MDD (but not bipolar disorders)
the risk of bipolar II disorder tends to be higher among relatives of those with what disorder
with bipolar II (compared to those with relatives with bipolar I or MDD)
rapid cycling is associated with what prognosis
poorer prognosis
what three features are independently associated with functional recovery in individuals with bipolar disorder
being married
more education
fewer years of illness
(this holds true even when type of bipolar illness, current depressive symptoms and presence of psych comorbidity are taken into account)
in clinical samples, is bipolar II more common in males or females
females (but other samples suggest no gender difference)
females are more likely to have what types of specifiers with their illness in bipolar II disorder
more likely to be rapid cycling and more like to present with hypomania with mixed depressive features
what may be a specific trigger for a hypomanic episode
childbirth
can occur in 10-20% of females in nonclinical populations and more typically in the early post partum period
how does lethality of suicide attempt compare between those with bipolar II disorder and those with bipolar I
seems to be higher lethality in bipolar II
what genetic risk factor is there for suicide in those with bipolar II disorder
higher risk of suicide among first degree relatives of those with bipolar II (compared with bipolar I)
how do rates of suicide attempt compare between bipolar I and II
similar (about 1/3)
what % of those with bipolar II disorder continue to experience inter-episode dysfunction
about 15%
what % of those with bipolar II disorder transition directly into another mood episode without inter-episode recovery
about 20%
how does cognitive impairment compare between bipolar I and II
similar
(except for memory and semantic fluency, which is better in bipolar II)
what 4 features in those with bipolar disorder are associated with prolonged unemployment
more episodes of depression
older age
increased rates of current panic disorder
lifetime hx of AUD
ddx of bipolar II disorder
MDD
cyclothymic disorder
schizophrenia spectrum and other related psychotic disorders
panic disorder and other anxiety disorders
SUDs
ADHD
personality disorders
other bipolar disorders
how do you distinguish between cyclothymic and bipolar II disorder
bipolar II has 1 or more MDEs
*if the first MDE occurs after the first TWO YEARS of cyclothymic disorder, ADDITIONAL dx of bipolar II is given
how do you distinguish between bipolar II disorder and schizophrenia/specturm disorders
schizophrenia/spectrum disorders have prominent psychotic symptoms that occur in the ABSENCE of prominent mood symptoms
what is the most commonly comorbid class of disorders with bipolar II disorder
anxiety disorders
what % of those with bipolar II disorder have THREE more MORE co-occurring disorders
about 60%
what % of those with bipolar II disorder also have an anxiety disorder
about 75%
approx what % of those with bipolar II disorder also have a SUD
about 37%
approx what % of those with bipolar II disorder have at least one lifetime eating disorder? which eating disorder is most common?
about 14%
*binge eating disorder more common than BN or AN
what is the COMBINED prevalence of ALL bipolar disorders
about 1.8%
describe the distribution patter for age of onset of bipolar disorders
age of onset appears to have a TRI-MODAL distribution pattern
distinct groups represented by onset in late teens, mid 20s and early 40s
what % of patient will experience relapse when ON TREATMENT vs with placebo
25% of those on treatment and 40% of those on placebo will experience recurrence
list risk factors for episode recurrence in bipolar disorder
rapid cycling
young age of onset
psychotic features
comorbid substance use
comorbid anxiety
what % of individuals with bipolar disorder will die by suicide
6-7%
*over 70% of suicide deaths occur during depressive and mixed episodes
list factors associated with GOOD prognosis in bipolar disorder
lack of early childhood adversity
good treatment adherence
higher age of onset
good social supports
absence of rapid cycling
absence of personality disorder
list factors associated with POOR prognosis in bipolar disorder
male gender
mixed episodes/features
rapid cycling
comorbid anxiety disorder
comorbid substance use
comorbid PD
obesity
what is the relative risk of bipolar disorder if a 1st degree relative is affected
9%
what is the relative risk of bipolar disorder if a monozygotic twin is affected
40-45%
what % of bipolar disorders are considered inherited
79-93%
one of the most heritable psychiatric disorders–> higher than for diseases such as breast cancer
what are the five features of “anxious distress”? how many must be present to include this as a specifier in bipolar disorder
- feeling keyed up or tense
- feeling unusually restless
- difficulty concentrating because of worry
