BPAD 2018 guidelines Flashcards
Acute mania 1st line (CANMAT BPAD 2018)
Lithium Quetiapine Divalproex Asenapine Aripiprazole Paliperidone Risperidone Cariprazine Quetiapine + Li/DVP Aripirazole +Li/DVP Risperidone + Li/DVP Asenapine + Li/DVP
Acute mania psychotherapy (CANMAT BPAD 2018)
none
Hypomania (BD II)
TX (BPAD CANMAT 2018)
- d/c worsening agents (antidepressants, stimulants)
- suggests Li, DVP, atypical antipsychotic (experts)
Acute mania children/adolescents
Tx (CANMAT BPAD 2018)
1st: Li, risperidone, aripiprazole, asenapine, quetiapine
2nd: olanzapine, ziprasidone, quetiapine adjunct
3rd divalproex
Acute mania 2nd line Tx (CANMAT BPAD 2018)
olanzapine carbamazepine olanzapine + Li/DVP Li + DVP ziprasidone haldol ECT
Acute depression (BD) 1st line(CANMAT BPAD 2018)
quetiapine lurasidone + Li/DVP lithium lamotrigine lursidone lamotrigine (adjunct)
Acute depression (BD) 2nd line(CANMAT BPAD 2018)
Divalproex SSRI/buproprion adjunct ECT cariprazine olanzapine-fluoxetine
Acute depression psychotherapy (CANMAT BPAD 2018)
1st: none
2nd: CBT, family focused
3rd IPSRT
Acute depression BD II(CANMAT BPAD 2018)
1st: quetiapine
2nd: Li, lamotrigine, bupropion adj, ECT, sertraline, venlafaxine
Acute depression BD children/adolescents (CANMAT BPAD 2018)
1st: lurasidone
2nd: lithium, lamotrigine
3rd: olanzapine-fluoxetine, quetiapine
* cautious use of antidepressants and only with mood stabilizing medications
Young women (childbearing) (CANMAT BPAD 2018)
- divalproex contraindicated
- lamotrigine, topiramate and carbamazepine interfere with OCP
- risperidone may decrease fertility
Women in pregnancy (CANMAT BPAD 2018)
-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
Women post partum (CANMAT BPAD 2018)
- 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
Maintenance BD I- 1st line (CANMAT BPAD 2018)
Lithium quetiapine divalproex lamotrigine asenapine quetiapine + Li/DVP Aripirazole +Li/DVP Aripiprazole (oral and LAI)
Maintenance 2nd line (CANMAT BPAD 2018)
Olanzapine Risperidone LAI (solo and adjunct) carbamazepine paliperidone lurasidone + Li/DVP Ziprasidone + LI/DVP
Maintenance psychotherapy (CANMAT BPAD 2018)
1st line: psychoeducation
2nd: CBT, family focused
3rd: IPSRT, peer support
BD II maintenance (CANMAT BPAD 2018)
1st: quetiapine, Li, Lamotrigine
2nd: venlafaxine
3rd: carbamazepine, divalproex, escitalopram, fluoxetine, other antidepressants, risperidone
Children and Adolescents Maintenance (CANMAT BPAD 2018)
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)
Older adults acute mania (CANMAT BPAD 2018)
1st: Li or divalproex monotherapy
2nd: quetiapine
3rd: asenapine, aripiprazole, risperidone, carbamazapine
Treatment resistant: ECT or clozapine
Acute depression- older adults (CANMAT BPAD 2018)
1st: quetiapine, lurasidone
or Li or lamotrigine (adult evidence)
3rd: divalproex, aripiprazole, carbamazepine
Tx resistant: ECT
Maintenance- older (CANMAT BPAD 2018)
Li, lamotrigine, divalproex
Agitation- 1st line (CANMAT BPAD 2018)
Aripiprazole IM
Lorazepam Im
Loxapine inhaled
Olanzapine IM
Agitation 2nd line (CANMAT BPAD 2018)
Asenapine sl haloperidol IM Haldol + midazolam IM Haldol + promethazine IM Risperidone ODT Ziprasidone IM 3rd: Haldol po, Loxapine IM, quetiapine Po, risperidone po
Depressive symptoms suggestive of Bipolar depression (CANMAT BPAD 2018)
- 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
Features suggestive of unipolar depression (CANMAT BPAD 2018)
- 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
Rating scales BPAD (CANMAT BPAD 2018)
-mood disorders questionnaire (screening)– really just screens mania
-also use mood charting when possible
(also Young Mania Rating scale– but not in guidelines)
Suicide risk of attempts in BPAD(CANMAT BPAD 2018)
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
Risk of completed suicide
CANMAT BPAD 2018
- 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
Chronic disease model(CANMAT BPAD 2018)
- 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)
Risk for treatment non-adherence(CANMAT BPAD 2018)
- 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
Clinical features for Lithium (CANMAT Bipolar 2018)
- classic euphoric, grandiose mania
- fewer episodes of illness
- course of mania- depression- euthymia
- family hx of BD- esp with Li responsiveness
Clinical features for Divalproex (CANMAT Bipolar 2018)
○ 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
Clinical features for Carbamazepine (CANMAT bipolar 2018)
○ Carbamazepine § Hx of head trauma § Comorbid anxiety and substance use § Schizoaffective presentation with mood -incongruent delusions § No family hx of BD in relatives
Clinical features for combination atypical + Li/DVP (CANMAT bipolar 2018)
○ Combination atypical + Li/Divalproex § Need response quickly § Patients judged at risk § Prior hx of partial acute response to monotherapy § More severe manic episodes
Clinical considerations for anxious distress (CANMAT bipolar 2018)
§ 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
Clinical considerations for mixed features (CANMAT bipolar 2018)
§ 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
Clinical features for psychotic features (CANMAT bipolar 2018)
§ 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
Clinical considerations for Rapid cycling (CANMAT bipolar 2018)
§ 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
Clinical consideration for seasonal pattern (CANMAT bipolar 2018)
no evidence for superiority of any agent
Clinical consideration for rapid response in bipolar depression (CANMAT bipolar 2018)
○ 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
Risk factors for recurrence (CANMAT BPAD 2018)
○ 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
