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3153 Psychiatry > IC12 Bipolar Disorder > Flashcards

IC12 Bipolar Disorder Flashcards

1
Q

What are some substances/drugs that induces mania? Which NTM are increased?

A

substances/medications esp. by ↑NE & DA, e.g. antidepressants, alcohol, drug withdrawal, DA-augmenting agents, NE-augmenting agents, steroids, thyroid preparations e.g. levothyroxine, pseudoephedrine

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2
Q

What medical conditions can induce mania?

A

other medical conditions e.g. strokes, head injuries, multiple sclerosis, Cushing’s disease, hyperthyroidism (mania), hypothyroidism (depression)

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3
Q

Is bipolar disorder curable?

A

no

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4
Q

What are the symptoms of Mania in bipolar disorder? How many to diagnose someone with mania?

A

Manic Symptoms:

  • Abnormal & persistently elevated / expansive / irritable mood
  • DIGFAST (At least 3sx + elevated/expansive mood / 4sx if the mood is irritable)
    o Distractable
    o Irresponsible / impulsive
    o Grandiose
    o Flight of ideas
    o Activity ↑
    o Sleep need ↓
    o Talkativeness
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5
Q

What is the duration of the different types of mood episodes of bipolar? Include whether there is functional impairment.

A

Mood episodes/duration:

  • Depression (>2wks, functional impairment)
  • Mania (>1wk, functional impairment)
  • Hypomania (>4days, NO functional impairment, no psychosis)

Bipolar I = Depression + Mania

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6
Q

What lab tests need to be done to diagnose one with bipolar disorder? (optional)

A

Lab tests to do when diagnosing:

  • FBC (infection, anemia)
  • U/E/Cr (kidney function)
  • LFTs (all mood stabilizers go through the liver except for lithium)
  • TFTs
  • ECG (lithium, antipsychotics can cause arrythmias)
  • Fasting blood glucose
  • Pregnancy test (many mood stabilizers are teratogenic esp. valproate and lithium)
  • Urine toxicology (substance abuse)
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7
Q

What is the goal of treatment for bipolar disorder?

A
  • Goal: Reduce frequency, duration, severity (and suicidality) of mood episodes
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8
Q

What are the possible non-pharm for bipolar disorder?

A

Non-pharmacological:

  • Recognises early S&S using journal/diary
  • Psychotherapy
  • Stress reduction techniques
  • Sleep hygiene
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9
Q

During acute phase, what meds should be given? Generally.

A

start BZD + mood stabilizers

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10
Q

What is the adjunctive therapy given to patients with bipolar disorder in the acute phase?
How does it help?
When to stop adjunctive meds?

A

Adjunctive Treatment: Benzodiazepines PRN during acute phase. Omit dose for ECT.

  • Help patient relax and sleep
  • Onset within hrs
  • Taper off when condition improves and mood stabilisers are optimised
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11
Q

For bipolar mania, what are the possible meds that can be given? Order them

A

For mania (in order)

  1. Antipsychotic e.g. olanzapine, quetiapine, risperidone, aripiprazole, haloperidol
  2. Lithium (1st line for maintenance & relapse/suicide prevention) –> if poorly tolerated, then consider olanzapine, quetiapine, valproate
  3. Valproate (last line)
  4. Consider combining lithium and/or valproate +/- antipsychotics
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12
Q

For bipolar depression, what are the meds that can be given? Order them.

A

For depression (in order)

  1. Lithium (1st line for maintenance & relapse/suicide prevention)
  2. Quetiapine (but usually use this before lithium)
  3. Olanzapine + fluoxetine combination
  4. Lamotrigine
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13
Q

Which meds are usually for maintenance?

A

Maintenance phase:

  • Lithium (1st line)
  • Olanzapine, aripiprazole, quetiapine (all are off label use)
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14
Q

How to manage no response in 2-4wks?

A
  • IF no response in 2-4wks
    o Switch to another 1st line agent e.g. SGA olanzapine
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15
Q

IF severe/treatment resistant, then what?

A
  • IF severe/treatment resistant
    o ECT
    o Ensure NO Li, anticonvulsants, BZD 12hrs before starting ECT
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16
Q

IF recurrent depressive episodes, then what?

