Chapter 65: Bipolar Disorder

Question 1

Bipolar I definition

Answer 1

at least one episode of mania, and usually, bouts of intense depression

Question 2

Mania is associated with at least one of the following:

Answer 2

significant impairment in social/work functioning, psychosis/delusions or requires hospitalization

Question 3

Bipolar II definition

Answer 3

at least one episode of hypomania (lasting > 4 consecutive days) and at least one depressive episode (lasting > 2 weeks)

Question 4

Antidepressants can induce or exacerbate a manic episode when used as monotherapy, so they should only be used when

Answer 4

in combination with a mood stabilizer (i.e., lithium or antiepileptic drugs like valproate, lamotrigine, and carbamazepine)

Question 5

First-line treatment for a manic episode

Answer 5

valproate, lithium, or antipsychotic

Question 6

First-line treatment for a depressive episode & an alternative

Answer 6

antipsychotic (quetiapine or lurasidone)
Lithium, valporate, or lamotrigine can be used as an add on or alternative

Question 7

MedGuides are required with all antidepressants (primarily d/t ____) and with all antipsychotics (primarily d/t increased risk of ____ in elderly patients with dementia-related psychosis

Answer 7

suicide risk
risk of death

Question 8

Valproate exposure in pregnancy can increase the risk of fetal anomalies, including ____, fetal valproate syndrome and long-term adverse ____. Should it be avoided in pregnancy?

Answer 8

1. neural tube defects
2. cognitive effects
3. Avoid in pregnancy, if possible, especially during the first trimester

Question 9

Carbamazepine exposure in pregnancy can cause fetal carbamazepine syndrome, which can result in ____ and other significant issues. Avoid in pregnancy, if possible, especially during the first trimester

Answer 9

facial abnormalities

Question 10

Lithium exposure in pregnancy can cause an increase in ____ and other abnormalities

Answer 10

congenital cardiac malformations

Question 11

What is a safer option relative to the other mood stabilizers for pregnancy?

Answer 11

• lamotrigine
• lurasidone has the most favorable safety profile in pregnancy, but its use is limited since it is only approved for bipolar depression

Question 12

Several anticonvulsants are used for the treatment of bipolar disorder, including

Answer 12

Lamotrigine, Valproate, Carbamazepine

Question 13

A major concern with antipsychotics is the risk of EPS. Which generation of antipsychotics have a higher incidence of EPS

Answer 13

First generation (e.g., haloperidol)

Question 14

Lithium brand name

Answer 14

Lithobid

Question 15

Therapeutic range of lithium

Answer 15

0.6-1.2 mEq/L (trough level)

Question 16

Warnings of Lithium

Answer 16

serotonin syndrome, renal impairment, hyponatremia and dehydration

Question 17

Lithium SE when within therapeutic range

Answer 17

GI upset, cognitive effects, cogwheel rigidity, fine hand tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism

Question 18

Lithium SE when in toxic range (> 1.5 mEq/L)

Answer 18

ataxia, coarse hand tremor, vomiting

Question 19

Lithium SE when in toxic range (> 2.5 mEq/L)

Answer 19

CNS depression, arrhythmia, seizure, coma

Question 20

Lithium monitoring

Answer 20

lithium levels, renal function, thyroid function

Question 21

How is lithium cleared?

Answer 21

Renally

Question 22

Can lithium be used in pregnancy?

Answer 22

No - associated with cardiac malformations in the first trimester

Question 23

Lithium levels increase with:

Answer 23

↓ salt intake, sodium loss (e.g., with ACEi, ARBs, thiazide diuretics)

avoid NSAIDs except aspiring or sulindac are safer options

Question 24

Lithium levels decrease with:

Answer 24

↑ salt intake, caffeine and theophylline

Question 25

There is an ↑ risk of serotonin syndrome if Li is taken with

Answer 25

SSRIs, SNRIs, triptans, linezolid, and other serotonergic drugs

Question 26

__ mL of lithium citrate syrup = __ mEq of lithium ion

Answer 26

5
8

Question 27

__ mEq of lithium ion = __ mg lithium carbonate tabs/caps

Answer 27

8
300

Question 28

T/F: Lithium should be taken with food

Answer 28

True

to reduce nausea