IC12 Bipolar Disorder Flashcards
How does bipolar disorder usually manifest in males and females?
Manic episodes in males
Depressive episode in females
Describe bipolar disorder
lifelong cyclical mood disorder with a variable course, manifesting with recurrent fluctuations in mood, energy and behaviour
Which medications can induce mania in bipolar d/o? (8)
- Drugs of abuse (alcohol intoxication, hallucinogens)
- Drug withdrawal states (alcohol, barbituates, benzodiazepines)
- Antidepressants (MAOIs, TCAs, 5-HT and/or NE and/or DA reuptake inhibitors, 5HT antagonists)
- DA-augmenting agents (CNS stimulants like amphetamines, cocaine; sympathomimetics like DA agonists, releasers and reuptake inhibitors)
- NE-augmenting agents (α2-antagonists, β-agonsits, NE reuptake inhibitors)
- Steroids (anabolic, adrenocorticotropic hormone, corticosteroids)
- Thyroid preparations (T3 or T4 (T3 stronger))
- OTC decongestants (pseudoephedrine)
What is the key clinical feature of bipolar d/o?
History of mania or hypomania not caused by any other conditions or substances
What are the symptoms of mania? (7)
- Abnormal and persistently elevated, expansive or irritable mood (DIGFAST acronym)
- D: Distractabile and easily frustrated
- I: Irresponsible and uninhibited erratic behaviour (resentful of actions when high)
- G: Grandiosity and inflated self-esteem
- F: Flight of ideas (say things faster than we can write, too many thoughts)
- A: Activity increased (cannot sit still, psychomotor agitation)
- S: Sleep need decreased, feel well rested after only 3h, don’t feel the need to sleep (not insomnia)
- T: Talkativeness (difficulty in interpreting)
When is a patient considered to be having a manic episode in relation to the 7 DIGFAST mania symptoms?
at least 3 symptoms plus the elevated or expansive mood
What constitutes major depressive, manic and hypomanic states in terms of duration of symptoms, according to DSM-5?
major depressive if sx > 2 weeks
manic if sx ≥ 1 week (functional impairment)
hypomaniac if sx ≥ 4 days (no functional impairment)
What does Bipolar I and Bipolar II refer to?
Bipolar I refers to mania +/- depressive episodes
Bipolar II refers to hypomania + depressive episodes
Which labs are relevant to test for (general assessment) for bipolar d/o? (5)
- FBC, urea, electrolytes, creatinine, LFTs, TFTs → if liver fx not good, drugs can cause toxicity
- pregnancy test → many mood stabilisers are teratogenic like valproate and lithium
- urine toxicology → patients may lie, assess for barbituates, benzodiazepines, cocaine, ketaminoids (standard 23 items)
- exclude other general medical conditions or substance-induced or withdrawal symptoms
- test for HLA-B*1502 genotype mandated prior to starting carbamazepine
What are the 2 main treatment goals for bipolar d/o?
- Reduce frequency, severity and duration of mood episodes
- Prevent suicide
What are non-pharmacological management options for bipolar d/o? (5)
- Psychoeducation about the disorder, treatment and monitoring for the patient and the caregiver (recognise early signs and symptoms of mania and depression, keep a list of actions that they usually resort to (eg. excessive spending))
- Psychotherapy (individual, group or family) (iCBT or behavioural couples therapy
- Stress reduction techniques (relaxation therapy)
- Sleep hygiene (regular bedtime and awake schedule)
- Nutrition and exercise
What two main classes of drugs can be given for bipolar d/o and what symptoms do they help with?
- Benzodiazepines (help pt relax and sleep)
- Mood stabiliser
When should mood stabilisers be started and why?
start early as they usually take 3-5 days to work
Which 3 drugs can be given for mania in BPD?
- Antipsychotics (risperidone gd for severe mania)
- Lithium
- Valproate
(look at antipsychotics over lithium first in mania due to renal toxicity, hypothyroidism SE and DDIs)
Which 3 drugs can be given for bipolar DEPRESSION?