A
  • IF recurrent depressive episodes
    o Long term lithium, quetiapine, olanzapine + fluoxetine –> counsel on risk of suicidality
17
Q

IF bipolar disorder with rapid cycling, then what?

A
  • IF bipolar disorder with rapid cycling (no normal periods)
    o AVOID antidepressants (including combi drugs)
    o USE lithium, lamotrigine or valproate
18
Q

For pregnancy, liver impairment, suicidal/aggressive/violent, what meds should be given or avoided?

A

Special population:

  • Pregnancy
    o AVOID valproate
    o USE quetiapine, olanzapine, risperidone
    o ECT if severe symptoms
  • Liver impairment:
    o USE lithium
  • Suicidal:
    o Use lithium
  • aggressive / violent:
    o USE lithium/valproate +/- anti-psychotics
19
Q

What are the ADRs of Lithium? When do they usually occur (at what Li levels)?

A

1) Acne
2) Fine to coarse tremors
3) Polyuria
4) Hypothyroidism
5) ECG changes
6) Nausea
7) Weight gain
8) Fatigue
9) Cognitive impairment
10) Diabetes insipidus

SE more common when >0.8mEq/L

20
Q

What things cause Lithium toxicity?

A

Li tox with (STAND-up)

  • Sodium ↓
  • Thiazides
  • ACEi/ARBs
  • NSAIDs
  • Dehydration
21
Q

What increases Li elimination?

A

Caffeine and theophylline

22
Q

How is lithium cleared?

A

not affected by liver –> 100% cleared by kidneys

23
Q

What to monitor for when using Lithium?

A

Monitoring:
Physical exam (pregnancy test, ECG), FBC, renal panel & electrolytes e.g. Ca, TFTs, FBG, lipids, BMI, TDM (serum Li levels)

24
Q

What can lithium be used for?

A

Acute, long term maintenance, bipolar mania and depression, suicide prevention

25
Q

Which SGA can be used for mania, depression and long term maintenance?

A

mania
–> reduce agitation
–> all can use (haloperidol, quetiapine, olanzapine, risperidone)

Depression
–> quetiapine, olanzapine + fluoxetine

Long term maintenance: all are off label e.g. Aripiprazole, Quetiapine, Olanzapine

26
Q

What are the pros of antipsychotics compared to other mood stabilizers?

A
  • quetiapine, olanzapine, risperidone safe in pregnancy but look out for gestational diabetes
  • acute overdose safer than lithium
27
Q

What are the cons and ADRs of antipsychotics?

A
  • Haloperidol –> don’t help with depression & EPSE
  • Quetiapine –> orthostatic hypotension
28
Q

What is lamotrigine mainly useful for in bipolar disorders?

A

Bipolar depression

29
Q

What is the precaution of using lamotrigine?

A

1) SJS risk with valproate –> due to longer t1/2 with valproate

30
Q

What are the pros of lamotrigine?

A

Pros:
1) NOT as drowsy/sedating as other mood meds
2) does NOT cause weight gain
3) safe in pregnancy

31
Q

What is the con of lamotrigine?

A

Cons:

  • Don’t have anti-maniac effects
32
Q

What is the place in therapy for lamotrigine?

A

2nd line, pregnancy, bipolar disorder with rapid cycling

33
Q

What are the ADRs of sodium valproate?

A

1) Hepatotoxicity
2) SJS/TEN
3) Pancreatitis
4) Thrombocytopenia
5) weight gain

34
Q

What are the precautions we need to take when using valproate?

A

1) Risk of SJS with lamotrigine
2) Teratogenic (avoid in pregnancy & women of child-bearing potential)

35
Q

When do we use carbamazepine?

A

Very last line, don’t choose in exams:)

36
Q

What are the interactions that CBZ has?

A

1) CYP1A2, 2C9, 3A4 inducer
2) Autoinduction
3) Agranulocytosis with clozapine

37
Q

What mood episode is valproate usually used for in patients with bipolar disorders?

A

Mania

3153 Psychiatry (10 decks)

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