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Reasoning in mental health 3 > CANMAT bipolar > Flashcards

CANMAT bipolar Flashcards

1
Q

Factors reported to be significantly associated with suicidal attempt

A

female sex, younger age of illness onset, depressive polarity of first illness episode, depressive polarity of current or more recentnepisode, comorbid anxiety disorder, comorbid SUD, comorbid cluster B/borderline personality disorder, first-degree family history of suicide,
and previous suicide attempts.

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2
Q

most common method of suicide in this population

A

self-poisoning

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3
Q

mood diary

A

can help identify early warning signs of relapse,

as well as outline relationships between mood and treatment or lifestyle factors such as diet, exercise, or stress

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4
Q

Psychological , maintenance

A

Psychoeducation (PE) First-line (Level 2)
Cognitive behavioural therapy (CBT) Second-line (Level 2)
Family-focused therapy (FFT) Second-line (Level 2)
Interpersonal and social rhythm therapy (IPSRT) Third-line (Level 2)
Peer support Third-line (Level 2)

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5
Q

Psychological, depression

A

Cognitive behavioural therapy (CBT) Second-line (Level 2)
Family-focused therapy (FFT) Second-line (Level 2)
Interpersonal and social rhythm therapy (IPSRT) Third-line (Level 2)

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6
Q

Agitation

A

excessive motor activity associated with a feeling of inner tension

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7
Q

Acute mania: whether to treat a given patient with monotherapy or combination therapy

A

rapidity of response needed (eg, combination treatments tend to work faster), whether the patient had a previous history of partial response to monotherapy, severity of mania, tolerability concerns with combination therapy, and willingness of the patient to take combination therapy.

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8
Q

Acute mania: After how many weeks check for tolerability and efficacy

A

at the end of weeks 1 and 2

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9
Q

Response rate to mono therapy in acute mania

A

Approximately 50% of patients will respond to monotherapy with significant improvement in manic symptoms within 3-4 weeks.

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10
Q

Acute mania: what is generally preferred? Combo trx or mono?

A

Combination

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11
Q

Acute mania: switch or add-on strategies should be considered

A

If no response is observed within 2 weeks with therapeutic doses of antimanic agents

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12
Q

Acute mania, 3rd line

A 
Carbamazepine/oxcarbazepine + Li/DVP Level 3
Chlorpromazine Level 2
Clonazepam Level 2
Clozapine Level 4
Haloperidol + Li/DVP Level 2
rTMS Level 3
Tamoxifen Level 2
Tamoxifen + Li/DVP
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13
Q

lithium is preferred over divalproex for

A

individuals who display classical euphoric grandiose mania (elated mood in the absence of depressive symptoms), few prior episodes of illness, a mania-depression- euthymia course, and/or those with a family history of BD, especially with a family history of lithium response.

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14
Q

divalproex is recommended for

A

multiple prior episodes, predominant irritable or dysphoric mood and/or comorbid substance abuse or those with a history of head trauma

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15
Q

carbamazepine is recommended for

A

when a response is needed faster, in patients judged at risk, who have had a previous history of partial acute
or prophylactic response to monotherapy or in those with more severe manic episodes

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16
Q

Manic episode with anxious distress

A

divalproex, quetiapine, and olanzapine may have specific anxiolytic benefits and carbamazepine may be useful as well.

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17
Q

Manic episode with mixed features

A

atypical antipsychotics and divalproex

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18
Q

Manic episode with psychotic features

A

Li/ epically + atypical antispychotic

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19
Q

Time spent in depressed state

A

2/3s time unwell

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20
Q

Bipolar depression, Rx need response in

A

2 weeks

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21
Q

Acute bipolar 1 depression 3rd line

A 
Aripiprazole (adj) Level 4
Armodafinil (adj) Level 4
Asenapine (adj) Level 4
Carbamazepine Level 2
Eicosapentaenoic acid (EPA) (adj) Level 2
Ketamine (IV) (adj) Level 3
Light therapy +/− total sleep deprivation (adj) Level 3
Levothyroxine (adj) Level 3
Modafinil (adj) Level 2
N-acetylcysteine (adj) Level 3
Olanzapine Level 1
Pramipexole (adj) Level 3
Repetitive transmagnetic stimulation (rTMS) (adj) Level 2
SNRI/MAOI (adj) Level 2
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22
Q

Need for rapid response bipolar depression 1

A

lurasidone, quetiapine

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23
Q

depressive cognitions and psychomotor

slowing

A

lamictal

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24
Q

Bipolar 1 depression with anxious distress

A

quetiapine

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25
Q

MDD who had mixed features and anxiety

A

lurasidone

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26
Q

Bipolar 1 depression rapid cycling

A

Lithium, divalproex, olanzapine, and quetiapine all appear to have comparable maintenance efficacies in these patients

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27
Q

Risk factors for recurrence

A

younger age of onset, psychotic features, rapid cycling, more (and more frequent) previous episodes, comorbid
anxiety, and comorbid SUDs. Persistent subthreshold symptoms also increase risk for subsequent mood episodes.

