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BPAD Flashcards

1
Q

How long should maintenance treatment be continued?

A

At least 2 years after an episode of bipolar disorder or up to 5 years if the person has risk factors for relapse

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2
Q

How long to treat following first episode mania?

A

6 months

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3
Q

What medication has been shown to reduce the incidence of suicide in patients with bipolar affective disorder?

A

Lithium

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4
Q

What is the best treatment option for BPAD with renal impairment?

A

Sodium valproate

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5
Q

Which symptom is most likely in a patient with severe and acute lithium toxicity?

A

tremors

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6
Q

What is the most common ECG finding in a patient with acute lithium toxicity?

A

T wave flattening

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7
Q

What is the point prevalence of BPAD?

A

1.5%

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8
Q

What is the mean age of onset for BPAD 1 and BPAD 2?

A
  1. 18

2. 20

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9
Q

What is the suicide risk for patients with BPAD compared to the general population?

A

15-18x higher

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10
Q

According to NICE, what proportion of patients with BPAD have one or more a comorbid mental health conditions?

A

2/3

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11
Q

What is the Akiskal and Pinto classification system for BPAD (1999)?

A

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

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12
Q

Is there a prodrome for BPAD?

A

Yes, predominantly insidious prodrome seen in > half of patients

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13
Q

What percentage of patients with BPAD are initially misdiagnosed with unipolar depression?

A

40%

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14
Q

What is the median time taken to recover from a manic episode?

A

4-5 weeks

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15
Q

What proportion of BPAD patients display a pattern of predominant polarity?

A

55%

60% predominant depression, 40% predominant mania or hypomania

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16
Q

What clinical features are common to BPAD with depressive polarity (1/3 of all patients)?

A 
Usually BPAD2
Onset often with depressive episode
More seasonality
More suicide attempts
More exposure to antidepressants
Better response to lamotrigine long term
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17
Q

What clinical features are common to BPAD with depressive polarity (1/4 of all patients)?

A 
Usually BPAD1
Onset often with mania
Less seasonal
More substance abuse
Better response to antipsychotics long term
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18
Q

What is the suicide rate among patients with diagnosed BPAD?

A

10-19%

1/4 will attempt suicide at some point

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19
Q

When is risk of recurrence especially high?

A

In the first year after a mood episode

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20
Q

What are the indicators of relapse?

A

Residual symptoms (biggest predictor)
First presentation of depression (index phase)
Sleep disruption (?final common pathway)
Comorbidities (physical and mental health)

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21
Q

What is a ‘switch’ in BPAD?

A

An antidepressant induced mania which occurs within 2 months of commencing the antidepressant

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22
Q

What are the risk factors for antidepressant induced switch?

A

Previous antidepressant induced manias
FHx of BPAD
Exposure to multiple antidepressant trials
Initial illness beginning in adolescence/young adulthood

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23
Q

How do we differentiate between unipolar and bipolar depression?

A 
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
24
Q

How many mood episodes must a patient have in a year to meet the criteria for rapid cycling?

A

> 4 episodes per year
(>4 per month = ultra rapid cycling)
*mood episodes are more severe in rapid cycling

25
Q

What proportion of BPAD patients have rapid cycling?

A

20% (based on large cohort study)

26
Q

What are the risk factors for rapid cycling?

A

Being female
Earlier onset on illness
Hypothyroidism
Poor response to lithium

27
Q

What are the causes of secondary mania?

A 
Organic brain damage, particularly to R hemisphere (usually seen in elderly)
L-dopa
Steroids
Illicit drugs
Hyperthyroidism
28
Q

What is the difference between mania and hypomania?

A

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

29
Q

What is the first line treatment for acute mania (first episode)?

A
  1. Antipsychotics: haloperidol, olanzapine, quetiapine, risperidone (rapid anti-manic effect)
  2. Consider stopping antidepressants
  3. Adjunctive BZDs for agitation

*Mixed episodes to be treated as mania

30
Q

What is the first line treatment for acute mania (relapse)?

A
  1. Optimise mood stabiliser
  2. Consider adding an antipsychotic
  3. ECT may be considered for severe cases

*Mixed episodes to be treated as mania

31
Q

What electrolyte imbalance is carbamazepine associated with?

A

Hyponatraemia

32
Q

How should an acute episode of bipolar depression be treated?

A
  • Psychological intervention (all patients)
    1. Fluoxetine + Olanzapine OR Quetiapine (mod-severe depression, not on any medication previously)
    2. Lamotrigine
33
Q

When is maintenance treatment for BPAD indicated?

A

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)

34
Q

What is maintenance treatment for BPAD?

A
  1. Lithium monotherapy
  2. Valproate, olanzapine or quetiapine
  3. Carbamazapine or lamotrigine
35
Q

How should rapid cycling be managed?

A
  1. Manage hypothyroidism and/or substance misuse first
  2. Discontinue antidepressants
  3. Consider lithium, valproate or lamotrigine for initial treatment
  4. Consider other causes i.e. noncompliance, suboptimal medication regimes
36
Q

Which antidepressants have the greatest switch risk?

A

TCAs?

37
Q

Which AEDs have no role in treating BPAD?

A

Vigabtran (associated with visual field defects and can cause psychosis)
Topiramate
Phenytoin

38
Q

What is the difference in the diagnostic criteria for BPAD in children compared to adults?

A

Mania must be present
Euphoria must be present most days, most of the time for 7 days
Irritability is not a core diagnostic criterion

39
Q

Mean age of onset of adult BPAD?

A

17 in community

21 in hospital

40
Q

Which feature is seen more often in bipolar depression than unipolar depression?

A

Psychomotor changes

41
Q

What is the estimated rate of postpartum relapse for women with bipolar disorder?

A

40%

42
Q

% of new BPAD cases that occur after age 50

A

10%

43
Q

What is the length of rapid cycling bipolar disorder in 50% patients?

A

It lasts less than 2 years in approximately 50% of patients

44
Q

Which medication is thought to precipitate rapid cycling bipolar disorder?

A

Propanolol is thought to precipitate rapid cycling bipolar disorder

45
Q

Over what minimum period of time should lithium be stopped in order to reduce the risk of relapse?

A

1 month

46
Q

Which medication has been shown to be most acceptable to patients with acute mania?

A

Olanzapine

47
Q

The prevalence of mania among relatives of individuals with bipolar disorder, as determined by structured clinical interviews, is

A

2%

48
Q

Which medications can precipitate lithium toxicity when used in combination with lithium?

A

ACE inhibitors
Thiazide diretics
(Loop diuretics have no effect)
NSAIDS

49
Q

Risk factors for lithium toxicity include

A

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

50
Q

When compared to females, bipolar disorder occurs earlier in males by

A

5 years

51
Q

The type of bipolar disorder seen in Seasonal Affective Disorder and winter depression is

A

Type 2

52
Q

Central Nervous System features of severe lithium toxicity

A

Blackout spells, epileptiform seizures, slurred speech, dizziness, vertigo, incontinence of urine or feces, somnolence, psychomotor retardation, restlessness, confusion, stupor, coma, acute dystonia, downbeat nystagmus

53
Q

Average age of onset BPAD compared to unipolar depression is?

A

The average age of onset for bipolar affective disorder is around 6 years prior to that of unipolar depression

54
Q

Which treatment is most appropriate for managing mixed affective state?

A

Sodium valproate

55
Q

What is a recognised cause of hypospadias when used during pregnancy?

A

Sodium valproate

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