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4. Mood Disorders > CANMAT Guidelines: Bipolar Disorder part 1 > Flashcards

CANMAT Guidelines: Bipolar Disorder part 1 Flashcards

1
Q

list the agents recommended as FIRST line treatment for acute mania

A

lithium

quetiapine

divalproex

asenapine

aripiprazole

paliperidone

risperidone

cariprazine

(alone or in combo)

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2
Q

list the FIRST line treatments recommended for acute bipolar depression

A

quetiapine

lurasidone + lithium or divalproex

lithium

lamotrigine

lurasidone

adjunctive lamotrigine

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3
Q

for those initiating or switching treatments during the maintenance phase, which medications would be considered FIRST line for this phase of bipolar disorder

A

lithium

divalproex

lamotrigine

asenapine

aripiprazole

(monotherapy or in combination)

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4
Q

which types of treatments should be tried first in bipolar disorder management

A

those that show efficacy across the spectrum of the illness, as BD is cyclical with different phases

i.e lithium

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5
Q

what is the estimated lifetime prevalence of illness across bipolar I, II and subthreshold bipolar disorder subtypes according to the world mental health survey

A

2.4%

(1.5% 12 month prevalence)

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6
Q

what is the lifetime prevalence of bipolar I

A

0.6%

(0.4% 12 month prevalence)

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7
Q

what is the lifetime prevalence of bipolar II

A

0.4%

(0.3% 12 month prevalence)

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8
Q

when does BD typically manifest

A

late adolescence and young adulthood

overall age of onset at 25 years

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9
Q

how many “age of onset” groups are there within bipolar disorder I

A

3

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10
Q

what are the 3 “age of onset” age ranges for BDI

A

early onset (large/42%)–> around age 17 +/- 3 years

middle onset (smaller/26%)–> 24 years +/- 5 years

late onset (34%)–> 32 +- 12 years

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11
Q

what comorbid conditions/symptoms are associated with earlier age of onset

A

longer delay to treatment

greater depressive severity

higher levels of anxiety and substance use

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12
Q

in which cases should organic mania be considered and investigated

A

when mania onset occurs after age 50

(though manic episodes can occur for first time after age 50)

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13
Q

for what % of their lives do people with BD tend to be symptomatic with syndromal or subsyndromal symptoms

A

about 50% of their lives

leads to signifiant impairment

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14
Q

for what % of the time are people with BD generally unable to maintain proper work role function

A

about 30% of the time or mroe

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15
Q

list the specifiers included in the DSM V for manic episodes

A

anxious distress

mixed features

psychotic features

catatonia

peripartum onset

remission

current episode severity

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16
Q

list specifiers included in the DSM V for depressive episodes

A

anxious distress

mixed features

melancholic features

atypical features

psychotic features

catatonia

peripartum onset

remission

current episode severity

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17
Q

list specifiers listed in the DSM V for illness course in BD

A

rapid cycling

seasonal pattern

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18
Q

why do we are about preventing mood episodes in BD

A

because on average the risk of recurrence increases with # of previous episodes

also–> number of previous episodes is associated with increased duration and symptomatic severity of subsequent episodes

also–> number of episodes is associated with lower threshold for developing further episodes

also–> increased risk of dementia with more episodes

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19
Q

what are the three broad clinical stages in the staging system for BD

A
  1. individuals at increased risk for developing BD due to family history as well as certain subsyndromal symptoms predictive of conversion to full BD
  2. patients with fewer episodes and optimal functioning in interepisodic periods
  3. patients with recurrent episodes as well as decline in functioning and cognition

*heterogeneity in BD has prevented clinical use of staging systems

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20
Q

what is the most frequent midiagnosis in bipolar disorder

A

MDD

b/c patients are more likely to present for tx of depressive symptoms

may not recall periods of mania or hypomania or may not interpret as pathological

