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Mental Health > General Principles of Bipolar Treatment > Flashcards

General Principles of Bipolar Treatment Flashcards

1
Q

Bipolar treatment categories involve…

3 categories

A

Acute mania treatment
Acute depression treatment
Maintenance treatment

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2
Q

A good approach to starting treatment in any phase in BD involve the following steps:

4 steps (Really we should be doing this when starting any treatment)

A
  1. Review general principles and assess medication status; adherence
  2. Initiate or optimize therapy
  3. Add-on or switch therapy
  4. Monitor/Maintain
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3
Q

When assessing a patient in an acute manic episode, we need to assess some factors, such as…

A

Risk of aggressive behaviour, violence, suicide
Degree of insight
Ability to adhere to treatment
Co-morbidities
Physical condition and lab tests

Most appropriate treatment setting?

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4
Q

In acute mania treatment, we should discontinue…

A

AD’s
Stimulants (caffeine, amphetamines, CS)
Alcohol
Nicotine

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5
Q

We need to rule out other causes when assessing acute mania, such as…

A

Prescribed medication
Illicit-drug use/abuse
Endocrine/neurological disorders

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6
Q

1st line monotherapy indicated for acute mania treatment include…

Mood stabilizers, AAP’s; how many respond, and when?

A

Lithium, valproic acid, divalproex, aripiprazole, low dose paliperidone, risperdone

All have level 1 evidence :) Asenapine also included, but is newer

50% respond to monotherapy with significant improvement in mania, in 3-4 weeks

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7
Q

1st line combinations for acute mania treatment include…

___ + ___

A

Lithium/DVP + Quetiapine/risperidone/asenapine/aripiprazole

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8
Q

Combo therapy for acute mania is recommended when…

A

A response is needed faster
Patients with a previous history of partial response to monotherapy, or more severe manic episodes

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9
Q

In general, combination therapy is preferred to mood stabilizer monotherapy for acute mania treatment, because…

A

On average, about ~20% more patients will respond to combination therapy

Greater efficacy of combination compared to lithium/DVP alone

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10
Q

Some second-line treatment monotherapy options for acute mania include…

A

Olanzapine
Carbamazepine
Ziprasidone
Haloperidol

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11
Q

Some second-line combination options for acute mania include…

A

Olanzapine + lithium/DVP
Lithium + DVP

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12
Q

Lithium is preferred over divalproex for individuals who…

A

Display classical euphoric grandiose mania
Few prior episodes of illness
Family history of BD, especially with family history of lithium response

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13
Q

Divalproex is preferred over lithium for individuals who…

A

Have had multiple prior episodes
Predominant irritable/dysphoric mood, and/or comorbid substance abuse
History of head trauma

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14
Q

Carbamazepine may be a better option for acute mania treatment in patients with specific factors, such as…

A

Hx of head trauma or neurologic symptoms
Comorbid anxiety/substance abuse, or schizoaffective presentations with mood-incongruent delusions

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15
Q

Patients with mixed feature BD should use…

A

DVP +/- AP’s, especially effective in combination

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16
Q

After starting a 1st line agent for acute mania, some therapeutic response is expected within…

A

1-2 weeks

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17
Q

Switching therapy or add-on strategies in acute mania should be considered when…

A

No response is observed within 2 weeks, with therapeutic doses + other contributing factors are excluded

Either combination of 1st line agents, or 2nd line therapies

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18
Q

ECT may be recommended in mania treatment, when…

A

Mania is refractory

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19
Q

Agents NOT recommended for acute mania and should be avoided include…

A

Gabapentin
Lamotrigine
Omega 3 fatty acids
Topiramate

20
Q

With BD1 depression, we need to assess patient factors such as…

A

Severity of depression - risk of suicide/self-harm behaviour
Ability to function and adhere to treatment
Previous treatments

Consider appropriate treatment as well

21
Q

With BD1 depression, we should discontinue…

A

Stimulants
Nicotine, caffeine
Drug/alcohol use

22
Q

With BD1 depression, we need to rule out…

A

Symptoms due to alcohol/drug use, medications, and other treatments
General medical condition