- Lithium (1st line for maintenance, relapse and suicide prevention)
- Antipsychotics (use quetiapine alone or combination of olanzapine + fluoxetine (olanzapine alone is not as good for MDD))
- Lamotrigene (no anti-manic properties)
When should valproate not be used?
female patients of childbearing potential < 55 years old due to risk of fetal malformation
What are the side effects of lithium? (9)
- hypothyroidism
- tremors
- polyuria
- ECG changes
- nausea
- weight gain
- fatigue
- cognitive impairment
- diabetes insipidus
What circumstances can increase lithium levels? (5)
STAND
1. sodium depletion
2. thiazide diuretics
3. ACEi/ARBs
4. NSAIDs
5. dehydration (salt-restricted diets)
What is the target serum level for valproate and how long does it take to reach steady state?
50-125 mcg/mL
3-5 days
What are the prominent side effects of valproate? (4)
- Decreased platelets
- Pancreatitis
- SJS/TEN
- Weight gain
Which prominent drug interaction should be taken note of with valproate?
Lamotrigene (risk of SJS)
What is the target serum level for carbamazepine?
4-12 mcg/mL
What is the most prominent side effect of carbamazepine?
SJS/TEN
Which prominent drug interaction should be taken note of with carbamazepine?
Clozapine (risk of agranulocytosis)
Which side effects are less prominent with lamotrigene?
Sedation and weight gain
What are antipsychotics MOA in bipolar d/o?
D2 antagonism
SGA: 5-HT(2A) antagonism also
What should be monitored for if antipsychotics are used in pregnancy?
monitor for gestational diabetes
Which serum levels constitute mild lithium toxicity and what are the relevant side effects to remember?
1.5-2.0 mEq/L
GI: n&v
CNS: lethargy, confusion, coarse hand tremors
Which serum levels constitute moderate lithium toxicity and what are the relevant side effects to remember?
2.0-2.5 mEq/L
GI: severe nausea and vomiting
Which serum levels constitute severe lithium toxicity and what are the relevant side effects to remember?
> 3.0 mEq/L
CNS: coma
How is lithium eliminated?
100% cleared by the kidneys (not affected by liver)
What can prolong lamotrigene’s half life?
Hepatic impairment and co-administration with valproate
What is different about hepatic metabolism of carbamazepine?
Induces its own metabolism and that of other drugs (autoinduction)
Lithium monitoring parameters (5)
FBC
renal panel and electrolytes
TFTs
metabolic (FBG, lipids, BMI)
TDM
Valproate monitoring parameters (4)
FBC
LFTs
metabolic (FBG, lipids, BMI)
TDM
Carbamazepine monitoring parameters (4)
FBC
LFTs
renal panel and electrolytes
TDM
Lamotrigene monitoring parameters (3)
FBC
LFTs
renal panel and electrolytes
SGA monitoring parameters (1)
metabolic (FBG, lipids, BMI)
Patients should undergo physical exam before starting all drugs in the table. What should physical exam entail?
ECG, pregnancy test (counsel on proper contraception, especially for VPA) and urine toxicology
Watch out for SJS/TEN and ensure HLA*B1502 allele genotyping before carbamazepine initiation
Which electrolyte should be monitored for in the renal panel?
watch out for low sodium (risk for lithium toxicity)
How should TDM for lithium be conducted?
Take samples 12h after prev dose, for 5-7 days after initiation or change in dose
How should TDM for valproate be conducted?
Through sample needed
Take for at least 2-3 days after initiation or change in dose
How should TDM for carbamazepine be conducted?
Through sample needed
Takes 2-4 weeks to reach steady state (due to autoinduction)
What should you do if mania has not responded within 2 to 4 weeks with an established first-line mood stabiliser
consider augmenting with a second first-line agent or switching to a SGA (like olanzapine)
(reserve carbamazepine for after failing all of the above)
What can be used in treatment-resistant mania or depression?
Electroconvulsive therapy (ECT) can help to reduce manic or depressive symptoms in severe or treatment-resistant mania or depression
(omit lithium, anticonvulsants and benzodiazepines at least 12h before ECT)
What is indicated for recurrent depressive episodes in bipolar d/o?
long-term lithium
What should be avoided in bipolar disorder with rapid cycling (≥ 4 mood episodes per year)?
Avoid antidepressants or stimulants
What considerations have to be made for pregnant patients? (3)
- Pregnancy should be planned in consultation with a psychiatrist and obstetrician to weigh risks and benefits
- Avoid valproate in pregnancy
- Consider ECT for severe mania
What considerations have to be made for pts with liver impairment?
Consider lithium
What considerations have to be made for pts who are aggressive or violent?
Optimise dose and levels of existing lithium or valproate and consider adding antipsychotic