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21
Q

list 10 features of depression that may increase suspicion of bipolarity

A
  1. earlier age of illness onset
  2. highly recurrent depressive episodes
  3. family history of BD
  4. depression with psychotic features
  5. psychomotor agitation
  6. atypical depressive symptoms
    –hypersomnia
    –hyperphagia
    –leaden paralysis
  7. postpartum depression and psychosis
  8. past suicide attempts
  9. antidepressant induced manic symptoms
  10. rapid cycling
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22
Q

what is the second most common misdiagnosis for BD

A

schizophrenia and other psychotic disorders –> occurs as initial diagnosis in asm any as 30% of patients

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23
Q

what is considered “early onset of first depression” and thus more suspicious of bipolarity

A

under age 25

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24
Q

which psychiatric disorders are often labelled incorrectly as BD

A

borderline PD

SUDs

ADHD

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25
Q

what is a good screening tool for flagging patients who may have signs/symptoms of BD

A

the Mood Disorders Questionnaire (MDQ)

this is a validated self report instrument

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26
Q

what is a limitation of questionnaires like the MDQ

A

poor sensitivity and specificity especially in community or in high comorbid settings

elevated risk of flagging those with borderline traits

*should only be used as adjunct for screening clinical populations and not for diagnostic or treatment purposes

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27
Q

what disorders are particularly common alongside BD (common comorbidities)

A

SUDs

impulse control disorders

anxiety disorders

personality disorders (esp cluster B)

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28
Q

ddx BD

A

MDD

PDD

BD related to another medical condition

substance or med induced BD

cyclothymic disorder

psychotic disorders

borderline PD

narcissistic PD

antisocial PD

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29
Q

what % of identified patients with BD die by suicide

A

6-7%

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30
Q

what % of patients with BD worldwide report SI

A

43%

21% have plan

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31
Q

what % of patient with BD have attempted suicide in the past year worldwide

A

16%

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32
Q

which gender of people with BD have higher risk of dying by suicide

A

men

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33
Q

how does risk of suicide attempt + risk of fatality differ in those with BD

A

risk of suicide is substantially higher in BD (10.7 per 100 000 per year)

fatality of attempts is higher in BD

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34
Q

list 9 factors that have been significantly associated with suicidal ATTEMPT in BD

A
  1. female sex
  2. younger age of illness onset
  3. depressive polarity of first illness episode
  4. depressive polarity of current or more recent episode
  5. comorbid anxiety disorder
  6. comorbid SUD
  7. comorbid cluster B/borderline PD
  8. first degree family history of suicide
  9. previous suicide attempts
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35
Q

what are the only two risk factors that have been significantly associated with suicide DEATHS in BD

A
  1. male sex
  2. first degree family history of suicide

*older age also results in a higher degree of lethality of attempts with higher ratio of death:attempts

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36
Q

what periods of time are associated with higher risk of suicide in BD

A

periods during and following hospital admission

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37
Q

what % of suicides in BD occur DURING an inpatient stay

A

14%

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38
Q

what % of suicides in BD occur within 6 weeks of discharge

A

26%

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39
Q

what % of suicides in BD occur within the 6 weeks after an inpatient stay

A

26%

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40
Q

what medication used in BD has been shown to preventing suicide attempts + deaths

A

lithium

+anticonvulsants to a lesser extent

(limited data on APs and antidepressants)

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41
Q

what is the most common method of suicide in BD

A

self poisoning

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42
Q

what are the initial and foundational steps for all patients being treated for BD

A

patient health education + pharmacotherapy

(after basic clinical management like attention to dx, comorbidity, medical health)

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43
Q

what tool can patients use to monitor their symptoms and identify early warning signs of relapse

A

the NIMH Life Chart Method-Self Rating Scale

*has been shown to improve treatment but regular completion can be a burden

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44
Q

what is a phone app that might be an alternative to the NIMH Life Chart Method–Self Rating Scale if that is too cumbersome

A

the SIMPLE phone app

(self monitoring and psychoeducation in bipolar patients)

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45
Q

are there any specific recommendations for psychosocial interventions in acute mania?