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28
Q

adjunctive psychosocial treatments

reduce recurrence rates by about

A

15%

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29
Q

When a combination therapy of an atypical antipsychotic with lithium/divalproex was used to treat acute mania, continuing the atypical antipsychotic for
the first x months following response offered clear benefit in reducing risk of mood episode recurrence (level 2),367 but the benefits beyond x months remain uncertain.

A

6

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30
Q

maintenance treatment of bipolar I disorder Third-line

A

Aripiprazole + lamotrigine Level 2
Clozapine (adj) Level 4
Gabapentin (adj) Level 4
Olanzapine + fluoxetine Level 2

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31
Q

Responders to lamotrigine have

A

predominantly depressive polarity

as well as comorbid anxiety

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32
Q

may need to be discontinued to increase the likelihood of conception, as these medications often increase serum prolactin levels and thus interfere with ovulation and decrease fertility.

A

Conventional antipsychotics and risperidone

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33
Q

Taper off Rx for pregnancy criteria

A

stable for a minimum of 4-6 months and are considered at low risk of relapse

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34
Q

can affect the pharmacokinetics of oral contraceptives

and some might significantly reduce the effectiveness of oral contraceptives

A

carbamazepine, topiramate, and lamotrigine,

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35
Q

Don’t give to women of childdbearing age

A

valproate

36
Q

Epival when pregnant

A

elevated risk of neural tube defects (up to
5%), even higher incidences of other congenital abnormalities, and evidence of striking degrees of neurodevelopmental delay in children at 3 years of age and loss of an average of nine IQ points.

37
Q

Because of changes in physiology in the second and early third trimesters, such as increased plasma volume, hepatic activity, and renal clearance, patients

A

may require higher doses of medications towards

the later part of the pregnancy

38
Q

The postpartum period is a time of

A

elevated risk for recurrence

39
Q

postpartum mania Rx

A

benzodiazepines, antipsychotics, and lithium

40
Q

postpartum bipolar depression Rx

A

quetiapine

41
Q

preferred choices for breastfeeding

A

quetiapine and olanzapine

42
Q

Children with comorbid ADHD

A

Adjunctive mixed amphetamine salts (level 3) and methylphenidate (level 3)

43
Q

Comorbid substance use

A

Li , FFT

44
Q

Li monitoring for older adults

A

every 3-6 months, as well as 5-7 days following a lithium dose adjustment or adjustment of non-steroidal anti-inflammatory drugs (NSAIDs), antiontensin II receptor
blockers (ARBs), angiotensin-converting enzyme inhibitors (ACEIs), or thiazide diuretic dosing

45
Q

Divalproex side effects

A

motor side effects and db mellitus, weight gain

46
Q

Starting dose for older people Li

A

150 mghs

47
Q

Comorbid ROH misuse

A

Li + DVP

48
Q

Comorbid THC misuse

A

Li / DVP

49
Q

Comorbid stimulant misuse

A

Citicoline adjunctive therapy
Li/+ DVP
Quetiapine +/ mono
Risperdal+/mono

50
Q

reduction in cravings in hospitalized inpatients

A

olanzapine add on

51
Q

Comorbid GAD/ panic

A

quetiapine
Already on Li, add lamotrigine or olanzapine
when depressed: olanzapine + fluoxetine
gabapentin adj

52
Q

Comorbid OCD

A

lithium,anticonvulsants, olanzapine, risperidone, quetiapine and aripiprazole (all level 4 evidence).

53
Q

comorbid personality disorder

A

divalproex (level 3) and lamotrigine (level 4)

psychoeducation

54
Q

ADHD adults

A

Mixed amphetamine salts (level 3), methylphenidate (level 3), atomoxetine (level 4), bupropion (level 4), or lisdexamfetamine (level 4) add-ons

55
Q

Metabolic syndrome definition

A

abdominal adiposity, hypertension, impaired fasting glucose, diabetes mellitus, and atherogenic dyslipidaemia

56
Q

Baseline laboratory investigations in patients with

bipolar disorder

A 
CBC
Fasting glucose
Fasting lipid profile (TC, vLDL, LDL, HDL, TG)
Platelets
Electrolytes and calcium
Liver enzymes
Serum bilirubin
Prothrombin time and partial thromboplastin time
Urinalysis
Urine toxicology for substance use
Serum creatinine
eGFR
24h creatinine clearance (if history of renal disease)
Thyroid-stimulating
hormone
Electrocardiogram (>40 years or if indicated)
Pregnancy test (if relevant)
Prolactin
57
Q

