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DSM V > BPAD 2018 guidelines > Flashcards

BPAD 2018 guidelines Flashcards

1
Q

Acute mania 1st line (CANMAT BPAD 2018)

A 
Lithium
Quetiapine
Divalproex
Asenapine
Aripiprazole
Paliperidone
Risperidone
Cariprazine
Quetiapine + Li/DVP
Aripirazole +Li/DVP
Risperidone + Li/DVP
Asenapine + Li/DVP
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2
Q

Acute mania psychotherapy (CANMAT BPAD 2018)

A

none

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3
Q

Hypomania (BD II)

TX (BPAD CANMAT 2018)

A
  • d/c worsening agents (antidepressants, stimulants)

- suggests Li, DVP, atypical antipsychotic (experts)

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4
Q

Acute mania children/adolescents

Tx (CANMAT BPAD 2018)

A

1st: Li, risperidone, aripiprazole, asenapine, quetiapine
2nd: olanzapine, ziprasidone, quetiapine adjunct
3rd divalproex

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5
Q

Acute mania 2nd line Tx (CANMAT BPAD 2018)

A 
olanzapine
carbamazepine
olanzapine + Li/DVP
Li + DVP
ziprasidone
haldol
ECT
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6
Q

Acute depression (BD) 1st line(CANMAT BPAD 2018)

A 
quetiapine
lurasidone + Li/DVP
lithium 
lamotrigine
lursidone
lamotrigine (adjunct)
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7
Q

Acute depression (BD) 2nd line(CANMAT BPAD 2018)

A 
Divalproex
SSRI/buproprion adjunct
ECT
cariprazine
olanzapine-fluoxetine
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8
Q

Acute depression psychotherapy (CANMAT BPAD 2018)

A

1st: none
2nd: CBT, family focused
3rd IPSRT

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9
Q

Acute depression BD II(CANMAT BPAD 2018)

A

1st: quetiapine
2nd: Li, lamotrigine, bupropion adj, ECT, sertraline, venlafaxine

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10
Q

Acute depression BD children/adolescents (CANMAT BPAD 2018)

A

1st: lurasidone
2nd: lithium, lamotrigine
3rd: olanzapine-fluoxetine, quetiapine
* cautious use of antidepressants and only with mood stabilizing medications

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11
Q 
Young women (childbearing)
(CANMAT BPAD 2018)
A
  • divalproex contraindicated
  • lamotrigine, topiramate and carbamazepine interfere with OCP
  • risperidone may decrease fertility
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12
Q

Women in pregnancy (CANMAT BPAD 2018)

A

-same basic hierarchy considering FDA recommendations re pregnancy
-Divalproex contraindicated
-Li– fetal cardiac u/s
-atypical antipsychotics (except clozapine), lamotrigine and antidepressants safe
monotherapy at lowest effective dose
adjust for changes in physiology

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13
Q

Women post partum (CANMAT BPAD 2018)

A
  • eleveated risk of mania
  • benzos, antipsychotics and Li for post-partum mania
  • quetiapine for depression
  • quetiapine and olanzapine best for breast feeding
  • avoid antidepressants as high risk for switch
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14
Q

Maintenance BD I- 1st line (CANMAT BPAD 2018)

A 
Lithium
quetiapine
divalproex
lamotrigine
asenapine
quetiapine + Li/DVP
Aripirazole +Li/DVP
Aripiprazole (oral and LAI)
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15
Q

Maintenance 2nd line (CANMAT BPAD 2018)

A 
Olanzapine
Risperidone LAI (solo and adjunct)
carbamazepine
paliperidone
lurasidone + Li/DVP
Ziprasidone + LI/DVP
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16
Q

Maintenance psychotherapy (CANMAT BPAD 2018)

A

1st line: psychoeducation

2nd: CBT, family focused
3rd: IPSRT, peer support

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17
Q

BD II maintenance (CANMAT BPAD 2018)

A

1st: quetiapine, Li, Lamotrigine
2nd: venlafaxine
3rd: carbamazepine, divalproex, escitalopram, fluoxetine, other antidepressants, risperidone

18
Q

Children and Adolescents Maintenance (CANMAT BPAD 2018)

A

1st: aripiprazole, Li, divalproex, risperidone + Li/DVP, lithium + DVP/carbamazapine, lamotrigine adj
2nd line: none
3rd: asenapine, quetiapine, risperidone (oral/LAI), ziprasidone (solo or adj)

