Bipolar Pharmacy

Question 1

Mood swings causes are unknown, although catecholamine-related activity may be present.

1. Drugs that increase this activity tend to _______ mania?
2. Drugs that reduce activity of dopamine or norepinephrine ________ mania?

Answer 1

1. exacerbate

2. relieve

Question 2

Some important observations to make before discussing treatment of psychotic disorders:
1. Two factors must shape treatment…

Answer 2

1. • How the patient has been affected by the disorder
   • How the patient will be helped by the treatment

Question 3

Acute Mania and Hypomania.
Patients presenting with acute mania should be assessed for the following:
7

Answer 3

1. Suicide risk
2. Aggressiveness
3. Risk of violence to others
4. Ability to adhere to a treatment program
5. Substance abuse evaluation and treatment
6. Alcohol, caffeine and nicotine intake
7. Antidepressants should be discontinued

Question 4

Biological Therapies

1. ***Antipsychotic drugs treat what?
   - They do not treat what?
2. Classes of Meds? 4

Answer 4

1. the symptoms (They DO NOT cure the disorder)
2. Classes of Medications:
   - Lithium (Mood Stabilizer)
   - Anticonvulsants (Mood Stabilizer)
   - First Generation Antipsychotics
   - Second Generation Antipsychotics (Atypical Antipsychotics)

Question 5

Mood stabilizing agents
3

The choice of mood stabilizer is often based on what? 3

Answer 5

1. Lithium
2. Valproate (Depakote)
3. Carbamazepine (Tegretol)

The choice of a mood stabilizer is often based upon:

1. Previous history
2. Side-effect profiles
3. Co-existing medical illness

Question 6

Common side effects of mood stabilizing medications include:

8

Answer 6

1. Drowsiness
2. Dizziness
3. Headache
4. Diarrhea
5. Constipation
6. Heartburn
7. Mood swings
8. Stuffed or runny nose, or other cold-like symptoms

Question 7

LITHIUM
1. Significantly decreases the frequency and severity of what? 2

2. May decrease what turnover? 2
3. Blocks the development of what?
4. May augment the synthesis of of what? By doing what?
5. Use less first line with new what?.
6. May work better in the ___________ phase of therapy.

Answer 7

1. both manic and depressive episodes in about 70% of patients.
2. norepinephrine and dopamine
3. dopamine receptor supersensitivity
4. acetylcholine, by increasing cholamine uptake into nerve terminals
5. atypical antipsychotics
6. maintenance

Question 8

Lithium
Disadvantages?
7

Answer 8

1. Has a low therapeutic index (dont need much to have an effect)
2. Required constant blood level monitoring
3. Renal clearance of lithium is reduced about 25% by diuretics
4. Tremor is a common side effect (how could we counter this?)
5. Decreased thyroid function
6. Polydipsia, polyuria
7. Edema, weight gain

Question 9

Labs to monitor for Lithium? 3

Answer 9

Labs

1. Bun, Creatinine
2. Thyroid functions
3. Lithium levels

Question 10

1. Valproate (Depakote): Drug class?
2. Advanatges? 4
3. SE? 4
4. Labs to monitor? 3

Answer 10

1. Antiepileptic
2. • Side effect profile less than that of Lithium
   • Quick onset
   • May increase dose more rapidly (over a few days) to increase therapeutic range
   • Larger therapeutic window – 50-125
3. Side effects:
   - Weight gain
   - N & V
   - Hair loss
   - Tremor (not as significant as Lithium)
4. Labs
   - Liver functions
   - Platelets
   - Valproate levels

Question 11

Carbamazepine (Tegretol)

1. Drug class?
2. Therapeutic window?
3. SE? 5
4. Labs? 3

Answer 11

1. Anti-seizure
2. Comparable efficacy to Lithium
   —therapeutic window is 3-14
3. Side effects
   - N & V
   - Hyponatremia
   - Rash (Sevens Johnsons and TENS)**
   - Drowsiness, blurred vision
   - Blood dyscrasia’s
4. Labs
   - Liver functions
   - CBC, Serum NA
   - Carbamazepine levels

Question 12

1. Lamotrigine (Lamictal) drug class?
2. Treats bipolar depression without triggering what? 4
3. It has not demonstrated efficacy in the treatment of what?
4. Lamotrigine can be used as a first-line treatment what? 2

Answer 12

1. Anti-epileptic
2. Treats bipolar depression without triggering
   - mania,
   - hypomania,
   - mixed states, or
   - rapid cycling.
3. It has not demonstrated efficacy in the treatment of acute mania.
4. Lamotrigine can be used as a first-line treatment for
   - acute depression in bipolar disorder as
   - well as a maintenance therapy.

