BPAD Flashcards
How long should maintenance treatment be continued?
At least 2 years after an episode of bipolar disorder or up to 5 years if the person has risk factors for relapse
How long to treat following first episode mania?
6 months
What medication has been shown to reduce the incidence of suicide in patients with bipolar affective disorder?
Lithium
What is the best treatment option for BPAD with renal impairment?
Sodium valproate
Which symptom is most likely in a patient with severe and acute lithium toxicity?
tremors
What is the most common ECG finding in a patient with acute lithium toxicity?
T wave flattening
What is the point prevalence of BPAD?
1.5%
What is the mean age of onset for BPAD 1 and BPAD 2?
- 18
2. 20
What is the suicide risk for patients with BPAD compared to the general population?
15-18x higher
According to NICE, what proportion of patients with BPAD have one or more a comorbid mental health conditions?
2/3
What is the Akiskal and Pinto classification system for BPAD (1999)?
BPAD 1 = manic depressive illness
BPAD 1.5 = depression with protracted hypomania
BPAD 2 = depression with spontaneous hypomanic episodes
BPAD 2.5 = depression superimposed on cyclothymic temperament
BPAD 3 = recurrent depression + hypomania, occurring solely in association with antidepressant or other somatotherapy
BPAD 3.5 = mood swings that persist beyond stimulant or alcohol abuse
BPAD 4 = depression superimposed on a hyperthymic temperament
Is there a prodrome for BPAD?
Yes, predominantly insidious prodrome seen in > half of patients
What percentage of patients with BPAD are initially misdiagnosed with unipolar depression?
40%
What is the median time taken to recover from a manic episode?
4-5 weeks
What proportion of BPAD patients display a pattern of predominant polarity?
55%
60% predominant depression, 40% predominant mania or hypomania
What clinical features are common to BPAD with depressive polarity (1/3 of all patients)?
Usually BPAD2 Onset often with depressive episode More seasonality More suicide attempts More exposure to antidepressants Better response to lamotrigine long term
What clinical features are common to BPAD with depressive polarity (1/4 of all patients)?
Usually BPAD1 Onset often with mania Less seasonal More substance abuse Better response to antipsychotics long term
What is the suicide rate among patients with diagnosed BPAD?
10-19%
1/4 will attempt suicide at some point
When is risk of recurrence especially high?
In the first year after a mood episode
What are the indicators of relapse?
Residual symptoms (biggest predictor)
First presentation of depression (index phase)
Sleep disruption (?final common pathway)
Comorbidities (physical and mental health)
What is a ‘switch’ in BPAD?
An antidepressant induced mania which occurs within 2 months of commencing the antidepressant
What are the risk factors for antidepressant induced switch?
Previous antidepressant induced manias
FHx of BPAD
Exposure to multiple antidepressant trials
Initial illness beginning in adolescence/young adulthood
How do we differentiate between unipolar and bipolar depression?
Unipolar: More anxiety More somatic complaints Less withdrawal Less psychomotor slowing Insomnia Less atypicality
Bipolar: Less anxiety Fewer somatic complaints More withdrawal More psychomotor slowing Hypersomnia More atypical symptoms
How many mood episodes must a patient have in a year to meet the criteria for rapid cycling?
> 4 episodes per year
(>4 per month = ultra rapid cycling)
*mood episodes are more severe in rapid cycling
What proportion of BPAD patients have rapid cycling?
20% (based on large cohort study)
What are the risk factors for rapid cycling?
Being female
Earlier onset on illness
Hypothyroidism
Poor response to lithium
What are the causes of secondary mania?
Organic brain damage, particularly to R hemisphere (usually seen in elderly) L-dopa Steroids Illicit drugs Hyperthyroidism
What is the difference between mania and hypomania?
Degree of functional impairment
(Need for hospitalisation can be considered as proxy)
*DSMV states 4/7 symptoms for hypomania and 7/7 for mania but this is considered arbitrary
What is the first line treatment for acute mania (first episode)?
- Antipsychotics: haloperidol, olanzapine, quetiapine, risperidone (rapid anti-manic effect)
- Consider stopping antidepressants
- Adjunctive BZDs for agitation
*Mixed episodes to be treated as mania
What is the first line treatment for acute mania (relapse)?
- Optimise mood stabiliser
- Consider adding an antipsychotic
- ECT may be considered for severe cases
*Mixed episodes to be treated as mania
What electrolyte imbalance is carbamazepine associated with?
Hyponatraemia
How should an acute episode of bipolar depression be treated?
- Psychological intervention (all patients)
1. Fluoxetine + Olanzapine OR Quetiapine (mod-severe depression, not on any medication previously)
2. Lamotrigine
When is maintenance treatment for BPAD indicated?
Following a single manic episode (BAP)
Following a manic episode involving significant risk/adverse consequences OR BPAD1 with 2+ acute episodes OR BPAD2 with significant functional impairment or risk (NICE)
What is maintenance treatment for BPAD?
- Lithium monotherapy
- Valproate, olanzapine or quetiapine
- Carbamazapine or lamotrigine
How should rapid cycling be managed?
- Manage hypothyroidism and/or substance misuse first
- Discontinue antidepressants
- Consider lithium, valproate or lamotrigine for initial treatment
- Consider other causes i.e. noncompliance, suboptimal medication regimes
Which antidepressants have the greatest switch risk?
TCAs?
Which AEDs have no role in treating BPAD?
Vigabtran (associated with visual field defects and can cause psychosis)
Topiramate
Phenytoin
What is the difference in the diagnostic criteria for BPAD in children compared to adults?
Mania must be present
Euphoria must be present most days, most of the time for 7 days
Irritability is not a core diagnostic criterion
Mean age of onset of adult BPAD?
17 in community
21 in hospital
Which feature is seen more often in bipolar depression than unipolar depression?
Psychomotor changes
What is the estimated rate of postpartum relapse for women with bipolar disorder?
40%
% of new BPAD cases that occur after age 50
10%
What is the length of rapid cycling bipolar disorder in 50% patients?
It lasts less than 2 years in approximately 50% of patients
Which medication is thought to precipitate rapid cycling bipolar disorder?
Propanolol is thought to precipitate rapid cycling bipolar disorder
Over what minimum period of time should lithium be stopped in order to reduce the risk of relapse?
1 month
Which medication has been shown to be most acceptable to patients with acute mania?
Olanzapine
The prevalence of mania among relatives of individuals with bipolar disorder, as determined by structured clinical interviews, is
2%
Which medications can precipitate lithium toxicity when used in combination with lithium?
ACE inhibitors
Thiazide diretics
(Loop diuretics have no effect)
NSAIDS
Risk factors for lithium toxicity include
Drugs altering renal function
Decreased circulating volume (great heat, sauna)
Infections (viral infections, gastroenteritis with diarrhoea and vomiting)
Fever
Decreased oral intake of water
Renal insufficiency
Nephrogenic diabetes insipidus
When compared to females, bipolar disorder occurs earlier in males by
5 years
The type of bipolar disorder seen in Seasonal Affective Disorder and winter depression is
Type 2
Central Nervous System features of severe lithium toxicity
Blackout spells, epileptiform seizures, slurred speech, dizziness, vertigo, incontinence of urine or feces, somnolence, psychomotor retardation, restlessness, confusion, stupor, coma, acute dystonia, downbeat nystagmus
Average age of onset BPAD compared to unipolar depression is?
The average age of onset for bipolar affective disorder is around 6 years prior to that of unipolar depression
Which treatment is most appropriate for managing mixed affective state?
Sodium valproate
What is a recognised cause of hypospadias when used during pregnancy?
Sodium valproate
