Chapter 65 - Bipolar Disease Flashcards
Bipolar disorder is classified as bipolar I or bipolar II, which differ primarily by
the severity of mania experienced
BIPOLAR 1
- At least one episode of mania, and usually, bouts of intense depression (a depressive episode is not required for diagnosis).
- Mania is associated with at least one of the following:
1) significant impairment in social/work functioning,
2) psychosis/delusions or
3) requires hospitalization.
BIPOLAR II
- At least one episode of hypomania (lasting >= 4 consecutive days) and
- At least one depressive episode (lasting >= 2 weeks).
- Hypomania does not affect social/work functioning, does not cause psychosis nor require hospitalization.
BIPOLAR DEPRESSION
Predominant symptoms of a depressive episode include
- Feelings of sadness or depressed mood and/or
- Loss of interest in previously enjoyed activities.
PSYCHOSIS
Severe mental condition where there is a loss of contact with reality, involves abnormal thinking and perception (e.g.,hallucinations and delusions).
Cyclothymia
is a related disorder consisting of periods of hypomanic and depressive symptoms without meeting criteria for a major depressive, manic or hypomanic episode.
Symptoms of mania
Symptoms
■ Inflatedself-esteem
■ Needs less sleep
■ More talkative than normal
■ Jumping from topic to topic
■ Easilydistracted
■ Increase in goal-directed activity
■ High-risk,pleasurableactivities
(e.g.,buying sprees, sexual indiscretions, gambling)
Definition of mania
Definition
Abnormally elevated OR irritable mood for at least a week (or any duration if hospitalization is needed)
Diagnosis of mania
Diagnosis
- Exhibits >= 3 symptoms
- If mood is only irritable, exhibits >= 4 symptoms
Should you do any screening before diagnosis?
A toxicology screen should be done prior to starting treatment to rule out drug- induced mania.
Goal of treatment
The goal of treatment is to stabilize the mood without inducing a depressive or manic state.
What are the traditional mood stabilizers?
What do they treat?
The traditional mood stabilizers, such as:
- Lithium and
- Antiepileptic drugs (valproate, lamotrigine and carbamazepine),
treat both mania and depression without inducing either state.
What can help stabilize mood when mania occurs with psychosis?
Antipsychotics, while not traditional mood stabilizers, can help stabilize the mood when mania occurs with psychosis.
Can you give antidepressants as a monotherapy?
Antidepressants can induce or exacerbate a MANIC episode when used as monotherapy, so they should only be used in combination with a mood stabilizer.
To select treatment, consider the following:
■ The side effect profile of the drug.
■ The patient’s medication history and first-degree relatives’ medication history;
if the patient or a family member responded well to a drug, the same drug might be a reasonable option.
■ The drug formulations available and cost.
Acute Manic episode:
first-line treatment is:
- Valproate,
- Lithium or
- An antipsychotic.
A combination of an antipsychotic + lithium or valproate is preferred for SEVERE episodes.
Acute Depressive episode:
- First-line treatment is lithium,
- Lamotrigine can be used as an alternative.
Maintenance
1) Preferred monotherapy:
- Lithium
- Valproate
2) Alternatives:
- Lamotrigine,
- carbamazepine
- second-generation antipsychotics (SGAs)
3) Antipsychotics or antidepressants may be added to lithium or valproate
MedGuides are required with all antidepressants (primarily due to —) and with all antipsychotics (primarily due to—).
MedGuides are required with all antidepressants (primarily due to suicide risk) and with all antipsychotics (primarily due to increased risk of death in elderly patients with dementia- related psychosis).
Pregnancy and Valproate
Valproate exposure in pregnancy can increase the risk of fetal anomalies, including:
- neural tube defects,
- fetal valproate syndrome
- long-term adverse cognitive effects.
Avoid in pregnancy, if possible, especially during the first trimester.
Pregnancy and Carbamazepine
Carbamazepine exposure in pregnancy can cause:
- Fetal carbamazepine syndrome,
which can result in facial abnormalities and other significant issues.
Avoid in pregnancy, if possible, especially during the first trimester.
Pregnancy and Lithium
Lithium exposure in pregnancy can cause:
- An increase in congenital cardiac malformations and other abnormalities.
During pregnancy, — is a safer option relative to the other mood stabilizers mentioned in this section.
lamotrigine
— are safer choices than valproate, carbamazepine or lithium.
SGA