Question 13

Mood stabilizing agents
1. According to the APA recommendations:
1st line pharm therapy for patients with ACUTE severe manic or mixed episodes is what? 2

2. For less severe, what? 3
3. __________ as a first-line treatment for acute depression in bipolar disorder as well as a maintenance therapy, but not recommended for treatment of ACUTE mania.

Answer 13

1. • an antipsychotic agent
   • combined with either Lithium or Valproate.
2. monotherapy with either Lithium, Valproate or an antipsychotic agent.
3. Lamotrigine

Question 14

First Generation Antipsychotics
DOPAMINE ANTAGONISTS
2

Effective in treatment of what?

Answer 14

1. Haloperidol (Haldol)
2. Chlorpromazine (Thorazine)

Effective in the treatment of schizophrenia, especially the positive symptoms (e.g. hallucinations, delusions)

Question 15

First Generation Antipsychotics

DOPAMINE ANTAGONISTS two major shortcomings?

Answer 15

Two major shortcomings:

1. Only a small percentage of patients (around 25%) are helped enough to recover a reasonable amount of normal mental functioning
2. Associated with both annoying and serious adverse effects

Question 16

First Generation Antipsychotics
DOPAMINE ANTAGONISTS
Adverse effects
Some of the more common annoying effects are what? 2

Potenital serious effects? 2

Answer 16

1. akathisia (subjective feeling of muscular tension which can cause restlessness, pacing, repeated sitting or standing) and
2. parkinsonian-like rigidity and tremor

Potential serious effects include 1. tardive dyskinesia and
2. neuroleptic malignant syndrome

Question 17

First Generation Antipsychotics DOPAMINE ANTAGONISTS: SE.

Extrapyramidal symptoms 2

Answer 17

1. Dyskinesia
2. Tardive dyskinesia
3. Akathisia
4. Dystonia

Question 18

1. What is dyskinesia?

2. These movements can include? 5

Answer 18

Dyskinesia - movement disorders including any of a number of repetitive, involuntary, and purposeless body or facial movements.

2.

• Tongue movements, such as “tongue thrusts” or “fly-catching” movements
• Lip smacking
• Finger movements
• Eye blinking
• Movements of the arms or legs.

Question 19

Tardive dyskinesia can occur when?

Answer 19

occurs after long-term treatment with an antipsychotic medication.
Sometimes, this condition may become permanent.

Question 20

1. What is akathisia? 3symtpoms

2. Can be at risk for?

Answer 20

1. • an extreme form of internal or external restlessness.
   • A complete inability to sit still, with an undeniable urge to be moving constantly.
   • An entirely inner feeling of jitteriness or shakiness.
2. Can be exhausting and lead to suicide ideations

Question 21

1. Dystonia is what?

Answer 21

a muscle tension disorder involving very strong muscle contractions.
These uncontrollable muscle contractions can cause unusual twisting of parts of the body, especially the neck

Question 22

1. Extrapyramidal tracts are chiefly found in the reticular formation of the what and what,
2. and target neurons in the spinal cord involved in what? 4
3. These tracts are in turn modulated by various parts of the central nervous system, including the what? 5

Answer 22

1. pons and medulla
2. • reflexes,
   • locomotion,
   • complex movements, and
   • postural control
3. • nigrostriatal pathway,
   • the basal ganglila,
   • the cerebellum,
   • the vestibular nuclei, and
   • different sensory areas of the cerebral cortex.

Question 23

First Generation Antipsychotics DOPAMINE ANTAGONISTS
1. These extrapyrmidal side effects can happen with atypical antipsychotics, but the likelihood is much less than with drugs like what? 2

2. Is there anything to help?

Answer 23

1. Haldol and Thorazine.

2. Cogentin

Question 24

1. What is Cogentin?

2. MOA?

Answer 24

1. an anticholinergic medication

2. blocks the effects of the neurotransmitter acetylcholine.

