BPAD 2018 guidelines Flashcards

Question

Features suggestive of unipolar depression (CANMAT BPAD 2018)

Answer 1

- 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

Answer 2

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

Answer 3

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

Answer 4

- 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

Answer 5

- 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)

Answer 6

- 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

Answer 7

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

Answer 8

○ 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

Answer 9

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

Answer 10

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

Answer 11

§ 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

Answer 12

§ 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

Answer 13

§ 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

Answer 14

§ 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

Answer 15

no evidence for superiority of any agent

Answer 16

○ 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

Answer 17

○ 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