19
Q

Older adults acute mania (CANMAT BPAD 2018)

A

1st: Li or divalproex monotherapy
2nd: quetiapine
3rd: asenapine, aripiprazole, risperidone, carbamazapine
Treatment resistant: ECT or clozapine

20
Q

Acute depression- older adults (CANMAT BPAD 2018)

A

1st: quetiapine, lurasidone
or Li or lamotrigine (adult evidence)
3rd: divalproex, aripiprazole, carbamazepine
Tx resistant: ECT

21
Q

Maintenance- older (CANMAT BPAD 2018)

A

Li, lamotrigine, divalproex

22
Q

Agitation- 1st line (CANMAT BPAD 2018)

A

Aripiprazole IM
Lorazepam Im
Loxapine inhaled
Olanzapine IM

23
Q

Agitation 2nd line (CANMAT BPAD 2018)

A 
Asenapine sl
haloperidol IM
Haldol + midazolam IM
Haldol + promethazine IM
Risperidone ODT
Ziprasidone IM
3rd: Haldol po, Loxapine IM, quetiapine Po, risperidone po
24
Q

Depressive symptoms suggestive of Bipolar depression (CANMAT BPAD 2018)

A
  • hypersomnia and/or increased daytime napping
  • hyperphagia and/or increased weight
  • other atypical depressive sx like leaden paralysis
  • psychomotor retardation
  • psychotic features and/or pathological guilt
  • lability of mood; irritability; psychomotor agitation; racing thoughts
  • early onset of first depression (<25 yo)
  • multiple prior episodes (>5)
  • positive family hx of bipolar d/o
25
Q

Features suggestive of unipolar depression (CANMAT BPAD 2018)

A
  • initial insomnia/reduced sleep
  • appetite and/or weight loss
  • normal/increased activity levels
  • somatic complaints
  • late onset of first depression (>25 yo)
  • long duration of current episode (>6 months)
  • no family hx of bipolar d/o
26
Q

Rating scales BPAD (CANMAT BPAD 2018)

A

-mood disorders questionnaire (screening)– really just screens mania
-also use mood charting when possible
(also Young Mania Rating scale– but not in guidelines)

27
Q

Suicide risk of attempts in BPAD(CANMAT BPAD 2018)

A

Suicide attempts:

  • female, younger (older has higher lethality), young racial minority, single, divorced, single parents,
  • young age of onset, first episodes depression, mixed symptoms, mania assoc with more violent attempts, predominantly depressed,
  • occurs most during depressed or mixed episodes, greater number/severity of episodes, rapid cycling, anxiety, atypical features, SI
  • comorbidities- SUD, smoking, coffee intake, anxiety, eating d/o, borderline/cluster B PDs, obesity
  • family hx of mood disorders, BPAD, suicide
  • early life stress, abuse
  • interpersonal problems, occupational problems, bereavement, social isolation, sexual dysfunction
28
Q

Risk of completed suicide

CANMAT BPAD 2018

A
  • male
  • older– higher ratio of deaths/attempts
  • current episode depressed, mixed or manic with psychotic features
  • hopeless, psychomotor agitation
  • comorbid anxiety
  • family hx mood disorders, BPAD, suicide
  • prior suicide attempts
  • psychosocial stressors in last week
29
Q

Chronic disease model(CANMAT BPAD 2018)

A
  • self management support
  • decision support (evidence based care)
  • community
  • delivery system design (culturally sensitive, team based care, case management for complex pt)
  • clinical information systems (communication between providers and with patients)
  • health system (QI, coordinated care)
30
Q

Risk for treatment non-adherence(CANMAT BPAD 2018)

A
  • male, younger, low education, single
  • poor insight, neg attitude to treatment/meds, fear of side effects, low overall life satisfaction, low cognitive function, lack of disease awareness
  • alcohol, cannabis, OCD
  • no social activities, work impairment
  • young age onset, inpatient, hospital or suicide attempt in last year
  • hx of mixed episodes, rapid cycling, psychotic features, greater severity, BPAD I, more episodes
  • medication side effects, poor efficacy, antidepressant use, low treatment dose
31
Q

Clinical features for Lithium (CANMAT Bipolar 2018)