A

no–> no evidence exists, and thus there are no recommendations

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46
Q

for which psychosocial interventions is there positive evidence in the maintenance phase of BD

A

CBT (2nd line)

family focused therapy (2nd line)

interpersonal and social rhythm therapy (3rd line)

peer support (3rd line)

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47
Q

what psychosocial intervention is first line in maintenance phase of BD

A

psychoeducation

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48
Q

name two models of psychoeducation delivered in a group format to euthymic people with BD that have published manuals and substantial research support

A
  1. Barcelona BDs program (21 sessions over 6 months)
  2. Life Goals Program (phase I has 6 weekly sessions)

*both have level 2 evidence for prevention of relapse

49
Q

how many sessions of individual psychoeducation would be required to be a first line intervention for relapse prevention in BD?

A

at least 5 sessions

level 2 evidence for relapse prevention

50
Q

is psychoeducation + pharmacology improve illness course compared to pharmacology alone

A

yes–> striking overal improvement

*no clear evidence in either acute mania or depression, but has good evidence in maintenance

51
Q

is CBT recommended in acute bipolar depression

A

yes–> second line–> level 2 evidence

52
Q

how does interpersonal and social rhythm therapy differ from IPT

A

includes regulation of social and sleep rhythms specifically targeted to the bipolar population

24 individual sessions over 9 months

53
Q

in which types of patients with BD is agitation particularly common

A

those with mixed features

54
Q

what is the DSM V definition of agitation

A

“excessive motor activity associated with feeling of inner tension”

55
Q

list the 4 first line agents recommended for management of agitation in BD

A

aripiprazole IM (9.75 mg)

lorazepam IM (2mg)

loxapine inhaled (5mg)

olanzapine IM (2.5mg)

56
Q

list 6 second line agents (or combinations) recommended for managing agitation in mania

A

asenapine

haloperidol IM

haloperidol + midazolam

haloperidol + promethazine

risperidone

ziprasidone

57
Q

is loxapine IM first line for management of agitation in mania

A

no–> IM is third line, inhaled is first line

*absence of evidence does not constitute lack of efficacy

58
Q

how should you approach pharmacological treatment of acute mania when looking at the list of first and second line agents in CANMAT guidelines

A

they are listed HIERARCHICALLY

the implication is that those listed higher up in the table should be considered FIRST before moving on to the next on the list, unless other factors such as hx of previous non response or patient preference preclude such a strategy in a given patient

59
Q

should monotherapy be tried before combination therapy?

A

not necessarily–> treating clinician makes the decision for mono or combo therapy

*based on rapidity of response needed, whether hx previous partial response to monotherapy, severity of mania, tolerability concerns with combo therapy and willingness of patient to take combo therapy

60
Q

which works faster for acute mania, mono or combo therapy

A

combo

61
Q

what factors play into how first and second line treatments for acute mania are ranked

A

efficacy for acute mania

efficacy in preventing mania or depression

treating bipolar depression

safety/tolerability

risk of tx emergent switch

62
Q

what is the top ranked treatment for acute mania per the guidelines

A

lithium

63
Q

list the first line monotherapy treatments for acute mania IN ORDER per the guidelines (theres 8 on the list)

A
  1. lithium
  2. quetiapine
  3. divalproex
  4. asenapine
  5. aripiprazole
  6. paliperidone (above 6 mg)
  7. risperidone
  8. cariprazine
64
Q

what is a mnemonic for remembering the first line monotherapy treatments for acute mania

A

Love Quiet Days At A Placid Rustic Cabin

Lithium

Quetiapine

Asenapine

Aripiprazole

Paliperidone

Risperidone

Cariprazine

65
Q

List the 4 first line combination therapies for acute mania IN ORDER

A
  1. Quetiapine + lithium/divalproex
  2. Aripiprazole + lithium/divalproex
  3. Risperidone + lithium/divalproex
  4. Asenapine + lithium/divalproex
66
Q