Rx for metabolic syndrome that benefit mood

A

statins, aspirin and angiotensin antagonists

58
Q

hazard ratio for stroke over 11 years of for those prescribed

A

Li

59
Q

Li other labs to do

A

thyroid and renal function as well as plasma calcium should be assessed at 6 months and at least annually thereafter or as clinically indicated

60
Q

DVP other labs to do

A

Menstrual history (to assess for polycystic ovary syndrome), haematology profile (CBC= thrombocytopenia), PT/PTT and liver function (can increase, transaminase increase) tests should be obtained at 3-6 month intervals during the first year, and yearly thereafter and as clinically indicated serum ammonia if lethargy encephalopathy that they can get from high levels of ammonia

61
Q

Stevens-Johnson syndrome (SJS) and toxic epidermal

necrolysis (TEN) which Rx

A

Lamotrigine Carbamazepine

62
Q

Carbamazepine, other labs to do

A

Na annually (risk of hypoNa)

63
Q

atypical antipsychotics physical exam

A

weight monitored monthly in the first 3 months and every 3 months thereafter. Blood pressure, fasting glucose and lipid profile should be assessed at 3 and 6 months, and yearly thereafter

64
Q

Monitoring Li level

A

It is recommended that two consecutive serum levels be established in the therapeutic range during the acute phase and then measurement be repeated every 3-6
months or more frequently if clinically indicated. serum
levels should be obtained about 5 days after the most recent dose titration.

65
Q

The target serum level for lithium in acute treatment

A

0.8-1.2 mEq/L (0.4-0.8 mEq/L in older adults) while in maintenance treatment, serum levels of 0.6-1
mEq/L may be sufficient

66
Q

Monitoring DVP level

A

It is recommended that two consecutive serum levels be established in the therapeutic range during the acute phase and then measurement be repeated every 3-6
months or more frequently if clinically indicated

67
Q

Monitoring carbmazepine level

A

6-12 monthly intervals

68
Q

target serum level for divalproex is

A

350-700 mM/L in the acute phase and should be obtained 3-5 days after the most recent dose titration

69
Q

The medications most commonly associated with

weight gain

A

olanzapine, clozapine, risperidone, quetiapine, gabapentin, divalproex and lithium

70
Q

options associated with less weight gain

A

carbamazepine, lamotrigine, and ziprasidone

71
Q

reduce nausea

A

Gradual dose titration, taking the medication at bedtime, taking medications with food, and slow release preparations

72
Q

QTC prolongation

A

Li, risperidone, olanzapine, ziprasidone and asenapine

73
Q

Li endocrine

A

hypothyroidis, hyperparathryoidism

74
Q

Epival endocrine

A

New onset oligomenorrhoea or hyperandronism, PCOS,

75
Q

Hyperprolactinaemia can induce

A

amenorrhoea, sexual dysfunction,

and galactorrhoea, amongst other effects. In the long term, it can cause gynaecomastia and osteoporosis.

76
Q

Cognitive impairment

A

anticonvulsants except lamotrigine + Li, epival

77
Q

Sedation

A

epival and atypical antipsychotics

78
Q

Tremor

A

li, epival

79
Q

more likely to cause EPS

A

risperidone, aripiprazole, cariprazine, ziprasidone

and lurasidone

80
Q

comorbid PTSD

A

anticonvulsants

81
Q

target carbamazepine

A

4-12 mcg/mL

17-54 micromol/L

82
Q

Renal toxicity which Rx

A

Lithium has a well-recognized potential for renal toxicity, including nephrogenic diabetes insipidus (NDI), chronic tubulointerstitial nephropathy, and acute tubular necrosis. Upwards of 70% of patients on chronic lithium treatment will experience polyuria, which can cause impairment in work and daily functioning. Long-term
administration (ie, 10-20+ years) is further associated with decreased glomerular filtration rate and chronic kidney disease. While the overall risk for progressive renal failure is low, plasma creatinine concentrations and ideally estimated glomerular filtration rate (eGFR) for these patients should be measured at least every 3-6
months.

83
Q

risk of abnormal QT prolongation which Rx

A

Li

84
Q

Gastrointestinal symptomswhich Rx

A

Both lithium and divalproex are commonly associated with nausea, vomiting, and diarrhoea, with 35%-45% of patient experiencing these side effects. For lithium, this is particularly pronounced during treatment initiation, or rapid dose increases.812 Gradual dose titration, taking the medication at bedtime, taking medications with food, and slow release preparations may reduce nausea and other side effects.

85
Q

Weight gain, which Rx

A

The medications most commonly associated with weight gain are olanzapine, clozapine, risperidone, quetiapine, gabapentin, divalproex and lithium; with carbamazepine, lamotrigine, and ziprasidone being the safer or options associated with less weight gain.

Reasoning in mental health 3 (11 decks)

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