- fear that something awful may happen
- feeling that the individual might lose control of him/herself
*needs TWO
why is is helpful/useful to specify the presence and severity level of anxious distress in the treatment of bipolar disorder
because high levels of anxiety have been associated with higher suicide risk, longer duration of illness, greater likelihood of TREATMENT NONRESPONSE
useful for treatment planning and monitoring of response to tx
define mild bipolar disorder
few, if any, symptoms in excess of those required to make the diagnosis are present
intensity of sx distressing but manageable
symptoms result in minor impairment in social or occupational functioning
define moderate bipolar disorder
number of sx, intensity of sx and/or functional impairment are between mild and severe
define severe bipolar disorder
number of sx is substantially in excess of that required to make the diagnosis
intensity of sx is seriously distressing and unmanageable
symptoms markedly interfere with social and occupational functioning
list psychometric rating scales for bipolar disorder
Young Mania Rating Scale
(YMRS)
Mood Disorder Questionnaire (MDQ)
name two genes that have been identified as possibly being involved in the pathogenesis of bipolar disorder
ANK3 (ankyrin G)
+
CACNA1C (alpha 1C subunit of the L-type voltage gated calcium channel)
*both are genes for ion channels
*might be that CHANNELOPATHIES play role in development of bipolar disorder
what brain areas have been found to have abnormalities on neuroimaging in those with bipolar disorder
fronto-limbic network–>
i.e hippocampus, amygdala, striatum
some cortical regions hypothesized to be involved as well
functional neuroimaging studies have shown what findings in those with bipolar disorder
HYPER CONNECTEDNESS in the default mode network, salience network and central executive network
MRI has shown that those with bipolar disorder have what changes in their brains compared to general population
- smaller hippocampus
- smaller amygdala
- smaller thalamus
- smaller anterior cingulate regions
- larger ventricles
- increased white matter hyperintensities
- widespread cortical thickening
- cortical thickening in those on lithium and thinning in those on anticonvulsants
what medical conditions should be considered on the ddx for bipolar disorder
obstructive sleep apnea
vitamin B12 deficiency
endocrine dysfunction–> hypo or hyper thyroidism; hypercortisolemia
infectious–> HIV, neurosyphillis, Lyme disease, viral/autoimmune encephalitis
in those who present with late life onset bipolar disorder, what other conditions should you consider on the ddx
BROAD differential
stroke/cerebrovascular disease
dementias (i.e FTD)
epilepsy
CNS infection
TBI
tumours
endocrine disorders
vitamin deficiencies
medication side effects i.e steroid induced mania
how does the course of bipolar disorder differ when onset is in late life
more MIXED episodes
episodes tend to be less severe but last LONGER
increased mortality due to CV and physical comorbidity
also contributes to cognitive dysfunction separate from any other dementing processes
what baseline investigations should be done for bipolar disorder
CBC
fasting glucose and lipid profile
platelets
electrolytes + extended (including calcium, Mg, Phosphate)
liver enzymes
serum bilirubin
prothrombin time and Ptt
UA
Cr and eGFR
TSH
who should get an ECG when assessing/starting to treat bipolar disorder
if over 40 or if indicated
what is the gold standard treatment in all phases of bipolar disorder
lithium
list 3 possible adverse events with lithium
renal impairment
thyroid dysfunction
worsening of PSORIASIS
list two possible adverse events with valproic acid
PCOS
teratogenic
list 3 possible adverse events with carbamazepine
teratogen
hepatic CYP enzyme autoinduction
risk of SJS/TEN
list a possible adverse event with lamotrigine
SJS/TEN risk
for a patient with acute bipolar I depression who is NOT on any treatment, what med should they start
quetiapine
*if already on lithium with breakthrough depression, consider adding lurasidone, lamotrigine or quetiapine
what supplement has been found to improve symptoms of bipolar depression
coenzyme q10
define manic or hypomanic episode with MIXED FEATURES (i.e what are the mixed features)
full criteria for mania/hypomania met + at least THREE of the following are present during the majority of days of the current or most recent episode:
- prominent DYSPHORIA or depressed mood (either subj or obj)
- ANHEDONIA
- PSYCHOMOTOR retardation nearly every day
- fatigue/loss of energy
- feelings of worthlessness or GUILT
- recurrent thoughts of death/SI etc
how should you label the current episode of a person who currently meets both full criteria for mania AND depression
dx should be manic episode with mixed features (due to marked impairment and clinical severity of full mania)