23
Q

1st line therapies for BD1 depression include…

A

Quetiapine and/or lithium
Lurasidone monotx, or with Lithium/DVP
Lamotrigene monotx or adj

24
Q

Depressive symptoms in BD1 may take ____ for initial improvement to be observed…

A

4-6 weeks

No response - consider switch/add-on

25
Q

2nd line monotherapy for BD1 depression includes…

A

Divalproex

26
Q

2nd line add-on therapy/combo for BD1 depression includes…

A

Adjunctive SSRI/bupropion, added to lithium/DVP, or AAP
Olanzapine-fluoxetine

27
Q

ECT could be considered for BD1 depression, when…

A

Treatment refractory patients
Rapid response needed

28
Q

Agents that are NOT recommended and should be avoided for acute bipolar depression include…

A

Antidepressant monotx
Aripiprazole monotx
Ziprasidone
Lamotrigine, + folid acid
Mifepristone adj.

AD has safety concern of mood switching when not used with mood stabilizer

29
Q

Good lithium levels for acute bipolar depression are…

A

0.8-1.2 mmol/L

30
Q

Effective maintenance treatment of bipolar, helps to…

A

Reserve cognitive impairment
Preserve brain plasticity
Improved prognosis + minimization of illness progression

31
Q

Even with treatment, recurrence rates are around…

A

19-25%

32
Q

Risk factors for recurrence of BD1 episodes include…

A

Younger age at onset, more previous episodes
Comorbid anxiety + substance use
Rapid cycling
Psychotic features

33
Q

The only 1st line psychosocial intervention for maintenance therapy of BD that should be offered to all patients is…

A

Psychoeducation

34
Q

With maintenance of bipolar, we want to reassess the following continuously:

A

Medications effective in acute phase (usually effective in maintenance phase)
History of illness, comorbidities
Predominant illness polarity

35
Q

1st line monotherapy options for BD maintenance therapy to prevent any mood episodes include…

Think of our mood stabilizers, and that acute options are usually good for maintenance as well

A

Lithium
Quetiapine
Divalproex
Lamotrigine
Asenapine
Aripiprazole

If patient’s responded well to 1st line tx during acute episode, recommend to continue that agent

36
Q

1st line combination options for BD maintenance therapy to prevent any mood episodes, include…

A

Lithium/DVP + Quetiapine, or aripiprazole

37
Q

Second-line treatment options for BD maintenance therapy, to prevent any mood episodes include…

Similar to second line options for acute treatments

A

Olanzapine
Risperidone monotx + adj.
Carbamazepine
Low dose paliperidone
Lithium/DVP + lurasidone/ziprasidone

38
Q

Third-line treatment options for BD maintenance therapy may include…

A

Aripiprazole + lamotrigine
Clonzapine (adj)
Gabapentin (adj)
Olanzapine + fluoxetine

Usually not used due to lack/lower level of evidence

These would be the extremes of patients where all other options have been exhausted

39
Q

With antipsychotic usage in maintenance therapy, we could consider tapering off after ____ to…

A

6 months - reduce polypharmacy

Continuing for the 6 months is beneficial for maintenance therapy

40
Q

For mixed episodes of BD, we should discontinue…

A

Antidepressants, as they will worsen the overall condition

41
Q

Monotherapy and combination therapy recommended for mixed episodes of BD include…

A

Atypical antipsychotic +/- Lithium/divalproex

42
Q

The following drugs should be avoided in BD during pregnancy:

A

DVP, carbamazepine

Congenital malformations, neural tube defects

If risk of discontinuation outweighs risk of defect, could continue; supplement with folate + vitamin K

43
Q

Drugs that appear safe in pregnancy for BD include…

A

Lamotrigine
AAP’s - quetiapine, risperidone, aripiprazole, olanzapine
Lithium (small risk in 1st trimester)

44
Q

This drug has the most evidence of suicide prevention in patients with BD…

What is the proposed mechanism?

A

Lithium; reduced risk of depressive relapse, impulsivity/aggressive behaviour, and requires long-term monitoring

45
Q

Important roles as a pharmacist in BD treatment include…

A

Screening for presence/history of mania
Avoiding AD monotx
Patient education, supporting adherence
Appropriate dosing

Mental Health (11 decks)

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