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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
MDD who had mixed features and anxiety
lurasidone
26
Bipolar 1 depression rapid cycling
Lithium, divalproex, olanzapine, and quetiapine all appear to have comparable maintenance efficacies in these patients
27
Risk factors for recurrence
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.
28
adjunctive psychosocial treatments | reduce recurrence rates by about
15%
29
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.
6
30
maintenance treatment of bipolar I disorder Third-line
Aripiprazole + lamotrigine Level 2 Clozapine (adj) Level 4 Gabapentin (adj) Level 4 Olanzapine + fluoxetine Level 2
31
Responders to lamotrigine have
predominantly depressive polarity | as well as comorbid anxiety
32
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.
Conventional antipsychotics and risperidone
33
Taper off Rx for pregnancy criteria
stable for a minimum of 4-6 months and are considered at low risk of relapse
34
can affect the pharmacokinetics of oral contraceptives | and some might significantly reduce the effectiveness of oral contraceptives
carbamazepine, topiramate, and lamotrigine,
35
Don't give to women of childdbearing age
valproate
36
Epival when pregnant
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
Because of changes in physiology in the second and early third trimesters, such as increased plasma volume, hepatic activity, and renal clearance, patients
may require higher doses of medications towards | the later part of the pregnancy
38
The postpartum period is a time of
elevated risk for recurrence
39
postpartum mania Rx
benzodiazepines, antipsychotics, and lithium
40
postpartum bipolar depression Rx
quetiapine
41
preferred choices for breastfeeding
quetiapine and olanzapine
42
Children with comorbid ADHD
Adjunctive mixed amphetamine salts (level 3) and methylphenidate (level 3)
43
Comorbid substance use
Li , FFT
44
Li monitoring for older adults
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
Divalproex side effects
motor side effects and db mellitus, weight gain
46
Starting dose for older people Li
150 mghs
47
Comorbid ROH misuse
Li + DVP
48
Comorbid THC misuse
Li / DVP
49
Comorbid stimulant misuse
Citicoline adjunctive therapy Li/+ DVP Quetiapine +/ mono Risperdal+/mono
50
reduction in cravings in hospitalized inpatients
olanzapine add on
51
Comorbid GAD/ panic
quetiapine Already on Li, add lamotrigine or olanzapine when depressed: olanzapine + fluoxetine gabapentin adj
52
Comorbid OCD
lithium,anticonvulsants, olanzapine, risperidone, quetiapine and aripiprazole (all level 4 evidence).
53
comorbid personality disorder
divalproex (level 3) and lamotrigine (level 4) | psychoeducation
54
ADHD adults
Mixed amphetamine salts (level 3), methylphenidate (level 3), atomoxetine (level 4), bupropion (level 4), or lisdexamfetamine (level 4) add-ons
55
Metabolic syndrome definition
abdominal adiposity, hypertension, impaired fasting glucose, diabetes mellitus, and atherogenic dyslipidaemia
56
Baseline laboratory investigations in patients with | bipolar disorder
``` 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
Rx for metabolic syndrome that benefit mood
statins, aspirin and angiotensin antagonists
58
hazard ratio for stroke over 11 years of for those prescribed
Li
59
Li other labs to do
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
DVP other labs to do
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
Stevens-Johnson syndrome (SJS) and toxic epidermal | necrolysis (TEN) which Rx
Lamotrigine Carbamazepine
62
Carbamazepine, other labs to do
Na annually (risk of hypoNa)
63
atypical antipsychotics physical exam
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
Monitoring Li level
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
The target serum level for lithium in acute treatment
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
Monitoring DVP level
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
Monitoring carbmazepine level
6-12 monthly intervals
68
target serum level for divalproex is
350-700 mM/L in the acute phase and should be obtained 3-5 days after the most recent dose titration
69
The medications most commonly associated with | weight gain
olanzapine, clozapine, risperidone, quetiapine, gabapentin, divalproex and lithium
70
options associated with less weight gain
carbamazepine, lamotrigine, and ziprasidone
71
reduce nausea
Gradual dose titration, taking the medication at bedtime, taking medications with food, and slow release preparations
72
QTC prolongation
Li, risperidone, olanzapine, ziprasidone and asenapine
73
Li endocrine
hypothyroidis, hyperparathryoidism
74
Epival endocrine
New onset oligomenorrhoea or hyperandronism, PCOS,
75
Hyperprolactinaemia can induce
amenorrhoea, sexual dysfunction, | and galactorrhoea, amongst other effects. In the long term, it can cause gynaecomastia and osteoporosis.
76
Cognitive impairment
anticonvulsants except lamotrigine + Li, epival
77
Sedation
epival and atypical antipsychotics
78
Tremor
li, epival
79
more likely to cause EPS
risperidone, aripiprazole, cariprazine, ziprasidone | and lurasidone
80
comorbid PTSD
anticonvulsants
81
target carbamazepine
4-12 mcg/mL | 17-54 micromol/L
82
Renal toxicity which Rx
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
risk of abnormal QT prolongation which Rx
Li
84
Gastrointestinal symptoms which Rx
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
Weight gain, which Rx
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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