A
  • classic euphoric, grandiose mania
  • fewer episodes of illness
  • course of mania- depression- euthymia
  • family hx of BD- esp with Li responsiveness
32
Q

Clinical features for Divalproex (CANMAT Bipolar 2018)

A

○ Divalproex- equally effective for euphoric or grandiose mania,

  • recommended with multiple prior episodes
  • Predominant irritable or dysphoric mood and/or comorbid substance use or hx of trauma
  • Avoid in women of child bearing age
33
Q

Clinical features for Carbamazepine (CANMAT bipolar 2018)

A 
○ Carbamazepine
§ Hx of head trauma
§ Comorbid anxiety and substance use
§ Schizoaffective presentation with mood -incongruent delusions
§ No family hx of BD in relatives
34
Q

Clinical features for combination atypical + Li/DVP (CANMAT bipolar 2018)

A 
○ Combination atypical + Li/Divalproex
§ Need response quickly
§ Patients judged at risk
§ Prior hx of partial acute response to monotherapy
§ More severe manic episodes
35
Q

Clinical considerations for anxious distress (CANMAT bipolar 2018)

A

§ Anxious distress- mania
□ Predictor of poor outcome– greater severity of manic sx, longer time to remission, more reported side effects of medication
□ Divalproex, quetiapine, olanzapine, carbamazepine ○ Anxious distress- depression
§ Predictive of more persistent depressive sx and suicidal ideation
§ Quetiapine and olanzapine-fluoxetine evidence
§ Lurasidone
§ Not divalproex, risperidone and lamotrigine

36
Q

Clinical considerations for mixed features (CANMAT bipolar 2018)

A

§ Mixed features- mania
□ 10-30% of mania
□ More severe and disabling course, more frequent suicide
□ Prefer atypicals and divalproex– usually require combination tx
® Aripiprazole, asenapine, olanzapine, ziprasidone ○ Mixed features depression
§ Associated with more severe depressive sx and higher rates of substance use and CV disease
§ Requires combination therapy usually
§ Atypical antipsychotics show class effect with olanzpaine-fluoxetine, asenapine and lurasidone all demonstrating efficacy
§ Avoid antidepressants

37
Q

Clinical features for psychotic features (CANMAT bipolar 2018)

A

§ Psychotic features
□ 50% of manic episodes have psychotic features
® No change in prognosis with mood-congruent features, but incongruent features indicate more severe illness with poorer long term prognosis
□ No superiority in monotherapy, and no evidence for first line combinations
® Clinical experiences suggests Li/divalproex +atypical antipsychotic
® If schizoaffective is possible– suggest atypical antipsychotic either monotherapy or in combination with Li/Divalproex
§ Up to 20% of inpatients experience psychosis in acute bipolar depressive episode
§ ECT and antipsychotics recommended

38
Q

Clinical considerations for Rapid cycling (CANMAT bipolar 2018)

A

§ Rapid cycling
Ø 4 mood episodes/year– affects up to 1/3 of patients with BD
Ø Often associated with hypothyroidism, antidepressant use and substance abuse
Ø No evidence for superiority between first line treatments
Ø Combinations likely needed
§ No specific agent for treatment of acute depression in rapid cycling
§ Li, divalproex, olanzapine and quetiapine have equivalent maintenance efficacies
Ø Lamotrigine no evidence for maintenance

39
Q

Clinical consideration for seasonal pattern (CANMAT bipolar 2018)

A

no evidence for superiority of any agent

40
Q

Clinical consideration for rapid response in bipolar depression (CANMAT bipolar 2018)

A

○ Need for rapid response
§ Quetiapine and lurasidone have responses as early as week 1 in trials
§ ECT
§ 2nd line options- cariprazine, and olanzapine-fluoxetine
§ Avoid lamotrigine b/c slow titration- increased effectiveness with depressive cognitions and psychomotor slowing

41
Q

Risk factors for recurrence (CANMAT BPAD 2018)

A

○ Risk factors for recurrence
§ Younger age onset
§ Psychotic features
§ Rapid cycling
§ More and more frequent previous episodes
§ Comorbid anxiety
§ Comorbid SUDs
§ Persistent subthreshold sx–> should indicate need for further optimization
○ Protective for recurrence: availability of psychosocial support and lower levels of stress

DSM V (14 decks)

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