define depressed episode with mixed features
full criteria are met for MDE + at least THREE of the following manic/hypomanic sx are present for the majority of days of the current or most recent episode:
- elevated/expansive mood
- inflated self esteem or grandiosity
- more talkative than usual/pressure to keep talking
- flight of ideas or subjective experience that thoughts are racing
- increase in energy or goal directed activity
- increased involvement in activities with high potential for painful consequences
- decreased need for sleep
what must be present to use the specifier “with melancholic features”
A–> ONE of the following must be present during the most severe period of the current episode:
–loss of pleasure in all, or almost all, activities
–lack of reactivity to usually pleasurable stimuli
B–> THREE or more of the following:
–a distinct quality of depressed mood characterized by profound despondency, despair and/or moroseness or by so-called empty mood
–depression that is regularly worse in the morning
–early morning awakening (at least 2 hours before normal awakening)
–marked psychomotor agitation or retardation
–significant anorexia or weight loss
–excessive or inappropriate guilt
can you have “atypical depression” if criteria for “with melancholic features” or “with catatonia” have been met during the SAME episode
no
what are the criteria for atypical depression
A–> mood REACTIVITY (brightens in response to a positive event)
B–> TWO or more of the following
–significant weight gain or increase in appetite
–hypersomnia
–leaden paralysis
–long standing pattern of interpersonal rejection sensitivity that results in social or occupational dysfunction (not just limited to mood disturbance)
when can you use the specifier “with peripartum onset” for bipolar disorder
if onset of mania or hypomania during pregnancy or within 4 weeks of delivery
what was the research question in the BALANCE trial?
what year was the trial published?
is lithium plus valproate better than monotherapy with either drug alone for RELAPSE PREVENTION in bipolar I disorder?
published 2010
what was the primary outcome studied in the BALANCE trial
whether or not patients required a new intervention for an emergent mood episode (after being all started on both lithium and valproate, then being randomized to ongoing tx with the combo or with monotherapy with one or the other)
*secondary outcomes were global ax of functioning, deliberate self harm, QoL, adverse events, adherence to assigned tx
what were the results of the BALANCE trial
basically, combo of lithium + valproate was better than valproate monotherapy, but about equal to lithium monotherapy
*treatment allocation was not blinded
what was the BALANCE trial
landmark study
found that combo of lithium + valproate was not substantially superior to lithium alone in the treatment of bipolar I disorder
some benefit of combo vs just valproate alone
*because of this, APA recommends using lithium + valproate as prophylactic tx for episodic mood disturbance for people with bipolar disorder
what was the research question in the STEP-BED trial
among patient with bipolar disorder receiving mood-stabilizing agents, does adjunctive antidepressant therapy reduce the symptoms of bipolar depression without increasing mania?
when was STEP-BD published
2007
how were patients randomized in the step-bd trial
patients with bipolar depression were randomized to either mood stabilizer + antidepressant or mood stabilizer + placebo
*DOUBLE BLIND
what antidepressants were used in the step-bd trial
buproprion or paroxetine
why were buproprion and paroxetine chosen in the step-bd trial
deemed to have low rate of affective switch to represent the standard of antidepressant therapy commonly prescribed for bipolar depression at the time of the study and due to the fact they had different mechanisms of action and side effect profiles
what was the primary endpoint in the step-bd trial?
durable recovery (8 weeks or more consecutively of euthymia meaning no more than 2 depressive or manic symptoms)
*secondary outcomes: treatment remission, treatment effectiveness response without meeting criteria for hypomania, treatment emergent affective switch, and discontinuation of study med due to adverse event
what were the results of the STEP-BD trial
no significant differences in the groups with regard to effectiveness–> NONsignificant trend towards worse outcomes in the mood stabilizer + antidepressant group (compared to placebo)
antidepressants were not effective but were well tolerated–> equal rates of affective switch between control and study groups (and similar rates of other adverse events)
how did the STEP-BD trial affect APA recommendations for bipolar disorder treatment
recommend mood stabilizers as first line treatment for bipolar depression and adjunctive antidepressant therapy should only be considered in refractory cases