Question 25

By blocking the effects of acetylcholine, Cogentin helps to re-establish a normal balance between what?

Answer 25

dopamine and acetylcholine.

Question 26

``` SEROTONIN-DOPAMINE ANTAGONISTS (SDAS) ATYPICAL ANTIPSYCHOTICS Second Generation Antipsychotics 1. Referred to as what? 2. Interact with different subtypes of what compared to standard antipsychotics? 3. Fewer what? 3 4. Effective for what symtpoms? 5. Effective for who? 6. It is suggested that antipsychotics may be slightly more effective than _______________ as monotherapy for acute mania, and may also be used as adjunctive therapy with mood stabilizers? ```

Answer 26

1. Referred to as “atypical antipsychotics” 2. dopamine receptors than standard antipsychotics 3. - Produce fewer neurological and - endocrine side effects - Cause very few, if any, extrapyramidal side effects 4. Effective in treating negative symptoms (such as withdrawal) in addition to the positive symptoms. 5. Effective for a broader range of patients 6. mood stabilizers

Question 27

``` SEROTONIN-DOPAMINE ANTAGONISTS (SDAS) ATYPICAL ANTIPSYCHOTICS Second Generation Antipsychotics 1. SE? 4 2. Labs and other tests? 4 ```

Answer 27

1. Side effects: - Weight gain - Glucose intolerance - Diabetes mellitus - Hyperlipidema 2. Labs and other - Serum glucose - Lipids - Weight - Waist circumference

Question 28

SEROTONIN-DOPAMINE ANTAGONISTS (SDAS) ATYPICAL ANTIPSYCHOTICS Second Generation Antipsychotics Other Side Effects? 7

Answer 28

1. Drowsiness 2. Dizziness when changing positions 3. Blurred vision 4. Rapid heartbeat 5. Sensitivity to the sun 6. Skin rashes 7. Menstrual problems for women

Question 29

SEROTONIN-DOPAMINE ANTAGONISTS (SDAS) ATYPICAL ANTIPSYCHOTICS 6

Answer 29

1. Quetiapine (Seroquel) 2. Olanzapine (Zyprexa) 3. Risperidone (Risperdal) 4. Clozapine (Clozaril) 5. Ziprasidone (Geodon) 6. Aripiprazole (Abilify)

Question 30

Quetiapine (Seroquel) 1. Main SE? 2. Olanzapine (Zyprexa) Main SE??

Answer 30

1. Drowsiness | 2. Weight gain most pronounced

Question 31

Clozapine (Clozaril) | 2 big SE??

Answer 31

1. Weight gain most pronounced | 2. Steady monitoring of white count (agranulocytosis)*****

Question 32

Ziprasidone (Geodon) advantage? Disadvantage of Aripiprazole (Abilify)?

Answer 32

less weight gain Expensive

Question 33

2002 APA practice guidelines 1. 1st line therapy for acute depression in patients with bipolar disorder is what? 2 2. Lamotrigine (Lamictal) seems to be helpful in controlling depressive symptoms of what? 3. Antipsychotic medications may have some efficacy in the treatment of what? 4. _____________ have little impact on improving bipolar depression, in fact, they may worsen it, or cause increase in manic symptoms.

Answer 33

1. Lithium or Lamotrigin (Lamictal) 2. bipolar depression. 3. bipolar depression, in addition to their effects in mania. 4. Antidepressants

Question 34

Hospitalization for psychosis is indicated in the following circumstances: 4

Answer 34

1. For diagnostic purposes 2. For stabilization of medications 3. For patients’ safety (e.g. because of suicidal or homicidal ideation) 4. For grossly disorganized or inappropriate behavior

Question 35

1. Patients presenting with acute mania, mixed, or hypomania should be assessed for what? 4 2. __________ should be discontinued, and substance abuse treated. 3. The mainstays of treatment are what? 3

Answer 35

1. - suicide and homicide, - aggressiveness, - psychotic features, and - poor judgement. 2. Antidepressants 3. - lithium, - anticonvulsants and - antipsychotics