what is a mnemonic for the 4 first line combination therapies for acute mania

A

Quiet A Righteous Asshole

Quetiapine
Aripiprazole
Risperidone
Asenapine
+lithium/divalproex

67
Q

list second line treatments (combo + mono) for acute mania IN ORDER

A
  1. olanzapine
  2. carmabazepine
  3. olanzapine + lithium/divalproex
  4. lithium + divalproex
  5. ziprasidone
  6. haloperidol
  7. ECT
68
Q

what is a mnemonic for second line treatments for acute mania

A

Only Cows On LSD Zipline Happily Evermore

69
Q

with which treatment for acute mania is there a concern for depressive switch

A

haldol

70
Q

does aripriprazole treat acute bipolar depression

A

no

71
Q

which first line treatments for acute mania have data for treating acute depression as well

A

lithium

quetiapine

divalproex

cariprazine

72
Q

which first line treatments for acute mania have data for preventing depression

A

lithium

quetiapine

divalproex

asenapine

73
Q

which first line agents for treatment of acute mania have evidence for preventing mania

A

all EXCEPT cariprazine

74
Q

which first line agent for acute mania has the most tolerability concerns in the acute period

A

quetiapine

75
Q

which first line agents for acute mania (3) have the most safety concerns in the maintenance period

A

lithium

quetiapine

divalproex

76
Q

which first line agents for acute mania (4) have the most tolerability concerns in the maintenance period

A

lithium

quetiapine

paliperidone

risperidone

77
Q

which first line combination therapies for acute mania have the most safety concerns in the maintenance period

A

quetiapine + lithium/divalproex

risperidone + lithium/divalproex

*significant impact on treatment selection

78
Q

which combination therapy for acute mania seems to have the best tolerability and safety profile in the maintenance period

A

asenapine + lithium/divalproex

*but this is also ranked fourth in the combo ranking

the next safest/most tolerable is aripiprazole + lithium/divalproex followed by the quetipaine and risperidone combos

79
Q

does lithium treat and/or prevent bipolar deprssion

A

yes it both treats and prevents

80
Q

does olanzapine treat and/or prevent bipolar deprssion

A

yes it both treats and prevents

81
Q

does ziprasidone treat and/or prevent bipolar deprssion

A

no data for prevention

data shows it does NOT treat bipolar depression

82
Q

does ECT treat and/or prevent bipolar deprssion

A

it seems to do both (level 4 evidence)

83
Q

does haloperidol treat and/or prevent bipolar deprssion

A

data suggests it does NOT prevent

no data with regard to treating bipolar depression

84
Q

which 3 second line agents for acute mania have the most safety concerns in the maintenance period

A

olanzapine

olanzapine + li/dvp

haloperidol

85
Q

which second line treatment for acute mania appears to be best tolerated in the maintenance phase

A

ziprasidone

86
Q

when should efficacy of treatment for acute mania be evaluated

A

at the end of weeks 1 and 2 and then treatment options modified accordingly

87
Q

what do you do if a patient presents manic, but is currently on antidepressants

A

stop the antidepressants

if this is first presentation of mania, then should observe patient for a period of time after antidepressant discontinuation before starting antimanic therapy and obtain collateral

88
Q

what % of patients presenting with acute mania will respond to monotherapy? in what time frame?

A

50% within 3-4 weeks

89
Q

how does efficacy compare in acute mania treatment between the first line monotherapy agents

A

comparable efficacy

90
Q

despite having level 1 evidence for efficacy, why are carmabazepine, olanzapine, ziprasidone and haloperidol downgraded to second line treatments for acute mania

A

due to safety/tolerability risks

91
Q

why is combination therapy preferred to mood stabilizer monotherapy in acute mania

A

on average, about 20% more patients will respond to combo therapy

*though there are fewer trials, there is also evidence for combo therapy compared to atypical antipsychotic monotherapy for efficacy

92
Q

which is associated with more adverse events, combo or monotherapy (in acute mania)

A

combo

93
Q

after how long did almost all anti-manic agents separate from placebo in trials

A

after one week

therefore, expect some therapeutic response to antimanic agents within 1-2 weeks

94
Q

which first line anti manic agents that are recommended for monotherapy are NOT recommended for combination therapy

A

paliperidone and ziprasidone

due to lack of evidence for additional efficacy

95
Q

what % of patients is it estimated will respond to ECT as antimanic treatment

A

up to 80%

96
Q

what type of ECT has been used for treating mania

A

brief pulse therapy with 2-3 treatments per week

bifrontal electrode placement preferred over bitemporal

97
Q

why is bifrontal electrode placement preferred in ECT for treatment of mania rather than bitemporal

A

assoc with faster treatment response and fewer cognitive side effects

98
Q

what non-AP or mood stabilizer has level 2 evidence for treatment of acute mania and is third line

A

tamoxifen

(downgraded because of the risk of uterine cancer and lack of clinical experience DESPITE EVIDENCE FOR EFFICACY)

99
Q

what neurostimulation therapy, other than ECT, can be considered as third line in treatment of acute mania

A

rTMS

100
Q

is lamotrigine indicated for treatment of acute mania

A

no

101
Q

name a non pharmacologic intervention that has level 3 evidence for treatment of acute mania when combined with other anti manic agents

A

glasses that block blue light

102
Q

list 3 “nutraceuticals” that have shown indications of efficacy when used adjuctively with other antimanic agents

A

folic acid (level 2 evidence)

blocked chain amino acids (level 3 evidence)

L-tryptophan (level 3 evidence )

103
Q

when would you usually choose lithium over divalproex when treating mania

A
  1. those who display classical euphoric grandiose mania
  2. few episodes of prior illness
  3. a mania-depression-euthymia course

and/or

  1. those with family history of BD (especially if family hx of lithium response)
104
Q

when would you usually choose divalproex over lithium when treating mania

A
  1. person has multiple prior episodes
  2. predominant irritable or dysphoric mood
  3. comorbid substance use

and/or

  1. those with hx head trauma
105
Q

in what population must care be taken with divalproex

A

women of childbearing age–> teratogenic

106
Q

which two antimanic agents may be particularly considered in those with a history of head trauma

A

divalproex

carbamazepine

107
Q

does the presence of anxious distress during a manic episode give any prognostic information

A

yes–>

predictor of poor outcome

i.e greater severity of manic symptoms, longer time to remission, more reported side effects of medication

108
Q

are there specific agents recommended to treat anxious distress is mania

A

not studies specifically examining this–> anxious distress tends to improve as the mood episode improves

post hoc analyses:
divalproex
quetiapine
olanzapine
may be helpful

109
Q

in what % of cases do depressive symptoms CO-OCCUR alongside mania

A

10-30%

110
Q

does the presence of mixed features give clues as to prognosis

A

indicative of more SEVERE and DISABLING course

HIGHER RATE OF SUICIDE

111
Q

what pharmacologic treatment plan is preferred in patients presenting with BD with mixed features

A

preferential use of atypical APs + DIVALPROEX combo therapy

112
Q

what % of manic episodes are characterized by the presence of psychosis

A

at least HALF

113
Q

does it matter whether psychotic symptoms are mood congruent or incongruent in BD

A

if psychosis is mood incongruent seem t have more severe illness with poorer long term prognosis

114
Q

is there any evidence of superiority of any first line antimanic monotherapy compared to any other when psychotic features are present?

A

no

also no evidnece that any particular combo therapy is better for psychotic features

**clinical experience suggests combo therapy of atypical AP + li/dvp more appropriate for manic patients with mood-incongruent psychotic features

115
Q

what is the definition of rapid cycling BD

A

course of illness that includes four or more mood episodes in a year

116
Q

what % of patients with bipolar I have rapid cycling BD

A

about 30%

117
Q

what three other factors are often associated with rapid cycling in BD

A

hypothyroidism

antidepressant use

substance use

118
Q

what should you try if your patient is rapid cycling

A

check thyroid function

stop antidepressants, stimulants or other psychotropic agents that may be contributing to cycling

consider withdrawing substances

4. Mood Disorders (17 decks)

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